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Report of a demonstration dental care program for homebound chronically ill and aged patients
A method for making tooth and dental arch measurements
Inder Jit Singh, BDS, and Bhim Sen Savara, D M D , MS, Portland, Ore
In making prints of dental casts, often used in dentistry and anthropology, in vestigators found a X erox duplicating machine is easy to use and accurate. Conventional photography requires much equipment and complicated procedures. Surveyor instruments are tedious to use, imprecise and unsuitable for tooth measurements.
Dental casts and their photographs have been used widely in dentistry and an thropology for measuring tooth size and arch dimensions, and various instru ments, notably the dental pantograph1
and cubic craniophor,2 have been devised for reproducing the dental arch. Arch re productions from such instruments or photographic technics make it possible to relate arch form to a rectangular coordi nate system ; however, both methods have their limitations. For instance, conven tional photographic methods require elaborate equipment and factors of en largement, object-to-image distance, light ing and so forth, have to be considered.3 Arch reproductions from surveyor-type instruments are tedious, limited in preci sion and unsuitable for making tooth measurements. A new technic of making prints of den tal casts is recommended here for its sim
Left: Dental cast. R ight: Its Xerox print. Buccal cusp tips of first perm anent molars, cusp tips of cuspids and two points along palatal midline are marked with black instant lettering (Letraset) dots
48/720 • T H EJO U R N A L O FT H E A M E R IC A N DENTAL A SSO C IA TIO N
Table • Errors of measurements (tested by repeat measurements) on dental casts, on Xerox prints and between dental casts and Xerox prints M ean* + standard deviation of the differences for measurements Variable
No. On dental casts
On Xerox prints
Between dental casts and Xerox prints
Arch length
10
0.08 ± 0.35
0.10 + 0.20
-
Intercuspid width
10
0.04 + 0.32
0.09 ± 0.20
- 0.10 ± 0.25
0.10 + 0.10
Intermolar width
10 -
0.04 ± 0.23
- 0.06 + 0.33
0.06 ± 0.20
*Mean differences in mm., tested by t statistic, were not significantly different at I per cent level of significance {degrees of freedom = 9).
plicity and accuracy. The dental cast is laid teeth down on the glass table of a Xerox duplicating and printing machine (M odel 914, manufactured by Xerox Corporation, New York) and reproduc tions obtained. Specific landmarks to be located are marked or shaded dark for better contrast. The illustration shows a photograph o f a dental cast and its Xerox print. Instant lettering (Letraset) black dots were used to locate buccal cusp tips o f first permanent molars, cusp tips of cuspids and two points along the palatal midline. T o standardize the technic, a Xerox print of a 25 by 20 cm. graph paper was made. Each millimeter division on the X erox print then was measured along both length and width and various angu lar measurements made to determine if any distortion or enlargement in any di mension was discernible. A 0.5 per cent enlargement in the 20-cm. distance along the width was found. On further analysis, it was observed that there was no en largement in the middle 10 cm. of the graph paper; the 5 cm. on each side had a maximum enlargement of 0.25 mm. each. Angular measurements showed similar errors in the peripheral 5 cm. on both sides along the width o f the graph paper. N o errors of magnification or distortion could be detected along the length of the paper. Considering the dimensions of most dental casts, a maximum enlargement of 0.2 mm. would be expected if the cast
were placed anywhere in the peripheral 5 cm. o f the glass plate of the Xerox ma chine. No enlargement should result if care were taken to place the cast in the middle 10 cm. The amount of error in the peripheral part will vary with each machine because of slight differences in focusing adjustments. It is found mainly in the peripheral part and along the width of the table rather than along the length because of the curved surface of the reflecting mirrors used in such ma chines. The error will be constant for the same machine, however, unless focusing adjustments are altered either directly on the machine or indirectly by moving the object more than an eighth inch away from the glass table. Accuracy of reproduction and meas urements was tested on ten dental casts, randomly selected from the records of the Child Study Clinic. Arch length (from the mesioincisal edge of left central in cisor to distobuccal cusp tip on left first permanent m olar), intercuspid width at cusp tips and intermolar width at disto buccal cusp tips of first permanent m o lars were measured. Duplicate measure ments were made on each cast independ ently. T w o Xerox prints were obtained for each cast, and the same measure ments obtained independently on each print. The table shows an analysis of measurement errors (mean difference and standard deviation of differences) between paired measurements on dental casts and Xerox prints. Errors between
S IN G H — SAVARA . . . VOLUME 6?, DECEMBER 1964 • 49/721
Xerox prints and dental casts also were tested and were not significantly different (table). This method of making meas urements from such prints is justified on the basis of the aforementioned analyses. In testing for measurement error, a duplicate set of reproductions eliminates possibilities of examiner bias and damage to cast. Tooth and arch measurements also can be made directly to 0.1-mm. accuracy by orienting the photograph or reproduction on an analog reader and decimal converter. As pointed out by Gam ,4 the use of automation in collec tion and analysis of data reduces work load and human error to a minimum. The simplicity of the procedure, its low cost and the fact that Xerox prints of four to five dental casts can be made on one sheet of paper, make it economical and timesaving. Letraset dots can be rubbed on and off the dental casts with great ease and with no damage to the cast.
This technic offers a simple, repro ducible and objective method for anthro pologic and genetic studies of tooth and arch dimensions, palatal and arch form or area or their application to orthodon tics, and it now is being used to investi gate interrelations of crowding or spacing of teeth to measures of arch and tooth dimensions. 611 South W est Campus Drive
This study was supported bv Grant HD 00157-05, National Institute of Child Health and Human Devel opment, National Institutes of Health, USPHS. From the Child Study Clinic, University of Oregon Dental School, Portland, Ore. 1. Stanton, F. L., Fish, G . D., and Ashley-Montagu, M. F. Description of three instruments for use in ortho dontic and cephalometric investigations, with some remarks on map construction. J . D. Res. 11:885 Dec. 1931. 2. Hayashi, Toshio. A mathematical analysis of the curve of dental arch. Bui. Tokyo Med. D. Univ. 3:175 Dec. 1956. 3. Speck, N. T. A longitudinal study of developmental changes in human lower dental arches. Angle Orthodont. 20:215 Oct. 1950. 4. Garn, S. M. Automation in anthropometry, Am. J . Phy. Anthropol. 20:387 Sept. 1962.
R espect • D onald K . W eilburg, the president of the class o f 1967 at the University o f Pennsyl vania School o f Dental M edicine, recently received a letter from the chairman of the medical school’ s department of anatomy that is self-explanatory: “ It was brought to my attention this morning, follow ing the funeral service for the cadavers used by the University of Pennsylvania during the past year, that the First Year Dental Class had contributed flowers and that you were in attendance as a representative and as President o f the First Year Class. Although I have not been involved in any way in the teaching o f dental students, I feel called upon as an anatomist to express m y pleasure and appreciation at this action of you and your class. I understand that this is the first time this has been done and it therefore represents, not a blind follow ing o f tradition, but a genuine act of thoughtfulness and respect to the deceased persons who were as truly your teachers as were the faculty."’ M edical W orld News, August 14, 1964.
Report of a demonstration dental care program for homebound chronically ill and aged patients
H. Barry Waldman,* DDS, M PH , Cleveland
The chief of dentistry at a Cleveland hos pital, Western Reserve University School of Dentistry, the Cleveland Dental So ciety and the Visiting Nurse Association of Cleveland cooperated to set up and operate a program of furnishing dental care to aged and ill homebound patients at their residences. Voluntary and public agencies referred patients who needed the care which was provided by the program and private practitioners. The United States Public Health Service provided funds through the Ohio State Depart ment of Health.
The dentist, because of his training, ex perience and the nature of his equip ment, has become closely associated with a fixed, circumscribed office setting. There, the dentist treats patients o f all ages and most physical conditions. Yet an ever-increasing population exists which the dentist is either unable to reach or o f which he is unaware. These people, because of age, chronic illness or physical disability, ordinarily are unable to come to the dental office or clinic. The almost total lack o f comprehensive treatment facilities for them in this country came under intensive study by
W A L D M A N . . .V O LU M E 69, DECEMBER 1964 • 51/723
the US Public Health Service in metro politan Kansas City during the late 1950’s.1,2 Under USPHS direction, a program was begun to provide dental care at the place of residence (using portable dental equipment) and at a dental clinic where the aged and chron ically ill were transported if medical status permitted. Using the experience gained from this program, the chief of dentistry at High land View Hospital, in cooperation with Western Reserve University School of Dentistry, the Cleveland Dental Society and the Visiting Nurse Association’s Home Care Program, developed a pro gram for providing comprehensive den tal care at the residences of chronically ill and aged people in Cleveland. An advisory committee, consisting of representatives of local and state volun tary and nonvoluntary agencies, was or ganized to help formulate further plans for the program. This demonstration program, begun in July, 1961,3 was financed by the US Public Health Service through the Ohio State Department of Health, the Visit ing Nurse Association, Western Reserve University School of Dentistry and, since July, 1963, the Cuyahoga County Chronic Illness Center. Western Reserve University and Highland View Hospital, with the cooperation of the Cleveland Dental Society, administered the pro gram. Highland View Hospital, the county hospital for treatment of the chronically ill, was the base of operation for the pro gram. P R O G R A M O B JE C T IV E S
The basic objectives of the program in cluded : (1) providing comprehensive dental services to homebound patients in the metropolitan Cleveland area; (2) orienting and training both the dental student and the private practitioner in providing dental services for the chroni cally ill and aged at the patient’s place
of residence, and (3) integrating the program with existing community health agency activities. Providing dental services to the homebound calls for identification of these pa tients. Because this demonstration was not designed to meet the dental needs of this entire population, the advisory com mittee decided not to spend much effort and money to develop extensive lists of homebound patients. The committee de cided to start providing dental services early in the program to those already known to need care and to find others as the program progressed. Since no prevalence study was avail able to locate and select program pa tients, referral procedures with the vari ous voluntary and nonvoluntary agencies were needed. This created a close work ing relationship with local agencies, one of the program’s important assets (Table 1 }Because the program involved pro viding services outside the dental office, equipment and procedures used in Kansas City were modified to meet the specific problems encountered by the Cleveland program.
Table 1 • Referrals Patient referrals by source
N o.
Nursing homes
180
Cleveland Home C a re Program
103
Multiple Sclerosis-Nutrition Research Study
48
Highland View Hospital
37
Visiting Nurse Association
32
Family
27
Dentists
22
Aid for Aged
19
Western Reserve University
8
Jewish Family Service
7
Physicians
6
Multiple Sclerosis Society
3
County W elfare
3
Others Total
14 509
52/724 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA TIO N
The Ritter standard portable unit (in cluding dental engine, suction, air pres sure and light) met the needs o f the program most adequately. The compact ness and relatively light weight (40 lb.) of the equipment permitted maneuvera bility and provided adequate operating room in smaller residences. For those procedures that did not re quire extensive equipment, such as den ture adjustments, a hand motor and a headlight were sufficient. Since most chronically ill patients are confined to wheelchairs, an aluminum bar and headrest were designed to at tach to wheelchairs, affording comfort to the patient and dentist. All small instru ments and supplies for the procedures to be performed during a day’s visits were carried in an aluminum carrying case. Available portable x-ray units were unsatisfactory for use in the home, pri marily because of weight and bulkiness. Roentgenograms were made, therefore, only when the patient was brought by ambulance to an outpatient service at a hospital. PR O G R A M
A CTIV ITIE S
• The lack of comprehensive local dental treatment facilities for the homebound population was almost com plete. The program’ s effort to provide a full range of dental services showed the community a feasible way to meet this need. The nature and extent of den tal services were consistent with the overall medical and physical status of the patient. This comprehensive approach to the dental needs of this population in cluded examination, prophylaxis, extrac tions, postoperative treatment, restora tions, prosthetic appliances (including complete and partial dentures), repair and relining of dentures, adjustments and maintenance on a recall basis. Services
Orienting Dental Students • The senior dental student orientation program was
closely associated with the program’ s service activities. This phase of a more comprehensive orientation program fa miliarized the student with the equip ment and philosophy of dental care for the homebound chronically ill and aged. Recent graduates of Western Reserve University School of Dentistry who re ceived this training did use program serv ices to provide dental care for their pri vate patients at the place of residence, showing their receptivity to the program. Orienting Private Practitioners • Realiz ing that only by including the private practitioner could the plan meet the needs of the homebound population, the program lent equipment, supplies, and made available the services of an assistant so the dentist could perform needed serv ices for his own patients. Association with Dental Society • T o suc
ceed, any dental program must have the support and cooperation of the local den tal society. The close association between the program and the Cleveland Dental Society was immeasurably valuable. The repeated requests for table clinics and sci entific exhibits, the mailing of program brochures, the Society’ s efforts to bring the program to public attention by ar ranging television and radio sessions all played their part in making the program a success. In addition, financial support by the Society for community edu cational purposes showed what a close working relationship can accomplish. Integration of Program with Com munity Health Activities
Existing
• More than 75 voluntary and governmental agencies have cooperated with the pro gram as have more than a third o f the nursing homes in the metropolitan Cleve land area. These endorsements, financial support and referral systems with local health and welfare agencies show the firm rela tionship that has developed between the program and the community since the
W A L D M A N . . . VO LUM E 69, DECEMBER 1964 • 53/725
program started (Table 1).
T a b le 2
• Examination data (recall examinations in
cluded) Examination data by age
O B S E R V A T IO N S
The efforts expended by the program at various dental society meetings and con ventions helped introduce the dental pro fession to the idea of providing dental care at home, using portable equipment and toned down much of the initial re luctance to provide care to the homebound patient. This reluctance stemmed from a com bination of several factors, including ( 1) the inability to “ spare the time,” (2) in sufficient compensation to warrant the effort, (3) belief that the work could not be performed adequately at the place of residence and (4) the inclination not to provide care because the patient was “ chronically ill.” Despite this reluctance 40 private practitioners (3.5 per cent of the local dental profession) provided dental care to 88 patients; they performed 363 pro cedures during 120 home visits. 1. More older practitioners partici pated in the program than did young ones. 2. The constant effort to reach the private practitioner succeeded when he was told that the program would work with him. 3. Some dentists were reluctant to participate in the program because they knew that it had “ governmental financial support.” This fear of “ creeping social ism” was met effectively by explaining that private practitioners’ efforts to fill the needs of the population would protect their province. Dentists have recognized the impor tance of auxiliary personnel in the dental office. The findings of the dental home care program emphasized the extremely important role of these persons in the success of such a program. T h e actual help the dental assistant gives during the service procedures was almost secondary to the many other fac ets o f work carried ou tNby the assistant.
Younger than 45 years N o. of patients Edentulous One or more teeth
45 to 64 65 years iind older years <
Total
76 7
108 31
245 128
429 166
69
77
117
263
52
65
153
270
18 1 5
35 8
47 10 35
100 11 48
Care needed Yes No
71 5
103 5
161 84
335 94
Family dentist Yes No
29 47
31 77
24 221
84 345
Ability to pay* Full Part None Agency
22 26 21 7
33 37 26 12
55 39 36 115
110 102 83 134
26 14 24
29 9 24
74 39 67
44
183
249
Amenable to treatment Maximum care Intermediate care Questionable Untreatable
Time since last appointment 0-1 year 19 16 1—2 years 2-4 years 19 More than 22 4 years
■"Services charges are based on Western Reserve Uni versity School of Dentistry's fee schedule for home care patients.
The coordinating of appointments; the preparation, set-up and breakdown of equipment in foreign environments; the psychological assurance given to patients; the recording of data, and public rela tions efforts were some of the aspects of the program handled by the assistant. The dental hygienist performed most prophylaxis procedures. Although a fur ther visit and evaluation by a dentist was required before specific treatment could be chosen, the information obtained dur ing the preliminary screening usually per mitted the dentist to prepare and per form dental procedures on his first visit. Because many homebound patients are confined to nursing homes,.the hygienists tried to orient the personnel of nursing homes to the specific dental health needs
54/726 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA T IO N
Table 3 • Number of patients for whom treatment was recommended by age and total number of procedures recommended Ages of patients Examination data
N o . patients examined Treatment recommendations:* N o . patients requiring restorations Total no. restorations needed b y patients N o . patients requiring extractions Total no. extractions needed by patients N o. patients requiring surgery N o . patients requiring prophylaxis N o. patients requiring other treatments N o . patients requiring prosthetics N o. patients requiring single complete denture N o. patients requiring two complete dentures N o. patients requiring single partial denture N o . patients requiring two partial dentures N o . patients requiring denture repair N o. patients requiring reline of one denture N o. patients requiring reline of two dentures N o . patients requiring denture adjustment
Younger than 45 years
Total
45 to 64 years
65 years and older
76
108
245
429
51
45
28
124
?72 17
152 29
72 60
396 106
121 5 56
113 8 66
256 7 71
490 20 193
1 31
1 42
4 75
6 148
5
11
11
27
4
10
27
41
13
15
7
35
6
8
3
17
1
6
18
25
4
6
12
22
2
4
18
24
1
8
12
21
*Of the 76 pa+îenfs younger than 45 years, 93% required treatment; 95% of the 108 patients 45 to 64 years old and 65% of the 245 patients 65 years old and older required treatment.
of their patients. The training and experi ence of the dental hygienist adequately met the requirements o f this task. The hygienist permitted the program dentists to spend more time on those procedures that required their training. F IN D IN G S
O f 429 patients examined, 164 lived in nursing homes and 265 lived in private homes. Patients referred but not exam ined were too ill, refused examination or were referred to private practitioners (Table 2 ).
State of the Dentition • As in previous dental studies, the loss of teeth was in di rect relation to the increase in age. The
edentulous state increased from 9 per cent to 29 per cent to 52 per cent in the progressive age groupings. Treatability • The majority of all pa tients examined were amenable to treat ment. Only a segment o f the older age bracket posed treatment problems. Most of these problem patients had vascular lesions of the central nervous system. Care Needed • Nearly all of the patients under 65 needed dental care (Table 3 ). This finding was anticipated because the majority of these patients had not re ceived dental care during the past two years. O f the patients 65 years old and older, 35 per cent required no dental care. A significant number of these were edentu
W A L D M A N . . . VO LUM E 69, DECEMBER 1964 • 55/727
Table 4
• Time and number of visits required for patients examined at place of residence
Private residence Younger than 45 years
45 to 64 years
65 years and older
Nursing home
Weighted average*
N o. of visits
4.7
5.5
3.5
1.2
4.5
Total time (hr.) f
7.5
8.4
5.0
2.3
6.6
Actual treatment time (hr.)
2.0
2.0
0.9
0.9
1.4
Percentage of total time for actual treatment
27
24
18
41
21
*Thi$ average is based on the total program population weighted according to age group: younger than 45, 17%; 45 to 64 years, 27%, and 65 and older, 56%, and percentage of exam ined patients requiring treatment: 93%, 95% and 65%. tIncluding treatment time, set-up and breakdown time = 17 minutes per visit and travel time = 53 minutes per visit.
lous and residents of nursing homes. Some of this group were thought not to require dental care because they were satisfied with their present status. Patients seen on recall visits required relatively minor maintenance care. Be sides the need for prophylaxis, only 0.6 restorations per patient examined were required, as well as minimal surgical
procedures and denture relines and re pairs. These findings showed that cumulative needs of the homebound population are far greater than maintenance needs. Repeated time-motion studies have shown the dental profession the need to reduce lost procedural time (Table 4 ). The time lost in traveling by the dentist
Table 5 • Treatment procedures performed per 100 persons examined by age N o. of procedures Procedure
Weighted average*
Younger than 45 years
45 to 44 years
65 years and older
Examination and screening
107
107
107
107
Restorations Amalgam Silicate
120 87
114 52
11 6
53 30
Extractions
105
97
57
77
Prophylaxis and periodontal treatment
106
93
30
60
21
13
6
11
8 6 6 6
6 8 6 3 13 7 7 91
2 11 5
4 11 5
I*
r*
Postoperative treatment Prostheses: One complete denture Two complete dentures One partial denture Two partial dentures Denture repairs One denture relined Two dentures relined Adjustments
2 2 38
18 5 6 65
9 5 6 70
*This average is based on the total program population weighted according to age group: younger than 45, 17%; 45 to 64 years, 27%, and 65 and older, 56%, and percentage of examined patients requiring treatment: 93%, 95% and 65%.
56/728 • T H E J O U R N A L O F T H E A M E R IC A N DENTAL A SSO C IA TIO N
Tab le 6 • Service costs for each patient examined at picce of residence by age (excluding administrative and overhead costs! Private residence Less than 45 years
45 to 64 years
65 years and older
Nursing home
Weighted averag e*
Personnel (dentist, hygienist & assistant) costs each visit $8.90/hr.
$14.35
$13.35
$12.45
$13.35
$13.35
Personnel costs per patient
$66.75
$74.75
$44.50
$20.50 f
$58.75 $ 6 .25î
Laboratory costs
$65.00
Service costs
*This average is based on the total program population weighted according to age group: younger than 45; 45 to 64 years, 27%, and 65 and older, 56%, and percentage of examined patients requiring treatment: 93%, 95% and 65%. |An average of three nursing home patients seen per visit reduced equipment and travel time by two thirds. JCosts not available by age or residence.
to the place of residence is a decided dis advantage. Geographic clustering o f pa tient visits and completing as many pro cedures as possible during a single home visit have reduced this lost service time. Because of the demonstration status of the program, extensive periods were spent refining and modifying equipment and technics, and in orienting and train ing program staff and private practition ers. Considerable time was required for public relations activities and educational efforts (Table 5 ). Actual service costs can be determined, but administrative costs will be higher than those of a truly ongoing service program. A permanent dental home care program presumably would be associated with a parent, more comprehensive pro gram, and administrative costs for the overall program would be less than administrative costs for an isolated indi vidual program. For these reasons, ad ministrative costs are not included (T a ble 6 ). A significant finding of the program was that about 80 per cent of the homebound are not truly homebound for pur poses of receiving dental care. This pointed to the need for expanding means of providing dental care to the chroni cally ill and led to a combined outpa tient-home care program. It is antici
pated that, through this combined approach, significantly greater numbers of patients would be treated expeditiously and economically. The combined pro gram has received a Community Health Services and Facility Act grant. Table 4 shows time requirements for each patient. The remaining time is di vided between equipment time (set-up and breakdown) and travel time. Since treatment time and set-up and breakdown time were similar for private residences and nursing homes, the differ ence in total service time requirements is because of travel time and the number of patients seen per visit. With an aver age of three patients per nursing home visit (program experience), the decrease in travel time reflects this decrease in procedure time requirements for a nurs ing home patient. SUMMARY
A pilot program for dental care of the homebound, chronically ill and aged op erated for 32 months, sponsored by the US Public Health Service (through the Ohio State Department of H ealth), the County Chronic Illness Center, the Visit ing Nurse Association and Western Re serve University School of Dentistry. Although reluctant at first, the pri
W A L D M A N . . .VO LU M E 69, DECEMBER 1964 • 57/72»
vate practitioner has shown increased interest and cooperation in care of the homebound chronically ill since this dem onstration project has been in operation. The importance of auxiliary personnel in a home care program has been demon strated. They permit the dentist to spend more time on procedures that require his specific training. The isolated homebound patient re quires more expenditure of time, person nel and finances. Geographic clustering of patients, completing as many proce dures as possible during a single visit and seeing more patients at one visit (at nursing homes) all tend to reduce this expenditure.
An estimate that 80 per cent of the homebound are not truly homebound for purposes of receiving dental care led to a combined home care and outpatient program to expand the available means for the chronically ill to obtain dental care. This phase recently has begun. *Assistant professor of public health dentistry, School of Dentistry, Western Reserve University, and director, dental home care program, Highland View Hospital. The author wishes to acknowledge the efforts of Murray Stein, chief of dentistry at Highland View Hospital, in the preparation of this paper. 1. Lotzkar, Stanley. Dental care for the chronically il!, aged and homebound. JADA 67:71 July 1963. 2. US Department of Health, Education and Welfare, Public Health Service. Dental care for the chronically ill and aged: a community experiment. PHS Publ. No. 899, Washington, DC, US Government Printing Office, 1961. 3. Collins, John. Dental home care program. J. Mich igan D.A. 45:369 Nov. ¡963.
T h e Abrasive M an • W e have a shortage in journalism, in teaching and other fields of what I shall call “ the abrasive man.” H e is obviously a controversial figure. H e disturbs the peace of the affluent suburb and the apathetic city. He doesn’ t fit in. He creates ripples when we prefer calm water. O nce the w ell-rounded man was the w ell-educated man. N ow we are likely to think of him as a smooth, unabrasive fellow, a nice guy. H e revolves in a nice little circle, in a nice suburb, where nice people live, “ our kind of people. . . . ” It’ s a good life with one fatal weakness.lt often puts these nice people out of touch with the disturbing problems o f the city and the rest of the world. T o com municate is to share ideas and feelings in a m ood o f mutuality. W e cannot escape the moral and social consequences of noncom munication, o f self-isolation from the troubles of the world. In the long run, walling one’ sself off from our fellowman deadens the personality, makes it insensitive to the aspirations, the pain, the rich pleasure o f other people. Edgar D ale, Solomon M em orial L ectu re, University of Missouri.
Inder Jit Singh, BDS, and Bhim Sen Savara, D M D , MS, Portland, Ore
In making prints of dental casts, often used in dentistry and anthropology, in vestigators found a X erox duplicating machine is easy to use and accurate. Conventional photography requires much equipment and complicated procedures. Surveyor instruments are tedious to use, imprecise and unsuitable for tooth measurements.
Dental casts and their photographs have been used widely in dentistry and an thropology for measuring tooth size and arch dimensions, and various instru ments, notably the dental pantograph1
and cubic craniophor,2 have been devised for reproducing the dental arch. Arch re productions from such instruments or photographic technics make it possible to relate arch form to a rectangular coordi nate system ; however, both methods have their limitations. For instance, conven tional photographic methods require elaborate equipment and factors of en largement, object-to-image distance, light ing and so forth, have to be considered.3 Arch reproductions from surveyor-type instruments are tedious, limited in preci sion and unsuitable for making tooth measurements. A new technic of making prints of den tal casts is recommended here for its sim
Left: Dental cast. R ight: Its Xerox print. Buccal cusp tips of first perm anent molars, cusp tips of cuspids and two points along palatal midline are marked with black instant lettering (Letraset) dots
48/720 • T H EJO U R N A L O FT H E A M E R IC A N DENTAL A SSO C IA TIO N
Table • Errors of measurements (tested by repeat measurements) on dental casts, on Xerox prints and between dental casts and Xerox prints M ean* + standard deviation of the differences for measurements Variable
No. On dental casts
On Xerox prints
Between dental casts and Xerox prints
Arch length
10
0.08 ± 0.35
0.10 + 0.20
-
Intercuspid width
10
0.04 + 0.32
0.09 ± 0.20
- 0.10 ± 0.25
0.10 + 0.10
Intermolar width
10 -
0.04 ± 0.23
- 0.06 + 0.33
0.06 ± 0.20
*Mean differences in mm., tested by t statistic, were not significantly different at I per cent level of significance {degrees of freedom = 9).
plicity and accuracy. The dental cast is laid teeth down on the glass table of a Xerox duplicating and printing machine (M odel 914, manufactured by Xerox Corporation, New York) and reproduc tions obtained. Specific landmarks to be located are marked or shaded dark for better contrast. The illustration shows a photograph o f a dental cast and its Xerox print. Instant lettering (Letraset) black dots were used to locate buccal cusp tips o f first permanent molars, cusp tips of cuspids and two points along the palatal midline. T o standardize the technic, a Xerox print of a 25 by 20 cm. graph paper was made. Each millimeter division on the X erox print then was measured along both length and width and various angu lar measurements made to determine if any distortion or enlargement in any di mension was discernible. A 0.5 per cent enlargement in the 20-cm. distance along the width was found. On further analysis, it was observed that there was no en largement in the middle 10 cm. of the graph paper; the 5 cm. on each side had a maximum enlargement of 0.25 mm. each. Angular measurements showed similar errors in the peripheral 5 cm. on both sides along the width o f the graph paper. N o errors of magnification or distortion could be detected along the length of the paper. Considering the dimensions of most dental casts, a maximum enlargement of 0.2 mm. would be expected if the cast
were placed anywhere in the peripheral 5 cm. o f the glass plate of the Xerox ma chine. No enlargement should result if care were taken to place the cast in the middle 10 cm. The amount of error in the peripheral part will vary with each machine because of slight differences in focusing adjustments. It is found mainly in the peripheral part and along the width of the table rather than along the length because of the curved surface of the reflecting mirrors used in such ma chines. The error will be constant for the same machine, however, unless focusing adjustments are altered either directly on the machine or indirectly by moving the object more than an eighth inch away from the glass table. Accuracy of reproduction and meas urements was tested on ten dental casts, randomly selected from the records of the Child Study Clinic. Arch length (from the mesioincisal edge of left central in cisor to distobuccal cusp tip on left first permanent m olar), intercuspid width at cusp tips and intermolar width at disto buccal cusp tips of first permanent m o lars were measured. Duplicate measure ments were made on each cast independ ently. T w o Xerox prints were obtained for each cast, and the same measure ments obtained independently on each print. The table shows an analysis of measurement errors (mean difference and standard deviation of differences) between paired measurements on dental casts and Xerox prints. Errors between
S IN G H — SAVARA . . . VOLUME 6?, DECEMBER 1964 • 49/721
Xerox prints and dental casts also were tested and were not significantly different (table). This method of making meas urements from such prints is justified on the basis of the aforementioned analyses. In testing for measurement error, a duplicate set of reproductions eliminates possibilities of examiner bias and damage to cast. Tooth and arch measurements also can be made directly to 0.1-mm. accuracy by orienting the photograph or reproduction on an analog reader and decimal converter. As pointed out by Gam ,4 the use of automation in collec tion and analysis of data reduces work load and human error to a minimum. The simplicity of the procedure, its low cost and the fact that Xerox prints of four to five dental casts can be made on one sheet of paper, make it economical and timesaving. Letraset dots can be rubbed on and off the dental casts with great ease and with no damage to the cast.
This technic offers a simple, repro ducible and objective method for anthro pologic and genetic studies of tooth and arch dimensions, palatal and arch form or area or their application to orthodon tics, and it now is being used to investi gate interrelations of crowding or spacing of teeth to measures of arch and tooth dimensions. 611 South W est Campus Drive
This study was supported bv Grant HD 00157-05, National Institute of Child Health and Human Devel opment, National Institutes of Health, USPHS. From the Child Study Clinic, University of Oregon Dental School, Portland, Ore. 1. Stanton, F. L., Fish, G . D., and Ashley-Montagu, M. F. Description of three instruments for use in ortho dontic and cephalometric investigations, with some remarks on map construction. J . D. Res. 11:885 Dec. 1931. 2. Hayashi, Toshio. A mathematical analysis of the curve of dental arch. Bui. Tokyo Med. D. Univ. 3:175 Dec. 1956. 3. Speck, N. T. A longitudinal study of developmental changes in human lower dental arches. Angle Orthodont. 20:215 Oct. 1950. 4. Garn, S. M. Automation in anthropometry, Am. J . Phy. Anthropol. 20:387 Sept. 1962.
R espect • D onald K . W eilburg, the president of the class o f 1967 at the University o f Pennsyl vania School o f Dental M edicine, recently received a letter from the chairman of the medical school’ s department of anatomy that is self-explanatory: “ It was brought to my attention this morning, follow ing the funeral service for the cadavers used by the University of Pennsylvania during the past year, that the First Year Dental Class had contributed flowers and that you were in attendance as a representative and as President o f the First Year Class. Although I have not been involved in any way in the teaching o f dental students, I feel called upon as an anatomist to express m y pleasure and appreciation at this action of you and your class. I understand that this is the first time this has been done and it therefore represents, not a blind follow ing o f tradition, but a genuine act of thoughtfulness and respect to the deceased persons who were as truly your teachers as were the faculty."’ M edical W orld News, August 14, 1964.
Report of a demonstration dental care program for homebound chronically ill and aged patients
H. Barry Waldman,* DDS, M PH , Cleveland
The chief of dentistry at a Cleveland hos pital, Western Reserve University School of Dentistry, the Cleveland Dental So ciety and the Visiting Nurse Association of Cleveland cooperated to set up and operate a program of furnishing dental care to aged and ill homebound patients at their residences. Voluntary and public agencies referred patients who needed the care which was provided by the program and private practitioners. The United States Public Health Service provided funds through the Ohio State Depart ment of Health.
The dentist, because of his training, ex perience and the nature of his equip ment, has become closely associated with a fixed, circumscribed office setting. There, the dentist treats patients o f all ages and most physical conditions. Yet an ever-increasing population exists which the dentist is either unable to reach or o f which he is unaware. These people, because of age, chronic illness or physical disability, ordinarily are unable to come to the dental office or clinic. The almost total lack o f comprehensive treatment facilities for them in this country came under intensive study by
W A L D M A N . . .V O LU M E 69, DECEMBER 1964 • 51/723
the US Public Health Service in metro politan Kansas City during the late 1950’s.1,2 Under USPHS direction, a program was begun to provide dental care at the place of residence (using portable dental equipment) and at a dental clinic where the aged and chron ically ill were transported if medical status permitted. Using the experience gained from this program, the chief of dentistry at High land View Hospital, in cooperation with Western Reserve University School of Dentistry, the Cleveland Dental Society and the Visiting Nurse Association’s Home Care Program, developed a pro gram for providing comprehensive den tal care at the residences of chronically ill and aged people in Cleveland. An advisory committee, consisting of representatives of local and state volun tary and nonvoluntary agencies, was or ganized to help formulate further plans for the program. This demonstration program, begun in July, 1961,3 was financed by the US Public Health Service through the Ohio State Department of Health, the Visit ing Nurse Association, Western Reserve University School of Dentistry and, since July, 1963, the Cuyahoga County Chronic Illness Center. Western Reserve University and Highland View Hospital, with the cooperation of the Cleveland Dental Society, administered the pro gram. Highland View Hospital, the county hospital for treatment of the chronically ill, was the base of operation for the pro gram. P R O G R A M O B JE C T IV E S
The basic objectives of the program in cluded : (1) providing comprehensive dental services to homebound patients in the metropolitan Cleveland area; (2) orienting and training both the dental student and the private practitioner in providing dental services for the chroni cally ill and aged at the patient’s place
of residence, and (3) integrating the program with existing community health agency activities. Providing dental services to the homebound calls for identification of these pa tients. Because this demonstration was not designed to meet the dental needs of this entire population, the advisory com mittee decided not to spend much effort and money to develop extensive lists of homebound patients. The committee de cided to start providing dental services early in the program to those already known to need care and to find others as the program progressed. Since no prevalence study was avail able to locate and select program pa tients, referral procedures with the vari ous voluntary and nonvoluntary agencies were needed. This created a close work ing relationship with local agencies, one of the program’s important assets (Table 1 }Because the program involved pro viding services outside the dental office, equipment and procedures used in Kansas City were modified to meet the specific problems encountered by the Cleveland program.
Table 1 • Referrals Patient referrals by source
N o.
Nursing homes
180
Cleveland Home C a re Program
103
Multiple Sclerosis-Nutrition Research Study
48
Highland View Hospital
37
Visiting Nurse Association
32
Family
27
Dentists
22
Aid for Aged
19
Western Reserve University
8
Jewish Family Service
7
Physicians
6
Multiple Sclerosis Society
3
County W elfare
3
Others Total
14 509
52/724 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA TIO N
The Ritter standard portable unit (in cluding dental engine, suction, air pres sure and light) met the needs o f the program most adequately. The compact ness and relatively light weight (40 lb.) of the equipment permitted maneuvera bility and provided adequate operating room in smaller residences. For those procedures that did not re quire extensive equipment, such as den ture adjustments, a hand motor and a headlight were sufficient. Since most chronically ill patients are confined to wheelchairs, an aluminum bar and headrest were designed to at tach to wheelchairs, affording comfort to the patient and dentist. All small instru ments and supplies for the procedures to be performed during a day’s visits were carried in an aluminum carrying case. Available portable x-ray units were unsatisfactory for use in the home, pri marily because of weight and bulkiness. Roentgenograms were made, therefore, only when the patient was brought by ambulance to an outpatient service at a hospital. PR O G R A M
A CTIV ITIE S
• The lack of comprehensive local dental treatment facilities for the homebound population was almost com plete. The program’ s effort to provide a full range of dental services showed the community a feasible way to meet this need. The nature and extent of den tal services were consistent with the overall medical and physical status of the patient. This comprehensive approach to the dental needs of this population in cluded examination, prophylaxis, extrac tions, postoperative treatment, restora tions, prosthetic appliances (including complete and partial dentures), repair and relining of dentures, adjustments and maintenance on a recall basis. Services
Orienting Dental Students • The senior dental student orientation program was
closely associated with the program’ s service activities. This phase of a more comprehensive orientation program fa miliarized the student with the equip ment and philosophy of dental care for the homebound chronically ill and aged. Recent graduates of Western Reserve University School of Dentistry who re ceived this training did use program serv ices to provide dental care for their pri vate patients at the place of residence, showing their receptivity to the program. Orienting Private Practitioners • Realiz ing that only by including the private practitioner could the plan meet the needs of the homebound population, the program lent equipment, supplies, and made available the services of an assistant so the dentist could perform needed serv ices for his own patients. Association with Dental Society • T o suc
ceed, any dental program must have the support and cooperation of the local den tal society. The close association between the program and the Cleveland Dental Society was immeasurably valuable. The repeated requests for table clinics and sci entific exhibits, the mailing of program brochures, the Society’ s efforts to bring the program to public attention by ar ranging television and radio sessions all played their part in making the program a success. In addition, financial support by the Society for community edu cational purposes showed what a close working relationship can accomplish. Integration of Program with Com munity Health Activities
Existing
• More than 75 voluntary and governmental agencies have cooperated with the pro gram as have more than a third o f the nursing homes in the metropolitan Cleve land area. These endorsements, financial support and referral systems with local health and welfare agencies show the firm rela tionship that has developed between the program and the community since the
W A L D M A N . . . VO LUM E 69, DECEMBER 1964 • 53/725
program started (Table 1).
T a b le 2
• Examination data (recall examinations in
cluded) Examination data by age
O B S E R V A T IO N S
The efforts expended by the program at various dental society meetings and con ventions helped introduce the dental pro fession to the idea of providing dental care at home, using portable equipment and toned down much of the initial re luctance to provide care to the homebound patient. This reluctance stemmed from a com bination of several factors, including ( 1) the inability to “ spare the time,” (2) in sufficient compensation to warrant the effort, (3) belief that the work could not be performed adequately at the place of residence and (4) the inclination not to provide care because the patient was “ chronically ill.” Despite this reluctance 40 private practitioners (3.5 per cent of the local dental profession) provided dental care to 88 patients; they performed 363 pro cedures during 120 home visits. 1. More older practitioners partici pated in the program than did young ones. 2. The constant effort to reach the private practitioner succeeded when he was told that the program would work with him. 3. Some dentists were reluctant to participate in the program because they knew that it had “ governmental financial support.” This fear of “ creeping social ism” was met effectively by explaining that private practitioners’ efforts to fill the needs of the population would protect their province. Dentists have recognized the impor tance of auxiliary personnel in the dental office. The findings of the dental home care program emphasized the extremely important role of these persons in the success of such a program. T h e actual help the dental assistant gives during the service procedures was almost secondary to the many other fac ets o f work carried ou tNby the assistant.
Younger than 45 years N o. of patients Edentulous One or more teeth
45 to 64 65 years iind older years <
Total
76 7
108 31
245 128
429 166
69
77
117
263
52
65
153
270
18 1 5
35 8
47 10 35
100 11 48
Care needed Yes No
71 5
103 5
161 84
335 94
Family dentist Yes No
29 47
31 77
24 221
84 345
Ability to pay* Full Part None Agency
22 26 21 7
33 37 26 12
55 39 36 115
110 102 83 134
26 14 24
29 9 24
74 39 67
44
183
249
Amenable to treatment Maximum care Intermediate care Questionable Untreatable
Time since last appointment 0-1 year 19 16 1—2 years 2-4 years 19 More than 22 4 years
■"Services charges are based on Western Reserve Uni versity School of Dentistry's fee schedule for home care patients.
The coordinating of appointments; the preparation, set-up and breakdown of equipment in foreign environments; the psychological assurance given to patients; the recording of data, and public rela tions efforts were some of the aspects of the program handled by the assistant. The dental hygienist performed most prophylaxis procedures. Although a fur ther visit and evaluation by a dentist was required before specific treatment could be chosen, the information obtained dur ing the preliminary screening usually per mitted the dentist to prepare and per form dental procedures on his first visit. Because many homebound patients are confined to nursing homes,.the hygienists tried to orient the personnel of nursing homes to the specific dental health needs
54/726 • THE JO U R N A L OF THE A M E R IC A N DENTAL A SSO C IA T IO N
Table 3 • Number of patients for whom treatment was recommended by age and total number of procedures recommended Ages of patients Examination data
N o . patients examined Treatment recommendations:* N o . patients requiring restorations Total no. restorations needed b y patients N o . patients requiring extractions Total no. extractions needed by patients N o. patients requiring surgery N o . patients requiring prophylaxis N o. patients requiring other treatments N o . patients requiring prosthetics N o. patients requiring single complete denture N o. patients requiring two complete dentures N o. patients requiring single partial denture N o . patients requiring two partial dentures N o . patients requiring denture repair N o. patients requiring reline of one denture N o. patients requiring reline of two dentures N o . patients requiring denture adjustment
Younger than 45 years
Total
45 to 64 years
65 years and older
76
108
245
429
51
45
28
124
?72 17
152 29
72 60
396 106
121 5 56
113 8 66
256 7 71
490 20 193
1 31
1 42
4 75
6 148
5
11
11
27
4
10
27
41
13
15
7
35
6
8
3
17
1
6
18
25
4
6
12
22
2
4
18
24
1
8
12
21
*Of the 76 pa+îenfs younger than 45 years, 93% required treatment; 95% of the 108 patients 45 to 64 years old and 65% of the 245 patients 65 years old and older required treatment.
of their patients. The training and experi ence of the dental hygienist adequately met the requirements o f this task. The hygienist permitted the program dentists to spend more time on those procedures that required their training. F IN D IN G S
O f 429 patients examined, 164 lived in nursing homes and 265 lived in private homes. Patients referred but not exam ined were too ill, refused examination or were referred to private practitioners (Table 2 ).
State of the Dentition • As in previous dental studies, the loss of teeth was in di rect relation to the increase in age. The
edentulous state increased from 9 per cent to 29 per cent to 52 per cent in the progressive age groupings. Treatability • The majority of all pa tients examined were amenable to treat ment. Only a segment o f the older age bracket posed treatment problems. Most of these problem patients had vascular lesions of the central nervous system. Care Needed • Nearly all of the patients under 65 needed dental care (Table 3 ). This finding was anticipated because the majority of these patients had not re ceived dental care during the past two years. O f the patients 65 years old and older, 35 per cent required no dental care. A significant number of these were edentu
W A L D M A N . . . VO LUM E 69, DECEMBER 1964 • 55/727
Table 4
• Time and number of visits required for patients examined at place of residence
Private residence Younger than 45 years
45 to 64 years
65 years and older
Nursing home
Weighted average*
N o. of visits
4.7
5.5
3.5
1.2
4.5
Total time (hr.) f
7.5
8.4
5.0
2.3
6.6
Actual treatment time (hr.)
2.0
2.0
0.9
0.9
1.4
Percentage of total time for actual treatment
27
24
18
41
21
*Thi$ average is based on the total program population weighted according to age group: younger than 45, 17%; 45 to 64 years, 27%, and 65 and older, 56%, and percentage of exam ined patients requiring treatment: 93%, 95% and 65%. tIncluding treatment time, set-up and breakdown time = 17 minutes per visit and travel time = 53 minutes per visit.
lous and residents of nursing homes. Some of this group were thought not to require dental care because they were satisfied with their present status. Patients seen on recall visits required relatively minor maintenance care. Be sides the need for prophylaxis, only 0.6 restorations per patient examined were required, as well as minimal surgical
procedures and denture relines and re pairs. These findings showed that cumulative needs of the homebound population are far greater than maintenance needs. Repeated time-motion studies have shown the dental profession the need to reduce lost procedural time (Table 4 ). The time lost in traveling by the dentist
Table 5 • Treatment procedures performed per 100 persons examined by age N o. of procedures Procedure
Weighted average*
Younger than 45 years
45 to 44 years
65 years and older
Examination and screening
107
107
107
107
Restorations Amalgam Silicate
120 87
114 52
11 6
53 30
Extractions
105
97
57
77
Prophylaxis and periodontal treatment
106
93
30
60
21
13
6
11
8 6 6 6
6 8 6 3 13 7 7 91
2 11 5
4 11 5
I*
r*
Postoperative treatment Prostheses: One complete denture Two complete dentures One partial denture Two partial dentures Denture repairs One denture relined Two dentures relined Adjustments
2 2 38
18 5 6 65
9 5 6 70
*This average is based on the total program population weighted according to age group: younger than 45, 17%; 45 to 64 years, 27%, and 65 and older, 56%, and percentage of examined patients requiring treatment: 93%, 95% and 65%.
56/728 • T H E J O U R N A L O F T H E A M E R IC A N DENTAL A SSO C IA TIO N
Tab le 6 • Service costs for each patient examined at picce of residence by age (excluding administrative and overhead costs! Private residence Less than 45 years
45 to 64 years
65 years and older
Nursing home
Weighted averag e*
Personnel (dentist, hygienist & assistant) costs each visit $8.90/hr.
$14.35
$13.35
$12.45
$13.35
$13.35
Personnel costs per patient
$66.75
$74.75
$44.50
$20.50 f
$58.75 $ 6 .25î
Laboratory costs
$65.00
Service costs
*This average is based on the total program population weighted according to age group: younger than 45; 45 to 64 years, 27%, and 65 and older, 56%, and percentage of examined patients requiring treatment: 93%, 95% and 65%. |An average of three nursing home patients seen per visit reduced equipment and travel time by two thirds. JCosts not available by age or residence.
to the place of residence is a decided dis advantage. Geographic clustering o f pa tient visits and completing as many pro cedures as possible during a single home visit have reduced this lost service time. Because of the demonstration status of the program, extensive periods were spent refining and modifying equipment and technics, and in orienting and train ing program staff and private practition ers. Considerable time was required for public relations activities and educational efforts (Table 5 ). Actual service costs can be determined, but administrative costs will be higher than those of a truly ongoing service program. A permanent dental home care program presumably would be associated with a parent, more comprehensive pro gram, and administrative costs for the overall program would be less than administrative costs for an isolated indi vidual program. For these reasons, ad ministrative costs are not included (T a ble 6 ). A significant finding of the program was that about 80 per cent of the homebound are not truly homebound for pur poses of receiving dental care. This pointed to the need for expanding means of providing dental care to the chroni cally ill and led to a combined outpa tient-home care program. It is antici
pated that, through this combined approach, significantly greater numbers of patients would be treated expeditiously and economically. The combined pro gram has received a Community Health Services and Facility Act grant. Table 4 shows time requirements for each patient. The remaining time is di vided between equipment time (set-up and breakdown) and travel time. Since treatment time and set-up and breakdown time were similar for private residences and nursing homes, the differ ence in total service time requirements is because of travel time and the number of patients seen per visit. With an aver age of three patients per nursing home visit (program experience), the decrease in travel time reflects this decrease in procedure time requirements for a nurs ing home patient. SUMMARY
A pilot program for dental care of the homebound, chronically ill and aged op erated for 32 months, sponsored by the US Public Health Service (through the Ohio State Department of H ealth), the County Chronic Illness Center, the Visit ing Nurse Association and Western Re serve University School of Dentistry. Although reluctant at first, the pri
W A L D M A N . . .VO LU M E 69, DECEMBER 1964 • 57/72»
vate practitioner has shown increased interest and cooperation in care of the homebound chronically ill since this dem onstration project has been in operation. The importance of auxiliary personnel in a home care program has been demon strated. They permit the dentist to spend more time on procedures that require his specific training. The isolated homebound patient re quires more expenditure of time, person nel and finances. Geographic clustering of patients, completing as many proce dures as possible during a single visit and seeing more patients at one visit (at nursing homes) all tend to reduce this expenditure.
An estimate that 80 per cent of the homebound are not truly homebound for purposes of receiving dental care led to a combined home care and outpatient program to expand the available means for the chronically ill to obtain dental care. This phase recently has begun. *Assistant professor of public health dentistry, School of Dentistry, Western Reserve University, and director, dental home care program, Highland View Hospital. The author wishes to acknowledge the efforts of Murray Stein, chief of dentistry at Highland View Hospital, in the preparation of this paper. 1. Lotzkar, Stanley. Dental care for the chronically il!, aged and homebound. JADA 67:71 July 1963. 2. US Department of Health, Education and Welfare, Public Health Service. Dental care for the chronically ill and aged: a community experiment. PHS Publ. No. 899, Washington, DC, US Government Printing Office, 1961. 3. Collins, John. Dental home care program. J. Mich igan D.A. 45:369 Nov. ¡963.
T h e Abrasive M an • W e have a shortage in journalism, in teaching and other fields of what I shall call “ the abrasive man.” H e is obviously a controversial figure. H e disturbs the peace of the affluent suburb and the apathetic city. He doesn’ t fit in. He creates ripples when we prefer calm water. O nce the w ell-rounded man was the w ell-educated man. N ow we are likely to think of him as a smooth, unabrasive fellow, a nice guy. H e revolves in a nice little circle, in a nice suburb, where nice people live, “ our kind of people. . . . ” It’ s a good life with one fatal weakness.lt often puts these nice people out of touch with the disturbing problems o f the city and the rest of the world. T o com municate is to share ideas and feelings in a m ood o f mutuality. W e cannot escape the moral and social consequences of noncom munication, o f self-isolation from the troubles of the world. In the long run, walling one’ sself off from our fellowman deadens the personality, makes it insensitive to the aspirations, the pain, the rich pleasure o f other people. Edgar D ale, Solomon M em orial L ectu re, University of Missouri.