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Development of Modern Dentistry in Japan
A t M e iji Stadium, Tokyo, du ring Denta! H ealth W eek children line up on the fie ld fo r mass too thbrush drill
Development of Modern Dentistry in Japan Bruce L. D o u g la s* D .D .S., M .A ., M .P .H ., C hicago Isadore W einstein,f D .D .S., Philadelphia
D evelopm ents in Japanese undergradu ate and postgraduate dental education, licensure, school dental service, govern m ent health insurance and dental health education are traced. Alm ost all dentists serve under a governm ent-controlled health insurance program covering more than 95 per cent o f the people. This in surance program is a major obstacle to the advancem ent o f dental practice. Japanese dentistry excels in research; studies in all areas of dental science are emanating from Japanese dental schools, and through research Japan is making its greatest contribution to world dentistry.
In 1931 Tsurukichi Okum ura wrote the first comprehensive paper published in English about dentistry in Japan.1 H e summarized the early growth and devel
opm ent o f “ m odern dentistry” in the country and emphasized the role played by Am erican dentists w ho resided there. T h e M eiji Restoration, which began with the Em peror M eiji’s ascent to the throne in 1868, is com m only regarded as the beginning o f the m odernization o f Japan. It represented the end o f the isola tion to which the nation was subjected during the Tokugaw a reign, w hich lasted a few hundred years. D uring that time few foreigners entered Japan, and there was relatively strong suppression o f ac tivity o f those foreigners w ho did live there. T w o Americans, W illiam C . Eastlake and St. George Elliot, were the first fo r eign dentists to open practices in Japan. Okum ura com m ented that they brought with them the “ modern art o f dentistry.” T h ey each had student apprentices, one o f whom , Einosuke O bata, becam e the first licensed dentist in Japan in 1875.
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Dr. Obata, a noble by birth, opened an office in Tokyo and trained many young men who later became leaders in the Japanese dental profession. Okumura said that other American dentists spent varying periods of time in Japan. As the nineteenth century drew to a close, however, a number of young Japanese started studying dentistry in American schools, and a clique of American-trained dentists began to evolve. This trend continued into the twentieth cen tury and was responsible for early close ties between the dental professions of both countries. Bergemann2 said that the “Jap anese educational system attempted to combine recognition and acceptance of Western science and technology with tra ditional Japanese values and ideals.” He observed that Japanese dentistry relied largely on American influence. Neverthe less, in viewing Japanese dental education today, it is apparent that the close ties between Japan and Germany have also had a strong influence on Japanese dental educational philosophies. D E N T IS T R Y IN M E D IC A L S C H O O L S
In 1903 a dental infirmary was estab lished in Tokyo Imperial University Hos pital, marking the beginning of a distinct trend in Japanese dentistry. Eventually a professorship in dentistry on the medi cal faculty was created and a course in dentistry was included as part of the reg ular medical curriculum. A number of other medical colleges followed suit, and they continue to teach dentistry as part of the overall medical course. The developing relation between medi cine and dentistry was somewhat con fused for a time because a number of physicians, with only a rudimentary knowledge of dentistry, set themselves up as dental specialists. Douglas and Watanabe3 described the current system of teaching dentistry to medical students at one Japanese medical school and emphasized the advantages of acquainting physicians with the oral re gion and with dentistry in general.
Douglas comments4 that, in teaching dentistry to medical students, “the pa tients with dental maladies stand to bene fit substantially from closer relationship between the medical and dental profes sions.” G R O W T H O F D E N T A L L E G ISL A T IO N
The first dental examiners were ap pointed in 1884. The first National Den tal Law was proclaimed in 1906, and sub sequently it has been revised a number of times. By 1931 there were 17,000 regis tered dentists in the country, according to Okumura. Okumura said that the changing pat tern of dental legislation was influenced by the gradual growth of the Japan Den tal Association. The J.D.A. was estab lished by government authorization in 1926 as a “legal body with judicial pow ers.” Although there is some question about its “judicial powers” today, this authorization seems to have had a pro nounced effect on the Japan Dental Asso ciation’s subsequent activities. The J.D.A. has served primarily as a spokesman for the dentists of Japan in their relations with the government. In recent years, the J.D.A. has also had a voice in the National Health Insurance system. D E N T A L L IC E N S U R E E X A M IN A T IO N S
Although regulations for licensure exam inations were established in 1913, Oku mura said that it was not until 1928 that strict qualification requirements to take the examination were enforced. There fore, many dentists who had registered with the Department of Education and had not actually completed formal den tal education received licenses up to 1928. Some of these dentists are still practicing today. J A P A N E S E D E N T A L E D U CA TIO N
By 1931 there were nine dental colleges, one of which was in Japanese-occupied
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Toothbrush in hand, Japanese school children s it in spectators' stands and fo llo w instructions given over a loudspeaker
K orea. Entrance was granted after 13 years o f preliminary education (six years o f elementary school, fou r years o f middle school and three years o f higher s c h o o l). Graduates o f the dental colleges were au tomatically eligible to practice without further examination. W ith the exception o f one school, started in 1929, all dental colleges were privately operated as o f 1931, and only one o f those was affiliated with a univer sity. T h e establishment o f the government school was a significant m ove in Japan. It demonstrated government concern for dental education. Also, government schools in all areas and at all levels o f education have always held positions o f high prestige. This dental college even tually becam e affiliated with a medical college and was named T ok yo M edical and Dental University ( T ok yo Ikashika Daigaku) . P O S T G R A D U A T E E D U C A TIO N
In 1923 the first Igakuhakushi, a post graduate degree in m edical science, was awarded to a Japanese dentist. Subse quently thousands o f Japanese dentists and physicians have received this degree. In recent years, this degree has almost becom e a necessity for a doctor to be suc cessful in academ ic life. T h e prestige value o f the degree is im portant in other aspects o f dental and m edical practice as well. In the last few years, the system for earning the degree has becom e more formalized. Before 1959 it was possible to acquire the degree with minimal attend
ance in school and with the com pletion o f a research project and an examination. T oday, fou r years o f full-time attendance at a recognized m edical or dental college are required; however, each accredited school is free to administer and organize its program as it sees fit. Each department in each school may accept only two d e gree aspirants a year. Although the indi vidual program is supposed to be designed in consultation with the student, the organization o f the four-year course o f study depends largely on the professor heading the department. T h e course usu ally is divided between the clinic and the laboratory. T here are few lectures, and few , if any, examinations are required until the four-year period is com pleted and the student’ s research project is fin ished. I f there is form al course work, students are not required to attend classes, but this is true with classes at all levels o f Japanese higher education. A t the co n clusion o f the course, students must take a final examination. T h e nature o f a postgraduate student’ s research m ay vary widely. It usually d e pends on the department and the school. A dentist may work for his postgraduate degree in a m edical school and undertake a research project unrelated to dentistry. J A P A N E S E H IG H E R E D U C A T IO N
In order to com prehend the nature o f a student’ s research, it is necessary to un derstand the traditional autonomous role o f the professor in Japanese higher edu cation. H e usually decides what research projects his students should undertake,
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and the projects often coincide with his own interest and work. Therefore, one professor interested in a particular line of scientific inquiry is likely to have different students working on various aspects of the same overall project. In many instances, such project assignments lead to great productivity and a continual flow of sci entific publications in the select field; however, difficulties have been known to arise when a particular professor leaves his department and his successor has dif ferent major research interests. Research accomplishments and publications play a major prestige role in Japanese science. Therefore, there is great emphasis on re search in postgraduate education. There is relatively little formal empha sis on the learning process in Japanese higher education. It is generally assumed that a student’s presence indicates an adequate exposure to the subject matter. Students are expected to do extensive out side reading, but are rarely given specific assignments. In the clinical fields, the postgraduate student receives little formal instruction in the performance of opera tive or surgical work. He spends much time assisting his teachers. The professor of oral surgery, for example, usually at tends to almost all major surgical patients himself, and there is little conscious effort to teach his junior staff members or post graduate students. The general idea is that the younger doctor will learn by watching and assisting. Igakuhakushi is a postgraduate degree in medical science which may be earned either by a dentist or physician. In the dental colleges, the shigakuhakushi, a de gree in dental science, is awarded. The translation of the meaning of these de grees into English has become somewhat of a problem, since there has been no standardized translation adopted by the Japanese medical and dental professions. The most commonly used English trans lations of the degrees are “Doctor of Medical Science” and “Doctor of Dental Science.” The degree is not equivalent to the American Ph.D. degree.
S C H O O L D E N T A L H Y G IE N E
The Japanese early recognized the im portance of school dental hygiene. In 1919 a bill was passed by the Diet (na tional legislature) which provided for the organization of dental hygiene facilities for school children. This provision in cluded the establishment of clinics, a school dentist system and yearly free ex aminations for all children, with provi sions for reports to go to the parents. This system exists today, but it is beset by many inadequacies. Because of the pressure of the National Health Insur ance system and the dearth of funds in the majority of schools, only the examina tion provision of the legislation has been put into effect. The examinations gener ally are conducted under the most un ideal physical circumstances. One dentist usually is called upon to examine 500 or more patients in one day without ade quate lighting and assistance and without x-ray facilities. The dentist is paid from $2.75 to $5.00 for a full day’s work, the amount depending on the financial capa bilities of the individual school. The School Dentists’ Association, a national organization, attempts to work in close liaison with the schools to effect the objectives of the program. Yoshio Mukai, president of the association and chairman of the oral hygiene committee of the Japan Dental Association, describes the methods that are employed to exert social pressure on the children to strive for good dental health. Awards are given to children with good dental health, and a national mother-child “most perfect teeth contest” is held in September. The School Dentists’ Association en courages the promotion of improved den tal health among children in as many ways as possible, but progress has been slow. Despite the fact that it is the avowed aim to reduce 50 per cent of the decay in the permanent teeth of school children, the trend is in the opposite di rection, especially since Japan lacks water fluoridation. Only 10 per cent of the
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schools have organized com petitive pro grams in dental health, and widespread health education technics in prom oting im proved dental health are almost un known. Because most Japanese dentists are ex tremely busy caring for patients under the health insurance system, most o f them have little time for the care o f children. T h e School Dentists’ Association, in its concern about this problem , encourages dentists to set aside some time for the care o f children, especially in follow ing up re ports from school dental examinations. It has been found that the parents can not be relied on to take the children for dental treatment. Therefore, the emphasis in the program is to educate the child himself or to place him under some social pressure to achieve good dental health. It is noteworthy that parents often neglect dental care for their children (and them selves) in spite o f the fact that there is at least partial coverage fo r it under the health insurance program. A fter the war, the principle o f “ learn ing by doing” was introduced into the Japanese primary school system and was particularly emphasized in matters of health. As a result, school health com mittees were established in many schools, consisting o f representatives o f the chil dren, their parents, the teachers and the community. In many o f the m ore health conscious schools, meetings are held every month to discuss m edical and dental health. G O V E R N M E N T H E A L T H IN S U R A N C E
In 1927 the Japan Dental Association entered into an agreement with the gov ernment for diagnostic and therapeutic dental services for factory employees. This agreement has led through the en suing years (particularly after the war) to a long series o f negotiations between organized dentistry and the government to establish a suitable dental health insur ance system. From the start o f the program , insured
Fig. 3 • On th e fie ld , Japanese children form regim ental columns and perform exhibition o f how to use the too thbrush
persons could be treated only by dentists accepted by the Japan Dental Association and the health insurance offices in their local prefectures as “ insurance dentists.” In 1930 approxim ately 70 per cent o f the dentists were registered. T oday, membership in the J.D .A . and a m onthly fee are required if a dentist is to participate in the insurance system. Virtually 100 per cent o f the practicing dentists are included in the program, and all o f Japanese dentistry has been swept up in the current o f governm ent-controlled health insurance. A t the present time, the provision exists for every citizen o f Japan to be included in the system, and various estimates place m ore than 95 per cent o f the population under at least par tially active participation in the program. Douglas stated" that the health insur ance system is the one overriding and underlying factor which affects every aspect of dentistry in the country. . . . T h e Japanese dentist is almost completely submerged within it. . . . Health Insurance is a chronic, incurable disease, apparently neces sary in Japan’ s social system. Its presence in its present form is agreeable to the great m a jority o f patients and disagreeable to the great m ajority o f the physicians and dentists. . . . Because of its inherent weaknesses, it interferes with the perform ance o f good dentistry very frequently. T h e dentist is paid so little for pro viding dental care that he is forced to indulge in mass-production technics, and to have pa tients return endlessly for treatment that could,
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with careful expenditure o f time, be com pleted within a few visits. . . . In spite o f the fact that there is widespread discontent with the present health insurance system am ong the dentists, it does not discourage large numbers of men and w om en from applying for admis sion to schools o f dentistry. T h e status that the dentist acquires and the insured source o f a steady incom e apparently compensate for the drawbacks. In spite of the fact that the dentist is grossly underpaid, if he is willing to work long hours, relatively speaking, he can still make a sizable income.
Under the system, there is completely free choice of doctor. Some private com panies and government organizations have their own dental clinics, and employees are free to use them if they wish. Since the company often covers employees for broad health insurance benefits, they are still covered by the same policies if they seek care elsewhere. A few of the wealthier companies even provide dental coverage that would be considered luxur ious according to Japanese standards, for example, gold bridges; however, such coverage is available only if they use the facilities provided at their place of em ployment. In most cases, a dentist employed by a company works on a salary basis and may treat only employees and their families. There is a wide salary range among such dentists, and a few do better financially than dentists in private practice. Government employees working for the railways and post office department have separate medical care facilities, which are similar to those run by business organiza tions. Medical and dental fees are regulated by a point system established by the na tional government. Fees can be changed only if the point system is altered across the board. Apparently such changes are effected only after great pressure from the medical and dental professions. The dissension generated by this pressure led to a series of strike threats in 1961 and eventually to the first of a number of strikes in which members of the medical and dental professions went “off the job.” “Striking doctors” created an emotional
upheaval throughout the nation, espe cially when a number of deaths were at tributed to the unavailability of medical care on the days of the strike. Emergency staffs reportedly were left on duty at key hospitals and clinics throughout the coun try, but, in a nation where there is rela tively little private transportation, there were some mishaps because of the in evitable delays that accompanied the lim ited care available. In negotiations with the government relating to fees, the Japan medical and dental associations are the official repre sentatives of the two professions. There is dissension within the ranks of the physi cians on the legitimacy of this representa tion. The two national organizations do not enjoy the singular prestige possessed in the United States by their counterpart associations. In the case of the dental as sociation, this may be at least partially due to the fact that it has been almost continuously and solely concerned with matters of economic and political signifi cance, and it has had relatively little time or opportunity for what might otherwise be considered scientific responsibilities. Final decisions about changes in fee schedules rest with the government. The 1961 strikes led to an eventual increase of 10 per cent in fees. The personnel who represent the pro fessional associations in conferences with the Ministry of Welfare are also con cerned with methods of treatment and the drugs that are allowable in the health insurance fee schedule. The final deci sions are always made by professional politicians who represent the government. This fact is a constant source of friction between the two bodies. Public opinion is strongly in favor of the health insurance system. There is lit tle generalized concern among the Jap anese people for the quality of medical care. On the whole, they are satisfied to have it available, and they strongly sup port the government’s actions in disputes with the doctors. Physicians and dentists are employed
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by the local prefectural government wel fare offices to serve as investigators in the local health insurance system. There are numerous forms to be filled out, and they are surveyed by these representatives. Overt dishonesty usually leads to suspen sion from participation in the program. In view of the widespread nature of health insurance, this method of investi gation could be extremely harmful to a private practitioner. These checks refer to the type and frequency, but not specifi cally to the quality, of care. All doctors receive the same fees under the system regardless of training and ex perience. Therefore, the fees paid to a dental school for clinical care and those paid to a recent graduate or a long-estab lished practitioner are the same. This absence of scaled fees may be responsible, at least in part, for the fact that there is little specialization in dental practice in Japan. In the entire nation, there are only a few practitioners who limit their prac tices to orthodontics or oral surgery. Pedodontics is taught as a special area of dental practice only in one school and is unknown as a specialty. Neither endodontics nor periodontics is recognized any where in the nation as a specialty. Con sidering the absence of fee differences for special professional abilities, it seems rea sonable to assume that specialization may never develop to the degree that it has in the United States. One concluding point merits emphasis in regard to the effect of government health insurance in Japan. Many more people are now receiving medical and dental care than was the case before the widespread introduction of health insur ance. All evidence suggests that the quality of care leaves much to be desired and the nature of the doctor-patient relationship has become decidedly more distant. In Japan, however, other criteria exist for determining the strengths and weaknesses of medical and dental practice. Japanese people, in general, expect less from the physician or dentist than Americans do. Therefore, their relations with him may
not be nearly as important as in this coun try. In the final analysis, it is the people themselves who determine under which system of health care they wish to be treated, and the Japanese people are making their choice within the context of their own cultural values. S T A T U S OF D E N T A L E D U C A T IO N
Japanese dental education is presently en joying a period of relative prosperity. There are eight dental colleges— one in Kokura on the island of Kyushu, two in Osaka, one (established in 1961) in Nagoya and four in Tokyo. One in Osaka (Osaka University Dental School) and one in Tokyo (Tokyo Medical and Den tal University) are national governmentoperated institutions. The other five are locally or privately financed and admin istered. Three are directly affiliated with universities or colleges (Osaka University Dental School; Nihon University Dental School, which is located in Tokyo; the new school in Nagoya, Aichi-Gakuin University Dental School). In July 1951, a dental mission was sent to Japan by the American Dental Associ ation, under the auspices of the military occupation authorities, to report on the status of dentistry in the country. The members of the mission made a number of recommendations relating to dental education.6 As a result of these recom mendations, attempts were made during the postwar reconstruction to model Jap anese dental education after the Ameri can system. Some of the recommenda tions made by the mission were: (1) predental education should be obtained in recognized universities only, rather than in privately or governmentally oper ated dental colleges, with credits accepted toward a baccalaureate degree; (2) den tal colleges should be an intimate part of the university, with the same academic status as other colleges of the university; (3) dental education should be autono mous. The Japanese educational system was
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too well entrenched in tradition for these recommendations to be followed. There fore today predental students, in general, take their predental courses under the auspices of the dental schools in which they are already technically enrolled. Pre dental education takes two years, during which a large number of courses are taken in both cultural and scientific fields. There is no direct route to admis sion to the study of dentistry without having taken the predental years in the same institution. Therefore, the predental student, at the start of his course, is headed for a dental degree in six years. It is rare for a student to fail and be forced to leave school. According to the Japanese higher edu cational system, each school conducts an entrance examination, but it is generally agreed that admission to the two govern ment schools is considerably more diffi cult and competitive. For one thing, gov ernment schools have very low tuition and usually have a staff of better quali fied faculty members. Also, government schools have traditionally been regarded as the finest institutions in the country, and government dental educational insti tutions share the same high regard. This view is not to detract from the fine work being done by the privately operated schools. For example, in 1960 Tokyo Dental College started a fine dental jour nal printed in English. This journal exemplifies the extraordinary dental re search which is being done in many Japanese schools. The basic and peren nial financial problem of the privately operated institutions leads them to charge high tuition rates and admit too many students. Salaries of faculty members in the private schools are very low, forcing most of them to depend on outside sources of income. The same holds true for teach ers in government schools, but the status symbol of being associated with a govern ment institution seems to compensate somewhat for this inadequacy. Teachers in government schools are prohibited from accepting outside employment, but
the newspapers constantly carry stories about university professors who are forced to work in consultatory and other capaci ties because of their low incomes. There has been a remarkable growth of physical facilities in Japanese dental schools during the last decade. A number of schools were severely affected by bomb ings during the war and were severely run down because of a dearth of mate rials. High-speed operative dental equip ment, now becoming favored in private dental offices, is also finding its way into all schools, and the Japanese ingenuity in mechanics is apparent everywhere that dentistry is practiced and taught in the country. A T T IT U D E S T O W A R D D E N T A L P U B L IC H E A L T H
In general, the attitude of the Japanese people toward health is utilitarian. There is little appreciation for the concept of prevention. This is especially true of den tal public health. Fluoridation of public water supplies is almost nonexistent. Only in one small area of Kyoto, where the population is 12,000, has fluoridation been introduced as a pilot project. It was started in 1952. Although greater emphasis is gradually being placed on oral hygiene, the basic tenets of periodontics are often disre garded. Periodontal services are not cov ered under the health insurance program and little time is devoted to the teaching of the subject in the dental curriculum. Toothbrushing seems to be equated with total periodontal “ treatment,” and there is much emphasis on this aspect of oral hygiene. Nevertheless, Japanese tooth brushes are usually of poor quality and have extremely soft bristles. Rampant periodontal disease is apparent every where, even among those in the welleducated and higher socioeconomic strata. For several years, one of the toothbrush manufacturers, in cooperation with the Japan Dental Association, has sponsored toothbrush drills in various parts of the
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country. The yearly spectacle in a large athletic stadium in Tokyo, during Dental Health Week, is a fascinating sight. Over 30,000 children and some parents crowd into a large stadium and are given toothbrushing lessons via a loudspeaker system. The drills are accompanied by music from a large band (Fig. 1-3). Dental Health Week is sponsored by the Japan Dental Association, and posters are sent to all dentists and schools for health edu cation purposes. Teachers are encouraged to speak about dental health during that period and to display poster materials. This educational effort is still young. Its effects will not be felt for a number of years because the older generation lends it little support. The children eat many sweets, and there is little evidence of any concerted effort on the part of the dental profession to discourage this dietary prac tice. C O N C L U S IO N S
The presence of publicly accepted gov ernment health insurance in Japan seems to be the most powerful restraining force in the advancement of Japanese den tal practice; nevertheless, comparatively speaking, the Japanese people receive good dental care. Japan has the third largest number of dentists in the world, ranking behind the United States and West Germany. Although the present number is inadequate according to American standards, the dentists seem able to handle the demand, so long as they are willing to work long, hard hours. Japanese dentistry excels in dental re search. There is a well-entrenched respect for research among Japanese scholars that exhibits both quality and quantity. Japanese culture centers around the hu man characteristics so essential for quality research. Many studies in all areas of den tal science are now emanating from Japanese dental schools. It is in research that Japan is making, and will no doubt continue to make, its greatest contribu tion to world dentistry. Unfortunately,
there is limited direct transfer of results from the laboratory studies to application in the clinic and the treatment of pa tients, except in the dental schools, where clinical research is also taking place on a large scale. Japanese society in general is in the throes of a revolution which is having its effects on the practice of dentistry. The nation is presently adjusting to the tre mendous social upheaval which follows in the wake of economic reconstruction. It must be remembered that the dental educational system, the way the Japanese dentist practices his profession, and the way the Japanese people choose to pro vide for medical and dental care are all parts of a culture deeply rooted in the Oriental philosophy of life. The fact that Tokyo and other urban centers of Japan seem, on the surface, to be adapting to western ways does not indicate that the people as a whole are doing so. There fore, it is unjust and unrealistic to extend the comparison between Japanese and American dentistry too far. The progress that has been apparent throughout the nation since the war is adequate testi mony to the stamina and intelligence of the people of Japan. Their ways of pro gressing, through dental practice and dental science, are an intricate part of this struggle. 808 South W ood Street
*Formerly Fulbright Exchange Professor of Dentistry, Okayama University Medical School and Tokyo Medical and Dental University, 1959-61. Assistant professor and coordinator of oral medicine, College of Dentistry, University of Illinois. {Exchange Fellow in Oral and Maxillofacial Surgery, Osaka University Dental School, 1961-62. !. Okumura, Tsurukichi. Present status of dentistry in Japan. Japan Dental Association 1931. 2. Bergemann, Hugo. New impulses for international dentistry through the modern Japanese dental literature. Zahnarztl. Mitt. 44:616 Sept. I, 1956. 3. Douglas, Bruce L., and Watanabe, Yoshio. Teach ing dentistry to medical students. J. Med. Educ. 35:874 Sept. I960. 4. Douglas, Bruce L. Letter from Japan. J. Am. D. Soc. Anesthes. 7:26 Jan. I960. 5. Douglas, Bruce L. Final observations of Japanese dentistry. J. Am. D. Soc. Anesthes. 8:223 Aug.-Sept. 1961. 6. Mission to Japan: report to Medical Section, Pub lic Health and Welfare Division, GHQ, SCAP. J.A.D.A. 43:593 Nov. 1951.
Development of Modern Dentistry in Japan Bruce L. D o u g la s* D .D .S., M .A ., M .P .H ., C hicago Isadore W einstein,f D .D .S., Philadelphia
D evelopm ents in Japanese undergradu ate and postgraduate dental education, licensure, school dental service, govern m ent health insurance and dental health education are traced. Alm ost all dentists serve under a governm ent-controlled health insurance program covering more than 95 per cent o f the people. This in surance program is a major obstacle to the advancem ent o f dental practice. Japanese dentistry excels in research; studies in all areas of dental science are emanating from Japanese dental schools, and through research Japan is making its greatest contribution to world dentistry.
In 1931 Tsurukichi Okum ura wrote the first comprehensive paper published in English about dentistry in Japan.1 H e summarized the early growth and devel
opm ent o f “ m odern dentistry” in the country and emphasized the role played by Am erican dentists w ho resided there. T h e M eiji Restoration, which began with the Em peror M eiji’s ascent to the throne in 1868, is com m only regarded as the beginning o f the m odernization o f Japan. It represented the end o f the isola tion to which the nation was subjected during the Tokugaw a reign, w hich lasted a few hundred years. D uring that time few foreigners entered Japan, and there was relatively strong suppression o f ac tivity o f those foreigners w ho did live there. T w o Americans, W illiam C . Eastlake and St. George Elliot, were the first fo r eign dentists to open practices in Japan. Okum ura com m ented that they brought with them the “ modern art o f dentistry.” T h ey each had student apprentices, one o f whom , Einosuke O bata, becam e the first licensed dentist in Japan in 1875.
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Dr. Obata, a noble by birth, opened an office in Tokyo and trained many young men who later became leaders in the Japanese dental profession. Okumura said that other American dentists spent varying periods of time in Japan. As the nineteenth century drew to a close, however, a number of young Japanese started studying dentistry in American schools, and a clique of American-trained dentists began to evolve. This trend continued into the twentieth cen tury and was responsible for early close ties between the dental professions of both countries. Bergemann2 said that the “Jap anese educational system attempted to combine recognition and acceptance of Western science and technology with tra ditional Japanese values and ideals.” He observed that Japanese dentistry relied largely on American influence. Neverthe less, in viewing Japanese dental education today, it is apparent that the close ties between Japan and Germany have also had a strong influence on Japanese dental educational philosophies. D E N T IS T R Y IN M E D IC A L S C H O O L S
In 1903 a dental infirmary was estab lished in Tokyo Imperial University Hos pital, marking the beginning of a distinct trend in Japanese dentistry. Eventually a professorship in dentistry on the medi cal faculty was created and a course in dentistry was included as part of the reg ular medical curriculum. A number of other medical colleges followed suit, and they continue to teach dentistry as part of the overall medical course. The developing relation between medi cine and dentistry was somewhat con fused for a time because a number of physicians, with only a rudimentary knowledge of dentistry, set themselves up as dental specialists. Douglas and Watanabe3 described the current system of teaching dentistry to medical students at one Japanese medical school and emphasized the advantages of acquainting physicians with the oral re gion and with dentistry in general.
Douglas comments4 that, in teaching dentistry to medical students, “the pa tients with dental maladies stand to bene fit substantially from closer relationship between the medical and dental profes sions.” G R O W T H O F D E N T A L L E G ISL A T IO N
The first dental examiners were ap pointed in 1884. The first National Den tal Law was proclaimed in 1906, and sub sequently it has been revised a number of times. By 1931 there were 17,000 regis tered dentists in the country, according to Okumura. Okumura said that the changing pat tern of dental legislation was influenced by the gradual growth of the Japan Den tal Association. The J.D.A. was estab lished by government authorization in 1926 as a “legal body with judicial pow ers.” Although there is some question about its “judicial powers” today, this authorization seems to have had a pro nounced effect on the Japan Dental Asso ciation’s subsequent activities. The J.D.A. has served primarily as a spokesman for the dentists of Japan in their relations with the government. In recent years, the J.D.A. has also had a voice in the National Health Insurance system. D E N T A L L IC E N S U R E E X A M IN A T IO N S
Although regulations for licensure exam inations were established in 1913, Oku mura said that it was not until 1928 that strict qualification requirements to take the examination were enforced. There fore, many dentists who had registered with the Department of Education and had not actually completed formal den tal education received licenses up to 1928. Some of these dentists are still practicing today. J A P A N E S E D E N T A L E D U CA TIO N
By 1931 there were nine dental colleges, one of which was in Japanese-occupied
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Toothbrush in hand, Japanese school children s it in spectators' stands and fo llo w instructions given over a loudspeaker
K orea. Entrance was granted after 13 years o f preliminary education (six years o f elementary school, fou r years o f middle school and three years o f higher s c h o o l). Graduates o f the dental colleges were au tomatically eligible to practice without further examination. W ith the exception o f one school, started in 1929, all dental colleges were privately operated as o f 1931, and only one o f those was affiliated with a univer sity. T h e establishment o f the government school was a significant m ove in Japan. It demonstrated government concern for dental education. Also, government schools in all areas and at all levels o f education have always held positions o f high prestige. This dental college even tually becam e affiliated with a medical college and was named T ok yo M edical and Dental University ( T ok yo Ikashika Daigaku) . P O S T G R A D U A T E E D U C A TIO N
In 1923 the first Igakuhakushi, a post graduate degree in m edical science, was awarded to a Japanese dentist. Subse quently thousands o f Japanese dentists and physicians have received this degree. In recent years, this degree has almost becom e a necessity for a doctor to be suc cessful in academ ic life. T h e prestige value o f the degree is im portant in other aspects o f dental and m edical practice as well. In the last few years, the system for earning the degree has becom e more formalized. Before 1959 it was possible to acquire the degree with minimal attend
ance in school and with the com pletion o f a research project and an examination. T oday, fou r years o f full-time attendance at a recognized m edical or dental college are required; however, each accredited school is free to administer and organize its program as it sees fit. Each department in each school may accept only two d e gree aspirants a year. Although the indi vidual program is supposed to be designed in consultation with the student, the organization o f the four-year course o f study depends largely on the professor heading the department. T h e course usu ally is divided between the clinic and the laboratory. T here are few lectures, and few , if any, examinations are required until the four-year period is com pleted and the student’ s research project is fin ished. I f there is form al course work, students are not required to attend classes, but this is true with classes at all levels o f Japanese higher education. A t the co n clusion o f the course, students must take a final examination. T h e nature o f a postgraduate student’ s research m ay vary widely. It usually d e pends on the department and the school. A dentist may work for his postgraduate degree in a m edical school and undertake a research project unrelated to dentistry. J A P A N E S E H IG H E R E D U C A T IO N
In order to com prehend the nature o f a student’ s research, it is necessary to un derstand the traditional autonomous role o f the professor in Japanese higher edu cation. H e usually decides what research projects his students should undertake,
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and the projects often coincide with his own interest and work. Therefore, one professor interested in a particular line of scientific inquiry is likely to have different students working on various aspects of the same overall project. In many instances, such project assignments lead to great productivity and a continual flow of sci entific publications in the select field; however, difficulties have been known to arise when a particular professor leaves his department and his successor has dif ferent major research interests. Research accomplishments and publications play a major prestige role in Japanese science. Therefore, there is great emphasis on re search in postgraduate education. There is relatively little formal empha sis on the learning process in Japanese higher education. It is generally assumed that a student’s presence indicates an adequate exposure to the subject matter. Students are expected to do extensive out side reading, but are rarely given specific assignments. In the clinical fields, the postgraduate student receives little formal instruction in the performance of opera tive or surgical work. He spends much time assisting his teachers. The professor of oral surgery, for example, usually at tends to almost all major surgical patients himself, and there is little conscious effort to teach his junior staff members or post graduate students. The general idea is that the younger doctor will learn by watching and assisting. Igakuhakushi is a postgraduate degree in medical science which may be earned either by a dentist or physician. In the dental colleges, the shigakuhakushi, a de gree in dental science, is awarded. The translation of the meaning of these de grees into English has become somewhat of a problem, since there has been no standardized translation adopted by the Japanese medical and dental professions. The most commonly used English trans lations of the degrees are “Doctor of Medical Science” and “Doctor of Dental Science.” The degree is not equivalent to the American Ph.D. degree.
S C H O O L D E N T A L H Y G IE N E
The Japanese early recognized the im portance of school dental hygiene. In 1919 a bill was passed by the Diet (na tional legislature) which provided for the organization of dental hygiene facilities for school children. This provision in cluded the establishment of clinics, a school dentist system and yearly free ex aminations for all children, with provi sions for reports to go to the parents. This system exists today, but it is beset by many inadequacies. Because of the pressure of the National Health Insur ance system and the dearth of funds in the majority of schools, only the examina tion provision of the legislation has been put into effect. The examinations gener ally are conducted under the most un ideal physical circumstances. One dentist usually is called upon to examine 500 or more patients in one day without ade quate lighting and assistance and without x-ray facilities. The dentist is paid from $2.75 to $5.00 for a full day’s work, the amount depending on the financial capa bilities of the individual school. The School Dentists’ Association, a national organization, attempts to work in close liaison with the schools to effect the objectives of the program. Yoshio Mukai, president of the association and chairman of the oral hygiene committee of the Japan Dental Association, describes the methods that are employed to exert social pressure on the children to strive for good dental health. Awards are given to children with good dental health, and a national mother-child “most perfect teeth contest” is held in September. The School Dentists’ Association en courages the promotion of improved den tal health among children in as many ways as possible, but progress has been slow. Despite the fact that it is the avowed aim to reduce 50 per cent of the decay in the permanent teeth of school children, the trend is in the opposite di rection, especially since Japan lacks water fluoridation. Only 10 per cent of the
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schools have organized com petitive pro grams in dental health, and widespread health education technics in prom oting im proved dental health are almost un known. Because most Japanese dentists are ex tremely busy caring for patients under the health insurance system, most o f them have little time for the care o f children. T h e School Dentists’ Association, in its concern about this problem , encourages dentists to set aside some time for the care o f children, especially in follow ing up re ports from school dental examinations. It has been found that the parents can not be relied on to take the children for dental treatment. Therefore, the emphasis in the program is to educate the child himself or to place him under some social pressure to achieve good dental health. It is noteworthy that parents often neglect dental care for their children (and them selves) in spite o f the fact that there is at least partial coverage fo r it under the health insurance program. A fter the war, the principle o f “ learn ing by doing” was introduced into the Japanese primary school system and was particularly emphasized in matters of health. As a result, school health com mittees were established in many schools, consisting o f representatives o f the chil dren, their parents, the teachers and the community. In many o f the m ore health conscious schools, meetings are held every month to discuss m edical and dental health. G O V E R N M E N T H E A L T H IN S U R A N C E
In 1927 the Japan Dental Association entered into an agreement with the gov ernment for diagnostic and therapeutic dental services for factory employees. This agreement has led through the en suing years (particularly after the war) to a long series o f negotiations between organized dentistry and the government to establish a suitable dental health insur ance system. From the start o f the program , insured
Fig. 3 • On th e fie ld , Japanese children form regim ental columns and perform exhibition o f how to use the too thbrush
persons could be treated only by dentists accepted by the Japan Dental Association and the health insurance offices in their local prefectures as “ insurance dentists.” In 1930 approxim ately 70 per cent o f the dentists were registered. T oday, membership in the J.D .A . and a m onthly fee are required if a dentist is to participate in the insurance system. Virtually 100 per cent o f the practicing dentists are included in the program, and all o f Japanese dentistry has been swept up in the current o f governm ent-controlled health insurance. A t the present time, the provision exists for every citizen o f Japan to be included in the system, and various estimates place m ore than 95 per cent o f the population under at least par tially active participation in the program. Douglas stated" that the health insur ance system is the one overriding and underlying factor which affects every aspect of dentistry in the country. . . . T h e Japanese dentist is almost completely submerged within it. . . . Health Insurance is a chronic, incurable disease, apparently neces sary in Japan’ s social system. Its presence in its present form is agreeable to the great m a jority o f patients and disagreeable to the great m ajority o f the physicians and dentists. . . . Because of its inherent weaknesses, it interferes with the perform ance o f good dentistry very frequently. T h e dentist is paid so little for pro viding dental care that he is forced to indulge in mass-production technics, and to have pa tients return endlessly for treatment that could,
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with careful expenditure o f time, be com pleted within a few visits. . . . In spite o f the fact that there is widespread discontent with the present health insurance system am ong the dentists, it does not discourage large numbers of men and w om en from applying for admis sion to schools o f dentistry. T h e status that the dentist acquires and the insured source o f a steady incom e apparently compensate for the drawbacks. In spite of the fact that the dentist is grossly underpaid, if he is willing to work long hours, relatively speaking, he can still make a sizable income.
Under the system, there is completely free choice of doctor. Some private com panies and government organizations have their own dental clinics, and employees are free to use them if they wish. Since the company often covers employees for broad health insurance benefits, they are still covered by the same policies if they seek care elsewhere. A few of the wealthier companies even provide dental coverage that would be considered luxur ious according to Japanese standards, for example, gold bridges; however, such coverage is available only if they use the facilities provided at their place of em ployment. In most cases, a dentist employed by a company works on a salary basis and may treat only employees and their families. There is a wide salary range among such dentists, and a few do better financially than dentists in private practice. Government employees working for the railways and post office department have separate medical care facilities, which are similar to those run by business organiza tions. Medical and dental fees are regulated by a point system established by the na tional government. Fees can be changed only if the point system is altered across the board. Apparently such changes are effected only after great pressure from the medical and dental professions. The dissension generated by this pressure led to a series of strike threats in 1961 and eventually to the first of a number of strikes in which members of the medical and dental professions went “off the job.” “Striking doctors” created an emotional
upheaval throughout the nation, espe cially when a number of deaths were at tributed to the unavailability of medical care on the days of the strike. Emergency staffs reportedly were left on duty at key hospitals and clinics throughout the coun try, but, in a nation where there is rela tively little private transportation, there were some mishaps because of the in evitable delays that accompanied the lim ited care available. In negotiations with the government relating to fees, the Japan medical and dental associations are the official repre sentatives of the two professions. There is dissension within the ranks of the physi cians on the legitimacy of this representa tion. The two national organizations do not enjoy the singular prestige possessed in the United States by their counterpart associations. In the case of the dental as sociation, this may be at least partially due to the fact that it has been almost continuously and solely concerned with matters of economic and political signifi cance, and it has had relatively little time or opportunity for what might otherwise be considered scientific responsibilities. Final decisions about changes in fee schedules rest with the government. The 1961 strikes led to an eventual increase of 10 per cent in fees. The personnel who represent the pro fessional associations in conferences with the Ministry of Welfare are also con cerned with methods of treatment and the drugs that are allowable in the health insurance fee schedule. The final deci sions are always made by professional politicians who represent the government. This fact is a constant source of friction between the two bodies. Public opinion is strongly in favor of the health insurance system. There is lit tle generalized concern among the Jap anese people for the quality of medical care. On the whole, they are satisfied to have it available, and they strongly sup port the government’s actions in disputes with the doctors. Physicians and dentists are employed
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by the local prefectural government wel fare offices to serve as investigators in the local health insurance system. There are numerous forms to be filled out, and they are surveyed by these representatives. Overt dishonesty usually leads to suspen sion from participation in the program. In view of the widespread nature of health insurance, this method of investi gation could be extremely harmful to a private practitioner. These checks refer to the type and frequency, but not specifi cally to the quality, of care. All doctors receive the same fees under the system regardless of training and ex perience. Therefore, the fees paid to a dental school for clinical care and those paid to a recent graduate or a long-estab lished practitioner are the same. This absence of scaled fees may be responsible, at least in part, for the fact that there is little specialization in dental practice in Japan. In the entire nation, there are only a few practitioners who limit their prac tices to orthodontics or oral surgery. Pedodontics is taught as a special area of dental practice only in one school and is unknown as a specialty. Neither endodontics nor periodontics is recognized any where in the nation as a specialty. Con sidering the absence of fee differences for special professional abilities, it seems rea sonable to assume that specialization may never develop to the degree that it has in the United States. One concluding point merits emphasis in regard to the effect of government health insurance in Japan. Many more people are now receiving medical and dental care than was the case before the widespread introduction of health insur ance. All evidence suggests that the quality of care leaves much to be desired and the nature of the doctor-patient relationship has become decidedly more distant. In Japan, however, other criteria exist for determining the strengths and weaknesses of medical and dental practice. Japanese people, in general, expect less from the physician or dentist than Americans do. Therefore, their relations with him may
not be nearly as important as in this coun try. In the final analysis, it is the people themselves who determine under which system of health care they wish to be treated, and the Japanese people are making their choice within the context of their own cultural values. S T A T U S OF D E N T A L E D U C A T IO N
Japanese dental education is presently en joying a period of relative prosperity. There are eight dental colleges— one in Kokura on the island of Kyushu, two in Osaka, one (established in 1961) in Nagoya and four in Tokyo. One in Osaka (Osaka University Dental School) and one in Tokyo (Tokyo Medical and Den tal University) are national governmentoperated institutions. The other five are locally or privately financed and admin istered. Three are directly affiliated with universities or colleges (Osaka University Dental School; Nihon University Dental School, which is located in Tokyo; the new school in Nagoya, Aichi-Gakuin University Dental School). In July 1951, a dental mission was sent to Japan by the American Dental Associ ation, under the auspices of the military occupation authorities, to report on the status of dentistry in the country. The members of the mission made a number of recommendations relating to dental education.6 As a result of these recom mendations, attempts were made during the postwar reconstruction to model Jap anese dental education after the Ameri can system. Some of the recommenda tions made by the mission were: (1) predental education should be obtained in recognized universities only, rather than in privately or governmentally oper ated dental colleges, with credits accepted toward a baccalaureate degree; (2) den tal colleges should be an intimate part of the university, with the same academic status as other colleges of the university; (3) dental education should be autono mous. The Japanese educational system was
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too well entrenched in tradition for these recommendations to be followed. There fore today predental students, in general, take their predental courses under the auspices of the dental schools in which they are already technically enrolled. Pre dental education takes two years, during which a large number of courses are taken in both cultural and scientific fields. There is no direct route to admis sion to the study of dentistry without having taken the predental years in the same institution. Therefore, the predental student, at the start of his course, is headed for a dental degree in six years. It is rare for a student to fail and be forced to leave school. According to the Japanese higher edu cational system, each school conducts an entrance examination, but it is generally agreed that admission to the two govern ment schools is considerably more diffi cult and competitive. For one thing, gov ernment schools have very low tuition and usually have a staff of better quali fied faculty members. Also, government schools have traditionally been regarded as the finest institutions in the country, and government dental educational insti tutions share the same high regard. This view is not to detract from the fine work being done by the privately operated schools. For example, in 1960 Tokyo Dental College started a fine dental jour nal printed in English. This journal exemplifies the extraordinary dental re search which is being done in many Japanese schools. The basic and peren nial financial problem of the privately operated institutions leads them to charge high tuition rates and admit too many students. Salaries of faculty members in the private schools are very low, forcing most of them to depend on outside sources of income. The same holds true for teach ers in government schools, but the status symbol of being associated with a govern ment institution seems to compensate somewhat for this inadequacy. Teachers in government schools are prohibited from accepting outside employment, but
the newspapers constantly carry stories about university professors who are forced to work in consultatory and other capaci ties because of their low incomes. There has been a remarkable growth of physical facilities in Japanese dental schools during the last decade. A number of schools were severely affected by bomb ings during the war and were severely run down because of a dearth of mate rials. High-speed operative dental equip ment, now becoming favored in private dental offices, is also finding its way into all schools, and the Japanese ingenuity in mechanics is apparent everywhere that dentistry is practiced and taught in the country. A T T IT U D E S T O W A R D D E N T A L P U B L IC H E A L T H
In general, the attitude of the Japanese people toward health is utilitarian. There is little appreciation for the concept of prevention. This is especially true of den tal public health. Fluoridation of public water supplies is almost nonexistent. Only in one small area of Kyoto, where the population is 12,000, has fluoridation been introduced as a pilot project. It was started in 1952. Although greater emphasis is gradually being placed on oral hygiene, the basic tenets of periodontics are often disre garded. Periodontal services are not cov ered under the health insurance program and little time is devoted to the teaching of the subject in the dental curriculum. Toothbrushing seems to be equated with total periodontal “ treatment,” and there is much emphasis on this aspect of oral hygiene. Nevertheless, Japanese tooth brushes are usually of poor quality and have extremely soft bristles. Rampant periodontal disease is apparent every where, even among those in the welleducated and higher socioeconomic strata. For several years, one of the toothbrush manufacturers, in cooperation with the Japan Dental Association, has sponsored toothbrush drills in various parts of the
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country. The yearly spectacle in a large athletic stadium in Tokyo, during Dental Health Week, is a fascinating sight. Over 30,000 children and some parents crowd into a large stadium and are given toothbrushing lessons via a loudspeaker system. The drills are accompanied by music from a large band (Fig. 1-3). Dental Health Week is sponsored by the Japan Dental Association, and posters are sent to all dentists and schools for health edu cation purposes. Teachers are encouraged to speak about dental health during that period and to display poster materials. This educational effort is still young. Its effects will not be felt for a number of years because the older generation lends it little support. The children eat many sweets, and there is little evidence of any concerted effort on the part of the dental profession to discourage this dietary prac tice. C O N C L U S IO N S
The presence of publicly accepted gov ernment health insurance in Japan seems to be the most powerful restraining force in the advancement of Japanese den tal practice; nevertheless, comparatively speaking, the Japanese people receive good dental care. Japan has the third largest number of dentists in the world, ranking behind the United States and West Germany. Although the present number is inadequate according to American standards, the dentists seem able to handle the demand, so long as they are willing to work long, hard hours. Japanese dentistry excels in dental re search. There is a well-entrenched respect for research among Japanese scholars that exhibits both quality and quantity. Japanese culture centers around the hu man characteristics so essential for quality research. Many studies in all areas of den tal science are now emanating from Japanese dental schools. It is in research that Japan is making, and will no doubt continue to make, its greatest contribu tion to world dentistry. Unfortunately,
there is limited direct transfer of results from the laboratory studies to application in the clinic and the treatment of pa tients, except in the dental schools, where clinical research is also taking place on a large scale. Japanese society in general is in the throes of a revolution which is having its effects on the practice of dentistry. The nation is presently adjusting to the tre mendous social upheaval which follows in the wake of economic reconstruction. It must be remembered that the dental educational system, the way the Japanese dentist practices his profession, and the way the Japanese people choose to pro vide for medical and dental care are all parts of a culture deeply rooted in the Oriental philosophy of life. The fact that Tokyo and other urban centers of Japan seem, on the surface, to be adapting to western ways does not indicate that the people as a whole are doing so. There fore, it is unjust and unrealistic to extend the comparison between Japanese and American dentistry too far. The progress that has been apparent throughout the nation since the war is adequate testi mony to the stamina and intelligence of the people of Japan. Their ways of pro gressing, through dental practice and dental science, are an intricate part of this struggle. 808 South W ood Street
*Formerly Fulbright Exchange Professor of Dentistry, Okayama University Medical School and Tokyo Medical and Dental University, 1959-61. Assistant professor and coordinator of oral medicine, College of Dentistry, University of Illinois. {Exchange Fellow in Oral and Maxillofacial Surgery, Osaka University Dental School, 1961-62. !. Okumura, Tsurukichi. Present status of dentistry in Japan. Japan Dental Association 1931. 2. Bergemann, Hugo. New impulses for international dentistry through the modern Japanese dental literature. Zahnarztl. Mitt. 44:616 Sept. I, 1956. 3. Douglas, Bruce L., and Watanabe, Yoshio. Teach ing dentistry to medical students. J. Med. Educ. 35:874 Sept. I960. 4. Douglas, Bruce L. Letter from Japan. J. Am. D. Soc. Anesthes. 7:26 Jan. I960. 5. Douglas, Bruce L. Final observations of Japanese dentistry. J. Am. D. Soc. Anesthes. 8:223 Aug.-Sept. 1961. 6. Mission to Japan: report to Medical Section, Pub lic Health and Welfare Division, GHQ, SCAP. J.A.D.A. 43:593 Nov. 1951.