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Place of Orthodontia in the Impending Wider Health Service*
TH E J O U R N A L o f the A M E R I C A N
D EN TAL
ASSO CIATIO N
Vol. 21___________________ MARCH, 1934____________________ No. 3 O r ig in a l C o m m u n ic a tio n s
PLACE OF ORTHODONTIA IN THE IMPENDING WIDER HEALTH SERVICE* By H A R R Y E. KELSEY, D .D .S., F .A .C .D ., B altim ore, M d.
O the layman of average intelli result of it, tended to produce profound gence, as well as to those belonging and permanent changes in the individual to the professions directly concerned, which equipped him for a much more it must be apparent that there has been desirable station in life, both socially and during the development of our present economically, and was, therefore, re civilization a steady expansion in all those garded as of the first importance. Its agencies which minister to the health and pursuit was a m atter of daily concern and not to be lost sight of, except when physical w elfare of the public. Coincident w ith this, but at a greatly an emergency arose. accelerated pace, has been the expansion of Intellectual development was acquired those agencies which minister to or de by exercise of the mind, just as physical velop the intellectual welfare of the pub development was acquired by exercise of lic. T o w hat may be ascribed this un the body, but means for the latter were equal advancement (which has been most always at hand and, therefore, as is usu notable in the last hundred years) in the ally the case, not valued so highly; while two im portant factors in, broadly speak-' the former could be acquired only from ing, the w elfare of the individual and, of teachers, schools, universities and books, and a t a price beyond the reach of most ; course, collectively the public ? In p art at least, it would seem to be but they were things w ith which all were due to the fact that intellectual improve familiar, because they are as old as ment, and the culture which was the civilization itself, or even as the human race. *Read at the Seventy-Fifth Annual Session T h ey contained the sum of human of the American Dental Association in con knowledge, and knowledge gave position junction w ith the Chicago Centennial Dental and pow er; and these things seem in Congress, Aug. 10, 1933.
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dispensable and all im portant to the ambitious, and a m ajority of hum an be ings are ambitious, either for themselves or for their offspring. I t is tru e th at medicine in some form or other has been practiced since the dawn of history, but it was originally shrouded in mystery and treatm ent consisted as much in the use of charms and incanta tions as in the application of drugs; though this phase of it was not entirely unknown. In fact, the arm amentarium was rather large and was composed in many cases of . the most disgusting mate rials. Home treatm ent was much relied on, and the average family or individual had special or favorite medicine, even as many do today, which was used in almost all cases. In emergencies, the doctor, or whoever answered for the doctor, was called in, and often the treatm ent was either ineffective or fatal. N o real advance was made in medicine until people emerged from the thraldom of superstition and began to delve into the mysterious functions of the human body. T h e dissecting room and the mi croscope finally brought us out of the ig norance and superstition which charac terized all early medical treatm ent. T h is has only taken place quite re cently, and it is especially true of our branch of modern health service, being due largely to the oral hygiene campaign of the last tw enty years, which has at last convinced people that the care of the mouth and teeth as the gateway to the alimentary tract is essential to health and that the service offered by the dental pro fession is an essential part of that care. H aving accepted our teaching, they now offer us a counterproposition in the per fectly logical inquiry: W here can we get this service? And so we have come to a realization of the fact, or should have come to it, that this is one more
national problem and one moreover that we as a profession are not only vitally interested in, but also for the solution of which we are ethically responsible. M y own recollection of the oral hy giene movement dates back to the time when D r. Ebersole started the campaign in which he was assisted by a number of well-known and unselfish men. D r. Ebersole gave the remainder of the last period of his life to it and w ithout doubt he greatly shortened his life by intense application to this campaign in conjunc tion w ith carrying on his private practice. T h e profession dallied w ith the idea at first, but gradually it was taken up over almost the entire land. I t is questionable whether many of those who seemed in terested in and became champions of the cause were so interested in the public weal as was D r. Ebersole and many of the other pioneers. M en who sacrificed as much as they did could not be accused of being mercenary in their motives, and while I have not the least intention of arraigning the profession as being so gen erally, I do remember hearing many dis cussions on this subject in which certain men w ent even so far as to say that the advertising dentist was taking the bread out of the mouths of their children ; which was their main argument for do ing away w ith him. I t would seem th at their thought was for themselves, rather than for the public at large, and let me say that I am mak ing no defense of the advertising quack, whom I regard w ith as much aversion as does anyone. I t cannot be denied that the dental profession, as indeed all other professions, is a monopoly and one that has been created not by indirect but by direct legislation. Legislative bodies, in response to a demand from the budding professions, have, in the past, granted them certain powers and privileges which are denied to all others.
K elsey — P la ce of O rth o d o n tia in W id e r H e a lth S ervice
In no other way could the public be protected, and these legislative bodies recognized this. Business organizations have secured desired advantages, fre quently, in spite of legislative opposition, but w ith the professions these powers and privileges were usually secured by the aid and w ith the assistance of legislation. Recent legislation, or rather the recent legislative aspirations of some of the socie ties, naturally provoke criticism by the public and press which is not in all cases complimentary. T h e point is this, th at while we are constantly w arning the public th a t they should give better personal attention to the mouth and teeth and patronize den tists for reparative and preventive treat ment, w e are recommending legislation which w ill curtail the already small sup ply of dentists by actually lim iting and even decreasing the num ber of students who can become practicing dentists in the future. I f we are not lim iting the num ber of students, we are at least diminish ing the number of colleges, so th at the output is decreased at all events. T h is in itself is entirely right and as it should be, considering th at its object has been to eliminate those institutions which could not give a satisfactory course. T h e public does not understand this and is inclined to suspect our motives and view also w ith suspicion much of the legislative activity in which the dental societies engage from time to time and which is reported and commented on in the public press. A brief editorial which appeared in the Baltimore Evening Sun, M arch 31,1933, seems to bear on this. I t is entitled, “And N ow the D entist.” The effort of the dentists to tighten their monopoly of the tooth pulling, straightening and filling art is making satisfactory progress at Annapolis. Their bill providing for examination by the Board of Dentistry and the granting of licenses in return for a fee went up for its third read ing in the House yesterday.
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T h e lawyers, who are perhaps our most an cient profession or trade union if you prefer the word, started all this business in the pres ent Legislature by introducing a number of bills designed to secure to them a monopoly of the practice of the law. None of the bills pro vided in return for the monopoly that the law yers should relinquish their right to engage in such nonlegal activities as selling insurance and real estate. Since it was not beneath the dignity of the bar thus to seek the sanction of the State for their monopolistic ambitions, it w as perhaps inevitable th at their example should have been followed by the motion pic ture operators, the barbers and various other occupational groups. Surely, the old saying that every profession is a conspiracy against the laity is being demonstrated in the current session at Annapolis.
T h e dental bill referred to in this edi torial is one which was introduced by the M aryland State D ental Association and which provided numerous unques tionably beneficial changes in the present law. Probably the one to which excep tion was taken in the editorial just quoted was th at which referred to further re strictions on the advertising dentists. T o show my thorough approval of the law, I need only state th at I was a mem ber of the committee th at prepared it and presented it to the state association for approval before its being presented at Annapolis. I have felt th at our action would be misinterpreted by the public as it has often been in the past. W e are not really trying to curtail the number of dentists or the amount of dental service which can be given, although it might be suspected by the uninformed public that we w ere interfering with the price at which people have been able to procure dental service heretofore. Broadly speak ing, this legislation is designed only to put a stop to the false and misleading advertisements which are so often in dulged in by men who are themselves graduates and licensed practitioners, and who can continue to practice under the new conditions, just as others who are
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for it. About that time the more progressive element in society believed that all individuals should have at least some education; that be ing born free and equal did not enable an in dividual to w in out or even hold his own in the game of life unless he had some of the environmental advantages which were needed to enable him to compete with other individu als more fortunately born, so fa r as this world’s goods are concerned. In other words, if he had no education he could not compete in those pursuits where it was essential. T here fore, a very little free school was provided. T he results must have been convincing be cause from that time until the present there has been a steady development of the free school system, passing through the stage where all m ight have a reasonable education to the state w here all were required to attend the free schools if they did not go to private ones, and finally to the present state where not merely the abstract subjects are taught but where many trades can be partially learned. In other words, compulsory education has been achieved. T his is paid for out of the public funds and no child who goes to the public school, nor his parents feel th at they are in any sense accepting charity. T his de velopment of the intellectual side of the in dividual has been done in the belief that he should have a competing opportunity and also because it was believed that it made for bet ter citizenship; that the best citizen was the one who had at least a reasonable education. If this be true, how much more important is the physical well-being of the in d iv id u al; for if the physical well-being is seriously im paired, the individual is not only directly handicapped as a citizen but he is not even able to take full advantage of the educational opportunities which are offered. T his seems logical to me and I believe that it is beginning to seem logical to the general public. W e have educated the public to the need for health The country has been confronted w ith a service in our own specialty and the same similar problem in another matter and we thing has been going on in all branches of speak with pride today of its solution. I refer medicine. Is it surprising that they are be to universal education. There has always been ginning to inquire very anxiously where they educational service as well as health service can get this beneficial service? M y feeling is for those who could pay for it, but up to that we have about arrived at the time where about 100 years ago there was no educational the politician w ill see strong possibilities in service supplied to those who could not pay this question. He may represent to his con stituents that this thing which the professional 1. Kelsey, H. E .: Public Clinic as Measure man enjoys is a monopoly, and can we deny of Cost and Value of Universal H ealth Serv that it is a monopoly? No individual may ice, Internat. J. Orthodontia, 19:424 (A pril) practice or offer health service who has not 1933. conformed to certain rather long and strenu-
ethically minded do; but the public gen erally does not understand this and be lieve our activities are directed tow ard tightening our monopoly and improving our income by making it impossible for them to receive a service to which they have become accustomed and which is ad vertised to them as being just as good and far cheaper. In fact, to a very large part of the general public the advertiser appears to be the outstanding man. O ften, he is the only one they have heard of, and the fact th a t he is so enterprising as to advertise his wares seems to them, w ith their lack of ethical education, to stamp him as being at the forefront of his pro fession. T h ey do not know, although it is w ell known to us, th a t the advertiser charges just as much for his services as he can get, and th a t they often pay more to him than they would to an ethical practitioner and probably receive very inferior serv ice. O u r campaign of education, therefore, seems to have brought us to an impasse. W h a t are we going to do about it ? I f we do not do something, it w ill be done for us. A t this point, it might be w ell to re view the development of universal edu cational service and note w hether there are any phases of it which are applicable to a similar universal health service. In a paper read before the N ew Y ork Society of O rthodontists in M arch, 1932, I 1 referred to this subject.
K elsey— P la ce o f O rth o d o n tia in W id e r H e a lth S ervice ous requirements and has passed examinations which certify to his ability. If anyone else undertakes to offer any kind of health serv ice he is liable to severe penalties. T he politicians and the people will un doubtedly, sooner or later, realize that this monopoly has been granted through legisla tures which aw ard to colleges charters which give them the right to grant diplomas to those individuals complying w ith the specified re quirements. W ith this diploma as a prereq uisite, the graduate, and he only, is then eli gible to take an examination for a license to practice and if he successfully passes it, he then joins the ranks of those who are per mitted to offer their services to the public. The medical and dental professions have steadily elevated the standard for admission to their ranks and have given fully as much attention to the ethical as to the practical side of the matter. Our ideals are of the highest and the best element of the profession en deavors to live up to them, but we are working under a system which was inaugurated be fore the need for universal health service was recognized. For in the past little, if any, health service was given or advocated until the patient was ill, and under those conditions, of course, the demand for service was not universal; but now that the profession first and the laity secondly has realized the need for prevention and hygiene as well as reparative service, something will have to be done, and I am certain that something w ill be done, within a few years, to supply them. T he people will be informed, if they are not already, that they themselves have granted the power to the various professions to prac tice them exclusively and it w ill occur to them eventually that they can also make other regu lations concerning the situation. It behooves the profession, therefore, both in its own in terest and in the interest of the public gen erally to have a hand in w hatever changes may be brought about. T h at there will be changes there can be no doubt, and that they w ill be unwise if not guided by the conscien tious effort of the best element in the pro fession also cannot be doubted. Dental service and especially orthodontic service cannot be given cheaply and this has been one of the difficulties in establishing dental clinics in comparison w ith clinics for general medicine and other special branches of medicine. Compare, for instance, the time required for the correction of a case of m al occlusion with that required for a tonsillectomy.
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All the more, therefore, is it a matter which can only be adequately taken care of by serv ice supplied by the community or the state.
T his last statement expresses a convic tion which I have held for sometime past, but which has been shaken recently by the classic presentation by W illiam J. Gies,2 of Columbia University. H ere,w e have a man who, though a layman, ex hibits an enthusiasm which would do credit to the best members of our pro fession. H is object is clearly, first, the welfare of the general public, and, sec ondly, the improving of the standards and ideals of health service. I t is difficult, if not impossible, for one in the profession to get the same point of view as that of a layman who has become interested in the subject and who has, as in this in stance, had a vast amount of experience over a number of years in activities which have necessitated his making a complete and thorough analysis of this whole sub ject. T h e dental profession should, and I believe does, accord D r. Gies its grate ful acknowledgment for the splendid service he has rendered it. In a supplement to his report, he offers a substitute for state medicine. H e says, “T h is substitute would affect dentistry as one of the separately organized cooperat ing health service professions concerned.” I w ill quote only paragraph C, refer ring you to his report for a fuller ac quaintance with his careful analysis of the subject. State medicine would lose its appeal as a practical solution of the present economic diffi culties if the organized health service pro fessions in effective cooperation should meet the situation in harmony w ith their humani tarian purposes and in due recognition of exist ing economics in equality. T his they can do by systematically organizing and m aintaining institutions or groups to provide excellent pre ventive and clinical health service, at moder ate fees, specifically for patients having low 2. Gies, W . J . : Status of Dentistry, J . D. Res., 12:945 (Dec.) 1932.
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incomes. Such institutions or groups should be established under professional auspices only; if, where, when and as community needs would determine. Public spirited lay men would certainly cooperate in founding and m aintaining these health service agencies.
N ow if public spirited laymen w ould cooperate to a sufficient degree to provide universal health service agencies, and if the professions, at the same time, did their part, we would hear no more of state dentistry. W h en I read D r. Gies’ enthusiastic re port, and Colonel M essner’s thoughtful paper,3 I feel th at they w ill do so and th at the professions w ill correspondingly cooperate, but when I think of the diffi culty encountered by all agencies created as beneficent institutions, but which de pend on private endowments for support and maintenance, I am again throw n into doubt. O ne thing is sure, universal health service there w ill be, and in either case it behooves the professions concerned to take a prominent and influential part in its inception and organization. I t will be much easier if the proposal for uni versal health service comes from the pro fessions rather than from the public. As D r. Gies very tru ly remarks, “ If the professions concerned do not provide a wider health service the public in des peration w ill cast about for means to provide it themselves.” T h e politician w ill inevitably get into the game and state health service w ill undoubtedly be the result. If state health service is launched under the guidance and super vision of the professions, it may be done w ith no more, and probably less, of the pernicious political influence than has in varying degrees characterized state edu cation. H ad it not been for the long period of business and financial depres sion through which we have been pass ing, this question of universal health
service would have been in the first ex perimental stages. As we emerge from the depression, as we surely will, its pressing nature as a public need w ill again bring it rapidly to the front, and the profession should be prepared, at that time, to offer a rational plan whereby there can be instituted the beginnings of such a service, which may grow, in time, to cover the field as thoroughly as does universal education today. T h e enormous expense of universal education has come in for considerable criticism, and w ill prove to be one of the deterring influences delaying universal health service; and although I may be accused of taking a reactionary stand, I believe that enough money is wasted each year in attempting to educate, beyond a reasonable point, those who by nature can never assimilate such knowledge to prac tically pay for necessary health service. T h is naturally brings us back to a con sideration of the cost of education as com pared w ith the cost of health service. A few figures relating to the cost of free education may not be out of place. T o quote again from the paper1 before re ferred to:
A rough estimate of the time required for dental treatment,- including orthodontia, for the average child is fifteen hours a year. Add to this all the forms of treatment the child might require and it will amount to probably not over twenty-five hours a year. Now if that is actually the case and yet the child is provided w ith 1,200 or more hours of service per year in the educational field, does it not seem absurd that he should not have the twenty or thirty hours required for the care of the body? Much of the plant needed for this service already exists in the elaborate school buildings, and equipment, which in Baltimore (one city w ith which I am fam iliar) repre sents an outlay per pupil of $377.54. These buildings can provide the required space, without further expense, except for some spe cial equipment for giving practically all treatment, except that for which the patient 3. Messner, C. T . : Dentistry in Public must go to the hospital, or remain in bed at Health, J.A.D.A., 17:2313 (Dec.) 1930. home.
K e lse y — Pla&e of O rth o d o n tia in W id e r H e a lth Service No doubt there will be much objection in some quarters to supplying free medical and dental service, but I am told there was just the same objection raised to the supplying of free educational service. M y feeling is that some of the opposition that is expressed by dentists to universal free health service is based upon fear. In connection with that, I wish to say that it seems to me that universal service, supplied by the State, would be as great a boon to the professions as it would to the laity. All men of outstanding ability would continue to attract to themselves a clientele who would prefer to go to them, rather than to the more promiscuous public clinics, because they are fortunate enough to have the means to pay for the more exclusive service, so that, the private practitioner would be analogous to the teacher in the private school of today, and he would be relieved from the great burden of supplying much free service that ought, by right, to be paid for by the State. Those men who have ability, but do not succeed well today, would be much better off if employed by the State. T heir income would be much more secure and would be even larger. T he opportunity for research, on the part of both the public clinic practitioner and the private practitioner, would be immensely enhanced, and the private practitioner could w ith a good conscience refer those people who sought his services but could not pay the fees he felt justified in charging, to the service sup plied by the State, which should be just as thorough and painstaking as his own. I t is believed by many that the teaching supplied by the public schools of today is quite equal to and in many instances superior to that supplied by private schools; yet, in spite of this, there is now and probably always will be a demand for the private school, just as there will be if free health service is inaugurated, a demand for the private practitioner. The danger, of course, in establishing free health service lies in the possibility of pro ducing a large number of ill-equipped prac titioners and here again it is up to the pro fession to see that the large number of dentists which will be required when and if this thing comes to pass measures up to the standards which have already been made.
Nevertheless, if the welfare of the pub lic demands free health service, and if this should completely extinguish 'the present private health service, we must believe, if we are honest in our state
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ments, th at it would be for the general good, even if worse for us. In other words, we are practicing a profession which has been established in answer to a public need. W e have not created a ficti tious demand for something which we have to supply. T h e need or demand has been there all the time, and in spite of preventive measures, w ill be there for a long time to come. T o meet this need adequately, the num ber of our profession w ill have to be greatly augmented; that is, to meet it in a universal way, and this may be the next great problem which we w ill have to re spond to. G ranting, then, that universal health service is realized, whether it be through the intervention of the state or through endowments by th at w ealthy portion of the population who may become suffi ciently interested to provide the means for its establishment, we are brought to the final proposition indicated in the title: “T h e Place O rthodontia W ill Occupy in It.” As I have said, “ D ental service, and especially orthodontic service as it has been conducted in the past, cannot be given as cheaply as can some other forms of health service, but under more ideal conditions where all children are under observation from infancy so many maloc clusions can be prevented as to greatly reduce the amount of time and work which would have to be given to this particular phase of the service.” A thor ough study of the writings of D r. W ille tt4 4. W illett, R. C.: Children’s Dentistry from Orthodontist’s Point of View, Internat. J. Or thodontia, 17:552 (June) 1931. Improved Operative Technique for Deciduous Molars, D. Items Int., 53:489 (July) 1931. Coopera tion of Family Dentist in Mouth Hygiene Movement, J.A.D.A., 16:2151 (Nov.) 1929. Intercepting of Certain Types of Malocclusion, ibid., 16:389 (M arch) 1929. Radical De partures from Theories and Methods Pertain ing to Children’s Dentistry, ibid., 19:1085 (July) 1932.
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will convince anyone that if all children were brought under the care of men who understood as he does not only the impor tance but also the technic of heading off approaching malocclusion, the burden of the orthodontist would be greatly les sened. D r. W ille tt has called this work in the numerous papers which he has w ritten on the subject, “T h e interception of malocclusion” and I would advise any one at all interested in this subject to read carefully everything he has w ritten on i t ; for although there are others who have recently and at an earlier time w ritten ex cellent articles on this subject, there is no one th a t I know of who has treated it so exhaustively and followed up the technic of the principles upon which it is based as has D r. W illett. H is theories have all been put into practice, and he has demonstrated the feasibility of everything which he pro poses. M oreover, he has conducted most of his experimental work on a class of children who are the least promising as patients, believing that if he could ac complish his results in these cases, there would be no excuse for others more for tunately situated not securing similar benefits. Fundamentally, he believes that if the teeth and jaw s are maintained in a nor mal functional activity, development will take place along normal lines. W hile this theory has been held by many men, few, if any, have carried the technic out so thoroughly as he for bringing about and maintaining this condition. T h ere can be no doubt th at children receiving such service as this, in conjunction w ith all other health service, which of course, is just as im portant, would exhibit far fewer cases of malocclusion as they grow up, but none of us believe th at prevention can be carried out 100 per cent; nor do I mean to imply th at D r. W ille tt does not
recognize th at there are other varied and often complex factors in the etiology of malocclusion. T h ere w ill still be malocclusion in spite of universal health service and our best efforts, but it is reasonable to suppose that the amount of malocclusion may be greatly reduced as well as the complexity of many of the cases, and therefore, there w ill be a diminution in the amount of time required for their treatm ent. T h e other possible factor in lessening the bur den of orthodontic treatm ent is the in crease in our knowledge of the etiology of malocclusion, and, of course, w ith this, the possibility of a more exact diagnosis than we have hitherto been able to make. T hus, we may be able to determine ac curately the individual developmental possibilities of a case at the time we are confronted with it for treatm ent, saving thereby a great waste of time and effort. D uring the last ten years, a great num ber of diagnostic methods have been pre sented to the profession, from which we have hoped much, but so far not one of them has made it possible for us to diag nose a case w ith such certainty and accu racy th at we feel justified in pursuing a radical course at the outset. I t is our hope th a t this goal w ill be reached in time. I t would be ideal if we could say of an individual case: T his child’s den tal arches and supporting bony struc tures will never develop sufficiently to contain the thirty-two teeth which have been provided for it and, therefore, at the most suitable age, one or more of the pre molar teeth must be removed; this pro cedure to be followed, of course, by ade quate orthodontic treatm en t; but we have not yet travelled so far as this along the diagnostic road. I n a paper read before the M aryland State D ental Association several years
Kelsey— Place of O rthodontia in W ider H ealth Service ago, I 5 expressed my convictions w ith re gard to the extraction of teeth as a pro cedure in orthodontic treatm ent, and in spite of the vast amount of study by many able men which has been given to the subject of etiology and diagnosis since th at time, I find myself unable to change my views w ith regard to all those cases which have still before them the strong possibility of developmental changes, cases in which there is at least a portion of the temporary dentition still present, and cases even a year or tw o after the deciduous teeth have been lost and their successors have taken their places. M y opinion at that time was, and it still is, th at only after an honest effort had been made to reduce a case of malocclusion and bring about a normal relation of the teeth to each other, and all means to th at end had been exhausted and proved a failure, was it justifiable to resort to extraction. T h e reason for this is th at of two cases presenting an identical malocclusion, one w ill yield quite readily to orthodontic treatm ent and a normal occlusion of the teeth and relationship of one dental arch to the other can be secured, while the other, in spite of our best efforts, w ill tu rn out a failure. W e must still give the benefit of the doubt to both cases, and only resort to extraction when we have demonstrated experimentally th a t suffi cient development cannot be secured to make room for all of the thirty-tw o teeth in the dental arches, or th at a mesiodistal malrelation of the dental arches cannot be corrected along ideal lines. A fter the sixteenth year, the experienced orthodontist should be able to determine, in order not to waste his patient’s and
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his own time, w hether treatm ent along ideal lines may be successful, and if he decides that it w ill not, he should then have the courage to adopt a compromise treatm ent, removing a tooth or teeth if necessary. A t the inception of a universal health service, there would undoubtedly be a vast number of such cases which would be presented for treatm ent and decisions based upon wide experience would greatly curtail the time and energy needed to meet the situation. T h e danger in ever advocating extrac tion as an orthodontic measure is that so many general practitioners are apt to ac cept such advocacy as a justification for extraction in all cases which come under their observation. O n the contrary, it is not a justifica tion, and no one who has not had a broad orthodontic experience has any right to extract a tooth as an orthodontic meas ure w ithout securing the opinion of some one who has; for if he pursues such a practice, he w ill inevitably do immeasur able h arm ; first, because his lack of ex perience w ill not enable him to differen tiate between those cases which really call for extraction and those which are capable of being restored by good ortho- • dontic treatm ent to normal occlusion, and, secondly, because where extraction is indicated, it must still, w ith rare excep tions, be accompanied by intelligent or thodontic treatm ent. T o merely extract, w ithout being able to give the indicated orthodontic treatm ent also, w ill usually only aggravate the malocclusion, except, of course, in some very rare cases, the dis cussion of which is out of place here. In 5. Kelsey, H. E.: Consideration of Funda the w ider health service, then, which I mental Principles Underlying Classification believe to be impending, there is un and Diagnosis, and Some Factors or Conditions doubtedly a need and a place for ortho W hich If Observed in T im e M ay by Proper dontia, but it must for reasons already Advice A vert Impending Malocclusion or In sure Treatm ent at Most Favorable Age. (U n stated be under the supervision of the orthodontist. H is work and the work of published data.)
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the general practitioner w ill meet in the field of prevention and interception. T h e intelligent cooperation of all the special ties w ith the general practice of dentistry can, through painstaking and tireless ef fort, meet in a practical manner the den tal phases of a universal health service, and I believe at a cost which w ill not be out of proportion to the advantages which it w ill bestow. O f course, the figures here given as to the cost of education apply only to that portion of the population who are in the free public schools. I t w ill be argued th at free health service would involve the entire population and would, therefore, be in demand by four or five times as many individuals; but this is not so seri ous as it seems at first when it is con sidered th a t each of these individuals does not have all the various ills nor does each one go through the same almost continu ous regime as do pupils in the schools. Furtherm ore, the number who would apply for free health service would be greatly diminished by th at large class who would still prefer to have the more ex clusive private service and also by that class, th a t fairly large and fortunate class I may say, who remain w ell most or all • of the time. T h a t the public generally is becoming interested in orthodontia is manifest by the rapidly increasing num ber of applications for such service in the various clinics and at the college infirm aries. I am told by those in charge of the orthodontic departm ent in some of the colleges th a t the applications far outrun the capacity of the departm ent to take care of the cases and there is an increas ingly long w aiting list. T h is has also been my experience in the orthodontic di vision of the dental clinic at the Johns Hopkins Hospital. W hile this demand is due partly to the unfortunate financial situation of the present time, it reflects in a general way the appreciation which
the public has acquired for orthodontic service. I t is also significant th at many people of small means deny themselves much in order to give this treatm ent to their children. T h e need is obvious, and the results have been, in a general way (a t least in the eyes of the laity), suffi ciently successful to excite this constantly increasing demand for it. T o those associated w ith any public clinic or college infirmary, it is actually distressing to note the keen competition which exists among patrons to secure for their children the benefit of this service. I t seems th at almost all people, if not the entire public, have become aware of the need for orthodontic treatm ent where malocclusion exists and have learned th at there is such a service, which can be had if they can pay for it, and sometimes may be had in clinics at a more moderate charge. I t is also significant th a t there are often brought to the orthodontist for treatm ent children whose mouths have been seriously neglected in other respects, doubtless because the need for orthodon tic treatm ent was so much more obvious to the parents than was the need for re parative work such as fillings, for which they often w ait until the child is suffer ing, a most unfortunate phase of the sit uation. In a paper read before the meeting of the American Society of O rthodontists at T oronto, in M ay, 1932, Abram Hoff man6 referred to this subject. I quote : T he first step has been to discover the den tal health need of the public from the view point of the layman. Five hundred question naire forms were sent to persons residing in thirty-one states of the United States and eight provinces of Canada. These persons repre sented various vocations, and community in terests. T heir replies give interesting indica 6. Hoffman, A bram : W hat M ay Be Con sidered Rational Methods in Orthodontic Therapy, Internat. J. Orthodontia, 19:233 (M arch) 1933.
K else y— Place of O rth o d o n tia in W i d e r H e a lth Service tions of the conception of the health needs for which the dentist should render service (and please note this) that third in their list of needs is treatment of irregularities of the teeth. These laymen were also asked to indicate which dental health need, in their opinion, the dental profession fails to meet adequately, and here in the fourth position we find the treat ment of irregularities of the teeth.
I t is evident, then, that orthodontia will necessarily have an im portant place in the dental division of universal health service, when that greatly to be desired boon to humanity has been realized, and it is my conviction that as the country returns to normality in a financial way, the public will energetically support some method for bringing it about. If the method be a good one and under the supervision of the professions concerned, so much the b e tte r; but if they, the pro fessions, have nothing to offer, or rather if they do not take the initiative, it w ill undoubtedly be taken by someone else, possibly by those of political aspirations, who rarely fail to recognize an oppor tunity. I t is not reasonable to suppose that universal health service can be estab lished as an entirely new departm ent of government, supported by entirely new taxation. As stated before, we have probably gone too far w ith free education, and some of the money that we are spending in th at department may very well take care of a new departm ent of health service. I often think of w hat a very intelligent mother of three or four children who were patients of mine said to me when speaking of the difficulty of having chil dren keep all of the multifarious engage ments necessary to their education, and of visits to all of the various doctors who looked after their health. H er words were, “ I am determined th at my chil dren shall grow up w ith healthy bodies even if they do not know a thing” ; and
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she was one of the most cooperative par ents w ith whom I have dealt in a long experience. Those engagements which concerned the health of her children she regarded as of first importance, although she by no means underestimated the value of edu cation, and these children all went to the best private schools and got their lan guages from their governess and tu to r in addition. T h is woman’s attitude toward her children, if adopted by the government tow ard individuals, might well be termed governmental paternalism, something which in a broad sense is as objectionable to me as it can possibly be to anyone. Nevertheless, in matters of health, it is already conceded by practically everyone that the government should interfere w ith the personal liberty of the individual in order to protect the welfare of the public generally, as witness the govern m ental supervision of those individuals who have contracted some contagious disease. Such supervision does not yet extend to a great many communicable diseases which are in fact today much more seri ous than is smallpox (which is under governmental supervision), because, while they may not be so deadly, they are yet doing vastly more harm than smallpox, simply because they are not under super vision. T h e social, or so-called social, dis eases stand, of course, at the head of any such list. I have a sympathetic feeling for the person who objects to being forced to submit to vaccination for smallpox, not w ithstanding the fact that I believe that it is perfectly right and proper th at he should submit to it. I resent and always w ill resent govern m ental interference w ith my behavior as an individual which in no way affects the w elfare of those around me. T here are
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people who believe that it is quite justifi able for the government to interfere w ith our personal behavior even though that behavior only endangers our own per sonal w elfare and carries no menace to those about us. W e are only ju st recovering from one such experiment. Universal free health service could not be objected to by any one, save on economic grounds. .Com pulsory health service will undoubtedly
meet w ith very serious opposition, as it always has, even when exercised purely as a protection to the public. Nevertheless, after a thoughtful anal ysis of the subject, to me at least the con viction is inescapable that it would have benefits for the race as a whole (benefits which are now enjoyed by our domestic animals only) entirely outweighing its objectionable features. 833 Park Avenue.
FLEXURE FATIGUE STUDIES OF CAST DENTAL GOLD ALLOYS* By FLOYD A . P E Y T O N , D.Sc., A n n A rb o r, M ich.
S IN C E there are such varied demands on the structures used in reconstruc tion in dentistry, the development of suitable alloys is a complicated prob lem. T h e extreme limitations on the size of the structures, the severe stresses that are applied and the varied chemical prob lems involved in a consideration of the saliva, products of decomposition and food products furnish a variety of prob lems in dental alloy construction rarely equaled in any other branch of m etal lurgy. In some instances, structures are re quired which are fixed firmly in place by cements, w ith no flexure and no movement of the structure. In such cases, the m atter of strength is less im portant than is some others. A certain degree of strength w ith a high degree of ductility, which w ill permit the finishing *From a portion of a dissertation submitted to the G raduate School of the U niversity of Michigan, in partial fulfilment of the require ments for the degree of doctor of science. Jour. A .D .A ., March, 1934
of a tight margin, are most desirable properties. In other cases, if the piece is removable and therefore subjected to the hazard of fracture from falling and to a high degree of stress in the mouth, it cannot be malleable or ductile to the same degree as some metals and alloys used for other dental reconstruction pur poses. In such cases, the highest possible degree of strength w ith a high flexure fatigue limit are the properties most de sirable. In certain other cases in the mouth, if there is not proper care, struc tures which are used are subjected to processes of the most extreme discolora tion and disintegration by saliva, food and products of fermentation. These are only a few examples of many which could be mentioned to show the extremely intricate nature pf the production of dental alloys that meet all the needs of dental practice. In no case have the uncombined metals been suitable for this purpose. Gold, plat inum and palladium are the only metals
D EN TAL
ASSO CIATIO N
Vol. 21___________________ MARCH, 1934____________________ No. 3 O r ig in a l C o m m u n ic a tio n s
PLACE OF ORTHODONTIA IN THE IMPENDING WIDER HEALTH SERVICE* By H A R R Y E. KELSEY, D .D .S., F .A .C .D ., B altim ore, M d.
O the layman of average intelli result of it, tended to produce profound gence, as well as to those belonging and permanent changes in the individual to the professions directly concerned, which equipped him for a much more it must be apparent that there has been desirable station in life, both socially and during the development of our present economically, and was, therefore, re civilization a steady expansion in all those garded as of the first importance. Its agencies which minister to the health and pursuit was a m atter of daily concern and not to be lost sight of, except when physical w elfare of the public. Coincident w ith this, but at a greatly an emergency arose. accelerated pace, has been the expansion of Intellectual development was acquired those agencies which minister to or de by exercise of the mind, just as physical velop the intellectual welfare of the pub development was acquired by exercise of lic. T o w hat may be ascribed this un the body, but means for the latter were equal advancement (which has been most always at hand and, therefore, as is usu notable in the last hundred years) in the ally the case, not valued so highly; while two im portant factors in, broadly speak-' the former could be acquired only from ing, the w elfare of the individual and, of teachers, schools, universities and books, and a t a price beyond the reach of most ; course, collectively the public ? In p art at least, it would seem to be but they were things w ith which all were due to the fact that intellectual improve familiar, because they are as old as ment, and the culture which was the civilization itself, or even as the human race. *Read at the Seventy-Fifth Annual Session T h ey contained the sum of human of the American Dental Association in con knowledge, and knowledge gave position junction w ith the Chicago Centennial Dental and pow er; and these things seem in Congress, Aug. 10, 1933.
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dispensable and all im portant to the ambitious, and a m ajority of hum an be ings are ambitious, either for themselves or for their offspring. I t is tru e th at medicine in some form or other has been practiced since the dawn of history, but it was originally shrouded in mystery and treatm ent consisted as much in the use of charms and incanta tions as in the application of drugs; though this phase of it was not entirely unknown. In fact, the arm amentarium was rather large and was composed in many cases of . the most disgusting mate rials. Home treatm ent was much relied on, and the average family or individual had special or favorite medicine, even as many do today, which was used in almost all cases. In emergencies, the doctor, or whoever answered for the doctor, was called in, and often the treatm ent was either ineffective or fatal. N o real advance was made in medicine until people emerged from the thraldom of superstition and began to delve into the mysterious functions of the human body. T h e dissecting room and the mi croscope finally brought us out of the ig norance and superstition which charac terized all early medical treatm ent. T h is has only taken place quite re cently, and it is especially true of our branch of modern health service, being due largely to the oral hygiene campaign of the last tw enty years, which has at last convinced people that the care of the mouth and teeth as the gateway to the alimentary tract is essential to health and that the service offered by the dental pro fession is an essential part of that care. H aving accepted our teaching, they now offer us a counterproposition in the per fectly logical inquiry: W here can we get this service? And so we have come to a realization of the fact, or should have come to it, that this is one more
national problem and one moreover that we as a profession are not only vitally interested in, but also for the solution of which we are ethically responsible. M y own recollection of the oral hy giene movement dates back to the time when D r. Ebersole started the campaign in which he was assisted by a number of well-known and unselfish men. D r. Ebersole gave the remainder of the last period of his life to it and w ithout doubt he greatly shortened his life by intense application to this campaign in conjunc tion w ith carrying on his private practice. T h e profession dallied w ith the idea at first, but gradually it was taken up over almost the entire land. I t is questionable whether many of those who seemed in terested in and became champions of the cause were so interested in the public weal as was D r. Ebersole and many of the other pioneers. M en who sacrificed as much as they did could not be accused of being mercenary in their motives, and while I have not the least intention of arraigning the profession as being so gen erally, I do remember hearing many dis cussions on this subject in which certain men w ent even so far as to say that the advertising dentist was taking the bread out of the mouths of their children ; which was their main argument for do ing away w ith him. I t would seem th at their thought was for themselves, rather than for the public at large, and let me say that I am mak ing no defense of the advertising quack, whom I regard w ith as much aversion as does anyone. I t cannot be denied that the dental profession, as indeed all other professions, is a monopoly and one that has been created not by indirect but by direct legislation. Legislative bodies, in response to a demand from the budding professions, have, in the past, granted them certain powers and privileges which are denied to all others.
K elsey — P la ce of O rth o d o n tia in W id e r H e a lth S ervice
In no other way could the public be protected, and these legislative bodies recognized this. Business organizations have secured desired advantages, fre quently, in spite of legislative opposition, but w ith the professions these powers and privileges were usually secured by the aid and w ith the assistance of legislation. Recent legislation, or rather the recent legislative aspirations of some of the socie ties, naturally provoke criticism by the public and press which is not in all cases complimentary. T h e point is this, th at while we are constantly w arning the public th a t they should give better personal attention to the mouth and teeth and patronize den tists for reparative and preventive treat ment, w e are recommending legislation which w ill curtail the already small sup ply of dentists by actually lim iting and even decreasing the num ber of students who can become practicing dentists in the future. I f we are not lim iting the num ber of students, we are at least diminish ing the number of colleges, so th at the output is decreased at all events. T h is in itself is entirely right and as it should be, considering th at its object has been to eliminate those institutions which could not give a satisfactory course. T h e public does not understand this and is inclined to suspect our motives and view also w ith suspicion much of the legislative activity in which the dental societies engage from time to time and which is reported and commented on in the public press. A brief editorial which appeared in the Baltimore Evening Sun, M arch 31,1933, seems to bear on this. I t is entitled, “And N ow the D entist.” The effort of the dentists to tighten their monopoly of the tooth pulling, straightening and filling art is making satisfactory progress at Annapolis. Their bill providing for examination by the Board of Dentistry and the granting of licenses in return for a fee went up for its third read ing in the House yesterday.
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T h e lawyers, who are perhaps our most an cient profession or trade union if you prefer the word, started all this business in the pres ent Legislature by introducing a number of bills designed to secure to them a monopoly of the practice of the law. None of the bills pro vided in return for the monopoly that the law yers should relinquish their right to engage in such nonlegal activities as selling insurance and real estate. Since it was not beneath the dignity of the bar thus to seek the sanction of the State for their monopolistic ambitions, it w as perhaps inevitable th at their example should have been followed by the motion pic ture operators, the barbers and various other occupational groups. Surely, the old saying that every profession is a conspiracy against the laity is being demonstrated in the current session at Annapolis.
T h e dental bill referred to in this edi torial is one which was introduced by the M aryland State D ental Association and which provided numerous unques tionably beneficial changes in the present law. Probably the one to which excep tion was taken in the editorial just quoted was th at which referred to further re strictions on the advertising dentists. T o show my thorough approval of the law, I need only state th at I was a mem ber of the committee th at prepared it and presented it to the state association for approval before its being presented at Annapolis. I have felt th at our action would be misinterpreted by the public as it has often been in the past. W e are not really trying to curtail the number of dentists or the amount of dental service which can be given, although it might be suspected by the uninformed public that we w ere interfering with the price at which people have been able to procure dental service heretofore. Broadly speak ing, this legislation is designed only to put a stop to the false and misleading advertisements which are so often in dulged in by men who are themselves graduates and licensed practitioners, and who can continue to practice under the new conditions, just as others who are
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for it. About that time the more progressive element in society believed that all individuals should have at least some education; that be ing born free and equal did not enable an in dividual to w in out or even hold his own in the game of life unless he had some of the environmental advantages which were needed to enable him to compete with other individu als more fortunately born, so fa r as this world’s goods are concerned. In other words, if he had no education he could not compete in those pursuits where it was essential. T here fore, a very little free school was provided. T he results must have been convincing be cause from that time until the present there has been a steady development of the free school system, passing through the stage where all m ight have a reasonable education to the state w here all were required to attend the free schools if they did not go to private ones, and finally to the present state where not merely the abstract subjects are taught but where many trades can be partially learned. In other words, compulsory education has been achieved. T his is paid for out of the public funds and no child who goes to the public school, nor his parents feel th at they are in any sense accepting charity. T his de velopment of the intellectual side of the in dividual has been done in the belief that he should have a competing opportunity and also because it was believed that it made for bet ter citizenship; that the best citizen was the one who had at least a reasonable education. If this be true, how much more important is the physical well-being of the in d iv id u al; for if the physical well-being is seriously im paired, the individual is not only directly handicapped as a citizen but he is not even able to take full advantage of the educational opportunities which are offered. T his seems logical to me and I believe that it is beginning to seem logical to the general public. W e have educated the public to the need for health The country has been confronted w ith a service in our own specialty and the same similar problem in another matter and we thing has been going on in all branches of speak with pride today of its solution. I refer medicine. Is it surprising that they are be to universal education. There has always been ginning to inquire very anxiously where they educational service as well as health service can get this beneficial service? M y feeling is for those who could pay for it, but up to that we have about arrived at the time where about 100 years ago there was no educational the politician w ill see strong possibilities in service supplied to those who could not pay this question. He may represent to his con stituents that this thing which the professional 1. Kelsey, H. E .: Public Clinic as Measure man enjoys is a monopoly, and can we deny of Cost and Value of Universal H ealth Serv that it is a monopoly? No individual may ice, Internat. J. Orthodontia, 19:424 (A pril) practice or offer health service who has not 1933. conformed to certain rather long and strenu-
ethically minded do; but the public gen erally does not understand this and be lieve our activities are directed tow ard tightening our monopoly and improving our income by making it impossible for them to receive a service to which they have become accustomed and which is ad vertised to them as being just as good and far cheaper. In fact, to a very large part of the general public the advertiser appears to be the outstanding man. O ften, he is the only one they have heard of, and the fact th a t he is so enterprising as to advertise his wares seems to them, w ith their lack of ethical education, to stamp him as being at the forefront of his pro fession. T h ey do not know, although it is w ell known to us, th a t the advertiser charges just as much for his services as he can get, and th a t they often pay more to him than they would to an ethical practitioner and probably receive very inferior serv ice. O u r campaign of education, therefore, seems to have brought us to an impasse. W h a t are we going to do about it ? I f we do not do something, it w ill be done for us. A t this point, it might be w ell to re view the development of universal edu cational service and note w hether there are any phases of it which are applicable to a similar universal health service. In a paper read before the N ew Y ork Society of O rthodontists in M arch, 1932, I 1 referred to this subject.
K elsey— P la ce o f O rth o d o n tia in W id e r H e a lth S ervice ous requirements and has passed examinations which certify to his ability. If anyone else undertakes to offer any kind of health serv ice he is liable to severe penalties. T he politicians and the people will un doubtedly, sooner or later, realize that this monopoly has been granted through legisla tures which aw ard to colleges charters which give them the right to grant diplomas to those individuals complying w ith the specified re quirements. W ith this diploma as a prereq uisite, the graduate, and he only, is then eli gible to take an examination for a license to practice and if he successfully passes it, he then joins the ranks of those who are per mitted to offer their services to the public. The medical and dental professions have steadily elevated the standard for admission to their ranks and have given fully as much attention to the ethical as to the practical side of the matter. Our ideals are of the highest and the best element of the profession en deavors to live up to them, but we are working under a system which was inaugurated be fore the need for universal health service was recognized. For in the past little, if any, health service was given or advocated until the patient was ill, and under those conditions, of course, the demand for service was not universal; but now that the profession first and the laity secondly has realized the need for prevention and hygiene as well as reparative service, something will have to be done, and I am certain that something w ill be done, within a few years, to supply them. T he people will be informed, if they are not already, that they themselves have granted the power to the various professions to prac tice them exclusively and it w ill occur to them eventually that they can also make other regu lations concerning the situation. It behooves the profession, therefore, both in its own in terest and in the interest of the public gen erally to have a hand in w hatever changes may be brought about. T h at there will be changes there can be no doubt, and that they w ill be unwise if not guided by the conscien tious effort of the best element in the pro fession also cannot be doubted. Dental service and especially orthodontic service cannot be given cheaply and this has been one of the difficulties in establishing dental clinics in comparison w ith clinics for general medicine and other special branches of medicine. Compare, for instance, the time required for the correction of a case of m al occlusion with that required for a tonsillectomy.
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All the more, therefore, is it a matter which can only be adequately taken care of by serv ice supplied by the community or the state.
T his last statement expresses a convic tion which I have held for sometime past, but which has been shaken recently by the classic presentation by W illiam J. Gies,2 of Columbia University. H ere,w e have a man who, though a layman, ex hibits an enthusiasm which would do credit to the best members of our pro fession. H is object is clearly, first, the welfare of the general public, and, sec ondly, the improving of the standards and ideals of health service. I t is difficult, if not impossible, for one in the profession to get the same point of view as that of a layman who has become interested in the subject and who has, as in this in stance, had a vast amount of experience over a number of years in activities which have necessitated his making a complete and thorough analysis of this whole sub ject. T h e dental profession should, and I believe does, accord D r. Gies its grate ful acknowledgment for the splendid service he has rendered it. In a supplement to his report, he offers a substitute for state medicine. H e says, “T h is substitute would affect dentistry as one of the separately organized cooperat ing health service professions concerned.” I w ill quote only paragraph C, refer ring you to his report for a fuller ac quaintance with his careful analysis of the subject. State medicine would lose its appeal as a practical solution of the present economic diffi culties if the organized health service pro fessions in effective cooperation should meet the situation in harmony w ith their humani tarian purposes and in due recognition of exist ing economics in equality. T his they can do by systematically organizing and m aintaining institutions or groups to provide excellent pre ventive and clinical health service, at moder ate fees, specifically for patients having low 2. Gies, W . J . : Status of Dentistry, J . D. Res., 12:945 (Dec.) 1932.
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incomes. Such institutions or groups should be established under professional auspices only; if, where, when and as community needs would determine. Public spirited lay men would certainly cooperate in founding and m aintaining these health service agencies.
N ow if public spirited laymen w ould cooperate to a sufficient degree to provide universal health service agencies, and if the professions, at the same time, did their part, we would hear no more of state dentistry. W h en I read D r. Gies’ enthusiastic re port, and Colonel M essner’s thoughtful paper,3 I feel th at they w ill do so and th at the professions w ill correspondingly cooperate, but when I think of the diffi culty encountered by all agencies created as beneficent institutions, but which de pend on private endowments for support and maintenance, I am again throw n into doubt. O ne thing is sure, universal health service there w ill be, and in either case it behooves the professions concerned to take a prominent and influential part in its inception and organization. I t will be much easier if the proposal for uni versal health service comes from the pro fessions rather than from the public. As D r. Gies very tru ly remarks, “ If the professions concerned do not provide a wider health service the public in des peration w ill cast about for means to provide it themselves.” T h e politician w ill inevitably get into the game and state health service w ill undoubtedly be the result. If state health service is launched under the guidance and super vision of the professions, it may be done w ith no more, and probably less, of the pernicious political influence than has in varying degrees characterized state edu cation. H ad it not been for the long period of business and financial depres sion through which we have been pass ing, this question of universal health
service would have been in the first ex perimental stages. As we emerge from the depression, as we surely will, its pressing nature as a public need w ill again bring it rapidly to the front, and the profession should be prepared, at that time, to offer a rational plan whereby there can be instituted the beginnings of such a service, which may grow, in time, to cover the field as thoroughly as does universal education today. T h e enormous expense of universal education has come in for considerable criticism, and w ill prove to be one of the deterring influences delaying universal health service; and although I may be accused of taking a reactionary stand, I believe that enough money is wasted each year in attempting to educate, beyond a reasonable point, those who by nature can never assimilate such knowledge to prac tically pay for necessary health service. T h is naturally brings us back to a con sideration of the cost of education as com pared w ith the cost of health service. A few figures relating to the cost of free education may not be out of place. T o quote again from the paper1 before re ferred to:
A rough estimate of the time required for dental treatment,- including orthodontia, for the average child is fifteen hours a year. Add to this all the forms of treatment the child might require and it will amount to probably not over twenty-five hours a year. Now if that is actually the case and yet the child is provided w ith 1,200 or more hours of service per year in the educational field, does it not seem absurd that he should not have the twenty or thirty hours required for the care of the body? Much of the plant needed for this service already exists in the elaborate school buildings, and equipment, which in Baltimore (one city w ith which I am fam iliar) repre sents an outlay per pupil of $377.54. These buildings can provide the required space, without further expense, except for some spe cial equipment for giving practically all treatment, except that for which the patient 3. Messner, C. T . : Dentistry in Public must go to the hospital, or remain in bed at Health, J.A.D.A., 17:2313 (Dec.) 1930. home.
K e lse y — Pla&e of O rth o d o n tia in W id e r H e a lth Service No doubt there will be much objection in some quarters to supplying free medical and dental service, but I am told there was just the same objection raised to the supplying of free educational service. M y feeling is that some of the opposition that is expressed by dentists to universal free health service is based upon fear. In connection with that, I wish to say that it seems to me that universal service, supplied by the State, would be as great a boon to the professions as it would to the laity. All men of outstanding ability would continue to attract to themselves a clientele who would prefer to go to them, rather than to the more promiscuous public clinics, because they are fortunate enough to have the means to pay for the more exclusive service, so that, the private practitioner would be analogous to the teacher in the private school of today, and he would be relieved from the great burden of supplying much free service that ought, by right, to be paid for by the State. Those men who have ability, but do not succeed well today, would be much better off if employed by the State. T heir income would be much more secure and would be even larger. T he opportunity for research, on the part of both the public clinic practitioner and the private practitioner, would be immensely enhanced, and the private practitioner could w ith a good conscience refer those people who sought his services but could not pay the fees he felt justified in charging, to the service sup plied by the State, which should be just as thorough and painstaking as his own. I t is believed by many that the teaching supplied by the public schools of today is quite equal to and in many instances superior to that supplied by private schools; yet, in spite of this, there is now and probably always will be a demand for the private school, just as there will be if free health service is inaugurated, a demand for the private practitioner. The danger, of course, in establishing free health service lies in the possibility of pro ducing a large number of ill-equipped prac titioners and here again it is up to the pro fession to see that the large number of dentists which will be required when and if this thing comes to pass measures up to the standards which have already been made.
Nevertheless, if the welfare of the pub lic demands free health service, and if this should completely extinguish 'the present private health service, we must believe, if we are honest in our state
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ments, th at it would be for the general good, even if worse for us. In other words, we are practicing a profession which has been established in answer to a public need. W e have not created a ficti tious demand for something which we have to supply. T h e need or demand has been there all the time, and in spite of preventive measures, w ill be there for a long time to come. T o meet this need adequately, the num ber of our profession w ill have to be greatly augmented; that is, to meet it in a universal way, and this may be the next great problem which we w ill have to re spond to. G ranting, then, that universal health service is realized, whether it be through the intervention of the state or through endowments by th at w ealthy portion of the population who may become suffi ciently interested to provide the means for its establishment, we are brought to the final proposition indicated in the title: “T h e Place O rthodontia W ill Occupy in It.” As I have said, “ D ental service, and especially orthodontic service as it has been conducted in the past, cannot be given as cheaply as can some other forms of health service, but under more ideal conditions where all children are under observation from infancy so many maloc clusions can be prevented as to greatly reduce the amount of time and work which would have to be given to this particular phase of the service.” A thor ough study of the writings of D r. W ille tt4 4. W illett, R. C.: Children’s Dentistry from Orthodontist’s Point of View, Internat. J. Or thodontia, 17:552 (June) 1931. Improved Operative Technique for Deciduous Molars, D. Items Int., 53:489 (July) 1931. Coopera tion of Family Dentist in Mouth Hygiene Movement, J.A.D.A., 16:2151 (Nov.) 1929. Intercepting of Certain Types of Malocclusion, ibid., 16:389 (M arch) 1929. Radical De partures from Theories and Methods Pertain ing to Children’s Dentistry, ibid., 19:1085 (July) 1932.
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will convince anyone that if all children were brought under the care of men who understood as he does not only the impor tance but also the technic of heading off approaching malocclusion, the burden of the orthodontist would be greatly les sened. D r. W ille tt has called this work in the numerous papers which he has w ritten on the subject, “T h e interception of malocclusion” and I would advise any one at all interested in this subject to read carefully everything he has w ritten on i t ; for although there are others who have recently and at an earlier time w ritten ex cellent articles on this subject, there is no one th a t I know of who has treated it so exhaustively and followed up the technic of the principles upon which it is based as has D r. W illett. H is theories have all been put into practice, and he has demonstrated the feasibility of everything which he pro poses. M oreover, he has conducted most of his experimental work on a class of children who are the least promising as patients, believing that if he could ac complish his results in these cases, there would be no excuse for others more for tunately situated not securing similar benefits. Fundamentally, he believes that if the teeth and jaw s are maintained in a nor mal functional activity, development will take place along normal lines. W hile this theory has been held by many men, few, if any, have carried the technic out so thoroughly as he for bringing about and maintaining this condition. T h ere can be no doubt th at children receiving such service as this, in conjunction w ith all other health service, which of course, is just as im portant, would exhibit far fewer cases of malocclusion as they grow up, but none of us believe th at prevention can be carried out 100 per cent; nor do I mean to imply th at D r. W ille tt does not
recognize th at there are other varied and often complex factors in the etiology of malocclusion. T h ere w ill still be malocclusion in spite of universal health service and our best efforts, but it is reasonable to suppose that the amount of malocclusion may be greatly reduced as well as the complexity of many of the cases, and therefore, there w ill be a diminution in the amount of time required for their treatm ent. T h e other possible factor in lessening the bur den of orthodontic treatm ent is the in crease in our knowledge of the etiology of malocclusion, and, of course, w ith this, the possibility of a more exact diagnosis than we have hitherto been able to make. T hus, we may be able to determine ac curately the individual developmental possibilities of a case at the time we are confronted with it for treatm ent, saving thereby a great waste of time and effort. D uring the last ten years, a great num ber of diagnostic methods have been pre sented to the profession, from which we have hoped much, but so far not one of them has made it possible for us to diag nose a case w ith such certainty and accu racy th at we feel justified in pursuing a radical course at the outset. I t is our hope th a t this goal w ill be reached in time. I t would be ideal if we could say of an individual case: T his child’s den tal arches and supporting bony struc tures will never develop sufficiently to contain the thirty-two teeth which have been provided for it and, therefore, at the most suitable age, one or more of the pre molar teeth must be removed; this pro cedure to be followed, of course, by ade quate orthodontic treatm en t; but we have not yet travelled so far as this along the diagnostic road. I n a paper read before the M aryland State D ental Association several years
Kelsey— Place of O rthodontia in W ider H ealth Service ago, I 5 expressed my convictions w ith re gard to the extraction of teeth as a pro cedure in orthodontic treatm ent, and in spite of the vast amount of study by many able men which has been given to the subject of etiology and diagnosis since th at time, I find myself unable to change my views w ith regard to all those cases which have still before them the strong possibility of developmental changes, cases in which there is at least a portion of the temporary dentition still present, and cases even a year or tw o after the deciduous teeth have been lost and their successors have taken their places. M y opinion at that time was, and it still is, th at only after an honest effort had been made to reduce a case of malocclusion and bring about a normal relation of the teeth to each other, and all means to th at end had been exhausted and proved a failure, was it justifiable to resort to extraction. T h e reason for this is th at of two cases presenting an identical malocclusion, one w ill yield quite readily to orthodontic treatm ent and a normal occlusion of the teeth and relationship of one dental arch to the other can be secured, while the other, in spite of our best efforts, w ill tu rn out a failure. W e must still give the benefit of the doubt to both cases, and only resort to extraction when we have demonstrated experimentally th a t suffi cient development cannot be secured to make room for all of the thirty-tw o teeth in the dental arches, or th at a mesiodistal malrelation of the dental arches cannot be corrected along ideal lines. A fter the sixteenth year, the experienced orthodontist should be able to determine, in order not to waste his patient’s and
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his own time, w hether treatm ent along ideal lines may be successful, and if he decides that it w ill not, he should then have the courage to adopt a compromise treatm ent, removing a tooth or teeth if necessary. A t the inception of a universal health service, there would undoubtedly be a vast number of such cases which would be presented for treatm ent and decisions based upon wide experience would greatly curtail the time and energy needed to meet the situation. T h e danger in ever advocating extrac tion as an orthodontic measure is that so many general practitioners are apt to ac cept such advocacy as a justification for extraction in all cases which come under their observation. O n the contrary, it is not a justifica tion, and no one who has not had a broad orthodontic experience has any right to extract a tooth as an orthodontic meas ure w ithout securing the opinion of some one who has; for if he pursues such a practice, he w ill inevitably do immeasur able h arm ; first, because his lack of ex perience w ill not enable him to differen tiate between those cases which really call for extraction and those which are capable of being restored by good ortho- • dontic treatm ent to normal occlusion, and, secondly, because where extraction is indicated, it must still, w ith rare excep tions, be accompanied by intelligent or thodontic treatm ent. T o merely extract, w ithout being able to give the indicated orthodontic treatm ent also, w ill usually only aggravate the malocclusion, except, of course, in some very rare cases, the dis cussion of which is out of place here. In 5. Kelsey, H. E.: Consideration of Funda the w ider health service, then, which I mental Principles Underlying Classification believe to be impending, there is un and Diagnosis, and Some Factors or Conditions doubtedly a need and a place for ortho W hich If Observed in T im e M ay by Proper dontia, but it must for reasons already Advice A vert Impending Malocclusion or In sure Treatm ent at Most Favorable Age. (U n stated be under the supervision of the orthodontist. H is work and the work of published data.)
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the general practitioner w ill meet in the field of prevention and interception. T h e intelligent cooperation of all the special ties w ith the general practice of dentistry can, through painstaking and tireless ef fort, meet in a practical manner the den tal phases of a universal health service, and I believe at a cost which w ill not be out of proportion to the advantages which it w ill bestow. O f course, the figures here given as to the cost of education apply only to that portion of the population who are in the free public schools. I t w ill be argued th at free health service would involve the entire population and would, therefore, be in demand by four or five times as many individuals; but this is not so seri ous as it seems at first when it is con sidered th a t each of these individuals does not have all the various ills nor does each one go through the same almost continu ous regime as do pupils in the schools. Furtherm ore, the number who would apply for free health service would be greatly diminished by th at large class who would still prefer to have the more ex clusive private service and also by that class, th a t fairly large and fortunate class I may say, who remain w ell most or all • of the time. T h a t the public generally is becoming interested in orthodontia is manifest by the rapidly increasing num ber of applications for such service in the various clinics and at the college infirm aries. I am told by those in charge of the orthodontic departm ent in some of the colleges th a t the applications far outrun the capacity of the departm ent to take care of the cases and there is an increas ingly long w aiting list. T h is has also been my experience in the orthodontic di vision of the dental clinic at the Johns Hopkins Hospital. W hile this demand is due partly to the unfortunate financial situation of the present time, it reflects in a general way the appreciation which
the public has acquired for orthodontic service. I t is also significant th at many people of small means deny themselves much in order to give this treatm ent to their children. T h e need is obvious, and the results have been, in a general way (a t least in the eyes of the laity), suffi ciently successful to excite this constantly increasing demand for it. T o those associated w ith any public clinic or college infirmary, it is actually distressing to note the keen competition which exists among patrons to secure for their children the benefit of this service. I t seems th at almost all people, if not the entire public, have become aware of the need for orthodontic treatm ent where malocclusion exists and have learned th at there is such a service, which can be had if they can pay for it, and sometimes may be had in clinics at a more moderate charge. I t is also significant th a t there are often brought to the orthodontist for treatm ent children whose mouths have been seriously neglected in other respects, doubtless because the need for orthodon tic treatm ent was so much more obvious to the parents than was the need for re parative work such as fillings, for which they often w ait until the child is suffer ing, a most unfortunate phase of the sit uation. In a paper read before the meeting of the American Society of O rthodontists at T oronto, in M ay, 1932, Abram Hoff man6 referred to this subject. I quote : T he first step has been to discover the den tal health need of the public from the view point of the layman. Five hundred question naire forms were sent to persons residing in thirty-one states of the United States and eight provinces of Canada. These persons repre sented various vocations, and community in terests. T heir replies give interesting indica 6. Hoffman, A bram : W hat M ay Be Con sidered Rational Methods in Orthodontic Therapy, Internat. J. Orthodontia, 19:233 (M arch) 1933.
K else y— Place of O rth o d o n tia in W i d e r H e a lth Service tions of the conception of the health needs for which the dentist should render service (and please note this) that third in their list of needs is treatment of irregularities of the teeth. These laymen were also asked to indicate which dental health need, in their opinion, the dental profession fails to meet adequately, and here in the fourth position we find the treat ment of irregularities of the teeth.
I t is evident, then, that orthodontia will necessarily have an im portant place in the dental division of universal health service, when that greatly to be desired boon to humanity has been realized, and it is my conviction that as the country returns to normality in a financial way, the public will energetically support some method for bringing it about. If the method be a good one and under the supervision of the professions concerned, so much the b e tte r; but if they, the pro fessions, have nothing to offer, or rather if they do not take the initiative, it w ill undoubtedly be taken by someone else, possibly by those of political aspirations, who rarely fail to recognize an oppor tunity. I t is not reasonable to suppose that universal health service can be estab lished as an entirely new departm ent of government, supported by entirely new taxation. As stated before, we have probably gone too far w ith free education, and some of the money that we are spending in th at department may very well take care of a new departm ent of health service. I often think of w hat a very intelligent mother of three or four children who were patients of mine said to me when speaking of the difficulty of having chil dren keep all of the multifarious engage ments necessary to their education, and of visits to all of the various doctors who looked after their health. H er words were, “ I am determined th at my chil dren shall grow up w ith healthy bodies even if they do not know a thing” ; and
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she was one of the most cooperative par ents w ith whom I have dealt in a long experience. Those engagements which concerned the health of her children she regarded as of first importance, although she by no means underestimated the value of edu cation, and these children all went to the best private schools and got their lan guages from their governess and tu to r in addition. T h is woman’s attitude toward her children, if adopted by the government tow ard individuals, might well be termed governmental paternalism, something which in a broad sense is as objectionable to me as it can possibly be to anyone. Nevertheless, in matters of health, it is already conceded by practically everyone that the government should interfere w ith the personal liberty of the individual in order to protect the welfare of the public generally, as witness the govern m ental supervision of those individuals who have contracted some contagious disease. Such supervision does not yet extend to a great many communicable diseases which are in fact today much more seri ous than is smallpox (which is under governmental supervision), because, while they may not be so deadly, they are yet doing vastly more harm than smallpox, simply because they are not under super vision. T h e social, or so-called social, dis eases stand, of course, at the head of any such list. I have a sympathetic feeling for the person who objects to being forced to submit to vaccination for smallpox, not w ithstanding the fact that I believe that it is perfectly right and proper th at he should submit to it. I resent and always w ill resent govern m ental interference w ith my behavior as an individual which in no way affects the w elfare of those around me. T here are
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people who believe that it is quite justifi able for the government to interfere w ith our personal behavior even though that behavior only endangers our own per sonal w elfare and carries no menace to those about us. W e are only ju st recovering from one such experiment. Universal free health service could not be objected to by any one, save on economic grounds. .Com pulsory health service will undoubtedly
meet w ith very serious opposition, as it always has, even when exercised purely as a protection to the public. Nevertheless, after a thoughtful anal ysis of the subject, to me at least the con viction is inescapable that it would have benefits for the race as a whole (benefits which are now enjoyed by our domestic animals only) entirely outweighing its objectionable features. 833 Park Avenue.
FLEXURE FATIGUE STUDIES OF CAST DENTAL GOLD ALLOYS* By FLOYD A . P E Y T O N , D.Sc., A n n A rb o r, M ich.
S IN C E there are such varied demands on the structures used in reconstruc tion in dentistry, the development of suitable alloys is a complicated prob lem. T h e extreme limitations on the size of the structures, the severe stresses that are applied and the varied chemical prob lems involved in a consideration of the saliva, products of decomposition and food products furnish a variety of prob lems in dental alloy construction rarely equaled in any other branch of m etal lurgy. In some instances, structures are re quired which are fixed firmly in place by cements, w ith no flexure and no movement of the structure. In such cases, the m atter of strength is less im portant than is some others. A certain degree of strength w ith a high degree of ductility, which w ill permit the finishing *From a portion of a dissertation submitted to the G raduate School of the U niversity of Michigan, in partial fulfilment of the require ments for the degree of doctor of science. Jour. A .D .A ., March, 1934
of a tight margin, are most desirable properties. In other cases, if the piece is removable and therefore subjected to the hazard of fracture from falling and to a high degree of stress in the mouth, it cannot be malleable or ductile to the same degree as some metals and alloys used for other dental reconstruction pur poses. In such cases, the highest possible degree of strength w ith a high flexure fatigue limit are the properties most de sirable. In certain other cases in the mouth, if there is not proper care, struc tures which are used are subjected to processes of the most extreme discolora tion and disintegration by saliva, food and products of fermentation. These are only a few examples of many which could be mentioned to show the extremely intricate nature pf the production of dental alloys that meet all the needs of dental practice. In no case have the uncombined metals been suitable for this purpose. Gold, plat inum and palladium are the only metals