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" THE TEETH OF THE NATION ARE ROTTEN "
386
SPECIAL ARTICLES " THE
TEETH
OF THE NATION ROTTEN "
ARE
THE Minister of Health is informing the public that caries has the nation in its grip. Last year, in opening the Public Health Services Congress, he said, " The teeth of this country are bad. You might almost say the teeth of this country are rotten." A few weeks ago he repeated his grave statement. In his presidential address to the British Dental Association1 on Aug. 1, Mr. T. R. D. Walkinshaw took up the tale from the association’s point of view. The problem, he admitted, was a very real one, but the blame must really be laid on our half-hearted public dental-health service. The body, if out of the care of the panel doctor for a year or so, does not inevitably decay. With the teeth, on the other hand, this unhappily seems to be the case. A dental service, to be of any value at all, must be continuous. Otherwise, in a couple of years away from the dentist, the value of hours of previous careful conservative labour is lost. Officialdom has always been loth to admit that the nation has teeth which need caring for. Forty years ago, Mr. Walkinshaw said, at the outbreak of the Boer War, there was not a dentist in the whole of the British army. In the B.D.A.’s museum is a letter from the War Office replying to the late Captain A. F. A. Howe’s offer of his services as a dentist to the troops in South Africa ;9 in it the War Office stated that it was not necessary to send a dental officer to the front. Yet it is on record that 2450 men were invalided home as unfit for further service, on account of dental disability, and that another 4500 were admitted to hospital and were later returned to nominal duty "to be kept within reach of soft food." Inspection of the mouths of one draft of soldiers revealed a serious condition of their teeth, and instead of the obvious remedy-dental treatment-the War Office gave orders for the immediate supply of mincing machines ! Two large-size machines per company were therefore sent up from the base ! It was some time after the end of the war that a feeble attempt to deal with the matter was made by the appointment of 9 dental surgeons, but, for economy, even this puny attempt at a dental service for the Forces was discontinued. At the outbreak of the Great War the British army was again without a dental surgeon. Eventually dentists were given temporary commissions in the R.A.M.C., and Mr, Walkinshaw congratulated the B.D.A. on its persistent efforts, which resulted in the establishment after the war of the Navy, Army and Air Force dental branches. Unfortunately their conditions of service leave much to be desired and the number of recruits and trained men per dental officer is too high to permit of the maximum efficiency being achieved. THE TEETH OF CHILDREN
The school dental service
started in 1908, 900 whole- and partyet time school dentists, the dental condition of many school-children is little better than before. Most school dental schemes are so seriously understaffed that there is little time for thorough conservative work and less for educative work. It is not the technical standard of the school dental service which is at fault, but the rushed conditions make now,
although there
was
are over
1. Brit. dent. J
1939, 67, 115.
true preventive service number of dentists in the school dental service was one for 6000 children, although the Board of Education suggests a ratio of one to 5000 children in urban areas and one to 4000 in rural. The B.D.A., however, holds that to ensure complete treatment there should be one dental surgeon to every 2500 children. Cambridge has one dentist per 2250 children ; Croydon one per 5700 children ; and another area one per 7000 children. In Cambridge practically every child was examined, 75 per cent. needed treatment, and all but 2 per cent. In Croydon 13 per cent. were not received it. examined, and of those who were 75 per cent. needed treatment which more than half of them never received. In the unnamed area only 41 per cent. were examined and of these, strange to say, less than half were said to need treatment. This absurdly low figure is no doubt due partly to the shortage of staff and possibly to a lower standard of inspection being adopted in an effort to deal with the whole school population. In 1937 there were over 4 million school-children in England and Wales. About 31 million were dentally inspected, and of these approximately 2 million required treatment, but only It million received it, so that about 1 million went untreated. Assuming that of the 1 million who were not inspected the same proportion required treatment, then about 14 million who needed dental treatment did not receive it. Every year about 2t million temporary teeth and more than half a million unsavable permanent teeth have to be extracted at school dental clinics. The present service is now costing the country about Sl.000,000 per annum. To provide a complete school dental service on the present system it would apparently be necessary to spend twice this sum.
anything approaching a impossible. Last year the
EARLY PREVENTIVE TREATMENT
Unfortunately the whole structure of the Board of Education’s school dental treatment scheme, Mr. Walkinshaw thought, is built on a foundation of sand. Immunity from dental disease can only be obtained by early preventive treatment. The effort must begin by attention to the health of expectant and nursing mothers, and the teeth of children under school age. The 1918 Maternity and Child Welfare Act provides that a local authority may-not shallmake arrangements for attending to the health of expectant and nursing mothers, and children who have not attained 5 years of age. There are no statistics showing the number of authorities giving dental treatment for expectant and nursing mothers and young children, although steps are being taken by the Ministry of Health to require local authorities to submit details. In the north of England at least, provision of dental treatment for mothers and children is conspicuous by its inadequacy or entire absence. Until the problem of the pre-school child’s dental health is tackled, the dental treatment in the school services will be handicapped and retarded. If the pre-school child received dental attention, the school dental officer’s work would become more effective and gross irregularities due to early loss of deciduous teeth would be greatly reduced. The average child entering school has teeth in an appalling condition, so that during the first few years of school life the time devoted to dental treatment is largely taken up with removal of septic temporary molars. Besides the failure to provide adequate dental treatment in nursery schools there is the failure to provide dental treatment during adolescence in the gap
387 age and entry upon insurance At its least the gap appears to be two and a half years, and in some approved societies dental* letters are certainly not issued to members until they have been contributors for five years. In such circumstances a child leaving school at 14 is not eligible for dental benefit for seven years. Adolescence is known to every practising dentist as the age when dental caries is most active, and when periodic attention to the teeth is more necessary than during any other period of life. The recent Juvenile Contributors’ Act provides that a child at the age of 14 or more years, on entering an insurable occupation, shall at once be entitled to statutory medical benefit, but so far no provision has been made to include dental treatment, although on the second reading the Minister undertook to examinee the possibility of reducing the waiting period to one year. Anything, said Mr. Walkinshaw, more wasteful than the institution of a system of dental treatment given throughout the school life and then allowed to drop entirely during the period of adolescence would be difficult to imagine. The net result of all this is that when the ex-school child has reached maturity the conservative work of the school service is entirely nullified and the money spent by the state largely wasted. Those who examine the teeth of recruits to the Navy, Army and Air Force today say that what they see makes it difficult to believe a school dental service has been in existence for thirty years ; it is rare to find any evidence that these men have ever received dental attention.
between
school-leaving
benefit.
A BREAKDOWN SERVICE
Dental benefit under National Health Insurance has the unenviable title of a breakdown service. As an additional benefit, it is dependent upon the existence of a surplus. Approved societies having a large sickness claim have little surplus, and the very people who need dental treatment most cannot get it The vast majority of societies offer as a benefit. only 50 per cent., leaving the insured person to pay the balance-often a difficulty for the adult wageearner, and an impossibility for the insured adolescent. Unlike medical benefit, it is not statutory, and dental benefit is sought only on medical advice or for the relief of pain. Further, there is no regular inspection and treatment, and the approved societies often raise difficulties when insured persons apply frequently for dental letters. Prophylactic and conservative treatment is discouraged, and it is estimated that over 80 per cent. of the annual expenditure on dental benefit under the N.H.I. Act is represented by the cost of extractions and dentures. This costs the nation about f:2,000,000 per annum, apart from the proportion paid by the patients themselves, and achieves, said Mr. Walkinshaw, nothing as a contribution to health and fitness in the young men and women of the nation, who will be the parents of the next generation. If the " teeth of the nation are rotten," then no-one should be better aware of that fact than the Minister of Health, whose department, in conjunction with the Board of Education, must share the responsibility of their failure to exercise the wide powers both possess.
KITCHENER SCHOOL OF MEDICINE, KHARTOUM AT the request of the committee of management of the English Conjoint Board, Sir Alfred WebbJohnson visited the Kitchener School of Medicine at Khartoum during the final examinations in January, 1939. In his report he stated that, in addition to the care of the sick, the Sudan Medical Department shoulders the responsibility not only of controlling endemic and epidemic infective diseases but also of guarding against importation of infections from across the frontiers. Perpetual war is waged against the insect vectors of infecting agents, and the’keenest vigilance is exercised over the steady stream of aircraft which-bring distant countries within a few hours’ journey of the Sudan. These considerations influence the teaching in the,medical school; they lead to a close link between therapeutic and preventive medicine. The doctors are supplemented by a host of subsidiary officers working in native villages where, for economic, social and psychological reasons, no qualified medical man could be expected to live. In dispensaries and dressing-stations these subsidiary officers, who have had considerable training as hospital orderlies and have passed a special examination, act as outposts for the treatment of minor ailments and as scouts to give warning of suspected infection. Inspection of these units, which are all based on general hospitals, showed the system to be satisfactory and effective, and definitely preferable to peripatetic mobile units paying occasional visits to various districts. EDUCATION AND EXAMINATIONS
Last year it was arranged for the first time for the pupils of Gordon College to enter for the Cambridge School Certificate. Slight modifications were very sensibly made to meet local conditions. Arabic took the place of English as the native tongue, and English was counted as a foreign language and was made an obligatory subject. Of the 22 pupils entered for the examination 20 gained the certificate, and 16 reached matriculation standard. The students for the medical school are selected from among the most successful pupils of Gordon College; they are given their medical education without charge; they have to live in a students’ hostel for which again no charge is made ; and they are given an allowance of £ E 1 per month. Inefficient students are weeded out in the preliminary and intermediate parts of their training. The new students admitted in any one year are never allowed to exceed ten in number. The original objective was to reinforce the Sudan Medical Service by about six newly qualified doctors each year. At present about half this number is attained. The limitation of numbers leads to a high standard of individual tuition. The students work very hard, and never require any stimulating - own the contrary, the Registrar has to insist on a less serious concentration on reading. THE FINAL EXAMINATION AND THE POSTGRADUATE
It
THE number of inquests held by coroners in the county of London continues to decrease, and the L.C.C. consider that the number of coroners’ districts should be reduced from six to five. The coroners of London agree with this view. If the Secretary of State approves, the existing central and the southern districts will disappear, and a The new new south-western district will be created. arrangement will save about f:1700 a year in salaries.
unique experience for an examiner to find candidates taking all three clinical subjects at one time, only one failed to obtain a pass mark and then only in one part of the examinawas a
that, of
seven
tion. The pass mark was 60 per cent. and the standard was severe. There is no clinical examination in obstetrics, but this will be arranged for at the next examination. The papers were very legibly
SPECIAL ARTICLES " THE
TEETH
OF THE NATION ROTTEN "
ARE
THE Minister of Health is informing the public that caries has the nation in its grip. Last year, in opening the Public Health Services Congress, he said, " The teeth of this country are bad. You might almost say the teeth of this country are rotten." A few weeks ago he repeated his grave statement. In his presidential address to the British Dental Association1 on Aug. 1, Mr. T. R. D. Walkinshaw took up the tale from the association’s point of view. The problem, he admitted, was a very real one, but the blame must really be laid on our half-hearted public dental-health service. The body, if out of the care of the panel doctor for a year or so, does not inevitably decay. With the teeth, on the other hand, this unhappily seems to be the case. A dental service, to be of any value at all, must be continuous. Otherwise, in a couple of years away from the dentist, the value of hours of previous careful conservative labour is lost. Officialdom has always been loth to admit that the nation has teeth which need caring for. Forty years ago, Mr. Walkinshaw said, at the outbreak of the Boer War, there was not a dentist in the whole of the British army. In the B.D.A.’s museum is a letter from the War Office replying to the late Captain A. F. A. Howe’s offer of his services as a dentist to the troops in South Africa ;9 in it the War Office stated that it was not necessary to send a dental officer to the front. Yet it is on record that 2450 men were invalided home as unfit for further service, on account of dental disability, and that another 4500 were admitted to hospital and were later returned to nominal duty "to be kept within reach of soft food." Inspection of the mouths of one draft of soldiers revealed a serious condition of their teeth, and instead of the obvious remedy-dental treatment-the War Office gave orders for the immediate supply of mincing machines ! Two large-size machines per company were therefore sent up from the base ! It was some time after the end of the war that a feeble attempt to deal with the matter was made by the appointment of 9 dental surgeons, but, for economy, even this puny attempt at a dental service for the Forces was discontinued. At the outbreak of the Great War the British army was again without a dental surgeon. Eventually dentists were given temporary commissions in the R.A.M.C., and Mr, Walkinshaw congratulated the B.D.A. on its persistent efforts, which resulted in the establishment after the war of the Navy, Army and Air Force dental branches. Unfortunately their conditions of service leave much to be desired and the number of recruits and trained men per dental officer is too high to permit of the maximum efficiency being achieved. THE TEETH OF CHILDREN
The school dental service
started in 1908, 900 whole- and partyet time school dentists, the dental condition of many school-children is little better than before. Most school dental schemes are so seriously understaffed that there is little time for thorough conservative work and less for educative work. It is not the technical standard of the school dental service which is at fault, but the rushed conditions make now,
although there
was
are over
1. Brit. dent. J
1939, 67, 115.
true preventive service number of dentists in the school dental service was one for 6000 children, although the Board of Education suggests a ratio of one to 5000 children in urban areas and one to 4000 in rural. The B.D.A., however, holds that to ensure complete treatment there should be one dental surgeon to every 2500 children. Cambridge has one dentist per 2250 children ; Croydon one per 5700 children ; and another area one per 7000 children. In Cambridge practically every child was examined, 75 per cent. needed treatment, and all but 2 per cent. In Croydon 13 per cent. were not received it. examined, and of those who were 75 per cent. needed treatment which more than half of them never received. In the unnamed area only 41 per cent. were examined and of these, strange to say, less than half were said to need treatment. This absurdly low figure is no doubt due partly to the shortage of staff and possibly to a lower standard of inspection being adopted in an effort to deal with the whole school population. In 1937 there were over 4 million school-children in England and Wales. About 31 million were dentally inspected, and of these approximately 2 million required treatment, but only It million received it, so that about 1 million went untreated. Assuming that of the 1 million who were not inspected the same proportion required treatment, then about 14 million who needed dental treatment did not receive it. Every year about 2t million temporary teeth and more than half a million unsavable permanent teeth have to be extracted at school dental clinics. The present service is now costing the country about Sl.000,000 per annum. To provide a complete school dental service on the present system it would apparently be necessary to spend twice this sum.
anything approaching a impossible. Last year the
EARLY PREVENTIVE TREATMENT
Unfortunately the whole structure of the Board of Education’s school dental treatment scheme, Mr. Walkinshaw thought, is built on a foundation of sand. Immunity from dental disease can only be obtained by early preventive treatment. The effort must begin by attention to the health of expectant and nursing mothers, and the teeth of children under school age. The 1918 Maternity and Child Welfare Act provides that a local authority may-not shallmake arrangements for attending to the health of expectant and nursing mothers, and children who have not attained 5 years of age. There are no statistics showing the number of authorities giving dental treatment for expectant and nursing mothers and young children, although steps are being taken by the Ministry of Health to require local authorities to submit details. In the north of England at least, provision of dental treatment for mothers and children is conspicuous by its inadequacy or entire absence. Until the problem of the pre-school child’s dental health is tackled, the dental treatment in the school services will be handicapped and retarded. If the pre-school child received dental attention, the school dental officer’s work would become more effective and gross irregularities due to early loss of deciduous teeth would be greatly reduced. The average child entering school has teeth in an appalling condition, so that during the first few years of school life the time devoted to dental treatment is largely taken up with removal of septic temporary molars. Besides the failure to provide adequate dental treatment in nursery schools there is the failure to provide dental treatment during adolescence in the gap
387 age and entry upon insurance At its least the gap appears to be two and a half years, and in some approved societies dental* letters are certainly not issued to members until they have been contributors for five years. In such circumstances a child leaving school at 14 is not eligible for dental benefit for seven years. Adolescence is known to every practising dentist as the age when dental caries is most active, and when periodic attention to the teeth is more necessary than during any other period of life. The recent Juvenile Contributors’ Act provides that a child at the age of 14 or more years, on entering an insurable occupation, shall at once be entitled to statutory medical benefit, but so far no provision has been made to include dental treatment, although on the second reading the Minister undertook to examinee the possibility of reducing the waiting period to one year. Anything, said Mr. Walkinshaw, more wasteful than the institution of a system of dental treatment given throughout the school life and then allowed to drop entirely during the period of adolescence would be difficult to imagine. The net result of all this is that when the ex-school child has reached maturity the conservative work of the school service is entirely nullified and the money spent by the state largely wasted. Those who examine the teeth of recruits to the Navy, Army and Air Force today say that what they see makes it difficult to believe a school dental service has been in existence for thirty years ; it is rare to find any evidence that these men have ever received dental attention.
between
school-leaving
benefit.
A BREAKDOWN SERVICE
Dental benefit under National Health Insurance has the unenviable title of a breakdown service. As an additional benefit, it is dependent upon the existence of a surplus. Approved societies having a large sickness claim have little surplus, and the very people who need dental treatment most cannot get it The vast majority of societies offer as a benefit. only 50 per cent., leaving the insured person to pay the balance-often a difficulty for the adult wageearner, and an impossibility for the insured adolescent. Unlike medical benefit, it is not statutory, and dental benefit is sought only on medical advice or for the relief of pain. Further, there is no regular inspection and treatment, and the approved societies often raise difficulties when insured persons apply frequently for dental letters. Prophylactic and conservative treatment is discouraged, and it is estimated that over 80 per cent. of the annual expenditure on dental benefit under the N.H.I. Act is represented by the cost of extractions and dentures. This costs the nation about f:2,000,000 per annum, apart from the proportion paid by the patients themselves, and achieves, said Mr. Walkinshaw, nothing as a contribution to health and fitness in the young men and women of the nation, who will be the parents of the next generation. If the " teeth of the nation are rotten," then no-one should be better aware of that fact than the Minister of Health, whose department, in conjunction with the Board of Education, must share the responsibility of their failure to exercise the wide powers both possess.
KITCHENER SCHOOL OF MEDICINE, KHARTOUM AT the request of the committee of management of the English Conjoint Board, Sir Alfred WebbJohnson visited the Kitchener School of Medicine at Khartoum during the final examinations in January, 1939. In his report he stated that, in addition to the care of the sick, the Sudan Medical Department shoulders the responsibility not only of controlling endemic and epidemic infective diseases but also of guarding against importation of infections from across the frontiers. Perpetual war is waged against the insect vectors of infecting agents, and the’keenest vigilance is exercised over the steady stream of aircraft which-bring distant countries within a few hours’ journey of the Sudan. These considerations influence the teaching in the,medical school; they lead to a close link between therapeutic and preventive medicine. The doctors are supplemented by a host of subsidiary officers working in native villages where, for economic, social and psychological reasons, no qualified medical man could be expected to live. In dispensaries and dressing-stations these subsidiary officers, who have had considerable training as hospital orderlies and have passed a special examination, act as outposts for the treatment of minor ailments and as scouts to give warning of suspected infection. Inspection of these units, which are all based on general hospitals, showed the system to be satisfactory and effective, and definitely preferable to peripatetic mobile units paying occasional visits to various districts. EDUCATION AND EXAMINATIONS
Last year it was arranged for the first time for the pupils of Gordon College to enter for the Cambridge School Certificate. Slight modifications were very sensibly made to meet local conditions. Arabic took the place of English as the native tongue, and English was counted as a foreign language and was made an obligatory subject. Of the 22 pupils entered for the examination 20 gained the certificate, and 16 reached matriculation standard. The students for the medical school are selected from among the most successful pupils of Gordon College; they are given their medical education without charge; they have to live in a students’ hostel for which again no charge is made ; and they are given an allowance of £ E 1 per month. Inefficient students are weeded out in the preliminary and intermediate parts of their training. The new students admitted in any one year are never allowed to exceed ten in number. The original objective was to reinforce the Sudan Medical Service by about six newly qualified doctors each year. At present about half this number is attained. The limitation of numbers leads to a high standard of individual tuition. The students work very hard, and never require any stimulating - own the contrary, the Registrar has to insist on a less serious concentration on reading. THE FINAL EXAMINATION AND THE POSTGRADUATE
It
THE number of inquests held by coroners in the county of London continues to decrease, and the L.C.C. consider that the number of coroners’ districts should be reduced from six to five. The coroners of London agree with this view. If the Secretary of State approves, the existing central and the southern districts will disappear, and a The new new south-western district will be created. arrangement will save about f:1700 a year in salaries.
unique experience for an examiner to find candidates taking all three clinical subjects at one time, only one failed to obtain a pass mark and then only in one part of the examinawas a
that, of
seven
tion. The pass mark was 60 per cent. and the standard was severe. There is no clinical examination in obstetrics, but this will be arranged for at the next examination. The papers were very legibly