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Orthodontic schemes
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PUBLIC HEALTH.
Orthodontic
A UG[YST,
Schemes.
By ELWIN H. T. NASH, M.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health and School Medical Officer, Heston and Isleworth. The fact that Dr. Nash was to deliver an address on this subject was prominently announced in PUBLIC HEALTH and agenda papers of the Society. On the occasion of its delivery before the Home Counties Branch there was a fair attendance of members and others, but to the many who, unfortunately, were unable to be present, the appearance of the paper here will no doubt be welcome. for bringing this paper M Ymyreasons fellow administrators in the
before public health service are, first, that I can give a report on the place that, in my opinion, the practice of orthodontia must take in the future dental services of the country, based on five years' working of the pioneer municipal orthodontic clinic in this country ; secondly, that it may be a justification for my administrative methods which have been adversely criticised by some of the members of the school dental service; and thirdly, I want to show that necessity for treatment is not only dental, but medical and, particularly, psychological. Like all school medical officers, one was unaware of some of the awful mouths that afflicted children, and that orthodontic measures, other than extraction of teeth that were often quilte sound, were measures difficult of accomplishment amongst the dentally ignorant portion of the population. There is no school medical officer who has not had his patience tried to breaking point in trying to persuade the parent, where the offspring needs several fillings to save his teeth, only to be met with the reply that they can have them out but they " don't hold with stopping 'em." Again, how often has one tried to persuade this class and those more intelligent that the removal of two or four sound teeth is necessary to save ultimate overcrowding and deformity, only to be met with the blankest of refusals. My stimulus towards the utilisation of apparatus for the cases that could not be treated adequately by timely extractions was given by Mr. Cale Matthews, Dental Surgeon to King's College Hospital, who, during one of my presidential years of the Medical Officers of Schools Association, read a paper on the rectification of these deformities during school life. He was dealing with children in highclass preparatory schools and the junior forms of the public schools. My democratic soul rebelled that such beneficent treatment should be available only to the well-to-do and not to
the child population I am responsible for. I could not hope to emulate the exquisite pieces of apparatus fashioned by Mr. Cale Matthews, but I felt that something should be done to make the treatment available to my school population, despite the fact that the Board of Education had not progressed dentally at that time much, if any, beyond the vision beautiful of the six-year-old molar, and were not likely to look with any approval on the provision of apparatus in a dental clinic. I want all the critics in the dental service to appreciate that every step I took to establish orthodontia as a day-to-day part of our dental service was based on these facts. Had I attempted five years ago to do the work as I am doilag it now, I am certain that the Board of Education's attitude would have been entirely adverse. I am not unacquainted with the Board of Education's views on school and dental matters as a result of 26 years as a Chief School Medical Officer, and I felt that to educate them to my views meant that my motto had to be festina lente and my " factor of safety " very high. The questions that you will be asking are : (1) Is there a demand for this work ? (2) Is it justified (a) by reason of its expense; (b) by reason of the time it takes from what I call the ordinary routine work of the school dental officer ? With regard to the first question, the cases requiring orthodontic treatment have been assessed in one instance as high as 30 per cent. of the school population. This figure, of course, includes the minor cases, which certainly for the time being do not come within our purview. I think you may take our figure as a fair criterion of the cases that call for treatment. I use the word " call " advisedly, as I feel that it is the right expression to use in this case. Our school population is now 12,000, and in five years we have had 850 cases under treatment, of which 459 have been completed. Again, you will ask: " What has been the need for the treatment of these cases ? " The
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models I am exhibiting and the lantern slides of cases will, I hope, demonstrate to you the need for the treatment from the health point of view, as unless a mouth can function properly as a masticating machine its possession is of doubtful benefit to its owner. There is another point which is to my mind of immense importance in the case of the severer forms of deformity, particularly inferior retrusions, and that is the psychological damage, particularly in the case of females. There is in these cases a marked inferiority complex which overshadows everything. You have only to sit opposite one of these cases in the train to see the constant effort to cover the protruding teeth. Speech seems to bring into use facial muscles that normally are not in evidence. If I may use the expression, speech is almost a conscious muscular effort as regards the muscles that control the lips. It may be that it has been my lot to see the tragedies of these cases at close quarters. As I recently wrote in an article in the British Medical Journal, a very near relative of mine has had the whole of his life dominated by his bad inferior retrusion. His preparatory school days were made a misery by the gibes of his fellow pupils, and his later years a misery by his dental troubles and the fact that his deformity is such that an artificial denture would baffle even the genius of Wilfred Fish. Again, a friend who died recently, possessed a mouth which as a model would have brought sheer joy to the continental caricaturists like Simplicissimus when they wanted to illustrate an English aristocrat. To talk to him was difficult, as one's attention would become fixed on the constant efforts to cover his awfifl teeth. These in his later years got more and more discoloured until they looked like a row of lichen-covered tombstones reminiscent of the moping owl and the ivy mantled tower of Gray's immortal Elegy. His dental adviser would not tackle a denture. I recently reported in the British Medical Journal a case where a boy's whole outlook on life was jeopardised by his dental deformity. The boy won a scholarship to the county school just after we had made arrangements for treating his dental eondition--a set of supernumerary incisors in the upper j a w ~ w h i c h ultimately caused a very severe deformity to his mouth. He left school and got a post as interviewing clerk in an insurance office through the influence of his father, who was a member of the 8taft, At the end of his first week
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he was told that he could not do his job owing to the trouble he had with his dental deformity. The mother in her distress brought the boy to me on the Saturday morning of his first week at work, asking what I could do. As school medical officer--nothing, as he had left school. As an individual anxious to help--very little, as he was 16 and these cases can only be dealt with efficiently at about 10 to 11. I got Mr. Evans, .our orthodontic specialist, to take him over as a patient at the Royal Dental Hospital, hoping for some improvement after the removal of the supernumerary teeth. Again I want to emphasise the importance of the psychological effect of these dental deformities, a fact which seems, so far as I can make out, to have not been suffÉciently stressed. Its effect is lifelong in many cases, and is far worse from the point of view of the happiness and success of the individual than the actual dental deformity itself. As I have stressed before, one of the outstanding features of this work has been the manner in which a mother who has handed on to her daughter an inferior retrusion, which has made her own life a misery, will grude no money or time in order to ensure that her daughter does not suffer as she has done. What are the origins of these deformities which afflict our children, and can we as public health officers do anything to prevent their occurrence ? With regard to the causation there are two main causes : (1) Heredity. (2) Developmental (a) caused mainly by naso-pharyngeal obstruct i o n ; (b) caused by habits such as thumb sucking, dummy sucking, blanket sucking, lip sucking, etc. With regard to class (1), Professor Brash has called attention to the large number that are due to this cause, and one has only to see the parents of the patients to realise the frequency with which this tragic legacy has been involuntarily bequeathed to the offspring. With regard to class (2), the protagonists of the obstruction theory seem to claim this as the fons et origo mali in almost every case. To them a necessary preliminary is the removal of adenoids with or without tonsils. I am bound to say that in several of the cases I have seen, such adenoidal tissue as existed had at the age when the patient was seen, ceased to be a material cause of obstruction either per se or as the result of any accompanying catarrh. What I have seen is that a number of these cases that have been referred to hospitals for
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the removal of tonsils and adenoids have turned up again with little or no improvement as the result of the operative procedure. On examining the patients the reason has been abundantly apparent. The cause of the obstruction has been, and still remains, due either to enlarged turbinals, a deflected septum, or both. So gross are these that it is seldom I cannot demonstrate the condition to the parent by merely tilting up the end of the child's nose in front of a window. Here is the tragedy of the position which reflects no credit on us as a profession. In not a single case of this type when I have asked the parent if the child's nose was examined, has the answer ever been in the affirmative. With regard to the cases with deflected septa, a difficulty arises in that most surgeons dealing with the nose will not operate before the age of 12 owing to their dread of the operation damaging the support normally given by the septum. I have, however, found one surgeon who will operate on these cases, viz., Mr. Philip Franklin, to whom our deepest sympathies must go out in regard to the tragic happening in the fire at his house in Wimpole Street. In such cases as he has operated on, the results have been entirely satisfactory. It is surely imperative to see that the operative proceedings to relieve the obstruction are complete, as it is such things that bring operative procedures into disrepute. With regard to the habit-produced deformities, it is normally sufficient to stop the habit to prevent further progression, but these cases cannot be dealt with orthodontically until they reach the age of nine or ten. In the case of thumb and finger suckers there is often considerable difficulty in breaking the habit which, if not broken, often runs on for years. We have devised wire guards, made for us locally, which are worn night and day. These we find the most effective preventive. It is not, I find, appreciated by the medical profession at large, how great the deformity caused by thumb sucking can be. The upper incisors are pushed out and the lower incisors pushed in, as will be shown in the models and patients exhibiting this condition. Sir Robert Woods of Dublin, the famous oto-laryngotogist, in the British Medical Journal of October, 1935, urges that these deformities might be due to congenital syphilis. I have no hesitation in saying that in the cases under our observation there was never any suspicion of congenital syphilis. This deformity is so clear cut that it is possible from the mouth or models
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to say whether it has been caused by thumb sucking or dummy sucking. The latter does not push the lower incisors inwards in the same manner. With regard to the treatment of these cases, we as school medical officers cannot hope to employ the beautiful and elaborate pieces of apparatus, particularly those that are fixed, by reason of (a) the expense of providing them, (b) the fact that many of the parents lack the means or intelligence to bring their children up for adjustment of apparatus. If a child has to be brought some distance at frequent intervals, the cost of transport is a burden the parents cannot and will not face, in the latter case often due to the fact that they do not realise the importance of the dental deformity to the child. Moreover, I do not think we can claim that the cosmetic perfection that the orthodontic specialist provides at necessarily large fees is a part of our duty, which I consider to b e to provide an efficient and healthy masticating machine, and to remove any deformity which may be a cause of psychological disability in the years to come. We have only used one fixed apparatus and that was after repeated efforts to make a neurotic boy retain his plate. His fixed apparatus also was a failure. The choice has to be made between judicious extraction at the appropriate time, and the use of apparatus to expand the arch and perform other functions such as raising the bite or pushing forward the mandible. Judicious extraction, for instance, of the four sixes at the appropriate time, can give an excellent result. In some cases the closure of the gap is so close that a visiting card cannot be placed between the front edge of the sevens and the adjoining fives, and that in some cases is accomplished without any tilting whatever. This perfection of movement is not always the case, as when deciduous teeth have had to be removed as the result of caries, it is often necessary to insert a splint plate to keep the distance and space for an erupting tooth, and to prevent the teeth tilting into the vacant space, moving with the root apex as the fixed point. There are those who, like Dr. Sim Wallace, are whole-hearted enthusiasts for the removal of the proper teeth at the proper time, letting nature remodel the mouth. To Wallace, the expansion of the arch to make room for overcrowded teeth is anathema, and he pours scorn on what he calls the gorilla faces that are produced,
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It may be that in the lean and hungry looking type the expansion may produce a physiognomy more reminiscent of the Zoo than the drawingroom, but it has not been our experience. We use both according to the demands of the case and the psychology of the patient and parent. In the past more hostility was aroused in the uneducated parent by the desire to remove sound teeth for orthodontic reasons than anything else. My first step was to get my committee to purchase subscription tickets at the Royal Dental Hospital, each expenditure of one guinea providing us with four hospital letters. The provision of these hospital letters to the patients did not cover the cost of orthodontic apparatus, and as the Royal Dental Hospital required this to be " paid in one sum " before the apparatus was fitted, this produced difficulties very early in the scheme. This scheme failed by reason of the waste of time due to the multiple journeys made by the parents and patients. Even now there is insufficient appreciation of what it means to a parent to come up to a London hospital from a district in the periphery. It means in the first place, a financial expenditure of ls. 6d. for the adult fare, and half for tile child, if it can travel as a half, and this pre-supposes that they spend nothing on food, which is not usually the case. This expenditure I have found has meant to some families of restricted means that they have gone up by the workmen's train in the morning in order to save the difference in the cost, and loafed about London until noon when they were to be seen. If they take no food it means at least the railway fares for two persons; and still junior medical officers will light-heartedly tell a patient to come up every few days for some kind of treatment or to have an apparatus adjusted, not realising the terrific burden that they are placing on the family. Quite apart from the financial burden, there is the waste of time, which, if there are other children in the family, is a serious matter. It means the parents have got to spend the greater part of the working day in their visit to the hospital, and arrange for some kindly neighbour to supervise the other children, to attend to their meals, and see that they get off to school again in time. This arrangement also had the drawback that the patients were used for demonstration purposes, and entirely misconceived opinions were reported to us as the result of these
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demonstrations to students in front of the parents. It soon became apparent that there was no chance of success based on this method of administration. My next step was to approach the hospital authorities with a view to a more co-ordinated scheme whereby they would act as consultants, and we should do the work in our own dental department. I did not get much encouragement at first, except from Mr. Evans, who is in charge of the children's section, the reason being, apparently, that several schemes had been started with municipal authorities and had, without exception, broken down on administrative grounds. It took me some time and several visits to convince Mr. Evans that my ideas were workable, and it is to his enthusiasm that one must ascribe the success of the scheme as it now functions. There was some difficulty in assessing what my authority should pay for the services we asked. Eventually it was agreed that for a payment of 12s. we were to be provided with a specialist's opinion, such radiograms as were necessary, and any pathological report which might be required to elucidate the condition. Then came the difficulty of assessing what payment should be required from the parent for the necessary plates, bands, etc., which were necessary for the treatment that was advised by the Royal Dental Hospital Staff. This was the most difficult part of the whole proceeding, and it was only after many enquiries that Mr. Evans and I came to the conclusion that a flat rate fee of 15s. Was necessary to provide all that was required for the complete treatment of every case. This was to cover not only the dental mechanic's fee, but the cost of the necessary gold or other metals and materials requisite. As far as we were concerned, this 15s. worked out surprisingly well. It then became necessary to draw up some form which would accompany the patient to the hospital, which would bear on it the provisional diagnosis made by my dental staff, and would also leave accommodation for the report of the dental surgeon at the hospital in such terms that the work could be carried out in my own dental department. The form devised worked entirely satisfactorily, it being understood that it was a confidential document sent back to me by the hospital authorities. I found it absolutely necessary to insist that our patients were starred in some way and not used for teaching purposes, owing to the confusion which results in dentally ignorant
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minds from discussions taking place in front of them. This arrangement worked satisfactorily except in a few cases where the hospital surgeons had required the patients to go up at intervals. Otherwise it meant one visit only from this district to the hospital. As far as treatment was concerned, everything worked well. There was only one little difficulty, and that was that, as was inevitable, different members of the staff had different opinions on what was necessary to be done, particularly from the point of view of the removal of tonsils and adenoids. As time went on it was obvious that to get the best results the work had to, if possible, be decentralised from the hospital entirely. This at first I was unable to do, because I could not rely on getting the radiograms I wanted done elsewhere, but in June, 1932, I advised my committee to approach the Board of Education for permission to appoint an orthodontic consultant to visit once a month in the same way that the orthopaedic consultants do in so many districts. I am glad to say that the Board of Education were by now convinced of the value of the work we were doing, and agreed to the payment to Mr. Evans, as orthodontic consultant, of a fee of three guineas a visit, which is the highest fee they allow. This meant that, except for cases requiring radiograms, there was now no need for any visit outside our own area. Ultimately I got my committee to appoint Mr. Evans as the orthodontic consultant to the authority. It is this appointment which has caused so much heart-burning amongst school dental officers. Now the scheme works extraordinarily smoothly. Mr. Evans comes down once a month and sees a very large number of cases, many a time up to 65. This is made possible by the organisation of the work and the staff, which enables Mr. Evans to do this work within the limits of a morning session. A small work bench has been provided in the dental clinic, so that if the orthodontic consultant wants a piece of apparatus slightly altered, this can be accomplished while the patient waits. The children file in to a row of seats near the door, and each one is provided, by the nurse at the table, with its case card and box of models. There are three seats adjoining the dental chair in which the patients sit. As each patient in turn gets into the dental chair, the dental mechanic at the back on the left, having opened the box of models, has the last pair exhibited by the side of the patient ready
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for Mr. Evan's comparison. Directly the patient has moved into the dental chair, the other two patients in the chairs alongside move up, and the gap at the end is filled from the pool near the door. The stenographer is standing just to the right of the patient, and all Mr. Evans has to do is to examine the patient, compare with the model which the dental mechanic is holding, if necessary asking the nurse, who is standing behind on the right of the patient with the dental card, to read the last entries, and then simply to think aloud whilst the stenographer takes down what he is saying, the instructions being entered on the child's card for the guidance of my dental staff. I have been criticised by members of the school dental service for the methods I have utilised in launching this pioneer orthodontic scheme, and in order to, if possible, minimise their hostility, I would like them to see my point of view. My school dental surgeon (Mr. Cohen) is close on sixty ; he is practically stone deaf, and has been so for years ; consequently he has been cut off entirely from auditory commune with his fellows in the matter of meetings and things of that kind for many years. His enthusiasm and ability are enormous, and to compensate for his disability I see that he is supplied with everything in the way of literature. My school dental officer, therefore, had had no chances of that intercourse which is so necessary and valuable in keeping up-to-date although he read everything that could be got hold of. Further, one had a Board of Education to think of, and one recalled Osler's dictum in his earlier editions to this effect, that " there are other altars at which a young man may light fires than those of Bacchus and Venus," and one felt that it would want considerable persuasion to get the Board of Education to light fires at altars other than that to the six-year-old molar. I do not think there will be a large number of orthodontic consultants appointed after this. I am sure that the newer generation of school dental surgeons will be able to undertake the vast majority of the orthodontic eases which arise, but in every other branch of medicine it gives a sense of security to the practitioner, and is of value to the patient in a difficult ease, to have the advice of an expert, and difficult cases will arise in orthodontic practice as in every other form of medical, surgical or dental practice. Only this week, during the monthly
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morning session, two cases arose of great difficulty, which my staff had referred to Mr. Evans, and in one of these the difficulty was so great that Mr. Evans kept the models to ponder over later to see really what was the solution in the way of treatment. Sir Norman Bennett, writing to me on the subject says: " Even if it (orthodontics) becomes more general, I think that specialists would be needed. Although elaborate appliances would not be used, that does not make the correct diagnosis, prognosis and definition of scheme of treatment any the easier." I do not think that orthodontic specialists will be appointed in the same way that obstetric consultants are appointed in every area, but I think there will be, and should be available, within reasonable reach, the advice of an expert in dealing with really difficult cases. I am certain of this, however, that had I not assured the Board of Education that the work was being supervised by one of the most skilled men in the country, I should not have got the support that I have been able to rely on, and which was evidenced in a special section of their annual report. Still more, what to me is one of the most pleasing things, is the extension of the work which is taking place in various parts of the country. Above all, the most satisfactory thing is a letter I recently received from one who I know has criticised some of the administrative procedures in which the writer, noting the extension of orthodontic work that is taking place, ascribes it to the pioneer work which we had been doing in my district. The criticism has in some cases been unkind and un-understanding, and possibly somewhat jealous that an outside administrator has been able to convince the Board of Education of the necessity of something which they regard as their peculiar prerogative. I think the culmination of carping criticism is that of the school dental surgeon to the county borough of Ipswich, who writes in his annual report for 1934: " In my opinion the appointment of orthodontic specialists is a matter more for sorrow than imitation." In his case his age is somewhat similar to that of my school dental surgeon, but he has had, so far as I know, the blessings, and I cannot call them anything else, of normal hearing, and faculties which should have enabled him to get his orthodontic information and experience by contact with his
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fellows, which is denied to my senior school dental officer. Despite the criticism, I remain entirely unrepentant, as I feel that as a result of what I have done I have persuaded, shall I say, the Board of Education some years before they would normally have arrived at that point, that orthodontics are a real part of the dental work of the school service. Only those of us who have seen the beneficial results and seen the effect, not only on the child but on the parent, of the removal of these deformities, can appreciate the value of the work. My committee are enthusiastic, and I make bold to say that any committee who takes the work up and sees the results, will feel that they are contributing substantially to the sum of human happiness. The practice of orthodontia has a very definitely scientific basis behind it, and a language of its own which must be understood to interpret the findings of those who are carrying on the work. The classification which is generally adopted is that of Angle, which is based on the relationship of the mesio-buccal cusp of the upper first molar, with the buccal groove of the first lower molar. This produces three different categories : class (1), in which the relationship of the two aforementioned teeth is normal, and produces a normal mouth ; class (2), in which the relationship of the tooth in the upper jaw is anterior to its proper position, and produces a general class of deformity known previously as superior protrusion, but now as inferior retrusion, the upper teeth projecting beyond the lower jaw, sometimes into the external atmosphere ; and class (3) in which the relationship of the upper molar is posterior to its normal position, producing the prize-fighter's jaw, that is, the protrusion of the teeth in the lower beyond those in the upper jaw. With regard to definition, the departures from the normal in the orthodontic sense are described as versions, and described in relationship to the front of the mouth and the tongue and the cheek. I have not attempted so far to do my own dental radiography. At first I had an arrangement with the Royal Dental Hospital whereby they did such radiograms for me as were found to be necessary. This, of course, involved the tiresome journey up to town. I have recently been able to conclude an arrangement with the West London Hospital on the following.terms :
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First film . . . . . . 2 6 Subsequent films .... 1 6 Complete upper jaw . . . . 7 0 Complete lower jaw . . . . 7 0 Complete dental examination.. 12 6 They are sending me excellent radiograms and reports, and the railway journey, and, therefore, the expense to the parents, is reduced by more than a half. I am getting it efficiently done at a reasonable cost, and for the time being I do not think that the expenditure on an X-ray outfit is justified. As to the finances of the work, I had hoped to be able to give the fullest details as to the cost involved, but unfortunately the devastating fire in my offices has rendered that impossible. I am, therefore, unable to add anything to the figures I published in 1933 in a paper read at the Royal Sanitary Institute Congress at Blackpool. (Journal of the Royal Sanitary Institute, Vol. liv, No. 3, September, 1933, p. 171.) It is very difficult to separate the overhead charges to be set against a work of this character, which occupies a varying time of a number of members of a large staff. I was very anxious that these financial statistics should be accurate (a) from the point of view of the Board of Education and (b) from the point of view of any of my colleagues who intend to take up the work. The difference that has been made in the financial details are that the full fee chargeable to the parents has been reduced from 37s. to 25s., Le., by the amount paid to the Royal Dental Hospital, which was done after Mr. Evans was appointed on my staff as orthodontic consultant. In addition to this the scale of charges to the parents has been amended and is now as follows : -
Income per head after deducting rent. Less than 8s . . . . . Between 8s. and 10s . . Between 10s. and 12s. Above 12s. . . .
Charge to parent. . . . . . .... . . .
Nil. 6s. 12s. 25s. (full cost). In a few cases, difficulties have arisen where the plate has been lost or broken by the child. It has required much thought to assess the responsibility and with it the amount (if any) that the parent should pay. Where any payment has been judged due from the parent, practically without exception it has meant wrangling and numerous letters and interviews before the parents could be made to see the
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justice of the claim. Fortunately, the cases are few and far between. Dealing with difficulties, one of the questions one is so often asked is: " Don't you have difficulty in getting the children to wear their plates ? " Of the 850 cases that have been dealt with, the number of cases that have had to be abandoned for this cause can be numbered on the fingers of one hand, and they without exception are of the neurotic type. These cases, when they arise, give no end of trouble, and endless patience has to be displayed to try and overcome the difficulty with the child and, what is quite, if not more, important, in some cases the fond parent. The figures I referred to as covering our expenses were as follows :--
£s.d. For 1930 . . . . 18a 18 1 1931 . . . . 251 15 6 This, however, does not include any charges for staff or overhead expenses. We received in return from the patients : ~ £ s. d. In 1930 .... 207 10 6 ,, 1 9 3 1 .... 151 16 0 This means that, for the first year and a half our scheme was in existence, the cost to my authority was £76 7s. ld. Our financial commitments now are a fee of three guineas per session once a month to our orthodontic consultant, and payment to the dental mechanic on an agreed scale. When the orthodontic consultant was appointed I impressed on him, as firmly as possible, the fact that our public health work had to be viewed from an angle entirely different from that of his West End practice. I said that if I got an 85 per cent. efficiency for a small expenditure, I, from the public health point of view, should be satisfied. Mr. Evans is enthusiastic about the results, and he claims that my figure of 85 per cent. is being very materially exceeded, and that our results are little short of the best that West End specialists can produce. You will also want to know something of t h e apparatus which is used. The principal piece of apparatus, which is the foundation treatment in many cases, is what is known as a Badcock plate. This is a plate split in two halves with an expansion screw and guide bar, so arranged that the nut which has to be turned can be adjusted with accuracy by reason of the fact that the four facets are numbered. So far as I can make out, until we entered
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the field no one had ever a t t e m p t e d to e n t r u s t the parents of the e l e m e n t a r y school class with the manipulation of a Badcock plate. W e set to work to train our parents to use the adjusting spanner, the general instructions being that they gave the screw a quarter t u r n every two days. We have found the parents r e s p o n d to this, and it works entirely satisfactorily. T h e expansion plate, however, is often only the base on which other t r e a t m e n t s are added. Plates may also serve by means of an inclined plane added at the front to advance the m a n d i b l e in cases of inferior retrusion. P r o m i n e n t teeth are w i t h d r a w n into their hiding place within the m o u t h by means of labial wires with springs of different character. I t is amazing how small a pressure continuously exerted will p r o d u c e the m o v e m e n t or rotation of a tooth. I n addition, certain teeth can, if pressure is relieved, be b r o u g h t into their p r o p e r relationship merely by continuous pressure of the lips. This, however, can be assisted by means of what is k n o w n as a lip exerciser, that is, a curved flat plate with a lever attached, which the patient holds between the lips for long periods, as for instance, w h e n reading, and as time goes on the effort can be increased b y loading the lever with little weights in order to strengthen the action of the muscles. Again, t h r o u g h the u n f o r t u n a t e fire, I a m unable to give you our last year's figures with regard to the n u m b e r and character of the appliances used. I think you m a y assume that the following list which I put in m y first paper, is relatively similar : T h e total n u m b e r of appliances m a d e during the year were as follows : Coil springs ......... 9 Inclined planes . . . . . . . . . 2 Splints ............ 11 Retention . . . . . . . . . . . . 4 Labial Wire and coil springs ... 1 Expansion . . . . . . . . . . . . t4 Expansion and retraction ... 7 Retraction . . . . . . . . . . . . 30 Expansion and screws . . . . . . 2 Screws . . . .... . . . . . 26 Expansion and inclined plane ... 1 Bite plates ......... 3 Retraction and inclined plane ... 4 Lip exerciser ......... 1 Repairs . . . . . . . . . . . . 10 Progressive alterations . . . . . . 5 Gold bands ......... 4 Dentures for school children ... 2 Total . . . . . .
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T h e list of the different kinds of deformities also remains m u c h a b o u t the same : Narrow arches . . . . . . . . . 16 Labioversions ......... 20 Linguoversions . . . . . . . . . 2~ General crowding ...... 32 Interlocked bites ...... 2 Suckers--lip ......... 3 finger . . . . . . . . . 2 thumb . . . . . . . . . 2 tongue . . . . . . . . . 1 Open bite . . . . . . . . . . . . 2 Close bite . . . . . . . . . . . . 12 Perversions ......... 4 Torsoversions ......... 14 Supraversions ......... 2 Inferior retrusions ...... 21 Superior protrusions ...... 1 Impacted teeth . . . . . . . . . 2 I t is, perhaps, a little difficult, when so m a n y districts are definitely dentally under-staffed, to advise that this particularly beneficent work shall be added, as it is absolutely certain that if it is u n d e r t a k e n there will be a still further call for dental services in that area, particularly amongst the more intelligent section of the population. I have found that this work has b r o u g h t an entirely new conception to the parents of our school children of what dentistry really means. H i t h e r t o it has m e a n t the pulling-out (I use the word advisedly, because that is the one the parents use) of teeth too far decayed to be saved, and the filling of teeth in order to save them. T h e i r vision has b e e n b o u n d e d entirely by this" horizon, and the introduction of something which widens that horizon and makes t h e m u n d e r s t a n d for the first time what a really scientific profession that of the dental surgeon is, creates a respect for the advice given and the decisions arrived at. T h i s in t u r n means that the m o r e intelligent parents take a greater interest in their children's mouths, and this brings more work on the shoulders of the dental staff. As m o s t of you are aware, I a m generally p r o b i n g into the future in some way or another, but of all the work that I have u n d e r t a k e n in m y career as a medical officer, none has b r o u g h t me such satisfaction or such gratitude f r o m the parents as the institution of the orthodontic service which I have just described.
I)R. ()fficer Bristol, Health
A. (;. MoL~sox, 1)eputy Medical of H e a l t h for the City a n d P o r t of has been a p p o i n t e d Medical Officer of for ~ V e m b l e v .
PUBLIC HEALTH.
Orthodontic
A UG[YST,
Schemes.
By ELWIN H. T. NASH, M.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health and School Medical Officer, Heston and Isleworth. The fact that Dr. Nash was to deliver an address on this subject was prominently announced in PUBLIC HEALTH and agenda papers of the Society. On the occasion of its delivery before the Home Counties Branch there was a fair attendance of members and others, but to the many who, unfortunately, were unable to be present, the appearance of the paper here will no doubt be welcome. for bringing this paper M Ymyreasons fellow administrators in the
before public health service are, first, that I can give a report on the place that, in my opinion, the practice of orthodontia must take in the future dental services of the country, based on five years' working of the pioneer municipal orthodontic clinic in this country ; secondly, that it may be a justification for my administrative methods which have been adversely criticised by some of the members of the school dental service; and thirdly, I want to show that necessity for treatment is not only dental, but medical and, particularly, psychological. Like all school medical officers, one was unaware of some of the awful mouths that afflicted children, and that orthodontic measures, other than extraction of teeth that were often quilte sound, were measures difficult of accomplishment amongst the dentally ignorant portion of the population. There is no school medical officer who has not had his patience tried to breaking point in trying to persuade the parent, where the offspring needs several fillings to save his teeth, only to be met with the reply that they can have them out but they " don't hold with stopping 'em." Again, how often has one tried to persuade this class and those more intelligent that the removal of two or four sound teeth is necessary to save ultimate overcrowding and deformity, only to be met with the blankest of refusals. My stimulus towards the utilisation of apparatus for the cases that could not be treated adequately by timely extractions was given by Mr. Cale Matthews, Dental Surgeon to King's College Hospital, who, during one of my presidential years of the Medical Officers of Schools Association, read a paper on the rectification of these deformities during school life. He was dealing with children in highclass preparatory schools and the junior forms of the public schools. My democratic soul rebelled that such beneficent treatment should be available only to the well-to-do and not to
the child population I am responsible for. I could not hope to emulate the exquisite pieces of apparatus fashioned by Mr. Cale Matthews, but I felt that something should be done to make the treatment available to my school population, despite the fact that the Board of Education had not progressed dentally at that time much, if any, beyond the vision beautiful of the six-year-old molar, and were not likely to look with any approval on the provision of apparatus in a dental clinic. I want all the critics in the dental service to appreciate that every step I took to establish orthodontia as a day-to-day part of our dental service was based on these facts. Had I attempted five years ago to do the work as I am doilag it now, I am certain that the Board of Education's attitude would have been entirely adverse. I am not unacquainted with the Board of Education's views on school and dental matters as a result of 26 years as a Chief School Medical Officer, and I felt that to educate them to my views meant that my motto had to be festina lente and my " factor of safety " very high. The questions that you will be asking are : (1) Is there a demand for this work ? (2) Is it justified (a) by reason of its expense; (b) by reason of the time it takes from what I call the ordinary routine work of the school dental officer ? With regard to the first question, the cases requiring orthodontic treatment have been assessed in one instance as high as 30 per cent. of the school population. This figure, of course, includes the minor cases, which certainly for the time being do not come within our purview. I think you may take our figure as a fair criterion of the cases that call for treatment. I use the word " call " advisedly, as I feel that it is the right expression to use in this case. Our school population is now 12,000, and in five years we have had 850 cases under treatment, of which 459 have been completed. Again, you will ask: " What has been the need for the treatment of these cases ? " The
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models I am exhibiting and the lantern slides of cases will, I hope, demonstrate to you the need for the treatment from the health point of view, as unless a mouth can function properly as a masticating machine its possession is of doubtful benefit to its owner. There is another point which is to my mind of immense importance in the case of the severer forms of deformity, particularly inferior retrusions, and that is the psychological damage, particularly in the case of females. There is in these cases a marked inferiority complex which overshadows everything. You have only to sit opposite one of these cases in the train to see the constant effort to cover the protruding teeth. Speech seems to bring into use facial muscles that normally are not in evidence. If I may use the expression, speech is almost a conscious muscular effort as regards the muscles that control the lips. It may be that it has been my lot to see the tragedies of these cases at close quarters. As I recently wrote in an article in the British Medical Journal, a very near relative of mine has had the whole of his life dominated by his bad inferior retrusion. His preparatory school days were made a misery by the gibes of his fellow pupils, and his later years a misery by his dental troubles and the fact that his deformity is such that an artificial denture would baffle even the genius of Wilfred Fish. Again, a friend who died recently, possessed a mouth which as a model would have brought sheer joy to the continental caricaturists like Simplicissimus when they wanted to illustrate an English aristocrat. To talk to him was difficult, as one's attention would become fixed on the constant efforts to cover his awfifl teeth. These in his later years got more and more discoloured until they looked like a row of lichen-covered tombstones reminiscent of the moping owl and the ivy mantled tower of Gray's immortal Elegy. His dental adviser would not tackle a denture. I recently reported in the British Medical Journal a case where a boy's whole outlook on life was jeopardised by his dental deformity. The boy won a scholarship to the county school just after we had made arrangements for treating his dental eondition--a set of supernumerary incisors in the upper j a w ~ w h i c h ultimately caused a very severe deformity to his mouth. He left school and got a post as interviewing clerk in an insurance office through the influence of his father, who was a member of the 8taft, At the end of his first week
385
he was told that he could not do his job owing to the trouble he had with his dental deformity. The mother in her distress brought the boy to me on the Saturday morning of his first week at work, asking what I could do. As school medical officer--nothing, as he had left school. As an individual anxious to help--very little, as he was 16 and these cases can only be dealt with efficiently at about 10 to 11. I got Mr. Evans, .our orthodontic specialist, to take him over as a patient at the Royal Dental Hospital, hoping for some improvement after the removal of the supernumerary teeth. Again I want to emphasise the importance of the psychological effect of these dental deformities, a fact which seems, so far as I can make out, to have not been suffÉciently stressed. Its effect is lifelong in many cases, and is far worse from the point of view of the happiness and success of the individual than the actual dental deformity itself. As I have stressed before, one of the outstanding features of this work has been the manner in which a mother who has handed on to her daughter an inferior retrusion, which has made her own life a misery, will grude no money or time in order to ensure that her daughter does not suffer as she has done. What are the origins of these deformities which afflict our children, and can we as public health officers do anything to prevent their occurrence ? With regard to the causation there are two main causes : (1) Heredity. (2) Developmental (a) caused mainly by naso-pharyngeal obstruct i o n ; (b) caused by habits such as thumb sucking, dummy sucking, blanket sucking, lip sucking, etc. With regard to class (1), Professor Brash has called attention to the large number that are due to this cause, and one has only to see the parents of the patients to realise the frequency with which this tragic legacy has been involuntarily bequeathed to the offspring. With regard to class (2), the protagonists of the obstruction theory seem to claim this as the fons et origo mali in almost every case. To them a necessary preliminary is the removal of adenoids with or without tonsils. I am bound to say that in several of the cases I have seen, such adenoidal tissue as existed had at the age when the patient was seen, ceased to be a material cause of obstruction either per se or as the result of any accompanying catarrh. What I have seen is that a number of these cases that have been referred to hospitals for
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the removal of tonsils and adenoids have turned up again with little or no improvement as the result of the operative procedure. On examining the patients the reason has been abundantly apparent. The cause of the obstruction has been, and still remains, due either to enlarged turbinals, a deflected septum, or both. So gross are these that it is seldom I cannot demonstrate the condition to the parent by merely tilting up the end of the child's nose in front of a window. Here is the tragedy of the position which reflects no credit on us as a profession. In not a single case of this type when I have asked the parent if the child's nose was examined, has the answer ever been in the affirmative. With regard to the cases with deflected septa, a difficulty arises in that most surgeons dealing with the nose will not operate before the age of 12 owing to their dread of the operation damaging the support normally given by the septum. I have, however, found one surgeon who will operate on these cases, viz., Mr. Philip Franklin, to whom our deepest sympathies must go out in regard to the tragic happening in the fire at his house in Wimpole Street. In such cases as he has operated on, the results have been entirely satisfactory. It is surely imperative to see that the operative proceedings to relieve the obstruction are complete, as it is such things that bring operative procedures into disrepute. With regard to the habit-produced deformities, it is normally sufficient to stop the habit to prevent further progression, but these cases cannot be dealt with orthodontically until they reach the age of nine or ten. In the case of thumb and finger suckers there is often considerable difficulty in breaking the habit which, if not broken, often runs on for years. We have devised wire guards, made for us locally, which are worn night and day. These we find the most effective preventive. It is not, I find, appreciated by the medical profession at large, how great the deformity caused by thumb sucking can be. The upper incisors are pushed out and the lower incisors pushed in, as will be shown in the models and patients exhibiting this condition. Sir Robert Woods of Dublin, the famous oto-laryngotogist, in the British Medical Journal of October, 1935, urges that these deformities might be due to congenital syphilis. I have no hesitation in saying that in the cases under our observation there was never any suspicion of congenital syphilis. This deformity is so clear cut that it is possible from the mouth or models
HEALTH.
AUGUST,
to say whether it has been caused by thumb sucking or dummy sucking. The latter does not push the lower incisors inwards in the same manner. With regard to the treatment of these cases, we as school medical officers cannot hope to employ the beautiful and elaborate pieces of apparatus, particularly those that are fixed, by reason of (a) the expense of providing them, (b) the fact that many of the parents lack the means or intelligence to bring their children up for adjustment of apparatus. If a child has to be brought some distance at frequent intervals, the cost of transport is a burden the parents cannot and will not face, in the latter case often due to the fact that they do not realise the importance of the dental deformity to the child. Moreover, I do not think we can claim that the cosmetic perfection that the orthodontic specialist provides at necessarily large fees is a part of our duty, which I consider to b e to provide an efficient and healthy masticating machine, and to remove any deformity which may be a cause of psychological disability in the years to come. We have only used one fixed apparatus and that was after repeated efforts to make a neurotic boy retain his plate. His fixed apparatus also was a failure. The choice has to be made between judicious extraction at the appropriate time, and the use of apparatus to expand the arch and perform other functions such as raising the bite or pushing forward the mandible. Judicious extraction, for instance, of the four sixes at the appropriate time, can give an excellent result. In some cases the closure of the gap is so close that a visiting card cannot be placed between the front edge of the sevens and the adjoining fives, and that in some cases is accomplished without any tilting whatever. This perfection of movement is not always the case, as when deciduous teeth have had to be removed as the result of caries, it is often necessary to insert a splint plate to keep the distance and space for an erupting tooth, and to prevent the teeth tilting into the vacant space, moving with the root apex as the fixed point. There are those who, like Dr. Sim Wallace, are whole-hearted enthusiasts for the removal of the proper teeth at the proper time, letting nature remodel the mouth. To Wallace, the expansion of the arch to make room for overcrowded teeth is anathema, and he pours scorn on what he calls the gorilla faces that are produced,
1936.
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It may be that in the lean and hungry looking type the expansion may produce a physiognomy more reminiscent of the Zoo than the drawingroom, but it has not been our experience. We use both according to the demands of the case and the psychology of the patient and parent. In the past more hostility was aroused in the uneducated parent by the desire to remove sound teeth for orthodontic reasons than anything else. My first step was to get my committee to purchase subscription tickets at the Royal Dental Hospital, each expenditure of one guinea providing us with four hospital letters. The provision of these hospital letters to the patients did not cover the cost of orthodontic apparatus, and as the Royal Dental Hospital required this to be " paid in one sum " before the apparatus was fitted, this produced difficulties very early in the scheme. This scheme failed by reason of the waste of time due to the multiple journeys made by the parents and patients. Even now there is insufficient appreciation of what it means to a parent to come up to a London hospital from a district in the periphery. It means in the first place, a financial expenditure of ls. 6d. for the adult fare, and half for tile child, if it can travel as a half, and this pre-supposes that they spend nothing on food, which is not usually the case. This expenditure I have found has meant to some families of restricted means that they have gone up by the workmen's train in the morning in order to save the difference in the cost, and loafed about London until noon when they were to be seen. If they take no food it means at least the railway fares for two persons; and still junior medical officers will light-heartedly tell a patient to come up every few days for some kind of treatment or to have an apparatus adjusted, not realising the terrific burden that they are placing on the family. Quite apart from the financial burden, there is the waste of time, which, if there are other children in the family, is a serious matter. It means the parents have got to spend the greater part of the working day in their visit to the hospital, and arrange for some kindly neighbour to supervise the other children, to attend to their meals, and see that they get off to school again in time. This arrangement also had the drawback that the patients were used for demonstration purposes, and entirely misconceived opinions were reported to us as the result of these
as7
demonstrations to students in front of the parents. It soon became apparent that there was no chance of success based on this method of administration. My next step was to approach the hospital authorities with a view to a more co-ordinated scheme whereby they would act as consultants, and we should do the work in our own dental department. I did not get much encouragement at first, except from Mr. Evans, who is in charge of the children's section, the reason being, apparently, that several schemes had been started with municipal authorities and had, without exception, broken down on administrative grounds. It took me some time and several visits to convince Mr. Evans that my ideas were workable, and it is to his enthusiasm that one must ascribe the success of the scheme as it now functions. There was some difficulty in assessing what my authority should pay for the services we asked. Eventually it was agreed that for a payment of 12s. we were to be provided with a specialist's opinion, such radiograms as were necessary, and any pathological report which might be required to elucidate the condition. Then came the difficulty of assessing what payment should be required from the parent for the necessary plates, bands, etc., which were necessary for the treatment that was advised by the Royal Dental Hospital Staff. This was the most difficult part of the whole proceeding, and it was only after many enquiries that Mr. Evans and I came to the conclusion that a flat rate fee of 15s. Was necessary to provide all that was required for the complete treatment of every case. This was to cover not only the dental mechanic's fee, but the cost of the necessary gold or other metals and materials requisite. As far as we were concerned, this 15s. worked out surprisingly well. It then became necessary to draw up some form which would accompany the patient to the hospital, which would bear on it the provisional diagnosis made by my dental staff, and would also leave accommodation for the report of the dental surgeon at the hospital in such terms that the work could be carried out in my own dental department. The form devised worked entirely satisfactorily, it being understood that it was a confidential document sent back to me by the hospital authorities. I found it absolutely necessary to insist that our patients were starred in some way and not used for teaching purposes, owing to the confusion which results in dentally ignorant
3SS
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minds from discussions taking place in front of them. This arrangement worked satisfactorily except in a few cases where the hospital surgeons had required the patients to go up at intervals. Otherwise it meant one visit only from this district to the hospital. As far as treatment was concerned, everything worked well. There was only one little difficulty, and that was that, as was inevitable, different members of the staff had different opinions on what was necessary to be done, particularly from the point of view of the removal of tonsils and adenoids. As time went on it was obvious that to get the best results the work had to, if possible, be decentralised from the hospital entirely. This at first I was unable to do, because I could not rely on getting the radiograms I wanted done elsewhere, but in June, 1932, I advised my committee to approach the Board of Education for permission to appoint an orthodontic consultant to visit once a month in the same way that the orthopaedic consultants do in so many districts. I am glad to say that the Board of Education were by now convinced of the value of the work we were doing, and agreed to the payment to Mr. Evans, as orthodontic consultant, of a fee of three guineas a visit, which is the highest fee they allow. This meant that, except for cases requiring radiograms, there was now no need for any visit outside our own area. Ultimately I got my committee to appoint Mr. Evans as the orthodontic consultant to the authority. It is this appointment which has caused so much heart-burning amongst school dental officers. Now the scheme works extraordinarily smoothly. Mr. Evans comes down once a month and sees a very large number of cases, many a time up to 65. This is made possible by the organisation of the work and the staff, which enables Mr. Evans to do this work within the limits of a morning session. A small work bench has been provided in the dental clinic, so that if the orthodontic consultant wants a piece of apparatus slightly altered, this can be accomplished while the patient waits. The children file in to a row of seats near the door, and each one is provided, by the nurse at the table, with its case card and box of models. There are three seats adjoining the dental chair in which the patients sit. As each patient in turn gets into the dental chair, the dental mechanic at the back on the left, having opened the box of models, has the last pair exhibited by the side of the patient ready
AUGUST,
for Mr. Evan's comparison. Directly the patient has moved into the dental chair, the other two patients in the chairs alongside move up, and the gap at the end is filled from the pool near the door. The stenographer is standing just to the right of the patient, and all Mr. Evans has to do is to examine the patient, compare with the model which the dental mechanic is holding, if necessary asking the nurse, who is standing behind on the right of the patient with the dental card, to read the last entries, and then simply to think aloud whilst the stenographer takes down what he is saying, the instructions being entered on the child's card for the guidance of my dental staff. I have been criticised by members of the school dental service for the methods I have utilised in launching this pioneer orthodontic scheme, and in order to, if possible, minimise their hostility, I would like them to see my point of view. My school dental surgeon (Mr. Cohen) is close on sixty ; he is practically stone deaf, and has been so for years ; consequently he has been cut off entirely from auditory commune with his fellows in the matter of meetings and things of that kind for many years. His enthusiasm and ability are enormous, and to compensate for his disability I see that he is supplied with everything in the way of literature. My school dental officer, therefore, had had no chances of that intercourse which is so necessary and valuable in keeping up-to-date although he read everything that could be got hold of. Further, one had a Board of Education to think of, and one recalled Osler's dictum in his earlier editions to this effect, that " there are other altars at which a young man may light fires than those of Bacchus and Venus," and one felt that it would want considerable persuasion to get the Board of Education to light fires at altars other than that to the six-year-old molar. I do not think there will be a large number of orthodontic consultants appointed after this. I am sure that the newer generation of school dental surgeons will be able to undertake the vast majority of the orthodontic eases which arise, but in every other branch of medicine it gives a sense of security to the practitioner, and is of value to the patient in a difficult ease, to have the advice of an expert, and difficult cases will arise in orthodontic practice as in every other form of medical, surgical or dental practice. Only this week, during the monthly
1936.
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morning session, two cases arose of great difficulty, which my staff had referred to Mr. Evans, and in one of these the difficulty was so great that Mr. Evans kept the models to ponder over later to see really what was the solution in the way of treatment. Sir Norman Bennett, writing to me on the subject says: " Even if it (orthodontics) becomes more general, I think that specialists would be needed. Although elaborate appliances would not be used, that does not make the correct diagnosis, prognosis and definition of scheme of treatment any the easier." I do not think that orthodontic specialists will be appointed in the same way that obstetric consultants are appointed in every area, but I think there will be, and should be available, within reasonable reach, the advice of an expert in dealing with really difficult cases. I am certain of this, however, that had I not assured the Board of Education that the work was being supervised by one of the most skilled men in the country, I should not have got the support that I have been able to rely on, and which was evidenced in a special section of their annual report. Still more, what to me is one of the most pleasing things, is the extension of the work which is taking place in various parts of the country. Above all, the most satisfactory thing is a letter I recently received from one who I know has criticised some of the administrative procedures in which the writer, noting the extension of orthodontic work that is taking place, ascribes it to the pioneer work which we had been doing in my district. The criticism has in some cases been unkind and un-understanding, and possibly somewhat jealous that an outside administrator has been able to convince the Board of Education of the necessity of something which they regard as their peculiar prerogative. I think the culmination of carping criticism is that of the school dental surgeon to the county borough of Ipswich, who writes in his annual report for 1934: " In my opinion the appointment of orthodontic specialists is a matter more for sorrow than imitation." In his case his age is somewhat similar to that of my school dental surgeon, but he has had, so far as I know, the blessings, and I cannot call them anything else, of normal hearing, and faculties which should have enabled him to get his orthodontic information and experience by contact with his
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fellows, which is denied to my senior school dental officer. Despite the criticism, I remain entirely unrepentant, as I feel that as a result of what I have done I have persuaded, shall I say, the Board of Education some years before they would normally have arrived at that point, that orthodontics are a real part of the dental work of the school service. Only those of us who have seen the beneficial results and seen the effect, not only on the child but on the parent, of the removal of these deformities, can appreciate the value of the work. My committee are enthusiastic, and I make bold to say that any committee who takes the work up and sees the results, will feel that they are contributing substantially to the sum of human happiness. The practice of orthodontia has a very definitely scientific basis behind it, and a language of its own which must be understood to interpret the findings of those who are carrying on the work. The classification which is generally adopted is that of Angle, which is based on the relationship of the mesio-buccal cusp of the upper first molar, with the buccal groove of the first lower molar. This produces three different categories : class (1), in which the relationship of the two aforementioned teeth is normal, and produces a normal mouth ; class (2), in which the relationship of the tooth in the upper jaw is anterior to its proper position, and produces a general class of deformity known previously as superior protrusion, but now as inferior retrusion, the upper teeth projecting beyond the lower jaw, sometimes into the external atmosphere ; and class (3) in which the relationship of the upper molar is posterior to its normal position, producing the prize-fighter's jaw, that is, the protrusion of the teeth in the lower beyond those in the upper jaw. With regard to definition, the departures from the normal in the orthodontic sense are described as versions, and described in relationship to the front of the mouth and the tongue and the cheek. I have not attempted so far to do my own dental radiography. At first I had an arrangement with the Royal Dental Hospital whereby they did such radiograms for me as were found to be necessary. This, of course, involved the tiresome journey up to town. I have recently been able to conclude an arrangement with the West London Hospital on the following.terms :
390
PUBLIC HEALTH. $. d.
First film . . . . . . 2 6 Subsequent films .... 1 6 Complete upper jaw . . . . 7 0 Complete lower jaw . . . . 7 0 Complete dental examination.. 12 6 They are sending me excellent radiograms and reports, and the railway journey, and, therefore, the expense to the parents, is reduced by more than a half. I am getting it efficiently done at a reasonable cost, and for the time being I do not think that the expenditure on an X-ray outfit is justified. As to the finances of the work, I had hoped to be able to give the fullest details as to the cost involved, but unfortunately the devastating fire in my offices has rendered that impossible. I am, therefore, unable to add anything to the figures I published in 1933 in a paper read at the Royal Sanitary Institute Congress at Blackpool. (Journal of the Royal Sanitary Institute, Vol. liv, No. 3, September, 1933, p. 171.) It is very difficult to separate the overhead charges to be set against a work of this character, which occupies a varying time of a number of members of a large staff. I was very anxious that these financial statistics should be accurate (a) from the point of view of the Board of Education and (b) from the point of view of any of my colleagues who intend to take up the work. The difference that has been made in the financial details are that the full fee chargeable to the parents has been reduced from 37s. to 25s., Le., by the amount paid to the Royal Dental Hospital, which was done after Mr. Evans was appointed on my staff as orthodontic consultant. In addition to this the scale of charges to the parents has been amended and is now as follows : -
Income per head after deducting rent. Less than 8s . . . . . Between 8s. and 10s . . Between 10s. and 12s. Above 12s. . . .
Charge to parent. . . . . . .... . . .
Nil. 6s. 12s. 25s. (full cost). In a few cases, difficulties have arisen where the plate has been lost or broken by the child. It has required much thought to assess the responsibility and with it the amount (if any) that the parent should pay. Where any payment has been judged due from the parent, practically without exception it has meant wrangling and numerous letters and interviews before the parents could be made to see the
AuGusT,
justice of the claim. Fortunately, the cases are few and far between. Dealing with difficulties, one of the questions one is so often asked is: " Don't you have difficulty in getting the children to wear their plates ? " Of the 850 cases that have been dealt with, the number of cases that have had to be abandoned for this cause can be numbered on the fingers of one hand, and they without exception are of the neurotic type. These cases, when they arise, give no end of trouble, and endless patience has to be displayed to try and overcome the difficulty with the child and, what is quite, if not more, important, in some cases the fond parent. The figures I referred to as covering our expenses were as follows :--
£s.d. For 1930 . . . . 18a 18 1 1931 . . . . 251 15 6 This, however, does not include any charges for staff or overhead expenses. We received in return from the patients : ~ £ s. d. In 1930 .... 207 10 6 ,, 1 9 3 1 .... 151 16 0 This means that, for the first year and a half our scheme was in existence, the cost to my authority was £76 7s. ld. Our financial commitments now are a fee of three guineas per session once a month to our orthodontic consultant, and payment to the dental mechanic on an agreed scale. When the orthodontic consultant was appointed I impressed on him, as firmly as possible, the fact that our public health work had to be viewed from an angle entirely different from that of his West End practice. I said that if I got an 85 per cent. efficiency for a small expenditure, I, from the public health point of view, should be satisfied. Mr. Evans is enthusiastic about the results, and he claims that my figure of 85 per cent. is being very materially exceeded, and that our results are little short of the best that West End specialists can produce. You will also want to know something of t h e apparatus which is used. The principal piece of apparatus, which is the foundation treatment in many cases, is what is known as a Badcock plate. This is a plate split in two halves with an expansion screw and guide bar, so arranged that the nut which has to be turned can be adjusted with accuracy by reason of the fact that the four facets are numbered. So far as I can make out, until we entered
1936.
PUBLIC
the field no one had ever a t t e m p t e d to e n t r u s t the parents of the e l e m e n t a r y school class with the manipulation of a Badcock plate. W e set to work to train our parents to use the adjusting spanner, the general instructions being that they gave the screw a quarter t u r n every two days. We have found the parents r e s p o n d to this, and it works entirely satisfactorily. T h e expansion plate, however, is often only the base on which other t r e a t m e n t s are added. Plates may also serve by means of an inclined plane added at the front to advance the m a n d i b l e in cases of inferior retrusion. P r o m i n e n t teeth are w i t h d r a w n into their hiding place within the m o u t h by means of labial wires with springs of different character. I t is amazing how small a pressure continuously exerted will p r o d u c e the m o v e m e n t or rotation of a tooth. I n addition, certain teeth can, if pressure is relieved, be b r o u g h t into their p r o p e r relationship merely by continuous pressure of the lips. This, however, can be assisted by means of what is k n o w n as a lip exerciser, that is, a curved flat plate with a lever attached, which the patient holds between the lips for long periods, as for instance, w h e n reading, and as time goes on the effort can be increased b y loading the lever with little weights in order to strengthen the action of the muscles. Again, t h r o u g h the u n f o r t u n a t e fire, I a m unable to give you our last year's figures with regard to the n u m b e r and character of the appliances used. I think you m a y assume that the following list which I put in m y first paper, is relatively similar : T h e total n u m b e r of appliances m a d e during the year were as follows : Coil springs ......... 9 Inclined planes . . . . . . . . . 2 Splints ............ 11 Retention . . . . . . . . . . . . 4 Labial Wire and coil springs ... 1 Expansion . . . . . . . . . . . . t4 Expansion and retraction ... 7 Retraction . . . . . . . . . . . . 30 Expansion and screws . . . . . . 2 Screws . . . .... . . . . . 26 Expansion and inclined plane ... 1 Bite plates ......... 3 Retraction and inclined plane ... 4 Lip exerciser ......... 1 Repairs . . . . . . . . . . . . 10 Progressive alterations . . . . . . 5 Gold bands ......... 4 Dentures for school children ... 2 Total . . . . . .
136
HEALTH.
a91
T h e list of the different kinds of deformities also remains m u c h a b o u t the same : Narrow arches . . . . . . . . . 16 Labioversions ......... 20 Linguoversions . . . . . . . . . 2~ General crowding ...... 32 Interlocked bites ...... 2 Suckers--lip ......... 3 finger . . . . . . . . . 2 thumb . . . . . . . . . 2 tongue . . . . . . . . . 1 Open bite . . . . . . . . . . . . 2 Close bite . . . . . . . . . . . . 12 Perversions ......... 4 Torsoversions ......... 14 Supraversions ......... 2 Inferior retrusions ...... 21 Superior protrusions ...... 1 Impacted teeth . . . . . . . . . 2 I t is, perhaps, a little difficult, when so m a n y districts are definitely dentally under-staffed, to advise that this particularly beneficent work shall be added, as it is absolutely certain that if it is u n d e r t a k e n there will be a still further call for dental services in that area, particularly amongst the more intelligent section of the population. I have found that this work has b r o u g h t an entirely new conception to the parents of our school children of what dentistry really means. H i t h e r t o it has m e a n t the pulling-out (I use the word advisedly, because that is the one the parents use) of teeth too far decayed to be saved, and the filling of teeth in order to save them. T h e i r vision has b e e n b o u n d e d entirely by this" horizon, and the introduction of something which widens that horizon and makes t h e m u n d e r s t a n d for the first time what a really scientific profession that of the dental surgeon is, creates a respect for the advice given and the decisions arrived at. T h i s in t u r n means that the m o r e intelligent parents take a greater interest in their children's mouths, and this brings more work on the shoulders of the dental staff. As m o s t of you are aware, I a m generally p r o b i n g into the future in some way or another, but of all the work that I have u n d e r t a k e n in m y career as a medical officer, none has b r o u g h t me such satisfaction or such gratitude f r o m the parents as the institution of the orthodontic service which I have just described.
I)R. ()fficer Bristol, Health
A. (;. MoL~sox, 1)eputy Medical of H e a l t h for the City a n d P o r t of has been a p p o i n t e d Medical Officer of for ~ V e m b l e v .