- Email: [email protected]
Community Dental Care in Norway*†
Department of Dental Health Education
In regard to causative factors in the production of tooth decay, nutrition still holds first place in our observation. The disturbance of nutrition, as in rickets; various children diseases; syphilis, and diabetes, all play their parts. Disturbance of the internal se creting glands enters into many of these cases. Too extended periods of feeding at the breast, that is, months beyond the normal weaning time, produces poor teeth in every case that we have ob served especially if the mother’s diet is poor. O f course, lack of cleanliness of the teeth surely must play a part in the production of decay. In considering nutrition, we must not lose sight of the great importance attached to the pre natal diet of the mother. The use of artificial feeding for babies is a phase of child nutrition that seems to have much to do with the poor character of the teeth of many children. The use of the highly advertised baby food is to be
935
discouraged. A modified cow’s milk seems to produce better teeth. Of course, breast feeding is always to be encouraged, and a well balanced diet for the mother is a great aid in making this possible. C O N C L U S IO N
This work has proved highly success ful, but as occurs in many good activi ties whose progress depends on political backing, this educational program for mother and child health appears to be on its last year of life. Congress, at the last session failed to provide for a continuation of the Act beyond the originally provided term of years. It is still hoped that something may develop which will make it possible to continue, in a still more aggressive manner, the educational work just begun, making it possible for every child to have eventu ally a healthy mouth, which makes for a useful, healthy and happy adult life.
COMMUNITY DENTAL CARE IN NORWAY* By JOHN NILSEN,t Oslo, Norway
T
H E constituted authorities of Nor way, both state and community, are displaying great interest in dental clinics as a civic enterprise. law passed in December, 1917, pro vides: “The children must be assured the necessary dental treatment, and this must be accomplished in the space of
♦Read before the Section on M outh Hy giene, Preventive Dentistry and Public Health at the Seventh International Dental Congress, Philadelphia, Pa., Aug. 25, 1926. •(•Secretary of the Norwegian Association for Combating Dental Disease.
ten years.” This period is now ex tended by ten years, because of the present economic difficulties. The county communities occasionally receive A from the state, in conformity with the cities, 25 per cent of their expenses in paying the salaries of dpntists and in financing the dental service. There are but a few cities without school clinics, but in both city and country, the work has been rendered difficult lately owing to economic condi tions after the War. Hitherto, school dental care was
936
The Journal of the American Dental Association
organized as a civic institution, just as is the dental care of adults, which, under sick fund compensation, is limited to extractions and a few minor operations at a fixed rate. In connection with this, it may be mentioned that dental service has been established in the army and navy and that a great number of soldiers and sailors have their dental work done at these clinics. As the result of the distribution of a circular to the greater hospitals of the country by the Norwegian Associa tion for Combating Dental Disease, a permanent dental clinic has been es tablished at the city hospital in Oslo, and we hope that others will be estab lished. There is a dentist employed at Fredricsvern-Hospital-by-the-Shore for Scrofulous Children, and one at the public school for deaf and abnormal children, and dentists are also employed at the insane asylums. This about covers the community dental care in Norway at the present time. The Norwegian Association for Combating Dental Disease has organ ized systematic propaganda for com munity dental care among the population, through the existing organ ization, particularly by educating the school children the school nurses and the nurses at the board of health. The association is cooperating with the Nor wegian National Tuberculosis Associa tion, the Sanitary Association of Norwegian Women and the Red Cross. Dentists are becoming increasingly in terested in giving public lectures. Dur ing their military service, they are obliged to educate the soldiers through lectures. In this way, we not only spread information among the mass of the people, but we also promote a de mand for the consideration, by the
government, of dental disease as on the plane of other diseases. We believe that if only the great mass of the popu lation, through educational work, get a clear understanding of the funda mental importance of good teeth in the general health, this need will be real ized. For this purpose, the association dis tributes pamphlets and has provided a series of films, available to every one, free of charge. As formerly mentioned, we are of the opinion that systematic propaganda will lay the foundation for carrying out the dental care of the adult popula tion. We must be prepared with a well-considered plan, attainable, in due time, at the smallest possible cost. I presume that this congress has more interest in the actual problem than in a detailed report regarding the present state of school dentistry. This work is going forward after a well-founded plan, although, with us, as elsewhere, it is incomplete. The development of the community dental care of the future must, as I see it, include the following considerations. 1. This development must come about through community enterprise, not through that of private or semi-official associations, such as the establishment of public dental infirmaries by dental socie ties or other agencies. This latter will result only in weak institutions of short duration and slow growth, and, as tempo rary arrangements, they will only retard well-organized dental care. 2. The development must go on step by step; that is, when we work for our goal with school dental care as a basis, we increase the yearly service only by those cases in which systematic treatment has already been
D e p a r t m e n t o f D e n t a l H e a l th E d u c a tio n given, or the teeth have been satisfac torily cared for by a private dentist. Experience shows that to attempt to solve the entire problem at once will, in the first place, call for an amount of work which we could scarcely dare hope to finance by the authorities, because of the amount of apparatus and the number of operations required. I here refer to clinical treatment. But suppose a municipal clinic has been established which is large enough to receive this large clientele: when the work is finished— if this could be imagined— the apparatus will prove too large for further community service. Even if we were to base this reform on the idea that all would thereafter frequent the dental office of his choice, we should meet with boundless diffi culties, perhaps particularly in an eco nomic way. The reform must be subject to the municipal sick funds, which are, in Norway, based mostly upon a kind of cooperative insurance. The annual premium of the members forms the greater part of the funds. W ho dare, under such circumstances, determine the annual premium? And would it not, at all events, have to be fixed so high that the members would object? Sup posing the contributions to the fund were limited at a fixed maximum, the provision would be principally for emergency treatment, and we should never attain systematic and suitable service worthy of the community and our science. I f we, on the other hand, prefer to approach the ideal step by step, we shall surely gain our goal, and, at a mini mum of expense, easily calculated and attainable, provided the work is organ ized in the right way. It is of vital importance that for the success of the
937
entire movement this phase should be thoroughly canvassed before the pro posal is presented to the authorities. Success or failure depends entirely on detailed annual systematic examination and treatment. In the directions addressed to the societies of the respective countries by the Hygiene Commission, the principle of dental treatment by the dentist of choice is established. The question will then be: W ill effective control under this arrangement be possible? After considering this matter thoroughly, I must answer in the negative. It appears to me that the only possible and worthy solution of the question regarding com munity dental care of adults lies in founding clinics supplied with perma nently appointed and salaried dentists (along the lines of the school dental infirmaries connected with and managed by the municipal sick funds). As a first step toward universal com munity dental care in Norway, I have proposed the following to the Nor wegian Association for Combating Dental Disease. The proposal has not yet been discussed and is thus only my individual opinion as to what we should do first. My proposal is that the municipal sick fund include in its contributions dental care for children before entering school and after leaving school, up to the age of 15 (the sick fund’s limit for children) ; treatment to take place at the school infirmaries in idle hours (eventually in the afternoon hours) and to be given by the permanently appointed personnel, and, for this treat ment, the sick funds to supply the community a fixed sum per child. The intention of this proposal is, in the first place, to insure treatment of the decidu ous teeth and the first permanent molars
938
T h e J o u r n a l o f th e A m e r ic a n D e n t a l A s s o c ia tio n
before it is too late, which, as a rule, is now the case. This is a step in the right direction, a shorter step made of that procedure by which the entire re form, by and by, ought to be realized. I also have, on the basis of the working expenses of Oslo school den tal clinics and the number of children in question, attempted to fix the annual sum per child, as the Oslo sick fund would have to take this into account. I am of the opinion that the calcula tion is too high, but I prefer to be on the safe side. From the pecuniary point of view, the community should, for its own part, consider what prophylactic treatment of minors will mean as re gards the budget of the school dental clinics, and that the sick fund will surely be able to save this expense on
the other accounts. It will, in other words, setting the hygienic considera tions aside, pay both the communities and the sick fund to bring about the proposed reform, even if the compensa tion as regards the community, and the increase of the premium for the sick fund, will be lower than the estimate indicates. It will, for many of the communi ties, offer a solution of the school dentis try problem, probably the only solution. I ask that this be considered my con tribution to the discussion of the most important problem within our profes sion today. I f we attempt to establish a system that, in practice, will not answer our purpose and will reflect on our profession, our work will be at a standstill for many years.
ORAL HYGIENE MOVEMENT IN JAPAN * B y Y O S H I O M X J K A I , D .D .S ., T o k y o , Japan
I T was in 1913 that the oral hygiene
movement in Japan entered its ac tive stage after a period of prepara tion extending over about twenty years. In February of that year, Tomijiro Kobayashi established the “ Lion” itin erant dental corps, whose work was to disseminate oral hygiene among the masses. The Dental Federation of Japan, which had been making prepara tions for several years, held its first oral hygiene exhibition and meeting in July, 1915. Since that time, meetings
; * R e a d b e fo re the Section on M o u th H y g ien e, P re v e n tiv e D e n tistry and P u b lic H ealth at the Seventh In te rn a tio n al D e n ta l C o n gress, P h ila d e lp h ia , P a ., A u g . 23, 19 2 6 .
have been held at various places, with great success. Tomijiro Kobayashi is the chief director of the itinerant corps and Sosaku Midorikawa is the lecturer. The late Dr. Sekiichi Enomoto was president of the Dental Federation of Japan. He was later succeeded by Morinosuke Chiwaki. Tsurukichi Okumura is in charge of the oral hygiene department, and I am the lecturer for the federation. The activities of these two organiza tions have led the dental profession in Japan to direct more and more attention to matters of oral hygiene. The oral hygiene movement has shown remark able progress in recent years.
In regard to causative factors in the production of tooth decay, nutrition still holds first place in our observation. The disturbance of nutrition, as in rickets; various children diseases; syphilis, and diabetes, all play their parts. Disturbance of the internal se creting glands enters into many of these cases. Too extended periods of feeding at the breast, that is, months beyond the normal weaning time, produces poor teeth in every case that we have ob served especially if the mother’s diet is poor. O f course, lack of cleanliness of the teeth surely must play a part in the production of decay. In considering nutrition, we must not lose sight of the great importance attached to the pre natal diet of the mother. The use of artificial feeding for babies is a phase of child nutrition that seems to have much to do with the poor character of the teeth of many children. The use of the highly advertised baby food is to be
935
discouraged. A modified cow’s milk seems to produce better teeth. Of course, breast feeding is always to be encouraged, and a well balanced diet for the mother is a great aid in making this possible. C O N C L U S IO N
This work has proved highly success ful, but as occurs in many good activi ties whose progress depends on political backing, this educational program for mother and child health appears to be on its last year of life. Congress, at the last session failed to provide for a continuation of the Act beyond the originally provided term of years. It is still hoped that something may develop which will make it possible to continue, in a still more aggressive manner, the educational work just begun, making it possible for every child to have eventu ally a healthy mouth, which makes for a useful, healthy and happy adult life.
COMMUNITY DENTAL CARE IN NORWAY* By JOHN NILSEN,t Oslo, Norway
T
H E constituted authorities of Nor way, both state and community, are displaying great interest in dental clinics as a civic enterprise. law passed in December, 1917, pro vides: “The children must be assured the necessary dental treatment, and this must be accomplished in the space of
♦Read before the Section on M outh Hy giene, Preventive Dentistry and Public Health at the Seventh International Dental Congress, Philadelphia, Pa., Aug. 25, 1926. •(•Secretary of the Norwegian Association for Combating Dental Disease.
ten years.” This period is now ex tended by ten years, because of the present economic difficulties. The county communities occasionally receive A from the state, in conformity with the cities, 25 per cent of their expenses in paying the salaries of dpntists and in financing the dental service. There are but a few cities without school clinics, but in both city and country, the work has been rendered difficult lately owing to economic condi tions after the War. Hitherto, school dental care was
936
The Journal of the American Dental Association
organized as a civic institution, just as is the dental care of adults, which, under sick fund compensation, is limited to extractions and a few minor operations at a fixed rate. In connection with this, it may be mentioned that dental service has been established in the army and navy and that a great number of soldiers and sailors have their dental work done at these clinics. As the result of the distribution of a circular to the greater hospitals of the country by the Norwegian Associa tion for Combating Dental Disease, a permanent dental clinic has been es tablished at the city hospital in Oslo, and we hope that others will be estab lished. There is a dentist employed at Fredricsvern-Hospital-by-the-Shore for Scrofulous Children, and one at the public school for deaf and abnormal children, and dentists are also employed at the insane asylums. This about covers the community dental care in Norway at the present time. The Norwegian Association for Combating Dental Disease has organ ized systematic propaganda for com munity dental care among the population, through the existing organ ization, particularly by educating the school children the school nurses and the nurses at the board of health. The association is cooperating with the Nor wegian National Tuberculosis Associa tion, the Sanitary Association of Norwegian Women and the Red Cross. Dentists are becoming increasingly in terested in giving public lectures. Dur ing their military service, they are obliged to educate the soldiers through lectures. In this way, we not only spread information among the mass of the people, but we also promote a de mand for the consideration, by the
government, of dental disease as on the plane of other diseases. We believe that if only the great mass of the popu lation, through educational work, get a clear understanding of the funda mental importance of good teeth in the general health, this need will be real ized. For this purpose, the association dis tributes pamphlets and has provided a series of films, available to every one, free of charge. As formerly mentioned, we are of the opinion that systematic propaganda will lay the foundation for carrying out the dental care of the adult popula tion. We must be prepared with a well-considered plan, attainable, in due time, at the smallest possible cost. I presume that this congress has more interest in the actual problem than in a detailed report regarding the present state of school dentistry. This work is going forward after a well-founded plan, although, with us, as elsewhere, it is incomplete. The development of the community dental care of the future must, as I see it, include the following considerations. 1. This development must come about through community enterprise, not through that of private or semi-official associations, such as the establishment of public dental infirmaries by dental socie ties or other agencies. This latter will result only in weak institutions of short duration and slow growth, and, as tempo rary arrangements, they will only retard well-organized dental care. 2. The development must go on step by step; that is, when we work for our goal with school dental care as a basis, we increase the yearly service only by those cases in which systematic treatment has already been
D e p a r t m e n t o f D e n t a l H e a l th E d u c a tio n given, or the teeth have been satisfac torily cared for by a private dentist. Experience shows that to attempt to solve the entire problem at once will, in the first place, call for an amount of work which we could scarcely dare hope to finance by the authorities, because of the amount of apparatus and the number of operations required. I here refer to clinical treatment. But suppose a municipal clinic has been established which is large enough to receive this large clientele: when the work is finished— if this could be imagined— the apparatus will prove too large for further community service. Even if we were to base this reform on the idea that all would thereafter frequent the dental office of his choice, we should meet with boundless diffi culties, perhaps particularly in an eco nomic way. The reform must be subject to the municipal sick funds, which are, in Norway, based mostly upon a kind of cooperative insurance. The annual premium of the members forms the greater part of the funds. W ho dare, under such circumstances, determine the annual premium? And would it not, at all events, have to be fixed so high that the members would object? Sup posing the contributions to the fund were limited at a fixed maximum, the provision would be principally for emergency treatment, and we should never attain systematic and suitable service worthy of the community and our science. I f we, on the other hand, prefer to approach the ideal step by step, we shall surely gain our goal, and, at a mini mum of expense, easily calculated and attainable, provided the work is organ ized in the right way. It is of vital importance that for the success of the
937
entire movement this phase should be thoroughly canvassed before the pro posal is presented to the authorities. Success or failure depends entirely on detailed annual systematic examination and treatment. In the directions addressed to the societies of the respective countries by the Hygiene Commission, the principle of dental treatment by the dentist of choice is established. The question will then be: W ill effective control under this arrangement be possible? After considering this matter thoroughly, I must answer in the negative. It appears to me that the only possible and worthy solution of the question regarding com munity dental care of adults lies in founding clinics supplied with perma nently appointed and salaried dentists (along the lines of the school dental infirmaries connected with and managed by the municipal sick funds). As a first step toward universal com munity dental care in Norway, I have proposed the following to the Nor wegian Association for Combating Dental Disease. The proposal has not yet been discussed and is thus only my individual opinion as to what we should do first. My proposal is that the municipal sick fund include in its contributions dental care for children before entering school and after leaving school, up to the age of 15 (the sick fund’s limit for children) ; treatment to take place at the school infirmaries in idle hours (eventually in the afternoon hours) and to be given by the permanently appointed personnel, and, for this treat ment, the sick funds to supply the community a fixed sum per child. The intention of this proposal is, in the first place, to insure treatment of the decidu ous teeth and the first permanent molars
938
T h e J o u r n a l o f th e A m e r ic a n D e n t a l A s s o c ia tio n
before it is too late, which, as a rule, is now the case. This is a step in the right direction, a shorter step made of that procedure by which the entire re form, by and by, ought to be realized. I also have, on the basis of the working expenses of Oslo school den tal clinics and the number of children in question, attempted to fix the annual sum per child, as the Oslo sick fund would have to take this into account. I am of the opinion that the calcula tion is too high, but I prefer to be on the safe side. From the pecuniary point of view, the community should, for its own part, consider what prophylactic treatment of minors will mean as re gards the budget of the school dental clinics, and that the sick fund will surely be able to save this expense on
the other accounts. It will, in other words, setting the hygienic considera tions aside, pay both the communities and the sick fund to bring about the proposed reform, even if the compensa tion as regards the community, and the increase of the premium for the sick fund, will be lower than the estimate indicates. It will, for many of the communi ties, offer a solution of the school dentis try problem, probably the only solution. I ask that this be considered my con tribution to the discussion of the most important problem within our profes sion today. I f we attempt to establish a system that, in practice, will not answer our purpose and will reflect on our profession, our work will be at a standstill for many years.
ORAL HYGIENE MOVEMENT IN JAPAN * B y Y O S H I O M X J K A I , D .D .S ., T o k y o , Japan
I T was in 1913 that the oral hygiene
movement in Japan entered its ac tive stage after a period of prepara tion extending over about twenty years. In February of that year, Tomijiro Kobayashi established the “ Lion” itin erant dental corps, whose work was to disseminate oral hygiene among the masses. The Dental Federation of Japan, which had been making prepara tions for several years, held its first oral hygiene exhibition and meeting in July, 1915. Since that time, meetings
; * R e a d b e fo re the Section on M o u th H y g ien e, P re v e n tiv e D e n tistry and P u b lic H ealth at the Seventh In te rn a tio n al D e n ta l C o n gress, P h ila d e lp h ia , P a ., A u g . 23, 19 2 6 .
have been held at various places, with great success. Tomijiro Kobayashi is the chief director of the itinerant corps and Sosaku Midorikawa is the lecturer. The late Dr. Sekiichi Enomoto was president of the Dental Federation of Japan. He was later succeeded by Morinosuke Chiwaki. Tsurukichi Okumura is in charge of the oral hygiene department, and I am the lecturer for the federation. The activities of these two organiza tions have led the dental profession in Japan to direct more and more attention to matters of oral hygiene. The oral hygiene movement has shown remark able progress in recent years.