- Email: [email protected]
Undergraduate education
H.
A.
Ph2LisviEle,
HANNETT,
B.S.,
D.D.S.*
Ey.
INTRODUCTION
of the most frequent observations of men who have the temerity to speak in public about any orthodontic education problem is that during the years ahcad WC must build a better orthodontic ~~ndergraduat.e curricul~lm for ow student program (for our children, as it were). It is a noble statement which r’spresses the aspirations of every teacher. Yet> over the years it has becomes an almost meaningless clich&, because all too often we who make the speeches fail to go beyond our speeches. We content ourselves with the broad generalities, possibly because we ourselves have too little idea of exact.ly what we mean. In the spirit of making the thought the father of the deed, I will try to get down to some specifics, to set up some standards; and t,o discuss some minimum rcquiremcnts which, it seems to me, have direct bearing on this better orthodontic curriculum for our future students. I want to discuss the essentials of a successful l~ndergraduate program which, when lacking, can destroy it.
ONE
HISTORICAL
DEVELOPMENT
OF
UNDERGRAD7~~~TE
ORTHODONTIC
TEACHIXG
It does not seem necessary to go back to the beginning of undergraduaic orthodontic teaching. Others have done this very well and have reported in the lit,erature from time to time. More than 35 years ago William J. Gies’ stated, in the Carnegie Survey of Dental Schools in the United States and Canada: “ ThertI is a great need for closer correlation of the dent~al curriculum with the demands of the actual practice of dentistry. ” Even then there were not enough qualified orthodontic specialists to cope with the demands of the actual pract,icAe of orthodontics. In the last 30 years, there have been at. least four major admonitions on orthodontic education. Presented ah 28, *2nstructor,
at 1963.
the School
Conference of Dentistry,
on Orthodontic University
Education, of
Louisville.
Pittsburgh,
‘Fe.,
M~I&
27
508
Hannett
The first was the 1935 Report of the (‘urriculum Survey Committee of the American Association of Dental Xchoo1s,2 which indicated the great need for a closer correlation of the curriculum and the demands made on the dmltist’ in private practice. This survey pointed to the lack of st,andardization and the inadequacies of the undergraduate curriculum. It also enumerated the 01~ jectives by which undergraduate tGning could bc made more uniform and thus give the dental student adequate training. I!nfort~unately, those men rcsponsible for undergraduate orthodontic teaching felt that the criticisms wc’r~ directed to other phases of dentistry and paid little attention to the report 01 to the recommendations that it contained. A second academic milestone with immediate orthodontic implications was the excellent evaluation of undergradnatc training presented to the American Association of Dental Schools in 1949.‘+.4 The same criticisms were made, the same objectives were stressed, and recommendations w\‘crc made to implement, the report. Orthodontic educators listened, but, as one observer has put it, they thought : “Surely this is not for us-they must mean the people teaching operative, or prosthetics. ” In 1958 the Orthodontic Workshop in Ann Arbor,j sponsored jointly by the Kellogg Foundation and the American Association of Orthodontists, gal-c orthodontics a third opportunity to get its academic house in order. This beautifully organized conference brought together the clinical and didactic leaders of the profession. The proceedings, as published by Meyers and Jay” in Orthodontics in Mid-Century, are a tribute to t,he diligence and determination of all to solve our problems. In a spirit of true self-analysis, att,cmpts were made to study our educational ills and provide ans\ycrs t,o the many questions posed. Answers were given, recommendations were made, and both graduate and undcrgraduate education had but to implement the rccornnlrndations. To date, however, it would appear that, whiIe we recognize our problems, w’c have not undcrtaken their solution even though the way has been clearly pointed out to us. Adams6 wrote, in 1962: “It is interesting but disheartening to note that the same objectives, with slightly different wording, wcrc suggested in the ‘Report, of the American Association of Dental Schools in 1935.’ ” I was a member; of the committee assigned to study undergraduate tcaching at the 3958 Workshop. Adams wrote further: “In this same workshop rcport, in a discussion of aims and objcctivcs of undergraduate orthodontic education, the following significant statcmcnt was made : Since no to be adopted nature. ’ ’
undergraduate as a standard,
orthodontic: orthodontic
training teaching
program in all
has schools
attained sufficiwt swcess ha.q been cxpcrimental in
This is hardly a favorable commentary on a mature and established program. In 1960, in his presidential address before the American Association of Orthodontists in Washington, I). C., Anderson’ warned that WC arc being severely criticized for failing the profession by not fulfilling teacher needs; that we should try to stimulate interest and develop a list of men available for teaching assignments.
That the time is now ripe for action is emphasized by Xdamq6 in his article on ’ i The Challenge of Orthodontic Education ’ ’ and by Abel8 in his article cntit14 ” Hociocconomic Trends Relating to Orthodontics, ” both of which appearc~cl in the l)wemher, 1962, issue of the AMERICAN JOURXAL OP ORTH~DOXTICS. It is further emphasized by Graber’9 most complete and provocative study entillcd I’ Arr Orthodontic Educational Opport,unities Adeyuattl? ” I urge you to wad tlrwc soul-searching analyses. I am confident that we shall not leaw this WE f’crcnw \vith platitudes to serve as yet another well-meaning but inrffwtr~al effort
What is the status of orthodontic education now”? ~\n impartial ohscrv~~l might facet,iously label this section “ The Impending I)cmiw of L’ndergraduato Orthodontics ’ ’ ox “If the Orthodontist Doesn’t Want It, Someone Else Will” I The basis for such a judgment, is easy to find if we look at t,he number of nonrcgulnted courses being given to general practitioners by general practitioners on bitt plates, guide planes, modified EIawleys, space maintainers, space rw gainers, functional appliances, extraoral force, etc. Thcw arc signs of a tiyilight zone takrovcr on an international scale that \vc cannot ignore. Ewn a cursory examination of graduate and undcrgraduatc pedodontic curricula and semiofficial statements made in the pedotlontists’ journal on the SCO~Cof pedodontics indicates an increasing interest in t,he specialty of orthodontics. This magnetic attraction of orthodontics for the pedodontist, has twn attributed to several factors. Both orthodontic and pcdodontit department,s work on children, and the two departments arc of’tc>n thrown together becauw oi inadqnatct facilities. Graber” writes : “1:~ 01’ tli(a same facilities in training. constant association with orthodontists, great public demand for orthodontics a~~cl the inadcynate supply of trained specialists. the seeming simplicity 01 ilpp1kUlCe adjustments to some who arc not il\Viil’t’ of the t rcmendons drmantls in ~1inical training and judgment, and other considerations hay-e teamed togetht>l. to b~aden the pcdodontic horizon by trespassing on orthodontics. ” >1t prcwnt, several dental schools arc either contcmplnting or have alrwd~ (2r(~ilt4 a childrw~ ‘s department-heacfcci by a pc~dotlontist. More antI mot’( pedodontists speak in the vernacular of the orthodontist ; more and more JW dodontists are doing more and more orthodont,ics ; alt increasing number o 1 pc~tlodontists arc limitin g their practices to orthodontics as bona fitlc nwm twl5 ol’ the Intwuational Academy of Orthodontics. These people arc sneaking ill through the back door. Again, quoting from (:rabcr!’ : “ Thus. highly important aspwts ot’ orthodontics, the oldest specialty in dtwtistr\- with the third oldw~ specialty boilrtl in medicine or dentistq-, havcb been arrogat4 b,v persons \r-l~c~ lack the training or ability to treat these cases. For the good of the public \\-(‘ serve, it is imperative that orthodontists safeguarcl thcii* legitimate field nl’ (III (lea\-or. ” (~‘onscicntions dentists are frankly disturbed ovw the lack of adequate orthndontir scrvicc for their patients. Few of them have had the training or espcricrwc~ to permit them to administer to even the simplest orthodontic needs. I~ndw
510
Hannett
Am. J. Orthodontics
July1963
graduate orthodontic indoctrination has been generally inadequate and little continuation education is available for dentists sincerely interested in rendering limited services within the framework of general practice. The less conscientious dentists often consider the service aspect subordinate to the material return. These men have turned to so-called orthodontic laboratories, commercial opportunists which prey on the profession by pointing out the pecuniary return possible and ply the dentist with literature pointing out the seeming simplicity of orthodontic manipulations: ‘LDo~tor, send us your models and we mill design and fabricate an appliance that is guaranteed to do the job. Full instructions are enclosed with each appliance, outlining in detail the adjustments to be made each time. Try our consulting service. Send us your plaster models in the enclosed convenient carton. You are under no obligation. ” Such lures are not calculated to increase the amount or to uplift the level of professional orthodontic service. Joseph D. Eby has said that two thirds of the orthodontic treatment in New York City is done by the general practitioner. If me do not believe it, he says, ask the laboratories. At this very moment too many general practitioners arc learning more orthodontics from commercial laboratories that are sending informative pamphlets through the mails, diagnosing, planning treatment, and constructing appliances without prescriptions than they did in the entire undergraduate program during their school pears. The orthodontist cannot consider himself blameless for the situations just described. He has been preoccupied with training the specialist and with graduate orthodontic courses. The demands of private practice are overwhelming, and it is not necessary to enumerate the relatively more favorable circumstances that heighten the appeal of this choice as opposed to semidependent and underpaid institutional affiliations. Enough men have examined the inside of the halo surrounding the summit of the “Halls of Ivy” to observe that the golden glow of prestige, the attraction of intellectual camaraderie, and the mellifluous appeal of such ego-inflating titles as ‘(professor” often coat only the surface. Beneath the golden glow are the endemic problems of politics, petty jealousies, interdepartmental rivalries, personal animosities, and red tape to hamstring the dedicated pedagogue. Severe staff shortages plague the graduate courses, too. Since most orthodontic graduate departments are part of the university graduate school, there is relatively more uniformity and control, but it is no secret that the variability from school to school is greatly excessive. I refer you again to Graber’s” article in the February issue of the AMERICAS JOURNAL OF ORTHODONTICS for an elaboration of this point. Whatever problems graduate orthodontics has, undergraduate orthodontics can say, “Me too, only more so ! ” The same problems of course content, staff, and facilities must be solved. If we are to continue with any degree of autonomy, we must have some definite goal, set up some very definite standards, and provide some basic guidelines. It is necessary at this meeting for us to come to some agreement, regardless of preconceived ideas. We must attack this problem with an open mind-prepared to compromise if necessary, for the good of orthodontics. If we listen only
until. it is our turn to speak our piece, then WC’will not get far. We do not, seem to realize that without a collective knowledge of dir&on-of where WC are going-we cannot very well get anywhere ! \Vhc!tht~r w like it or not, WC’ are at this moment at the very crossroads of orthodontic education at the undergraduate level in the dental school, Let us now discuss course content, staff, and facilities, in that order, and then make some recomnlendatiorls. COURSE
CONTENT
From time to time on the great ships which ply the oceans of the world, an officer will walk to the wing of the navigation bridge, raise his sextant to his the sun. He will then make the necessary calculations and eye, and “shoot” determine his exact position. He will compare his exact, position with the position that he should be occupying and, if there is a variance, make the necessary corrections by steering a slightly different course. This is navigation, and it keeps the ships arriving at the ports toward which they are sailing. They stay on course.
I believe that teachers should do a similar thing. From time to t,ime every teacher of undergraduate orthodontics should ask himself : “Am I sure I know the destination toward which I am sailing? What is the point in time that I have set as target date for arrival? Am I now on coursc:2” It works in navigation. Teaching is a kind of navigation-getting rronr where wc were, or are, to the point that we have decided to reach. A teacher without a settled purpose, as Carlgle put it, is like a ship without a rudder. He is subject to every wind and tide. He sails first this way and then t,hat way. If a landfall should appear on the horizon, he would not knorr what it is-or where it is-or whether it is worth sailing toward. This is a nictl analogy, but what happens if there are three or four landfalls? There may 1~: two or three stars in the sky that permit ccl&al navigation, all leading in different directions. Depending where hc lands, thc~ orthodonbic teacher may find that he has aimed for one course which is called “orthodontics’ ’ bnt consists of little mere than anthropology, comparatiyc anatomy, development of occlusion, and growth and development; or his st~md landfall may bring him in cont,act with a course that has the undergraduate students handling all sort;; of appliance problems and treating cases routinely in the clinic. Which is right! Whose star should he follow? Does the brightest star always lead in the right direction? We had better decide that if none of the choices scem right, we might as well put up our own navigational satellite in the orhit which we collectiveI> believe is calculated to serve the public and the profession best. A good place, to start is with the objectives recommended in 1952 by tile Education Comnriti CC” OSthe American Association of Orthodontist,s :I” :I. The anticipation and detection of malocclusion. 2. The prevention or interception of malocclusion wherever possible. 3. The treatment of simple cases or the simple immediate problrms of complex cases. (I would differ somewhat with this objective.) 4. The use of this knowledge as an adjwnct. to procedures in all other phases of dental practice.
5 12
IIwnne
tt
5. The acquisition of skill in detcrrninin, 0 which cases to avoid ant1 which to refer to more experienced men in the field. Here arc the same ubiquitous ohjcctivcs, having arm again withstood the test of committee investigation and the test of time. Why, then, has all of this undergraduate t,caching been as cxperimcntal as the Michigan Workshop reported? One reason is the major confusion of terms. We have a host of terms, some synonyn~ous to some people but very different to others. In 1913 Lischcrl’ admonished 11s to develop a greater uniformity of terms, and we are still doing just that, Again, what we need are some very definite guidelines, some very specific definitions to aid in the organization of a lecture-clinic program without straitjacketing the individuality of the dedicated teacher. In line with the need for a clearer understanding of terms, &Iayne” has written : “The important thing is to be able to analyst t,he dento-facial complex early and by a differential diagnosis to know whether prerentivc, interceptive or corrective measures are to be employed. ” In~plementing the A. A. 0. objectives, Mayne defines these terms as follows: Preventive orthodontics is t,he action taken to preserve the integrity of what appears to be normal occlusion at a specific tirne. Interceptive orthodontics irnplies that an abnormal situation exists. When there is a manifest malocclusion developing because of a hereditary pattern or extrinsic or intrinsic factors, certain procedures may be taken to lessen the severity or to eliminate the cause. Corrective orthodontics recognizes the need for employing technical procedures to reduce the problem, usually requiring mechanics and demanding special training. I urge you to accept these definitions, so that we may have some definite guidelines to follow. The welter of terms, such as limited orthodontics, prophylactic orthodontics, pedodontic orthodontics--all apparently synonomous with one group or another and wit,h the three terms defined by Mayne-only confuses the issue. “Preventive orthodontics implies action taken to preserve the integrity of the occlusion after analysis has revealed that a normal occlusion exists. Thus preventive orthodontics attempts to maintain the occlusal status yno; to guard against untoward environmental influences which would change the normal course of events. The early detection of detrirnental tongue, lip or thumb habit . . . placing of a space maintainer when a deciduous molar is prematurely lost, proper operative care which quickly restores full tooth dimensions and normal contacts [are] actually the very backbone of preventive orthodontics.” one is confronted by a developing fait With interceptive orthodontics, accompli. “This is something quite different from preventive orthodontics where one attempts to prevent an untoward occurrcncc, which is being set in motion at that moment. [In interceptive orthodontics] one then faces the challenge of detecting such circumstances postnatally and employing measures to intercept
this malocclusion, on its journey to maturity. Thus the early recogrlitiorl Of :L tooth jaw disharmony at age eight or nine and t,hc institut,ing of serial extraction procedures is interceptive orthodontics. ” (lorrcctiw orthodontics assumes the need foil climinat ing i\ frank rnaloccliision. This is principally a matter of appliance thcral)y. fit in this pictarc ? Mayne” Now, whrrc does the gcncral practitioner answers this clearly : “Most preventive mcasurcbs must bc handled by the gctutral practitioner. Such a program requires considerable specialized knowledge, but such knowledge is not beyond the scope of the dental curriculum. lnterceptiv: mcasurw arc generally more complex and it is questionable whether certain of these should be used by the student or general practitioner. (‘orrcctivr procedures fall rnore in the realm of the specialist. ” Nayrle’” lists four prerequisites which the general practitioner should satisfy before he embarks on any interceptive procedures : 1. The dentist must have adequate knowledge of the sub,jwt. Suc~h knowledge, in itself, would eliminate the dcpendcnce of many men on laboratories for guidance or attempts at treat,ment for iinancial rewartl alone. Adequate knowledge would include consultatiw advice and real orthodontic help from a qualified orthodontist, most of whom are willing to help if for no other reason than to ;I\-oid mistreatment, through improper diagnosis by a laboratory. 2. IIc must have a patient under continual care. There is nothing quite so disheartening as to csamine a child anxious for appliances t,o correct ’ Lo~~c~ front, tooth,” only to find t tic four first molars missing, mutilated, or involved with rampant earics. 3. The patient and the parents must rtcognixo that a defect csists. -l. The parents must have confidence in the dentist’s abilit,y to can’> out the rccommendcd treatment program. In 1958 the Michigan Workshop Group I: listed coutw content for undcrgraduate lect~urcs as follows: (I) growth and dcrclopmtrnt, (2) physiology OI occlusions, (a) nomenclature and classification, (4) etiology of malocclusion, (5) diagnosis and case analysis, (6) records, and (7) general principles oC orthodontic therapy. In the A. A. 0. pronouncement I3 in the Ailgust, 1960, issue of the Jwxx-nr,. which was signed by A. A. 0. and A. B. 0. officers, the objectives of undcrgraduate orthodont,ic education were amplified to twclvc headings :
-1. A definition of terms: a, concept,, a diagnosis, and a discipline. Prcvcntivc, interceptive and corrective orthodontics. 1Vhat the tlental student should know about each. 2. Growth and development. 3. Physiology of stomatognathic system. 4. Incidence and recognition of malocclusion. 5. Etiology of malocclusion. 6. Diagnost,ic records and their interpretation.
514
Hannett 7. Unfavorable sequelae of maIoccIusion. 8. Biomechanical principles of t>ooth movcmcnt. 9. General principles of orthodontic thcrnpv , , giving some description of appliances now in use to familiarize students with treatment methods. 10. Preventive orthodontics. 11. Interceptive orthodontics. 12. Corrective orthodontics.
The Michigan Workshop recognized that differences exist among the schools with regard to teacher personnel, teacher-student ratios, facilities, basic science departments, etc. and that the outline was not a hard and fast rule to follow. Likewise, the 1960 A. A. 0. statement was not proposed as a mold for all undergraduate courses. These course content listings are there to show what an ideal course would include, and emphasis must be determined by each teacher. It would not be inappropriate to say that the orthodontist is “setting the boundaries,” so to speak, for those orthodontic considerations that he feels best qualified to teach. He accepts full responsibility for the material included and does not think that choice sections should be delegated to other departments less well qualified to teach the subject. 911 material taught is not necessarily for clinical use. Hardly ! But the general practitioner must know what the orthodontist is trying to do. He should have knowledge of certain orthodontic concepts in order better to apply his knowledge to other phases of the dental curriculum. Orthodontic limitations, percentage of failures, retreatment problems, posttreatment adjustments, etc. must receive due consideration. With respect to the last three objectives listed in the 1960 A. A. 0. statement on specialty practice in dentistry, further study is indicated to develop more definitive guidelines, Preventive orthodontics means many things to many people. The definition stated above would provide much material for the teacher to discuss with the undergraduate. If we are to teach correlation of orthodontics with all other phases of clinical dentistry, we certainly must begin with preventive dentistry, of which preventive orthodontics is but a part. Such problems as abnormal resorption and its association with space deficiencies, space control in the deciduous and mixed dentitions, space maintainers and the prerequisites for their application (whether fixed or functional), caries repair, oral habits as related to prevention, the labial frenum, and occlusal equilibration in both the deciduous and the permanent dentitions certainly afford ample opportunity for the teacher to fulfill orthodontic responsibilities and to give t,hc student orthodontic training and experience not available in any other department. Only he, the orthodontist, can properly correlat,e all facets of prevention to fulfill adequately his primary charge of preventive orthodontics to his student, that of normal occlusion maintenance! Interceptive orthodontics, as defined above, implies that an abnormal occlusion either exists or is developing. There could be some overlapping of prerentive and interceptive procedures, but most people agree that the real difference is in the timing of the services rendered. Abnormal habits and their control,
Volume A-umber
49 ‘i
1 Tndergradua~te
education
5 15
abnormal diastemas, and elimination of premature contacts resulting in possible tooth or mandibular guidance are major interceptive procedures. Perhaps serial. extraction is the most misunderstood procedure under discussion in almost ever? orthodontic circle and study club in the United States today. Completely undt:rstood, properly evaluated, and adequately supervised by informed personnel, wrial extraction is a great satisfaction to those practicing interceptive orthodontics. The sad fact of the matter is that too few orthodontists are pra.cticing wrial estrartion and too few teachers are adequately training eit,her the undergraduate or the general practitioner in the fundamentals of this proceduw. 11 seems to rn(~ that everyone practicing dentistry should bc full? aware of t.hc possibilities of this extremely important orthodontic procedure. ’ * Fully apart’ ” wrtainl; includes the limitations of serial extraction. (treat care must, bc V’S= cwised in 111~discussion of this phase of intercept,ive orthodontics, for unless the pitfalls arc spelled out in great detail a real disserriw to the young patient results. A thumbnail recommendation at this point can only admonish anyorw not. adeyuatcly trained and experienced in the serial txtraction techniqur: to avail himself of the sttrviccs of a trained orthodontist. Serial extraction wrnnol br taught or prarticcd “by the numbers,” and yet the student and the genera i practitioner should be informed ; they should bc taught \\hat (aan be at~complishetl as ~(41 as the great disscrvicc that can be gi\-cn through the improper diagnosis and acWI)tancc of a cast for serial extraction. Only the orthodontist, can propwl~ rvdn;ltc~ such a problem; only he can decitlc the proper time to intcrvcncb uitlr mccllanotherapv; only hc can set up the timctablc for extractions, space maintenanw > and/or appliance therapy. Therefore, it would seem logical that II(~ serial extraction should be attempted withollt an ort,hodontist, in very close c~onsultation. I)e~cl~~~ has stated : “A need exists, how\-or. to define the major areas of dental practice that fall within th(l jurisdiction of each individual spwiality. The American Association of Orthodontists urges that this be done SOthat 110 speciality will find it possible to cstend it,s area (Jt‘ speaializat,ion 1o iwlude scrviws that more properly belong to iinotllcl’ speciality. ’ ! It would uppcar to me that the whole area of serial extraction is only orthodontic. In thr normal course of the day, the general practitioner sees many malo+ elusions that are not ’ ’ full blown. ” Hc does not require advanced technical skills and training to treat many OF these problems. It is with thcsa nralowlusions that limited cwwectiue orthodontics is conwrncd. The anterior cross-bitt., thck csccssivc overbite, the exaggerated curve of Spw, thtt bite plate, the posterior cross-bite, spacr retainers, space closers, ligation of tectll, passive lingual archw constructed and fixed for bilateral space maintenance-all are within the rcal~n of limited corrective orthodontics. liess l.imitctl correctiw procedures must lw l(bt’t to the postgraduate and graduate departments. Bcforc turning to questions of staff and facilities, 1. would like to emphasiw again that the main purpose of the twel\-e points is to srt, definite orthodontica boundaries, indicating the domain of orthodontics in the undergraduate rurriculnm. It is not our aim to require the orthodontic teacher to conform to ali twelve points. iK0 assessment is necessary from the standpoint of emphasis ot’ clock hours. Xach man detcrmincs this himself. But the t\velye points scrw ah
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Hannett
Am.
J. Orthodontics July 1963
a clear statement that this material is primarily orthodontic in nature responsibility for it rests with the orthodontic department only.
and that
FACILITIES
Study Group I of the Michigan Workshop” observed: “The chief obstacles to a successful undergraduat,e program in orthodontics could be lack of teaching time, staff, funds, space, adequate library, and a sympathetic dental faculty and administration.” The tangible factors mentioned directly or indirectly may be placed under facilities and staff. The best possible curriculum falls short unless attention is given to these important considerations. Since orthodcntics plays such a relatively small role in general dental practice, as compared to operative dentistry, prosthetics, crown and bridge, or periodontics, it is only natural that facilities and time are oriented first to give the student a sound background in these subjects. Little time is left over in many cases. For the dental school dean, it is a constant battle as he withstands the assaults of various departments and their requests for funds, time, and facilities. Each man thinks that his department is the most important. Yet orthodontics, by virtue of its physiologic orientation and dynamic character and its constant dependence on material taught in the basic science courses, occupies a unique position as the great correlator of the dental curriculum. Anatomy, growth and development, histology, comparatire anatomy, genetics, physiology, dental materials, periodontics, radiology-all these become much more meaningful to the student. Sufficient time for presentation of the curriculum is a “must. ” Lecture hours should be in the morning, if at all possible. The departmental file should be adequately equipped with well-developed audio-visual aids to assist in course presentation. Stale teachin g material is a miserable opiate, even as regurgitated text, taken verbatim from standard texts and read to the students. This is still seen all too frequently. A laboratory course should be presented, if at all possible. The student needs more than theory; he must gain practical experience in impression techniques, fabrication of study models, band forming, the making of space maintainers and space regaincrs, soldering, welding, and wire bending. I consider the development of a suitable departmental audio-visual facility along the lines of our Kentucky Dental Association program of top priority. The decision was made in 1959 to make a series of color-slide and tape-recorded sequences by well-known clinicians. To date, more than forty sequences have been produced and have been circulated throughout the state. The merit of such a program has been recognized by the A. A. O., and a series of eight to ten fully automated sequences mill be shown at the Association’s 1.963 meeting in Miami in May. If these are received favorabl.v, a permanent Audio-Visua.1 Library will be established in the Central Office for the disseminat,ion of these and other slide-tape series by equally outstanding authorities. You can imagine that such aids will be a boon to undergraduate as well as graduate teaching. Our tentative program for Miami calls for presentations by Burstone on “Root, Movement, ” Gore on “ Crozat Appliances, ” Jarabak on “Differential Light Growth,” Mayne on “Serial Extraction,” Forces, ’ ’ Krogman on “Physical
Technique, ’ ’ Aloyers on ” The Role of Musculature,” Oliver on ’ * l,abio-Lingual Sims on “ Begg Philosophy, ” Rocky Mountain Products on “The Nuk Sawer St,ory, ’ ! and Unitck on “Resistance Welding, Soldering and llcat Trca.ting. ” Future sequences by Weber on “Twin-Wire Tcchniquc,” Rcitan on “Tissuv \;llIIal)l(~ dt:~XL~tI~l~~~lt?tl IihKlV) (‘hanges, ’ ’ Richer on ’ ’ Bone, ’ ’ CtC. SllOW hO\V (aan be accumulated to augment and amplify the prop~kr undcrgraduatc~ (‘111’riculum. There is no question that these scquenccs may rcdnce the critical staf? problems, if our “giants’ ’ in orthodont,ics will rooperatc \~holt~heart~~tll~ ant1 unse1fishl.v. il
In his February article Graber” writes: “lt has been said many times thilt a school is only as good as its teachers. . . . C;ood st.udents are important alltl physical facilities obviously must be adequate, bnt, the best course falls shorl -wlit,h inadequa.te instruction. Of all the problems in orthodontic education today, that, of staff is the greatest. Solve it, and many others will be solid in the process. ’ ’ If the foregoing statement, made in reference to graduatr orthodontic training courses is valid, it is even more so with respect to undergraduate progranrs. St,udy (iroap I of the Michigan Workshop5 listed the rc~commended tcac*hinc priority in the orthodontic department as follows : 1. I’ndergraduate teaching 2. Interdepartmental consultation 3. (iraduate and/or postgraduate teaching 4. Refresher courses for orthodontists .5. Refresher courses for interceptive orthodont~ics for the general practitioner In actual practice, however, a realistic listing based on the ma.jority present orthodontic departments would be as follows : 1. Graduate and/or postgraduate teaching 2. Refresher courses for orthodontists 3. Undergraduate teaching 4. Interdepartmental consultation 5. Refresher courses for interceptive orthodontics practitioner
ol
for the general
We need more qualified teaching personalitics in our undergraduat,c programs-trained, enthusiastic, cooperative, respected men. Such men exist in orthodontics today. They also exist in kindred specialties, and their enthusiasm for teaching the orthodontic aspects of their specialties waxtls warm. When iu the world arc WC going to put in the first team?
By way of recapitulation, closing.
I want to emphasize srveral points again befort&
5 18
Hannett
1. Historical analysis shows that the pattern was set as early as 1935 and has been repeated several times, only to fall on deaf ears. Wc must get our house in order now with definitive criteria for the undergraduate curriculum. 2. Our status quo belies the dynamic nature of our specialty. Signs point, to the imminent loss of responsibility for orthodontic indoctrination to others more willing to incorporate orthodontic philosophies in t,hcir specialties and to teach them. 3. Present undergraduate courses show a fantastic variability-of such degree as to be termed “experimental ” during the 1958 Michigan Workshop. Minimum standards, uniformity, and the staking out of t,hr legitimate domain of orthodontics are essential now. 4. Orthodcntics, as the great coordinator of dentistry in the undergraduate curriculum, needs more adequate facilities and more time with the students. Utilization of current audio-visual developments, leading to complete departmental libraries, will be of significant help. 5. We must raise orthodontic staff needs to first priority, particularly on the undergraduate level. We must recruit qualified teachers by all means at our disposal. We must encourage didactic training courses for prospective staff members and provide sufficient auxiliary personnel to make their teaching time most profitable. REFERENCES 1. Gies, William J.: Dental Education in the United States and Canada, New York, 1926, The Carnegie Foundation, Editorial: AM. J. ORTHODONTICS 47: 50, 1961. 2. A Course of Study in Dentistry, Report of the Curriculum Survey Committee, American Association of Dental Schools, Chicago, Ill., 1935. 3. Moore, George R.: Teaching Orthodontics to the Undergraduate Dental Students. In Proceedings of the American Association of Dental Schools, puhlished by American Association of Dental Schools, 1949, pp. 97-109. 4. Progress Report on Teaching Orthodontics to Undergraduate Dental Students, AM. J. ORTHOWNTICS 38: 43, 1952. 5. Moyers, Robert E., and Jay, Philip (editors) : Orthodontics in Mid-Century; St. Louis, 1959, The C. V. Mosby Company. 6. Adams, Philip E.: The Challenge of Orthodont,ic Education, AM. J. ORTHODONTICS 48: 890, 1962. 7. Anderson, George M.: President’s Address, American Association of Orthodontists, AM. J. ORTHODONTICS 46: 321, 1960. 8. Abel, John R.: Socioeconomic Trends Relating to Orthodontics, AM. J. ORTHODONTICS 48: 893, 1962. 9. Graber, T. M.: Are Orthodontic Educat,ional Opportunities Adequate? A&f. J. ORTHODONTICS 49: 105134, 1963. 10. Report of the Committee on Education, American Association of Orthodontists, AH. J. ORTHODONTICS 38: 46, 1952. 11. Lischer, B. E.: Principles and Methods of Orthodontics, Philadelphia, 1912, Lea & Febiger. 12. Mayne, W. R.: A Concept, a Diagnosis and a Discipline, D. Clin. North America, July, 1959, pp. 281-288. 13. Specialty Practice in Dentistry, AM. J. ORTHODONTICS 46: 591, 1960.
Discussion by Robert E. Moyed Accept,ing an invitat,ion to discuss a paper that one has not yet seen is XYX?’ much like signing a blank check. Happily, the paper that we have just hrard is an easy one to discuss because of the eorrectncss of its tone and its emphasis on the most important problems encountered in teaching orthodontics at the undergraduate level. Dr. Hannctt first, pointed up our major problem when he noted our historical wnsistcncy in stating well what should be done and our equally consistent inability to implement suggestions made at. a series OF conferences going back at least, a generation. When discussing the status quo, he arrived at what is the most important part of t,he paper for us at this time. In the opinion of some, we can no longer enjoy the luxury of discussing at length whether or not orthodontics will be taught to the undergraduate and practiced lo- the general practitioner and pcdodontist. The dentists outside orthodontics always have and always will practice some orthodontics, if for no other reason than that they are legall) wtitled to do so. The primary decision today concerns who will teach them. \%I1 they learn from one another? Will they allow mail-order laboratories to make their diagnoses? Will foreign orthodontists and teachers come htw to cwatc an entire new level of therapy and practicr 2 Or will orthodontic t,cachet~s assume their proper responsibilities and refuse to default to those less well trained 1 The basic question is, “What is best for the children of this country 1” The answw is clear. As Dr. Hannett points out, the time is short and the decision has already been made wrongly in some placrs. With respect to course cont,ent, there has been general agreement, on paper, whcncrw WC confer and write a report, but again there is little to show for OUI agrremwts. Why? Dr. IIannctt gayc 11s the answer. Few orthodontic teachers are trained to practice and teach in this awa. What the average ethical orthodontist, does in his practice and what. needs to be done and taught, in an undergraduate orthodontic curriculum arc two ver- diffcwnt things. This problcm is far tleepcr than the important semantic difficulty which Hannctt descritws SO car(~fllll~. Walt Whitman said : “Our attitudes are the victims of our (Is1wrience. ’ ’ Most orthodont,ists have little rxpericwc in prcvwtire and intt~rcoptivc orthodontics. Indeed, man?- have not cver~ had a gcntrral practice. Is it an,v wonder that they have difficulty in understanding the nwds of the undergratluate student, or the family dentist? I do not t’or one second suggest that, any others in drntistry arc likely to he superior teachers of ort.hodontics, for no one is in a better position to teach orthodontics than the orthodontist. However. undcrgraduatc teaching of orthodontics requires sppc&ll training and at,titudcs on the part, of cvcn the hcst clinical orthodontist if htr is to do the job wrll I&n Roy (:. Ellis was correct when hc calletl this arca “the no man’s land ok dent istr:,. ’ ’ ‘Professor
of
Dentidry,
Department
of
Orthodontics,
University
of
Michigan.
All of us in teaching complain frcquentl~- of our farilitic>s and equil~mr~nt. While this is a constant problem, it does not worry me, since \vc usually can get that for which me arc willing to fight. Howcvc~‘, we fight for only those things that we deem most important. When undergraduate orthodontic programs burst their seams and t,he entire dental school sees the good job that is being done, many of the inadequacies will be solved for us. I enjoyed the discussion of the priority placed on departmental responsibilities, probably because WC had a serious discussion of this very point in our own department several years ago. Very few departments recognize undergraduate t,eaching as their first duty; some frankly hope it will be done by others. The recent development of fringe groups and off-beat orthodontic societies and the present lack of understanding between orthodontics and the rest of dentistry are directly related, in part, to our failure to inform a whole generation of dentists adequately about the fundamentals of facial growth, the principles of occlusal development, the diagnosis of malocclusion, and what can and cannot be done easily in interceptive orthodontics. We are in for even more discontent until a sufficient number of dentists are well enough informed to realize that we have not been harboring ulterior motives and that the problem is far more difficult than they, in their honest ignorance, realize. Isn’t it ironic that most dentists know so little about the single subject around which the entire undergraduate curriculum should revolve, namely, occlusion! At least one university has developed a program in orthodontic teacher training and will begin operating this fall. Trained orthodontists will be accepted for one year’s training in teaching methods, statistics, the scientific method, educational psychology, and university and college administrative procedures, and will be encouraged to take advanced work in areas of particular interest (for example, anatomy and genetics). Each man’s program will be different and will be tailor-made for him and the school to which he will go. All trainees will get undergraduate orthodontic tea&in, ~7experience. Those sponsored by a particular dental school will be helped in planning the best possible undergraduate program for their school, taking into account the number of hours available, personnel, etc. Dr. Hannett has fairly stated one of orthodontics biggest problems. I urge that we take particular steps at this conference so that all may know that the teachers of orthodontics at least arc facing up to their duties, for we, more than any others in our specialty, determine its future. There is one optimistic note not mentioned in Dr. Hannett’s fine paper: Much progress has been made since the 1958 workshop-progress that many in the American Association of Orthodontists do not seem to be aware of, probably because there are so few teachers among the membership that their activities are not always well known. For example, the Canadian orthodontic teachers have just held a conference on this problem. A number of undergraduate programs have been revised and copied exactly after the model written by Study Group I of the 1958 workshop. In addition, several textbooks written primarily for the undergraduate student hare appeared. We arc headed in the right direction but the tempo is too slow, for t,he matter is an urgent one.
A.
Ph2LisviEle,
HANNETT,
B.S.,
D.D.S.*
Ey.
INTRODUCTION
of the most frequent observations of men who have the temerity to speak in public about any orthodontic education problem is that during the years ahcad WC must build a better orthodontic ~~ndergraduat.e curricul~lm for ow student program (for our children, as it were). It is a noble statement which r’spresses the aspirations of every teacher. Yet> over the years it has becomes an almost meaningless clich&, because all too often we who make the speeches fail to go beyond our speeches. We content ourselves with the broad generalities, possibly because we ourselves have too little idea of exact.ly what we mean. In the spirit of making the thought the father of the deed, I will try to get down to some specifics, to set up some standards; and t,o discuss some minimum rcquiremcnts which, it seems to me, have direct bearing on this better orthodontic curriculum for our future students. I want to discuss the essentials of a successful l~ndergraduate program which, when lacking, can destroy it.
ONE
HISTORICAL
DEVELOPMENT
OF
UNDERGRAD7~~~TE
ORTHODONTIC
TEACHIXG
It does not seem necessary to go back to the beginning of undergraduaic orthodontic teaching. Others have done this very well and have reported in the lit,erature from time to time. More than 35 years ago William J. Gies’ stated, in the Carnegie Survey of Dental Schools in the United States and Canada: “ ThertI is a great need for closer correlation of the dent~al curriculum with the demands of the actual practice of dentistry. ” Even then there were not enough qualified orthodontic specialists to cope with the demands of the actual pract,icAe of orthodontics. In the last 30 years, there have been at. least four major admonitions on orthodontic education. Presented ah 28, *2nstructor,
at 1963.
the School
Conference of Dentistry,
on Orthodontic University
Education, of
Louisville.
Pittsburgh,
‘Fe.,
M~I&
27
508
Hannett
The first was the 1935 Report of the (‘urriculum Survey Committee of the American Association of Dental Xchoo1s,2 which indicated the great need for a closer correlation of the curriculum and the demands made on the dmltist’ in private practice. This survey pointed to the lack of st,andardization and the inadequacies of the undergraduate curriculum. It also enumerated the 01~ jectives by which undergraduate tGning could bc made more uniform and thus give the dental student adequate training. I!nfort~unately, those men rcsponsible for undergraduate orthodontic teaching felt that the criticisms wc’r~ directed to other phases of dentistry and paid little attention to the report 01 to the recommendations that it contained. A second academic milestone with immediate orthodontic implications was the excellent evaluation of undergradnatc training presented to the American Association of Dental Schools in 1949.‘+.4 The same criticisms were made, the same objectives were stressed, and recommendations w\‘crc made to implement, the report. Orthodontic educators listened, but, as one observer has put it, they thought : “Surely this is not for us-they must mean the people teaching operative, or prosthetics. ” In 1958 the Orthodontic Workshop in Ann Arbor,j sponsored jointly by the Kellogg Foundation and the American Association of Orthodontists, gal-c orthodontics a third opportunity to get its academic house in order. This beautifully organized conference brought together the clinical and didactic leaders of the profession. The proceedings, as published by Meyers and Jay” in Orthodontics in Mid-Century, are a tribute to t,he diligence and determination of all to solve our problems. In a spirit of true self-analysis, att,cmpts were made to study our educational ills and provide ans\ycrs t,o the many questions posed. Answers were given, recommendations were made, and both graduate and undcrgraduate education had but to implement the rccornnlrndations. To date, however, it would appear that, whiIe we recognize our problems, w’c have not undcrtaken their solution even though the way has been clearly pointed out to us. Adams6 wrote, in 1962: “It is interesting but disheartening to note that the same objectives, with slightly different wording, wcrc suggested in the ‘Report, of the American Association of Dental Schools in 1935.’ ” I was a member; of the committee assigned to study undergraduate tcaching at the 3958 Workshop. Adams wrote further: “In this same workshop rcport, in a discussion of aims and objcctivcs of undergraduate orthodontic education, the following significant statcmcnt was made : Since no to be adopted nature. ’ ’
undergraduate as a standard,
orthodontic: orthodontic
training teaching
program in all
has schools
attained sufficiwt swcess ha.q been cxpcrimental in
This is hardly a favorable commentary on a mature and established program. In 1960, in his presidential address before the American Association of Orthodontists in Washington, I). C., Anderson’ warned that WC arc being severely criticized for failing the profession by not fulfilling teacher needs; that we should try to stimulate interest and develop a list of men available for teaching assignments.
That the time is now ripe for action is emphasized by Xdamq6 in his article on ’ i The Challenge of Orthodontic Education ’ ’ and by Abel8 in his article cntit14 ” Hociocconomic Trends Relating to Orthodontics, ” both of which appearc~cl in the l)wemher, 1962, issue of the AMERICAN JOURXAL OP ORTH~DOXTICS. It is further emphasized by Graber’9 most complete and provocative study entillcd I’ Arr Orthodontic Educational Opport,unities Adeyuattl? ” I urge you to wad tlrwc soul-searching analyses. I am confident that we shall not leaw this WE f’crcnw \vith platitudes to serve as yet another well-meaning but inrffwtr~al effort
What is the status of orthodontic education now”? ~\n impartial ohscrv~~l might facet,iously label this section “ The Impending I)cmiw of L’ndergraduato Orthodontics ’ ’ ox “If the Orthodontist Doesn’t Want It, Someone Else Will” I The basis for such a judgment, is easy to find if we look at t,he number of nonrcgulnted courses being given to general practitioners by general practitioners on bitt plates, guide planes, modified EIawleys, space maintainers, space rw gainers, functional appliances, extraoral force, etc. Thcw arc signs of a tiyilight zone takrovcr on an international scale that \vc cannot ignore. Ewn a cursory examination of graduate and undcrgraduatc pedodontic curricula and semiofficial statements made in the pedotlontists’ journal on the SCO~Cof pedodontics indicates an increasing interest in t,he specialty of orthodontics. This magnetic attraction of orthodontics for the pedodontist, has twn attributed to several factors. Both orthodontic and pcdodontit department,s work on children, and the two departments arc of’tc>n thrown together becauw oi inadqnatct facilities. Graber” writes : “1:~ 01’ tli(a same facilities in training. constant association with orthodontists, great public demand for orthodontics a~~cl the inadcynate supply of trained specialists. the seeming simplicity 01 ilpp1kUlCe adjustments to some who arc not il\Viil’t’ of the t rcmendons drmantls in ~1inical training and judgment, and other considerations hay-e teamed togetht>l. to b~aden the pcdodontic horizon by trespassing on orthodontics. ” >1t prcwnt, several dental schools arc either contcmplnting or have alrwd~ (2r(~ilt4 a childrw~ ‘s department-heacfcci by a pc~dotlontist. More antI mot’( pedodontists speak in the vernacular of the orthodontist ; more and more JW dodontists are doing more and more orthodont,ics ; alt increasing number o 1 pc~tlodontists arc limitin g their practices to orthodontics as bona fitlc nwm twl5 ol’ the Intwuational Academy of Orthodontics. These people arc sneaking ill through the back door. Again, quoting from (:rabcr!’ : “ Thus. highly important aspwts ot’ orthodontics, the oldest specialty in dtwtistr\- with the third oldw~ specialty boilrtl in medicine or dentistq-, havcb been arrogat4 b,v persons \r-l~c~ lack the training or ability to treat these cases. For the good of the public \\-(‘ serve, it is imperative that orthodontists safeguarcl thcii* legitimate field nl’ (III (lea\-or. ” (~‘onscicntions dentists are frankly disturbed ovw the lack of adequate orthndontir scrvicc for their patients. Few of them have had the training or espcricrwc~ to permit them to administer to even the simplest orthodontic needs. I~ndw
510
Hannett
Am. J. Orthodontics
July1963
graduate orthodontic indoctrination has been generally inadequate and little continuation education is available for dentists sincerely interested in rendering limited services within the framework of general practice. The less conscientious dentists often consider the service aspect subordinate to the material return. These men have turned to so-called orthodontic laboratories, commercial opportunists which prey on the profession by pointing out the pecuniary return possible and ply the dentist with literature pointing out the seeming simplicity of orthodontic manipulations: ‘LDo~tor, send us your models and we mill design and fabricate an appliance that is guaranteed to do the job. Full instructions are enclosed with each appliance, outlining in detail the adjustments to be made each time. Try our consulting service. Send us your plaster models in the enclosed convenient carton. You are under no obligation. ” Such lures are not calculated to increase the amount or to uplift the level of professional orthodontic service. Joseph D. Eby has said that two thirds of the orthodontic treatment in New York City is done by the general practitioner. If me do not believe it, he says, ask the laboratories. At this very moment too many general practitioners arc learning more orthodontics from commercial laboratories that are sending informative pamphlets through the mails, diagnosing, planning treatment, and constructing appliances without prescriptions than they did in the entire undergraduate program during their school pears. The orthodontist cannot consider himself blameless for the situations just described. He has been preoccupied with training the specialist and with graduate orthodontic courses. The demands of private practice are overwhelming, and it is not necessary to enumerate the relatively more favorable circumstances that heighten the appeal of this choice as opposed to semidependent and underpaid institutional affiliations. Enough men have examined the inside of the halo surrounding the summit of the “Halls of Ivy” to observe that the golden glow of prestige, the attraction of intellectual camaraderie, and the mellifluous appeal of such ego-inflating titles as ‘(professor” often coat only the surface. Beneath the golden glow are the endemic problems of politics, petty jealousies, interdepartmental rivalries, personal animosities, and red tape to hamstring the dedicated pedagogue. Severe staff shortages plague the graduate courses, too. Since most orthodontic graduate departments are part of the university graduate school, there is relatively more uniformity and control, but it is no secret that the variability from school to school is greatly excessive. I refer you again to Graber’s” article in the February issue of the AMERICAS JOURNAL OF ORTHODONTICS for an elaboration of this point. Whatever problems graduate orthodontics has, undergraduate orthodontics can say, “Me too, only more so ! ” The same problems of course content, staff, and facilities must be solved. If we are to continue with any degree of autonomy, we must have some definite goal, set up some very definite standards, and provide some basic guidelines. It is necessary at this meeting for us to come to some agreement, regardless of preconceived ideas. We must attack this problem with an open mind-prepared to compromise if necessary, for the good of orthodontics. If we listen only
until. it is our turn to speak our piece, then WC’will not get far. We do not, seem to realize that without a collective knowledge of dir&on-of where WC are going-we cannot very well get anywhere ! \Vhc!tht~r w like it or not, WC’ are at this moment at the very crossroads of orthodontic education at the undergraduate level in the dental school, Let us now discuss course content, staff, and facilities, in that order, and then make some recomnlendatiorls. COURSE
CONTENT
From time to time on the great ships which ply the oceans of the world, an officer will walk to the wing of the navigation bridge, raise his sextant to his the sun. He will then make the necessary calculations and eye, and “shoot” determine his exact position. He will compare his exact, position with the position that he should be occupying and, if there is a variance, make the necessary corrections by steering a slightly different course. This is navigation, and it keeps the ships arriving at the ports toward which they are sailing. They stay on course.
I believe that teachers should do a similar thing. From time to t,ime every teacher of undergraduate orthodontics should ask himself : “Am I sure I know the destination toward which I am sailing? What is the point in time that I have set as target date for arrival? Am I now on coursc:2” It works in navigation. Teaching is a kind of navigation-getting rronr where wc were, or are, to the point that we have decided to reach. A teacher without a settled purpose, as Carlgle put it, is like a ship without a rudder. He is subject to every wind and tide. He sails first this way and then t,hat way. If a landfall should appear on the horizon, he would not knorr what it is-or where it is-or whether it is worth sailing toward. This is a nictl analogy, but what happens if there are three or four landfalls? There may 1~: two or three stars in the sky that permit ccl&al navigation, all leading in different directions. Depending where hc lands, thc~ orthodonbic teacher may find that he has aimed for one course which is called “orthodontics’ ’ bnt consists of little mere than anthropology, comparatiyc anatomy, development of occlusion, and growth and development; or his st~md landfall may bring him in cont,act with a course that has the undergraduate students handling all sort;; of appliance problems and treating cases routinely in the clinic. Which is right! Whose star should he follow? Does the brightest star always lead in the right direction? We had better decide that if none of the choices scem right, we might as well put up our own navigational satellite in the orhit which we collectiveI> believe is calculated to serve the public and the profession best. A good place, to start is with the objectives recommended in 1952 by tile Education Comnriti CC” OSthe American Association of Orthodontist,s :I” :I. The anticipation and detection of malocclusion. 2. The prevention or interception of malocclusion wherever possible. 3. The treatment of simple cases or the simple immediate problrms of complex cases. (I would differ somewhat with this objective.) 4. The use of this knowledge as an adjwnct. to procedures in all other phases of dental practice.
5 12
IIwnne
tt
5. The acquisition of skill in detcrrninin, 0 which cases to avoid ant1 which to refer to more experienced men in the field. Here arc the same ubiquitous ohjcctivcs, having arm again withstood the test of committee investigation and the test of time. Why, then, has all of this undergraduate t,caching been as cxperimcntal as the Michigan Workshop reported? One reason is the major confusion of terms. We have a host of terms, some synonyn~ous to some people but very different to others. In 1913 Lischcrl’ admonished 11s to develop a greater uniformity of terms, and we are still doing just that, Again, what we need are some very definite guidelines, some very specific definitions to aid in the organization of a lecture-clinic program without straitjacketing the individuality of the dedicated teacher. In line with the need for a clearer understanding of terms, &Iayne” has written : “The important thing is to be able to analyst t,he dento-facial complex early and by a differential diagnosis to know whether prerentivc, interceptive or corrective measures are to be employed. ” In~plementing the A. A. 0. objectives, Mayne defines these terms as follows: Preventive orthodontics is t,he action taken to preserve the integrity of what appears to be normal occlusion at a specific tirne. Interceptive orthodontics irnplies that an abnormal situation exists. When there is a manifest malocclusion developing because of a hereditary pattern or extrinsic or intrinsic factors, certain procedures may be taken to lessen the severity or to eliminate the cause. Corrective orthodontics recognizes the need for employing technical procedures to reduce the problem, usually requiring mechanics and demanding special training. I urge you to accept these definitions, so that we may have some definite guidelines to follow. The welter of terms, such as limited orthodontics, prophylactic orthodontics, pedodontic orthodontics--all apparently synonomous with one group or another and wit,h the three terms defined by Mayne-only confuses the issue. “Preventive orthodontics implies action taken to preserve the integrity of the occlusion after analysis has revealed that a normal occlusion exists. Thus preventive orthodontics attempts to maintain the occlusal status yno; to guard against untoward environmental influences which would change the normal course of events. The early detection of detrirnental tongue, lip or thumb habit . . . placing of a space maintainer when a deciduous molar is prematurely lost, proper operative care which quickly restores full tooth dimensions and normal contacts [are] actually the very backbone of preventive orthodontics.” one is confronted by a developing fait With interceptive orthodontics, accompli. “This is something quite different from preventive orthodontics where one attempts to prevent an untoward occurrcncc, which is being set in motion at that moment. [In interceptive orthodontics] one then faces the challenge of detecting such circumstances postnatally and employing measures to intercept
this malocclusion, on its journey to maturity. Thus the early recogrlitiorl Of :L tooth jaw disharmony at age eight or nine and t,hc institut,ing of serial extraction procedures is interceptive orthodontics. ” (lorrcctiw orthodontics assumes the need foil climinat ing i\ frank rnaloccliision. This is principally a matter of appliance thcral)y. fit in this pictarc ? Mayne” Now, whrrc does the gcncral practitioner answers this clearly : “Most preventive mcasurcbs must bc handled by the gctutral practitioner. Such a program requires considerable specialized knowledge, but such knowledge is not beyond the scope of the dental curriculum. lnterceptiv: mcasurw arc generally more complex and it is questionable whether certain of these should be used by the student or general practitioner. (‘orrcctivr procedures fall rnore in the realm of the specialist. ” Nayrle’” lists four prerequisites which the general practitioner should satisfy before he embarks on any interceptive procedures : 1. The dentist must have adequate knowledge of the sub,jwt. Suc~h knowledge, in itself, would eliminate the dcpendcnce of many men on laboratories for guidance or attempts at treat,ment for iinancial rewartl alone. Adequate knowledge would include consultatiw advice and real orthodontic help from a qualified orthodontist, most of whom are willing to help if for no other reason than to ;I\-oid mistreatment, through improper diagnosis by a laboratory. 2. IIc must have a patient under continual care. There is nothing quite so disheartening as to csamine a child anxious for appliances t,o correct ’ Lo~~c~ front, tooth,” only to find t tic four first molars missing, mutilated, or involved with rampant earics. 3. The patient and the parents must rtcognixo that a defect csists. -l. The parents must have confidence in the dentist’s abilit,y to can’> out the rccommendcd treatment program. In 1958 the Michigan Workshop Group I: listed coutw content for undcrgraduate lect~urcs as follows: (I) growth and dcrclopmtrnt, (2) physiology OI occlusions, (a) nomenclature and classification, (4) etiology of malocclusion, (5) diagnosis and case analysis, (6) records, and (7) general principles oC orthodontic therapy. In the A. A. 0. pronouncement I3 in the Ailgust, 1960, issue of the Jwxx-nr,. which was signed by A. A. 0. and A. B. 0. officers, the objectives of undcrgraduate orthodont,ic education were amplified to twclvc headings :
-1. A definition of terms: a, concept,, a diagnosis, and a discipline. Prcvcntivc, interceptive and corrective orthodontics. 1Vhat the tlental student should know about each. 2. Growth and development. 3. Physiology of stomatognathic system. 4. Incidence and recognition of malocclusion. 5. Etiology of malocclusion. 6. Diagnost,ic records and their interpretation.
514
Hannett 7. Unfavorable sequelae of maIoccIusion. 8. Biomechanical principles of t>ooth movcmcnt. 9. General principles of orthodontic thcrnpv , , giving some description of appliances now in use to familiarize students with treatment methods. 10. Preventive orthodontics. 11. Interceptive orthodontics. 12. Corrective orthodontics.
The Michigan Workshop recognized that differences exist among the schools with regard to teacher personnel, teacher-student ratios, facilities, basic science departments, etc. and that the outline was not a hard and fast rule to follow. Likewise, the 1960 A. A. 0. statement was not proposed as a mold for all undergraduate courses. These course content listings are there to show what an ideal course would include, and emphasis must be determined by each teacher. It would not be inappropriate to say that the orthodontist is “setting the boundaries,” so to speak, for those orthodontic considerations that he feels best qualified to teach. He accepts full responsibility for the material included and does not think that choice sections should be delegated to other departments less well qualified to teach the subject. 911 material taught is not necessarily for clinical use. Hardly ! But the general practitioner must know what the orthodontist is trying to do. He should have knowledge of certain orthodontic concepts in order better to apply his knowledge to other phases of the dental curriculum. Orthodontic limitations, percentage of failures, retreatment problems, posttreatment adjustments, etc. must receive due consideration. With respect to the last three objectives listed in the 1960 A. A. 0. statement on specialty practice in dentistry, further study is indicated to develop more definitive guidelines, Preventive orthodontics means many things to many people. The definition stated above would provide much material for the teacher to discuss with the undergraduate. If we are to teach correlation of orthodontics with all other phases of clinical dentistry, we certainly must begin with preventive dentistry, of which preventive orthodontics is but a part. Such problems as abnormal resorption and its association with space deficiencies, space control in the deciduous and mixed dentitions, space maintainers and the prerequisites for their application (whether fixed or functional), caries repair, oral habits as related to prevention, the labial frenum, and occlusal equilibration in both the deciduous and the permanent dentitions certainly afford ample opportunity for the teacher to fulfill orthodontic responsibilities and to give t,hc student orthodontic training and experience not available in any other department. Only he, the orthodontist, can properly correlat,e all facets of prevention to fulfill adequately his primary charge of preventive orthodontics to his student, that of normal occlusion maintenance! Interceptive orthodontics, as defined above, implies that an abnormal occlusion either exists or is developing. There could be some overlapping of prerentive and interceptive procedures, but most people agree that the real difference is in the timing of the services rendered. Abnormal habits and their control,
Volume A-umber
49 ‘i
1 Tndergradua~te
education
5 15
abnormal diastemas, and elimination of premature contacts resulting in possible tooth or mandibular guidance are major interceptive procedures. Perhaps serial. extraction is the most misunderstood procedure under discussion in almost ever? orthodontic circle and study club in the United States today. Completely undt:rstood, properly evaluated, and adequately supervised by informed personnel, wrial extraction is a great satisfaction to those practicing interceptive orthodontics. The sad fact of the matter is that too few orthodontists are pra.cticing wrial estrartion and too few teachers are adequately training eit,her the undergraduate or the general practitioner in the fundamentals of this proceduw. 11 seems to rn(~ that everyone practicing dentistry should bc full? aware of t.hc possibilities of this extremely important orthodontic procedure. ’ * Fully apart’ ” wrtainl; includes the limitations of serial extraction. (treat care must, bc V’S= cwised in 111~discussion of this phase of intercept,ive orthodontics, for unless the pitfalls arc spelled out in great detail a real disserriw to the young patient results. A thumbnail recommendation at this point can only admonish anyorw not. adeyuatcly trained and experienced in the serial txtraction techniqur: to avail himself of the sttrviccs of a trained orthodontist. Serial extraction wrnnol br taught or prarticcd “by the numbers,” and yet the student and the genera i practitioner should be informed ; they should bc taught \\hat (aan be at~complishetl as ~(41 as the great disscrvicc that can be gi\-cn through the improper diagnosis and acWI)tancc of a cast for serial extraction. Only the orthodontist, can propwl~ rvdn;ltc~ such a problem; only he can decitlc the proper time to intcrvcncb uitlr mccllanotherapv; only hc can set up the timctablc for extractions, space maintenanw > and/or appliance therapy. Therefore, it would seem logical that II(~ serial extraction should be attempted withollt an ort,hodontist, in very close c~onsultation. I)e~cl~~~ has stated : “A need exists, how\-or. to define the major areas of dental practice that fall within th(l jurisdiction of each individual spwiality. The American Association of Orthodontists urges that this be done SOthat 110 speciality will find it possible to cstend it,s area (Jt‘ speaializat,ion 1o iwlude scrviws that more properly belong to iinotllcl’ speciality. ’ ! It would uppcar to me that the whole area of serial extraction is only orthodontic. In thr normal course of the day, the general practitioner sees many malo+ elusions that are not ’ ’ full blown. ” Hc does not require advanced technical skills and training to treat many OF these problems. It is with thcsa nralowlusions that limited cwwectiue orthodontics is conwrncd. The anterior cross-bitt., thck csccssivc overbite, the exaggerated curve of Spw, thtt bite plate, the posterior cross-bite, spacr retainers, space closers, ligation of tectll, passive lingual archw constructed and fixed for bilateral space maintenance-all are within the rcal~n of limited corrective orthodontics. liess l.imitctl correctiw procedures must lw l(bt’t to the postgraduate and graduate departments. Bcforc turning to questions of staff and facilities, 1. would like to emphasiw again that the main purpose of the twel\-e points is to srt, definite orthodontica boundaries, indicating the domain of orthodontics in the undergraduate rurriculnm. It is not our aim to require the orthodontic teacher to conform to ali twelve points. iK0 assessment is necessary from the standpoint of emphasis ot’ clock hours. Xach man detcrmincs this himself. But the t\velye points scrw ah
516
Hannett
Am.
J. Orthodontics July 1963
a clear statement that this material is primarily orthodontic in nature responsibility for it rests with the orthodontic department only.
and that
FACILITIES
Study Group I of the Michigan Workshop” observed: “The chief obstacles to a successful undergraduat,e program in orthodontics could be lack of teaching time, staff, funds, space, adequate library, and a sympathetic dental faculty and administration.” The tangible factors mentioned directly or indirectly may be placed under facilities and staff. The best possible curriculum falls short unless attention is given to these important considerations. Since orthodcntics plays such a relatively small role in general dental practice, as compared to operative dentistry, prosthetics, crown and bridge, or periodontics, it is only natural that facilities and time are oriented first to give the student a sound background in these subjects. Little time is left over in many cases. For the dental school dean, it is a constant battle as he withstands the assaults of various departments and their requests for funds, time, and facilities. Each man thinks that his department is the most important. Yet orthodontics, by virtue of its physiologic orientation and dynamic character and its constant dependence on material taught in the basic science courses, occupies a unique position as the great correlator of the dental curriculum. Anatomy, growth and development, histology, comparatire anatomy, genetics, physiology, dental materials, periodontics, radiology-all these become much more meaningful to the student. Sufficient time for presentation of the curriculum is a “must. ” Lecture hours should be in the morning, if at all possible. The departmental file should be adequately equipped with well-developed audio-visual aids to assist in course presentation. Stale teachin g material is a miserable opiate, even as regurgitated text, taken verbatim from standard texts and read to the students. This is still seen all too frequently. A laboratory course should be presented, if at all possible. The student needs more than theory; he must gain practical experience in impression techniques, fabrication of study models, band forming, the making of space maintainers and space regaincrs, soldering, welding, and wire bending. I consider the development of a suitable departmental audio-visual facility along the lines of our Kentucky Dental Association program of top priority. The decision was made in 1959 to make a series of color-slide and tape-recorded sequences by well-known clinicians. To date, more than forty sequences have been produced and have been circulated throughout the state. The merit of such a program has been recognized by the A. A. O., and a series of eight to ten fully automated sequences mill be shown at the Association’s 1.963 meeting in Miami in May. If these are received favorabl.v, a permanent Audio-Visua.1 Library will be established in the Central Office for the disseminat,ion of these and other slide-tape series by equally outstanding authorities. You can imagine that such aids will be a boon to undergraduate as well as graduate teaching. Our tentative program for Miami calls for presentations by Burstone on “Root, Movement, ” Gore on “ Crozat Appliances, ” Jarabak on “Differential Light Growth,” Mayne on “Serial Extraction,” Forces, ’ ’ Krogman on “Physical
Technique, ’ ’ Aloyers on ” The Role of Musculature,” Oliver on ’ * l,abio-Lingual Sims on “ Begg Philosophy, ” Rocky Mountain Products on “The Nuk Sawer St,ory, ’ ! and Unitck on “Resistance Welding, Soldering and llcat Trca.ting. ” Future sequences by Weber on “Twin-Wire Tcchniquc,” Rcitan on “Tissuv \;llIIal)l(~ dt:~XL~tI~l~~~lt?tl IihKlV) (‘hanges, ’ ’ Richer on ’ ’ Bone, ’ ’ CtC. SllOW hO\V (aan be accumulated to augment and amplify the prop~kr undcrgraduatc~ (‘111’riculum. There is no question that these scquenccs may rcdnce the critical staf? problems, if our “giants’ ’ in orthodont,ics will rooperatc \~holt~heart~~tll~ ant1 unse1fishl.v. il
In his February article Graber” writes: “lt has been said many times thilt a school is only as good as its teachers. . . . C;ood st.udents are important alltl physical facilities obviously must be adequate, bnt, the best course falls shorl -wlit,h inadequa.te instruction. Of all the problems in orthodontic education today, that, of staff is the greatest. Solve it, and many others will be solid in the process. ’ ’ If the foregoing statement, made in reference to graduatr orthodontic training courses is valid, it is even more so with respect to undergraduate progranrs. St,udy (iroap I of the Michigan Workshop5 listed the rc~commended tcac*hinc priority in the orthodontic department as follows : 1. I’ndergraduate teaching 2. Interdepartmental consultation 3. (iraduate and/or postgraduate teaching 4. Refresher courses for orthodontists .5. Refresher courses for interceptive orthodont~ics for the general practitioner In actual practice, however, a realistic listing based on the ma.jority present orthodontic departments would be as follows : 1. Graduate and/or postgraduate teaching 2. Refresher courses for orthodontists 3. Undergraduate teaching 4. Interdepartmental consultation 5. Refresher courses for interceptive orthodontics practitioner
ol
for the general
We need more qualified teaching personalitics in our undergraduat,c programs-trained, enthusiastic, cooperative, respected men. Such men exist in orthodontics today. They also exist in kindred specialties, and their enthusiasm for teaching the orthodontic aspects of their specialties waxtls warm. When iu the world arc WC going to put in the first team?
By way of recapitulation, closing.
I want to emphasize srveral points again befort&
5 18
Hannett
1. Historical analysis shows that the pattern was set as early as 1935 and has been repeated several times, only to fall on deaf ears. Wc must get our house in order now with definitive criteria for the undergraduate curriculum. 2. Our status quo belies the dynamic nature of our specialty. Signs point, to the imminent loss of responsibility for orthodontic indoctrination to others more willing to incorporate orthodontic philosophies in t,hcir specialties and to teach them. 3. Present undergraduate courses show a fantastic variability-of such degree as to be termed “experimental ” during the 1958 Michigan Workshop. Minimum standards, uniformity, and the staking out of t,hr legitimate domain of orthodontics are essential now. 4. Orthodcntics, as the great coordinator of dentistry in the undergraduate curriculum, needs more adequate facilities and more time with the students. Utilization of current audio-visual developments, leading to complete departmental libraries, will be of significant help. 5. We must raise orthodontic staff needs to first priority, particularly on the undergraduate level. We must recruit qualified teachers by all means at our disposal. We must encourage didactic training courses for prospective staff members and provide sufficient auxiliary personnel to make their teaching time most profitable. REFERENCES 1. Gies, William J.: Dental Education in the United States and Canada, New York, 1926, The Carnegie Foundation, Editorial: AM. J. ORTHODONTICS 47: 50, 1961. 2. A Course of Study in Dentistry, Report of the Curriculum Survey Committee, American Association of Dental Schools, Chicago, Ill., 1935. 3. Moore, George R.: Teaching Orthodontics to the Undergraduate Dental Students. In Proceedings of the American Association of Dental Schools, puhlished by American Association of Dental Schools, 1949, pp. 97-109. 4. Progress Report on Teaching Orthodontics to Undergraduate Dental Students, AM. J. ORTHOWNTICS 38: 43, 1952. 5. Moyers, Robert E., and Jay, Philip (editors) : Orthodontics in Mid-Century; St. Louis, 1959, The C. V. Mosby Company. 6. Adams, Philip E.: The Challenge of Orthodont,ic Education, AM. J. ORTHODONTICS 48: 890, 1962. 7. Anderson, George M.: President’s Address, American Association of Orthodontists, AM. J. ORTHODONTICS 46: 321, 1960. 8. Abel, John R.: Socioeconomic Trends Relating to Orthodontics, AM. J. ORTHODONTICS 48: 893, 1962. 9. Graber, T. M.: Are Orthodontic Educat,ional Opportunities Adequate? A&f. J. ORTHODONTICS 49: 105134, 1963. 10. Report of the Committee on Education, American Association of Orthodontists, AH. J. ORTHODONTICS 38: 46, 1952. 11. Lischer, B. E.: Principles and Methods of Orthodontics, Philadelphia, 1912, Lea & Febiger. 12. Mayne, W. R.: A Concept, a Diagnosis and a Discipline, D. Clin. North America, July, 1959, pp. 281-288. 13. Specialty Practice in Dentistry, AM. J. ORTHODONTICS 46: 591, 1960.
Discussion by Robert E. Moyed Accept,ing an invitat,ion to discuss a paper that one has not yet seen is XYX?’ much like signing a blank check. Happily, the paper that we have just hrard is an easy one to discuss because of the eorrectncss of its tone and its emphasis on the most important problems encountered in teaching orthodontics at the undergraduate level. Dr. Hannctt first, pointed up our major problem when he noted our historical wnsistcncy in stating well what should be done and our equally consistent inability to implement suggestions made at. a series OF conferences going back at least, a generation. When discussing the status quo, he arrived at what is the most important part of t,he paper for us at this time. In the opinion of some, we can no longer enjoy the luxury of discussing at length whether or not orthodontics will be taught to the undergraduate and practiced lo- the general practitioner and pcdodontist. The dentists outside orthodontics always have and always will practice some orthodontics, if for no other reason than that they are legall) wtitled to do so. The primary decision today concerns who will teach them. \%I1 they learn from one another? Will they allow mail-order laboratories to make their diagnoses? Will foreign orthodontists and teachers come htw to cwatc an entire new level of therapy and practicr 2 Or will orthodontic t,cachet~s assume their proper responsibilities and refuse to default to those less well trained 1 The basic question is, “What is best for the children of this country 1” The answw is clear. As Dr. Hannett points out, the time is short and the decision has already been made wrongly in some placrs. With respect to course cont,ent, there has been general agreement, on paper, whcncrw WC confer and write a report, but again there is little to show for OUI agrremwts. Why? Dr. IIannctt gayc 11s the answer. Few orthodontic teachers are trained to practice and teach in this awa. What the average ethical orthodontist, does in his practice and what. needs to be done and taught, in an undergraduate orthodontic curriculum arc two ver- diffcwnt things. This problcm is far tleepcr than the important semantic difficulty which Hannctt descritws SO car(~fllll~. Walt Whitman said : “Our attitudes are the victims of our (Is1wrience. ’ ’ Most orthodont,ists have little rxpericwc in prcvwtire and intt~rcoptivc orthodontics. Indeed, man?- have not cver~ had a gcntrral practice. Is it an,v wonder that they have difficulty in understanding the nwds of the undergratluate student, or the family dentist? I do not t’or one second suggest that, any others in drntistry arc likely to he superior teachers of ort.hodontics, for no one is in a better position to teach orthodontics than the orthodontist. However. undcrgraduatc teaching of orthodontics requires sppc&ll training and at,titudcs on the part, of cvcn the hcst clinical orthodontist if htr is to do the job wrll I&n Roy (:. Ellis was correct when hc calletl this arca “the no man’s land ok dent istr:,. ’ ’ ‘Professor
of
Dentidry,
Department
of
Orthodontics,
University
of
Michigan.
All of us in teaching complain frcquentl~- of our farilitic>s and equil~mr~nt. While this is a constant problem, it does not worry me, since \vc usually can get that for which me arc willing to fight. Howcvc~‘, we fight for only those things that we deem most important. When undergraduate orthodontic programs burst their seams and t,he entire dental school sees the good job that is being done, many of the inadequacies will be solved for us. I enjoyed the discussion of the priority placed on departmental responsibilities, probably because WC had a serious discussion of this very point in our own department several years ago. Very few departments recognize undergraduate t,eaching as their first duty; some frankly hope it will be done by others. The recent development of fringe groups and off-beat orthodontic societies and the present lack of understanding between orthodontics and the rest of dentistry are directly related, in part, to our failure to inform a whole generation of dentists adequately about the fundamentals of facial growth, the principles of occlusal development, the diagnosis of malocclusion, and what can and cannot be done easily in interceptive orthodontics. We are in for even more discontent until a sufficient number of dentists are well enough informed to realize that we have not been harboring ulterior motives and that the problem is far more difficult than they, in their honest ignorance, realize. Isn’t it ironic that most dentists know so little about the single subject around which the entire undergraduate curriculum should revolve, namely, occlusion! At least one university has developed a program in orthodontic teacher training and will begin operating this fall. Trained orthodontists will be accepted for one year’s training in teaching methods, statistics, the scientific method, educational psychology, and university and college administrative procedures, and will be encouraged to take advanced work in areas of particular interest (for example, anatomy and genetics). Each man’s program will be different and will be tailor-made for him and the school to which he will go. All trainees will get undergraduate orthodontic tea&in, ~7experience. Those sponsored by a particular dental school will be helped in planning the best possible undergraduate program for their school, taking into account the number of hours available, personnel, etc. Dr. Hannett has fairly stated one of orthodontics biggest problems. I urge that we take particular steps at this conference so that all may know that the teachers of orthodontics at least arc facing up to their duties, for we, more than any others in our specialty, determine its future. There is one optimistic note not mentioned in Dr. Hannett’s fine paper: Much progress has been made since the 1958 workshop-progress that many in the American Association of Orthodontists do not seem to be aware of, probably because there are so few teachers among the membership that their activities are not always well known. For example, the Canadian orthodontic teachers have just held a conference on this problem. A number of undergraduate programs have been revised and copied exactly after the model written by Study Group I of the 1958 workshop. In addition, several textbooks written primarily for the undergraduate student hare appeared. We arc headed in the right direction but the tempo is too slow, for t,he matter is an urgent one.