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The public dental service
PUBLIC HEALTH, October, 1945 The Child
So much for midwifery. What about the child ? Is the present division at five years of age to remain ? In 1943 your Committee presented a memorandum t o the Council of the Society in which, among other things, they recommended that the Maternity and Child Welfare Service---not the Child Welfare Service o n l y - - a n d the School Medical Service should be amalgamated. W e wished to emphasise the importance of regarding the mother and child as one unit. Not every practitioner has the right temperament to undertake work of this kind, nor can it be easily fitted in to the rush and tumble of ordinary curative work. It is, in fact, specialist work. Here again the general practitioner may have a special interest in and knowledge of the positive approach to child health. He will not take just an odd clinic here and there to make a few extra guineas, but will devote a definite and reasonable proportion of his time to this work. Even so, the bulk of the work will continue to be done by the whole-time specialist child welfare officer. Some of these officers may in time pass o n to be consultant paediatricians, as we at present understand the meaning of that term. In the future, no one w h o aspires to consultant rank in paediatrics should be considered to be adequately qualified until he has had adequate experience of such work. T h e r e will be many others, however, whose interest will continue to be on the preventive side r a t h e r than the curative, and who will have no wish to be curative physicians, consultant or otherwise. T h e y wilt wish to continue to have association with the hospital to give their own work balance, but their main interest will be in advisory and educational work such as is carried on at present in our clinics. In the future Maternity and Child Welfare Service there will probably be, in the larger urban areas at least, wholetime public health medical officers whose main interest will be maternity and the care of young infants for at least the neonatal period, if not longer, and others whose work will be among all children up to the age when they leave school. In other areas such differentiation will not be possible, certainly not for a long time to come, and medical officers will continue to be much as they are now, doing ante-natal and infant welfare and school medical work ; but, it is hoped, they will be able to have continued contact with the hospital, which they lack at presen t . It is regrettable that in some of the plans for Child Health Institutes the importance of the association with the Maternity and Child Welfare Services has been overlooked. T o reiterate, the mother and child are one u n i t ; they are not, however, a unit living in space but a unit living in a social environment w h i c h e x e r c i s e s a powerful influence on them. Take as an example the care of the unmarried mother and the illegitimate child. During the pregnancy the mother must be cared for not only medically but socially. She must be suitably housed, whether in her own home, in a hostel, or in lodgings. She must be assisted to make arrangements for her confinement and after delivery she must be encouraged and helped to do what is best for her child. Once again, in the early months, at least until her plans are made, shelter must be found for h e r - - n o t so easy this t i m e - - a t home, in a hostel, or in lodgings. If she decides to keep her child, she still needs assistance morally, if not materially, long after the end of the child's first year of life. Recently in Birmingham we have had a salutary shock. We are rather pleased with our arrangements for the care of the unmarried mother and her baby. Twice within the past five years has the illegitimate infant mortality rate been lower than the legitimate rate--a very satisfactory reward for our intensive care. Recently our health visitors reviewed the illegitimate children under five in their districts and commented on their condition from the physical, mental, and economic standpoints ; 91% of these children were with their natural mothers, but in only 60% of the cases were their condition and circumstances wholly salisfactory. Clearly there is more to be done for these children, and any scheme for improvement must take into consideration not only the child but also the mother and the environment of them both during the whole period, from the time of the pregnancy onwards. T h e work of the midwife and the health visitor, too, must be closely integrated.
3 Administration
Finally, a word about administration. Whatever may happen in the future, the need will remain for co-ordination in the administration of the Maternity and Child Welfare Services, in its widest sense. T h e administrator should be a medical administrator. T h e r e are some areas, usually counties, which are divided up in such a way that one medical officer is responsible for all the public health medical services in the area but has no responsibility for the planning of policy. Some one at head office may be thinking in terms of the Maternity and Child Welfare Service as a whole, but judging by the results as one sees them in the field this is not always apparent. In any event, no one is specifically designated as the administrative maternity and child welfare officer. In other areas the two services have been divided and there are two administrative officers--one for maternity and one for child welfare. In these circumstances one often finds that each of these officers is in fact a specialist clinician and not an administrator at all. It is difficult if not impossible to organise a complete and co-ordinated service for mother and child with an administrative set-up of this kind. N o t only will there still continue to be need for such administrative maternity and child welfare officers as there are at present, but it is to be hoped that areas of suitable size which are without such officers will appoint them in the future. In the smaller areas, one medical officer might be responsible for the administration of the Maternity and Child Welfare and School Medical Services. In the larger areas, for the time being at least, the present arrangement with one administrative medical officer for maternity and child welfare and another for schools may well continue, although there, too, at some future date, we may see an amalgamation. T h e observations made about the need for co-ordination in the administration of the Maternity and Child Welfare Service apply with even greater force to the central government departments. In the new planning of those departments, maternity should not be separated from child welfare, and the medical services for mother and child should be the sole responsibility of the Ministry of Health. This very desirable goal will not be achieved easily. Our negotiators will indeed deserve our congratulations and thanks if they succeed in overcoming the inertia which confronts them.
THE
PUBLIC
DENTAL
SERVICE
By J. J. HODSON, L.D.S., R.C.S. (EDIN.),
Dental Officer, Warwickshire C.C. It is proposed to discuss some of the factors which should be considered in the appointmeht of public health dental officers, their status, and the conditions under which they work. In the first place it is essential that the appointment of a dental surgeon to a public health authority be as carefully considered as to his suitability and qualifications (not entirely academic) for the work, as it is that the dean of a dental school should be quite certain that the intending student is suitable for admittance to the profession. T h e public service does not want men who come into it to shirk their responsibilities, and it does not want men who have failed in private practice. Further, it is not to the benefit of the public service that newly qualified practitioners are forced to seek entry solely on the grounds that they have not the capital to begin on their own account. In considering appointments for the Public Health Service, attention should be paid to attracting the right man, the man who wants and is suited to a public appointment, and is fully aware of the responsibilities. In some quarters there appears to be an idea that to be a public dental officer is an easy way of making a living. If the surgeon works conscientiously this is far from being the case. T h e School Dental Officer, in particular, must possess a great store of " n e r v o u s energy," and although he may work shorter hours than his colleague in private practice the shorter hours do not entirely recompense him for what is an arduous and difficult career.
6 Dental Paediatries
T h e present method of directing dentists not suitable for the armed forcea into the school service is not a happy one. T h e dental paed~atrician is a specialist in a very important sphere. What does the raw graduate know about the handling of babies and children ? Children demand a special technique which is vastly different from that employed in the treatment of adults. T h e lack of training in our hospitals for this important work is to be deprecated. The young surgeon leaving hospital has had little or no experience in treating children's mouths from a developmental point of view. Dental paediatrics is something more than fillings and extractions. T h e s e are only items in the treatment of the young mouth. There must be planning, after a careful study and considered diagnosis have been made of the mouth and the condition likely to be reached when fully developed. T h a t is why it is much better to obtain the parent's consent to treatment of the child during the whole school life, rather than from year to year ; then, from the age of 2 to 15 or 16, a planned accurate system of treatment can at least be attempted. It is useless to attempt odd fillings here and there and some extractions without due regard to development and adult result. The Curriculum Those who wish to become dental paediatricians need training and special supervision, and a special department of dental paediatrics should be set up in our dental schools. A special six-months' postgraduate course should also be instituted specifically for those intending to enter the Public Health Service. A certificate should be issued which would satisfy the chief dental officer and his committee that the applicant for an appointment is at least basically qualified to undertake his special duties. Such a course would include the subjects of orthodontics, maternity and child welfare work, anaesthesia for children, statistics, the working of a public health scheme, etc. T h e curriculum in our dental schools should include a course of lectures on the public health aspect of dentistry; the lecturer should preferably be a dental officer already engaged in public health work. His council should permit him to hold this appointment and to draw the salary appropilate to it. A public health authority should have on its dental staff a consultant specialist dental paediatilcian to advise the dental officers on any case which they feel calls for another opinion. Qualities of the Chief Dental Officer
In the appointment of chief dental officers consideration should be paid to organising ability, and a personality such as will create a spirit of co-operation and team work among the rest of the staff. He should be entirely responsible for the running of his own department and be directly responsible to the Health Committee. He must be a man of high professionat standard and be paid a salary in accordance with his position and the dignity of his profession. In the treatment of the maternity and adolescent classes the dental officer must be of good general practising ability and capable of treating all those cases which call for specialised knowledge --e.g., the patients in any of the Council's hospitals. To help this type of officer and to advise on major oral problems a dental surgeon should be appointed as consultant on oral surgery to the Council. Abnormal and difficult cases which are met with should, if the officer wishes, be referred to this specialist. Working FaeEi~ies A public health authority must provide facilities where other than routine dental operations can be carried out. Even in school dental work there are cases that cannot and should not be treated in the ordinary dental clinic. Facilities for beds in hospitals, the use of special equipment and nursing help, must be provided where the dental surgeon concerned or the dental specialist can perform dental operations in confortuity with modem standards and conveniences to which he and the patient are entitled. A good chief dental officer will do much to guide the responsible committee in the ways
PUBLIC HEALTH, October, 1945 of m o d e m oral surgery and modem dental treatment, planning, and methods. I n the matter of equipment, though some standardisation is obviously necessary, it must be adequate in variety of design and of the best quality. I n a satisfactory dental service provision must be made for an efficient yet simple system of record keeping. A patient's medical and dental history record is almost as important to the surgeon as the patient himself. Statistics and Reports
There is also the thorny question of statistics and returns. Dental treatment is such that if the patient is to get the full and lasting benefit from the service, the treatment must be complete. Unfortunately, and it is mainly due to our own fault, the public have learned to think in terms of an " itemised " surgical procedure. Public health reports showing the numbers of fillings, extractions, etc., and purporting to inform the public of the progress of dental treatment, are as misleading and as useless as a report showing the n u m b e r of applications necessary to cure a number of cases of impetigo. T h e most important information for any board or committee, or for the general public, is information concerning the n u m b e r of mouths made healthy. Detailed items are useful only for research and investigation. Moreover, the piecework method of portraying the activity of the dental surgeon is most deplorable. It is unparalleled in any other sphere of medicine or surgery. It bears no relation to the new outlook in diagnosis and treatment in m o d e m dental surgery. T h e teeth are merely parts of one organ, the organ of mastication. They are surrounded by one continuous soft tissue, the gum. I n place of the number of fillings, we should record the n u m b e r of cases o f caries treated--/.e., whole mouths, and instead of scalings and gum treatments we should record the n u m b e r of treated cases of gingival conditions or lesions, and above all the n u m b e r of mouths made healthy. Parodontal Disease
If a satisfactory scheme for the dental treatment of the general population is put into practice, the dental profession will have to deal much more seriously with the gum conditions known under the general heating of parodontal diseases, than they have hitherto done. I n people above the ages of 18 to 20, parodontal disease is a more urgent public health problem than caries. At the moment we seek to preserve the teeth of the school population so that they will retain them in adult life. It is not much use doing this if, when adult life comes, they lose their dentitions through parodontal disease. Restorative Treatment
Public authorities will have to come to an understanding about the various forms of restorative treatment. There is a difference between the type of treatment given in private practice to the rich and to the poor. In most cases, particularly in prosthetic restorations, the rich can have a superior appliance, and by no means can it be classed as " fancy treatment." For instance, a skeleton metal partial denture is the best t3~e of prosthesis for the restoration of a few missing teeth. This type of denture allows the patient to retain feeling and taste, together with the natural secretions of the mouth. Furthermore, it prevents the degeneration of the interdental tissues which occurs when they are permanently covered and irritated by the presence and pressure of a bulky denture fitted round the teeth. This type of skeleton east or struck prosthesis is much more expensive to produce than the usual type. If a public dental service is to be efficient, and if the public are to be given facilities for receiving the best and latest form of treatment, equal to what one would give a well-off private patient, then provision will have to be made for the skilled preparation of such things as the skeleton prosthesis referred to, jacket crowns, bridges, etc. Fortunately, the advent of the acrylic resins has very much simplified the technical process and reduced the cost of making such appliances as jacket crowns.
PUBLIC HEALTH, October, 1945
7
T h e dental profession must fight against the use and acceptance in any public service of out-of-date procedures, appliances, and treatment. Premises
At the moment possibly the greatest failing in the School Dental Service, other than shortage of staff, is the lack of adequate and respectable premises. While some of our city clinics have excellent equipment and are perfect examples of modem health centre architecture, yet the conditions under which rural dental officers have to work are appalling. What enthusiasm can the public have for accepting the benefits of modem dental treatment, and what sort of a service does a public health authority expect, when the dental officer is not only underpaid but is allowed to work in barns and hovels which are dirty and have no light or even water supply ? T h e answer is not to be found in the use of dental trailers. T h e disadvantages of limitation of space, heating, and transport difficulties, and the influence of climatic conditions, have convinced many experienced dental officers that their utility is over-rated. Every school which is not served by a central clinic should have a specially built medical and dental room. Conclusion
A healthy mouth is of vital importance. T h e dental surgeon alone is qualified to undertake this specialised work. If the public health authorities are to give the people an efficient dental service they must be prepared to provide adequate facilities for treatment, suitably remunerated officers to carry out the treatment, and an advisory and educational service which will school the public in the essentials of personal and communal health. NATIONAL MILK T E S T I N G AND ADVISORY SCHEME THE RESAZURIN
TEST AND THE BLUE TEST
METHYLENE
The National Milk Testing and Advisory Scheme, which has been operating since June, 1942, was designed by the Ministry of Agriculture to prevent, by means of routine testing of producers' milk supplies and consequent advisory work, large-scale losses of milk through souring. The test is carried out by the staff of the provincial advisory bacteriologists of the Ministry's Agricultural Advisory. Service. The test employed is the routine resazurin test, and as the relation of this to the methylene blue test is sometimes misunderstood, the Ministry of Agriculture and Fisheries has issued an explanatory leaflet, which we here reproduce. Comparisons have been made between results of the routine resazurin test and those of the methylene blue test, and apparent discrepancies between the two sets of results have led to some confusion and misgiving among those not familiar 'with the technical points involved. These two tests are essentially similar and depend on the capacity of bacteria in milk to bleach certain colour dyes. T h e Milk (Special Designations) Order, 1936, requires that T . T . and accredited milk, sold raw, should satisfy a methylene blue test after a period of storage. During the months of May to October inclusive the milk must not decolorise methylene blue in 4½ hours ; during the months of November o April inclusive methylene blue must not be decolorised n 5½ hours. U n d e r the National Milk Testing and Advisory Scheme the milk is examined by a resazurin test. This is also a colour test, but the colour change in the case of resazurin is continuous, and it is possible to compare the colour of the sample after any agreed incubation time against a standard set of colour discs. These are numbered 6 to 0, disc 6 being the initial colour, and disc 0 representing complete decolorisation. Time is therefore saved, because a result may be obtained in many cases in a shorter time than would be required for complete decolorisatioh. Instead of winter and summer standards a day-by-day adjustment is made based on the mean atmospheric temperature, and is achieved by altering the incubation time. At present the incubation times vary from 15
minutes, when the mean is over 60 ° F., to two hours, when the mean is 40 ° F. oi" lower. T h e results are classified as follows : Category " A " (disc reading 4 to 6).--Satisfactory keeping quality. Category "' B " (disc reading 1 to 3½).--Doubtful keeping quality.. Category " C " (disc reading ½ to 0).--Poor keeping quality. Standard techniques are published for both tests (Ministry of Health, Memo. 139/Foods; Ministry of Agriculture, C.158/T.P.Y.). Objeet of Tests
T h e two techniques are designed for different purposes. (a) T h e National Milk Testing and Advisory Scheme is primarily concerned with the improvement of the general keeping quality of milk, and the results of the routine resazurin test classification are used, not to differentiate among the higher qualities of milk, but principally to direct assistance and advice to those farms where it is most needed. (b) T h e Milk (Special Designations) Order defines certain high quality milks, for which a higher price is paid to the producer. T h e results of the methylene blue test are used to ensure that samples do not fall below a certain standard. Briefly, the results of the resazurin test are being used at present primarily as a basis for farm advisory work, whereas the results of the methylene blue test are being used to fix a datum below which high quality must not fall. Comparison of ResuRs I n view of the above it might be expected that no samples which satisfied the methylene blue standard would show results other than in Category " A " by the routine resazurin test, and conversely, that samples classified in "Category " B " or " C " by the resazurin test would not pass the methylene blue test. Results prove that in the main this is so, but it does not follow that exact agreement will occur in all cases. I n fact a true comparison is not possible in individual cases. There are important differences in respect of the times and conditions of storage of samlbles prior to testing, and differences in the method of compensating for changes in atmospheric temperature. These, and the other chief points of difference, are discussed below, and summarised in a table at the end of this note.
ATMOSP.HERICTEMPERATURE Designated milk is submitted to the methylene blue test, which requires the sample to be incubated in a water bath at a temperature of between 37 ° C. and 88 ° C. for 5½ hours during the winter months from November to April, and for 4½ hours from May to October. T h e routine resazurin test, to which the milk is submitted under the National Milk Testing and Advisory Scheme, requires that the period of incubation in the water bath, at 37 ° C. to 38 ° C., shall be determined by the mean atmospheric temperature of the previous 24 hours. T h e incubation period varies from 15 minutes when the mean atmospheric temperature is over 60 ° F. to two hours when the mean atmospheric temperature is 40 ° F. and under. Apart from day-to-day differences, it is clear that there may be extreme differences due to compensation for temperature both in very hot and in very cold weather when samples tested under the methylene blue test continue to be subject to only normal " s u m m e r " or " winter " standards. Designated milk samples are thus subject to a " calendar " or " seasonal " compensation scale and the N.M.T.A.S. samples to a daily "atmospheric temperature " compensation scale. Consequently the results of the two tests are not strictly comparable, even if obtained on the same milk. AGE AT TESTING There is an essential difference in the age and conditions of storage of the samples before examination by the two tests, and this has a considerable effect on the interpretation of the results obtained. I n the methylene blue test the sample is aged by storage at atmospheric shade temperature for 12 or 18 hours according to whether it is morning or evening milk, whereas in the resazurin test the sample is kept at atmospheric shade temperature for 24 or 28 hours.
So much for midwifery. What about the child ? Is the present division at five years of age to remain ? In 1943 your Committee presented a memorandum t o the Council of the Society in which, among other things, they recommended that the Maternity and Child Welfare Service---not the Child Welfare Service o n l y - - a n d the School Medical Service should be amalgamated. W e wished to emphasise the importance of regarding the mother and child as one unit. Not every practitioner has the right temperament to undertake work of this kind, nor can it be easily fitted in to the rush and tumble of ordinary curative work. It is, in fact, specialist work. Here again the general practitioner may have a special interest in and knowledge of the positive approach to child health. He will not take just an odd clinic here and there to make a few extra guineas, but will devote a definite and reasonable proportion of his time to this work. Even so, the bulk of the work will continue to be done by the whole-time specialist child welfare officer. Some of these officers may in time pass o n to be consultant paediatricians, as we at present understand the meaning of that term. In the future, no one w h o aspires to consultant rank in paediatrics should be considered to be adequately qualified until he has had adequate experience of such work. T h e r e will be many others, however, whose interest will continue to be on the preventive side r a t h e r than the curative, and who will have no wish to be curative physicians, consultant or otherwise. T h e y wilt wish to continue to have association with the hospital to give their own work balance, but their main interest will be in advisory and educational work such as is carried on at present in our clinics. In the future Maternity and Child Welfare Service there will probably be, in the larger urban areas at least, wholetime public health medical officers whose main interest will be maternity and the care of young infants for at least the neonatal period, if not longer, and others whose work will be among all children up to the age when they leave school. In other areas such differentiation will not be possible, certainly not for a long time to come, and medical officers will continue to be much as they are now, doing ante-natal and infant welfare and school medical work ; but, it is hoped, they will be able to have continued contact with the hospital, which they lack at presen t . It is regrettable that in some of the plans for Child Health Institutes the importance of the association with the Maternity and Child Welfare Services has been overlooked. T o reiterate, the mother and child are one u n i t ; they are not, however, a unit living in space but a unit living in a social environment w h i c h e x e r c i s e s a powerful influence on them. Take as an example the care of the unmarried mother and the illegitimate child. During the pregnancy the mother must be cared for not only medically but socially. She must be suitably housed, whether in her own home, in a hostel, or in lodgings. She must be assisted to make arrangements for her confinement and after delivery she must be encouraged and helped to do what is best for her child. Once again, in the early months, at least until her plans are made, shelter must be found for h e r - - n o t so easy this t i m e - - a t home, in a hostel, or in lodgings. If she decides to keep her child, she still needs assistance morally, if not materially, long after the end of the child's first year of life. Recently in Birmingham we have had a salutary shock. We are rather pleased with our arrangements for the care of the unmarried mother and her baby. Twice within the past five years has the illegitimate infant mortality rate been lower than the legitimate rate--a very satisfactory reward for our intensive care. Recently our health visitors reviewed the illegitimate children under five in their districts and commented on their condition from the physical, mental, and economic standpoints ; 91% of these children were with their natural mothers, but in only 60% of the cases were their condition and circumstances wholly salisfactory. Clearly there is more to be done for these children, and any scheme for improvement must take into consideration not only the child but also the mother and the environment of them both during the whole period, from the time of the pregnancy onwards. T h e work of the midwife and the health visitor, too, must be closely integrated.
3 Administration
Finally, a word about administration. Whatever may happen in the future, the need will remain for co-ordination in the administration of the Maternity and Child Welfare Services, in its widest sense. T h e administrator should be a medical administrator. T h e r e are some areas, usually counties, which are divided up in such a way that one medical officer is responsible for all the public health medical services in the area but has no responsibility for the planning of policy. Some one at head office may be thinking in terms of the Maternity and Child Welfare Service as a whole, but judging by the results as one sees them in the field this is not always apparent. In any event, no one is specifically designated as the administrative maternity and child welfare officer. In other areas the two services have been divided and there are two administrative officers--one for maternity and one for child welfare. In these circumstances one often finds that each of these officers is in fact a specialist clinician and not an administrator at all. It is difficult if not impossible to organise a complete and co-ordinated service for mother and child with an administrative set-up of this kind. N o t only will there still continue to be need for such administrative maternity and child welfare officers as there are at present, but it is to be hoped that areas of suitable size which are without such officers will appoint them in the future. In the smaller areas, one medical officer might be responsible for the administration of the Maternity and Child Welfare and School Medical Services. In the larger areas, for the time being at least, the present arrangement with one administrative medical officer for maternity and child welfare and another for schools may well continue, although there, too, at some future date, we may see an amalgamation. T h e observations made about the need for co-ordination in the administration of the Maternity and Child Welfare Service apply with even greater force to the central government departments. In the new planning of those departments, maternity should not be separated from child welfare, and the medical services for mother and child should be the sole responsibility of the Ministry of Health. This very desirable goal will not be achieved easily. Our negotiators will indeed deserve our congratulations and thanks if they succeed in overcoming the inertia which confronts them.
THE
PUBLIC
DENTAL
SERVICE
By J. J. HODSON, L.D.S., R.C.S. (EDIN.),
Dental Officer, Warwickshire C.C. It is proposed to discuss some of the factors which should be considered in the appointmeht of public health dental officers, their status, and the conditions under which they work. In the first place it is essential that the appointment of a dental surgeon to a public health authority be as carefully considered as to his suitability and qualifications (not entirely academic) for the work, as it is that the dean of a dental school should be quite certain that the intending student is suitable for admittance to the profession. T h e public service does not want men who come into it to shirk their responsibilities, and it does not want men who have failed in private practice. Further, it is not to the benefit of the public service that newly qualified practitioners are forced to seek entry solely on the grounds that they have not the capital to begin on their own account. In considering appointments for the Public Health Service, attention should be paid to attracting the right man, the man who wants and is suited to a public appointment, and is fully aware of the responsibilities. In some quarters there appears to be an idea that to be a public dental officer is an easy way of making a living. If the surgeon works conscientiously this is far from being the case. T h e School Dental Officer, in particular, must possess a great store of " n e r v o u s energy," and although he may work shorter hours than his colleague in private practice the shorter hours do not entirely recompense him for what is an arduous and difficult career.
6 Dental Paediatries
T h e present method of directing dentists not suitable for the armed forcea into the school service is not a happy one. T h e dental paed~atrician is a specialist in a very important sphere. What does the raw graduate know about the handling of babies and children ? Children demand a special technique which is vastly different from that employed in the treatment of adults. T h e lack of training in our hospitals for this important work is to be deprecated. The young surgeon leaving hospital has had little or no experience in treating children's mouths from a developmental point of view. Dental paediatrics is something more than fillings and extractions. T h e s e are only items in the treatment of the young mouth. There must be planning, after a careful study and considered diagnosis have been made of the mouth and the condition likely to be reached when fully developed. T h a t is why it is much better to obtain the parent's consent to treatment of the child during the whole school life, rather than from year to year ; then, from the age of 2 to 15 or 16, a planned accurate system of treatment can at least be attempted. It is useless to attempt odd fillings here and there and some extractions without due regard to development and adult result. The Curriculum Those who wish to become dental paediatricians need training and special supervision, and a special department of dental paediatrics should be set up in our dental schools. A special six-months' postgraduate course should also be instituted specifically for those intending to enter the Public Health Service. A certificate should be issued which would satisfy the chief dental officer and his committee that the applicant for an appointment is at least basically qualified to undertake his special duties. Such a course would include the subjects of orthodontics, maternity and child welfare work, anaesthesia for children, statistics, the working of a public health scheme, etc. T h e curriculum in our dental schools should include a course of lectures on the public health aspect of dentistry; the lecturer should preferably be a dental officer already engaged in public health work. His council should permit him to hold this appointment and to draw the salary appropilate to it. A public health authority should have on its dental staff a consultant specialist dental paediatilcian to advise the dental officers on any case which they feel calls for another opinion. Qualities of the Chief Dental Officer
In the appointment of chief dental officers consideration should be paid to organising ability, and a personality such as will create a spirit of co-operation and team work among the rest of the staff. He should be entirely responsible for the running of his own department and be directly responsible to the Health Committee. He must be a man of high professionat standard and be paid a salary in accordance with his position and the dignity of his profession. In the treatment of the maternity and adolescent classes the dental officer must be of good general practising ability and capable of treating all those cases which call for specialised knowledge --e.g., the patients in any of the Council's hospitals. To help this type of officer and to advise on major oral problems a dental surgeon should be appointed as consultant on oral surgery to the Council. Abnormal and difficult cases which are met with should, if the officer wishes, be referred to this specialist. Working FaeEi~ies A public health authority must provide facilities where other than routine dental operations can be carried out. Even in school dental work there are cases that cannot and should not be treated in the ordinary dental clinic. Facilities for beds in hospitals, the use of special equipment and nursing help, must be provided where the dental surgeon concerned or the dental specialist can perform dental operations in confortuity with modem standards and conveniences to which he and the patient are entitled. A good chief dental officer will do much to guide the responsible committee in the ways
PUBLIC HEALTH, October, 1945 of m o d e m oral surgery and modem dental treatment, planning, and methods. I n the matter of equipment, though some standardisation is obviously necessary, it must be adequate in variety of design and of the best quality. I n a satisfactory dental service provision must be made for an efficient yet simple system of record keeping. A patient's medical and dental history record is almost as important to the surgeon as the patient himself. Statistics and Reports
There is also the thorny question of statistics and returns. Dental treatment is such that if the patient is to get the full and lasting benefit from the service, the treatment must be complete. Unfortunately, and it is mainly due to our own fault, the public have learned to think in terms of an " itemised " surgical procedure. Public health reports showing the numbers of fillings, extractions, etc., and purporting to inform the public of the progress of dental treatment, are as misleading and as useless as a report showing the n u m b e r of applications necessary to cure a number of cases of impetigo. T h e most important information for any board or committee, or for the general public, is information concerning the n u m b e r of mouths made healthy. Detailed items are useful only for research and investigation. Moreover, the piecework method of portraying the activity of the dental surgeon is most deplorable. It is unparalleled in any other sphere of medicine or surgery. It bears no relation to the new outlook in diagnosis and treatment in m o d e m dental surgery. T h e teeth are merely parts of one organ, the organ of mastication. They are surrounded by one continuous soft tissue, the gum. I n place of the number of fillings, we should record the n u m b e r of cases o f caries treated--/.e., whole mouths, and instead of scalings and gum treatments we should record the n u m b e r of treated cases of gingival conditions or lesions, and above all the n u m b e r of mouths made healthy. Parodontal Disease
If a satisfactory scheme for the dental treatment of the general population is put into practice, the dental profession will have to deal much more seriously with the gum conditions known under the general heating of parodontal diseases, than they have hitherto done. I n people above the ages of 18 to 20, parodontal disease is a more urgent public health problem than caries. At the moment we seek to preserve the teeth of the school population so that they will retain them in adult life. It is not much use doing this if, when adult life comes, they lose their dentitions through parodontal disease. Restorative Treatment
Public authorities will have to come to an understanding about the various forms of restorative treatment. There is a difference between the type of treatment given in private practice to the rich and to the poor. In most cases, particularly in prosthetic restorations, the rich can have a superior appliance, and by no means can it be classed as " fancy treatment." For instance, a skeleton metal partial denture is the best t3~e of prosthesis for the restoration of a few missing teeth. This type of denture allows the patient to retain feeling and taste, together with the natural secretions of the mouth. Furthermore, it prevents the degeneration of the interdental tissues which occurs when they are permanently covered and irritated by the presence and pressure of a bulky denture fitted round the teeth. This type of skeleton east or struck prosthesis is much more expensive to produce than the usual type. If a public dental service is to be efficient, and if the public are to be given facilities for receiving the best and latest form of treatment, equal to what one would give a well-off private patient, then provision will have to be made for the skilled preparation of such things as the skeleton prosthesis referred to, jacket crowns, bridges, etc. Fortunately, the advent of the acrylic resins has very much simplified the technical process and reduced the cost of making such appliances as jacket crowns.
PUBLIC HEALTH, October, 1945
7
T h e dental profession must fight against the use and acceptance in any public service of out-of-date procedures, appliances, and treatment. Premises
At the moment possibly the greatest failing in the School Dental Service, other than shortage of staff, is the lack of adequate and respectable premises. While some of our city clinics have excellent equipment and are perfect examples of modem health centre architecture, yet the conditions under which rural dental officers have to work are appalling. What enthusiasm can the public have for accepting the benefits of modem dental treatment, and what sort of a service does a public health authority expect, when the dental officer is not only underpaid but is allowed to work in barns and hovels which are dirty and have no light or even water supply ? T h e answer is not to be found in the use of dental trailers. T h e disadvantages of limitation of space, heating, and transport difficulties, and the influence of climatic conditions, have convinced many experienced dental officers that their utility is over-rated. Every school which is not served by a central clinic should have a specially built medical and dental room. Conclusion
A healthy mouth is of vital importance. T h e dental surgeon alone is qualified to undertake this specialised work. If the public health authorities are to give the people an efficient dental service they must be prepared to provide adequate facilities for treatment, suitably remunerated officers to carry out the treatment, and an advisory and educational service which will school the public in the essentials of personal and communal health. NATIONAL MILK T E S T I N G AND ADVISORY SCHEME THE RESAZURIN
TEST AND THE BLUE TEST
METHYLENE
The National Milk Testing and Advisory Scheme, which has been operating since June, 1942, was designed by the Ministry of Agriculture to prevent, by means of routine testing of producers' milk supplies and consequent advisory work, large-scale losses of milk through souring. The test is carried out by the staff of the provincial advisory bacteriologists of the Ministry's Agricultural Advisory. Service. The test employed is the routine resazurin test, and as the relation of this to the methylene blue test is sometimes misunderstood, the Ministry of Agriculture and Fisheries has issued an explanatory leaflet, which we here reproduce. Comparisons have been made between results of the routine resazurin test and those of the methylene blue test, and apparent discrepancies between the two sets of results have led to some confusion and misgiving among those not familiar 'with the technical points involved. These two tests are essentially similar and depend on the capacity of bacteria in milk to bleach certain colour dyes. T h e Milk (Special Designations) Order, 1936, requires that T . T . and accredited milk, sold raw, should satisfy a methylene blue test after a period of storage. During the months of May to October inclusive the milk must not decolorise methylene blue in 4½ hours ; during the months of November o April inclusive methylene blue must not be decolorised n 5½ hours. U n d e r the National Milk Testing and Advisory Scheme the milk is examined by a resazurin test. This is also a colour test, but the colour change in the case of resazurin is continuous, and it is possible to compare the colour of the sample after any agreed incubation time against a standard set of colour discs. These are numbered 6 to 0, disc 6 being the initial colour, and disc 0 representing complete decolorisation. Time is therefore saved, because a result may be obtained in many cases in a shorter time than would be required for complete decolorisatioh. Instead of winter and summer standards a day-by-day adjustment is made based on the mean atmospheric temperature, and is achieved by altering the incubation time. At present the incubation times vary from 15
minutes, when the mean is over 60 ° F., to two hours, when the mean is 40 ° F. oi" lower. T h e results are classified as follows : Category " A " (disc reading 4 to 6).--Satisfactory keeping quality. Category "' B " (disc reading 1 to 3½).--Doubtful keeping quality.. Category " C " (disc reading ½ to 0).--Poor keeping quality. Standard techniques are published for both tests (Ministry of Health, Memo. 139/Foods; Ministry of Agriculture, C.158/T.P.Y.). Objeet of Tests
T h e two techniques are designed for different purposes. (a) T h e National Milk Testing and Advisory Scheme is primarily concerned with the improvement of the general keeping quality of milk, and the results of the routine resazurin test classification are used, not to differentiate among the higher qualities of milk, but principally to direct assistance and advice to those farms where it is most needed. (b) T h e Milk (Special Designations) Order defines certain high quality milks, for which a higher price is paid to the producer. T h e results of the methylene blue test are used to ensure that samples do not fall below a certain standard. Briefly, the results of the resazurin test are being used at present primarily as a basis for farm advisory work, whereas the results of the methylene blue test are being used to fix a datum below which high quality must not fall. Comparison of ResuRs I n view of the above it might be expected that no samples which satisfied the methylene blue standard would show results other than in Category " A " by the routine resazurin test, and conversely, that samples classified in "Category " B " or " C " by the resazurin test would not pass the methylene blue test. Results prove that in the main this is so, but it does not follow that exact agreement will occur in all cases. I n fact a true comparison is not possible in individual cases. There are important differences in respect of the times and conditions of storage of samlbles prior to testing, and differences in the method of compensating for changes in atmospheric temperature. These, and the other chief points of difference, are discussed below, and summarised in a table at the end of this note.
ATMOSP.HERICTEMPERATURE Designated milk is submitted to the methylene blue test, which requires the sample to be incubated in a water bath at a temperature of between 37 ° C. and 88 ° C. for 5½ hours during the winter months from November to April, and for 4½ hours from May to October. T h e routine resazurin test, to which the milk is submitted under the National Milk Testing and Advisory Scheme, requires that the period of incubation in the water bath, at 37 ° C. to 38 ° C., shall be determined by the mean atmospheric temperature of the previous 24 hours. T h e incubation period varies from 15 minutes when the mean atmospheric temperature is over 60 ° F. to two hours when the mean atmospheric temperature is 40 ° F. and under. Apart from day-to-day differences, it is clear that there may be extreme differences due to compensation for temperature both in very hot and in very cold weather when samples tested under the methylene blue test continue to be subject to only normal " s u m m e r " or " winter " standards. Designated milk samples are thus subject to a " calendar " or " seasonal " compensation scale and the N.M.T.A.S. samples to a daily "atmospheric temperature " compensation scale. Consequently the results of the two tests are not strictly comparable, even if obtained on the same milk. AGE AT TESTING There is an essential difference in the age and conditions of storage of the samples before examination by the two tests, and this has a considerable effect on the interpretation of the results obtained. I n the methylene blue test the sample is aged by storage at atmospheric shade temperature for 12 or 18 hours according to whether it is morning or evening milk, whereas in the resazurin test the sample is kept at atmospheric shade temperature for 24 or 28 hours.