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A comparison of the attitudes of selected groups toward the provision of dental care by the federal government with compulsory individual wage deductions, including provision for voluntary accept...

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A comparison of the attitudes of selected groups toward the provision of dental care by the federal government with compulsory individual wage deductions, including provision for voluntary accept...

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Content GOMPÆISOH OF THE ATTITODBS OF SELECTED GBOÜPS TOWmD THE PROVISION OF DENTAL CARE BY THE FEDERAL GOVERNMENT WITH COMHJLSC^y INDIVIDUAL WAGE DEDUCTIONS, INCLUDING PROVISION FOR VOLUNTARY ACCEPTANCE OF THE SERVICE A Thesis Presented to the;Faculty of the Department of Sociology iThe University of Southern California In Parti al Fulfillment of the Requirements for the Degree Master of Arts by Billyanna Niland June 1948 UMI Number: EP65668 All rights reserved INFORMATION TO ALL IJSFRS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation PublisMng UMI EP65668 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 £ £ 0 a-%) 3 s , , . .'fl VYk 1 his thesis, written by .............. under the guidance of A ..® .? ... Faculty Committee, and approved by a ll its members, has been presented to and accepted by the Council on Graduate Study and Research in p a rtia l fu lfill ment of the requirements fo r the degree of Master of Arts Dean Faculty Committee Chairman .. TABIÆ OF CONTENTS CHAPTER PAGE I. THE mOBIEM AND DEFINITIONS OF TERMS USED. ... 1 The problem................................. 1 Statement of the problem ........ 1 Importance of the study................... 2 Definitions of terms used. .......... 3 Lay person............................... 5 Professional person. ♦ .................... 3 Socialized medicine (or dentistry) ........ 3 Industrial dentistry .. ..... 4 Dental health............................. 4 Dental caries. . ............. 5 Pyorrhea............................. 5 Public health................ ......... • 5 Attitude . ............. 6 Value................. 6 Low income group ..... 6 Sources of data and methods of research. ... 7 Comparative study.......................... 9 Limitations of study ............. 10 Organization of remainder of the thesis. ... 11 II. REVIEW OF THE LITEBATOBE..................... 18 Growth of dentistry since 1840 ............ 12 The dental problem................... 15 ill CHAPTER PAGE Nature of tooth decay.................... . 15 Manpower shortage..................... 19 More equitable distribution of available manpower . .. .. ... .. .. 23 Socio-economic factors .................... 25 Ignorance of the value of, or lack of enthusiasm for, dental health. ...... 27 New fields in dentistry................. 28 Industrial dentistry..................... 28 Dentistry and public health......... 31 A hationeJ. dental care program.............. 35 Statement of goals..................... . 38 The three-point plan of the American Dental Association. .................... 41 An ideal clinic program for children .... 43 Responsibilities for dental health ........ 45 Attitudes of the American Dental Association toward the Wagner-Mirray-Dingell Bill. ... 48 Reasons for opposition to the bill........ 49 The insurance principle............. 53 III. ATTITUDES OF SUBJECTS TOWARD DENTAL CARE .... 56 Distribution of subjects by income and source ......................... 56 Comparison of subjects as to frequency of iv CHAPTER PAGE visits to dentist, and the relationship of frequency of visits to income.......... 60 Comparison of attitudes of subjects toward preference of private office or clinical care................................... 65 A comparison of attitudes of subjects toward quality of care........... . • . • 68 A comparison of past experiences of subjects as to postponement of care due to cost ... 68 Comparison of subjects from offices and clinics with regard to their evaluation of attitudes of dentist................. 70 A comparison of attitudes of subjects toward the present cost of dental care......... 73 A comparison of attitudes of subjects toward a government dental plan, if individuals were free to accept or reject the service, and the relationship of income to these attitudes........................ 75 Comparison of attitudes of subjects toward making use of the service, and the relationship of income to these attitudes. . 83 A comparison of attitudes of subjects toward payment of taxes for care, and the V CHAPTER PAGE relationship of income to these attitudes. . 88 Distribution of subjects who expressed willingness to pay specific amounts in deductions............................... 95 A comparison of attitudes of veterans and non-veterans toward government control of care. ................. 97 IV. SUMMARY AND CONCLUSIONS....................... 102 Summary......... 102 Reports of subjects concerning regularity of dental care . . . . . . . . . . 102 Attitudes toward private versus clinical care............. 103 Attitudes toward quality of care .......... 103 Attitudes toward cost of present dental care................... 104 Attitudes toward a government-sponsored dental program.......................... 104 Attitudes toward making use of government dental care........................... .. 105 Attitudes toward payment of taxes for government dental care......... 106 Attitudes of veterans and non-veterans toward government-controlled care......... 107 vi CHAPTER PAGE Attitudes of dentists toward need for care.................................. 107 A program of national dental health sponsored by The American Dental Association............................ 108 Importance of the local community in a program of dental health................ 109 Opposition to a federally sponsored program................................... 110 Conclusions. ............................. 110 BIBLIOGRAPHY ......................... 115 APPENDIX........................................... 121 LIST OF TABLES TABLE PAGE I. Population, Dentists, and Ratio of Population to Dentists in the United States, 1840 to 1940 ........... 13 II. Comparison of Present Dental Needs of Adult Population and Service Rendered............ 17 III. Amounts Spent in the United States in 1941 for Luxury Items and for Dental Care .... 20 IV. Number and Percentage of 430 Subjects by Source and Income......... 57 V. Number and Percentage of 375 Subjects by Occupation ....... .................. 56 VI. Number and Percentage of Frequency of Visits to Dentist by 402 Subjects from Office, Clinic, and Miscellaneous Groups.......... 61 VII. Frequency of Visits to Dentist as Related to Yearly Income for 402 Subjects, Compared for Office, Clinic, and Miscellaneous Groups, Recorded Numerically. ................. . 63 VIII. Frequency of Visits to Dentist as Related to Yearly Income for 402 Subjects, Compared for Office, Clinic, and Miscellaneous Groups, Recorded by viii TABLE PAGE Percentages............................... 64 IX. Preferential Attitudes of 383 Subjects for Private Office or Clinical Care by Number and Percentage..................... 66 X. Attitudes of 4SI Subjects Toward quality of Care by Number and Percentage. ....... 69 XI. Past Experiences Relative to Postponement of Dental Care Due to Cost as Reported by 452 Subjects from Office, Clinic, and Miscellaneous Groups . .................. 71 XII. Evaluation of Attitudes of Dentist According to 476 Responses of Subjects from Offices and Clinics............. 72 XIII. Attitudes Toward Present Cost of Dental Care, as Reported by 371 Subjects from Office, Clinic, and Miscellaneous Groups .......... 74 XIV. Attitudes Toward a Government Plan, Individuals Being Free to Accept or Reject Service, as Reported by 379 Subjects from Office, Clinic, and Miscellaneous Groups . . 77 XV. Attitudes Toward a Government Plan as Related to Yearly Income, Reported by 379 Subjects............................. 78 XVI. Attitudes Toward a Government Plan as ix TABLE PAGE Related to Yearly Income, as Reported by 379 Subjects from Office, Clinic, and Miscellaneous Groups .............. 80 XVII. Attitudes Toward Making Use of Government Dental Service as Reported by 360 Subjects from Office, Clinic, and Miscellaneous Groups............................. 85 XVIII. Attitudes Toward Making Use of Government Dental Service Related to Yearly Income, Reported by 379 Subjects.............. 87 XIX. Attitudes Toward Making Use of Government Dental Service as Related to Yearly Income as Reported by 379 Subjects from Office, Clinic, and Miscellaneous Groups ...... 89 XX. Attitudes Toward Payment of Taxes for Government Dental Care as Reported by 360 Subjects from Office, Clinic, and Miscellaneous Groups.................... . 91 XXI. Attitudes Toward Payment of Taxes for Government Dental Care as Related to Yearly Income, Reported by 379 Subjects. . . 92 XXII. Attitudes Toward Payment of Taxes for Government Dental Care as Related to Yearly Income as Reported by 379 subjects TABLE from Office, Clinic, and Miscellaneous Groups ................................. XXIII. Number and Percentage of 211 Subjects According to Willingness to Pay Specific Amounts in Deductions for Government Care. XXIV. Number and Percentage of 211 Subjects Who Expressed Willingness to Pay Specific Amounts in Deductions for Government Care According to Income..................... XXV. Attitudes of Veterans and Non-Veterans Toward Government Control of Dental Care as Reported by 315 Subjects by Number and Percentage ......................... X PAGE 94 96 98 LIST OF FIGURES FIGURE PAGE 1. Administrative Organization of a National Dental Care Program.......................... 37 GHAPTER I THE PROBLEM AND DEFINITIONS OF TERMS USED This study was an attempt to compare attitudes of se lected groups toward provision for dental care by the federal government with compulsory individual wage deductions, but with provision for voluntary acceptance of the service. Effort was made to secure the attitudes of different groups as a basis for comparison. These groups included dentists and lay persons of different economic levels who were re ceiving varying degrees of dental care. The attitudes of the professional group were those expressed by members of the American Dental Association principally in articles in The 1 Journal of the American Dental Association. The attitudes of the lay persons were those obtained by questionnaires distributed in selected private offices and clinics and also in miscellaneous groups. I. THE PROBLEM Statement of the problem. The purposes of this study were: (1) to discover the attitudes of selected groups of lay persons, (a) toward some of their own dental experiences. ^ This journal is the official publication of the American Dental Association. 2 (b) toward some type of government sponsored dental program, (o) toward availing themselves of the care offered under such a program, and (d) toward willingly supporting a government-sponsored plan; and (2) to discover the attitudes of the professional dental group toward a government- sponsored dental program. An attempt was made to discover any differences in attitudes and, where differences were found to exist, to discover various factors which may have been responsible for, or may have affected these attitudes. Importance of the study. There is a recognized need for more adequate dental service for the low income ^oups. Despite the fact that the United States leads the world in the field of dentistry, it is estimated that probably 70 per cent of the adult population receives no dental care what- P soever in the course of a year. Various reasons for these facts have been offered and many methods of attempting to solve the problem have been suggested. There have been different trends of thought, particularly among the members of the profession on one hand and the advocates of govern ment-sponsored dentistry on the other. Changes of attitudes toward the private practice of dentistry bring with them ^ Melvin L. Dollar, "The Present and Probable Future of Dentistry in American Society," The Journal of the American Dental Associ ation. 50:1459, September 1, 1^43. 3 changes in attitudes regarding the relationship of dentist to patient. The expansion of industrial dentistry, with industry assuming a responsibility for the dental health of the employee, would affect the attitude of employees toward employers, and the advent of a national dental program, with the government assuming a responsibility for the dental health of the nation, would influmce the attitudes of people toward government as an institution. This study was an attempt to uncover existing atti tudes within and outside the dental profession and to dis cover possible factors influencing opposition to, or support of, government - sp onsored dentistry. II. DEFINITIONS OF TERMS USED Lay person. A lay person is defined as one not of or from a particular profession, i.e., dentistry.^ Professional person. Webster^ defines a professional person as one engaged in one of the learned or skilled pro fessions. Socialized medicine (or dentistry). This is a broad Webster*s Collegiate Dictionary (third edition; Springfield, Massachusetts: G. and C. Merriam Company, 1930), p. 562. * Ibid.. p. 769. 4 term to indicate a new emphasis in modern medical practice; emphasis on new forms of medical practice designed to get modern scientific treatment to all the people regardless of income or ability to pay for it— and to do this systematic ally and beyond the charity of private physicians and local Industrial dentistry. Industrial dentistry is that specialty of dentistry which is concerned with the dental health of the industrial worker as it affects or is affected 6 by his general health or his working environment. It is that service administered by a dentist or dentists in a clinic or dental hospital on a salary or with fixed fees to be paid by the employer, by voluntary or involuntary assess ments on the employee or by some insurance plan. The service may be done in a pxlvate office at set fees to be paid by one of several arrangements.*^ Dental health. This term means the care of the teeth locally and the care of the surrounding tissues of the mouth, ® H. P. Fairchild, Dictionary of Sociology (New York: Philosophical Library, 1944), p7‘ 299. ^ B. R. Fast, "Industrial Dentistry," The Journal of the American Dental Association. 32:1278, October 1, 1645. ^ F. F. Petty, "What is Necessary to Make Industrial Dentistry a Credit to the Dental Profession?" The Journal of the American Dental Association- 30:1424, September 1, 19 4 ~ and the attendant effect upon «the body as a whole.^ Dental caries. This is a disease characterized by the disintegration of tooth structure. It is almost the sole cause of loss of teeth in children and adults up to thirty or thirty-five years of age.^ Pyorrhea. Pyorrhea is a disease characterized by a degeneration of the investing tissues of the teeth. Public health. Public health is the art and science ■ ‘ ' of preventing disease, prolonging life, and promoting physical and mental efficiency through organized community effort.It may be regarded as that body of knowledge and those practices that contribute to health in the aggregate l2 through either prevention or curative measures, or both. Testimony of S. V. Mead, quoted in "Further Testi mony from Hearings on Dental Research and Grants-in-Aid Bills, III, " The Journal of the American Dental Association. 32:1297, October 1, 1945. ^ J. W. Knutson, "Appraising the Dental Health Program, " The Journal of the American Dental Associ ation. 29:544, ApriT, 1942. igc. cit. G. E. A. Winslow, "Untilled Fields of Public Health," Science. 51:23, January 9, 1920, cited by A. 0. Gruebbel, "Dental Services and Dental Personnel in State Health Departments, " The Journal of the American Dental . Associ ation. 32:1282, October 1, 1945. H. S. Mustard, Introduction to Public Health (New York: The Macmillan Company, 1944)cited by Gruebbel, loc. cit. 6 The public health service is performed by state and local health agencies. Attitude. An attitude is an acquired, established tendency to act toward or against something.An attitude is an acquired, or learned, and established tendency to react toward or against something or somebody. Value. Value is the believed capacity of any object to satisfy a human desire. It is the quality of any object which causes it to be of interest to an individual or a group. Value is strictly a psychological reality, and is not measurable by any means yet devised. Low income group. Annual family incomes from $1, $2,000 constitute the low income group. The lower half of this branch of society might be regarded as a "medical indigent class. E. 8. Bogardus, Fundamentals of Social Psychology (third edition; New York: D. Appleton-Century Company, 1942), p. 65. Fairchild, cit.. p. 18. Ibid.. pp. 351-32. 16 E. 0. McDonagh, "Social Phases of the Group Health Association Movement in the United States," (unpublished Doctor*s dissertation. The University of Southern California, Los Angeles, 1942), p. 12. III. SOURCES OF DATA AND METHODS OF RESEARCH Two types of data were used in making this survey: (1) published material and (2) information obtained by use of a questionnaire. The attitudes and opinions of various dentists as expressed or implied in this paper were taken for the most part from articles written for The Journal of the American Dental Association. This journal is the official publication of the American Dental Association, and while the opinions of the various writers for the magazine may not represent a summary of the opinions of the members of organized dentistry, they do serve to represent the prin cipal trends of thought existing among the members of the profession on this subject. The material presented on the attitudes and experi ences of the lay people toward dental care was gathered entirely by means of questionnaires, and no literature was used to supplement this portion of the study. The subjects were divided into three groups: (1) those who were seeking care in a private dental office at the time they were given the questionnaire, (2) those who were seeking either dental or medical care in a part-ps^ clinic at the time they answered the questions, and (3) those who were not in an office or clinic at the specific time they accepted the questionnaire, but received it at some other time, through chance distribution by the writer or friends of the writer. 8 The subjects were divided Into these three groups because it was hoped that by this method of distribution it would be possible to obtain attitudes of persons of different economic levels who were receiving varying degrees of dental care.^^ The offices used were selected in various sections of Los Angeles County in an effort to obtain a sampling of private patients and included practices in an industrial area, downtown sections, and beach areas. In the case of the private office, the questionnaire was placed in a stamped, addressed envelope, which was given to the patient to fill out and mail at leisure. The subject was asked not to sign his or her name and none of the questionnaires were to be mailed back to the office from which they were taken. In the case of the clinics, it was believed that a larger percentage of returns could be obtained if the ques tionnaires were distributed and collected when completed. This could be done without jeopardizing the honesty of the answers because of the more impersonal relationship between doctor and patient in the clinic type of organization, questionnaires were taken to various centers in Los Angeles Some of the subjects who filled out the question naires did not answer all of the items listed. As a result, there is some variation in the total number of subjects used in the summaries of the different attitudes. However, per centages were given in each case, so comparisons can readily be made. 9 County, and included part-pay clinics for children and adults and one naval hospital clinic* In addition, a third group of questionnaires was dis tributed to miscellaneous groups of persons who were not in offices or clinics at the time they accepted the question naires. Some were taken to a community choral group while the remainder were used among friends and acquaintances of the writer. In these cases, also, the subjects were asked not to reveal their identity. Comparative study. A summary of the attitudes of the professional group was made. The results of the question naires were tabulated and analyzed and distributions of subjects according to income and occupation were charted. An attempt was then made to show differences in attitudes of the subjects from private offices, clinics, and miscellaneous groups, and to show differences among the subjects when the total number was divided into different economic levels according to income. Comparisons were also made of the attitudes of subjects of corresponding economic levels in the office, clinic, and miscellaneous groups. Charts were made to show whether previous dental experiences and amount of yearly income influenced attitudes toward dental care. Finally, an attempt was made to ascertain to what degree the various lay groups would favor, make use of, or willingly support a government-sponsored program; and a comparison of 10 the professional and lay attitudes toward such a program was made. Limitations of study. The comparison of attitudes on government-sponsored dentistry is such a comprehensive sub ject that many limitations were necessary in this brief study. It was not possible to obtain the same number of replies from the offices and clinics used because of the loss of unreturned questionnaires from the former and the necessity of placing a time limit for the completion of this part of the study. Also, the sample may have been affected by the fact that, in most cases, questionnaires were given only to those who expressed willingness to answer them. For the most part, the subjects in the private offices and clinics were persons who were receiving some type of medical or dental attention at the time. Although this was not necessarily true of all members of the miscellaneous group, their answers proved they were representative of substantial economic levels. It was possible to obtain a sampling of the lower economic groups by contacting patients who were making use of the care offered by various part-pay clinics, but the survey did not reach the great bulk of indigent persons who may need but do not obtain dental care because of inadequate economic resources or because of ignorance of, or indifference to, the need. 11 IV. ORGANIZATION OF REMAINDER OF THE THESIS next chapter is a discussion of the problem of national dental care from the viewpoint of organized dentistry. This is followed in Chapter III by a study of the attitudes of selected groups toward their own dental experiences and toward a government-sponsored program for national dental cafe. Chapter IV presents a summary of the findings described in the previous two chapters with a com parison of the attitudes of the professional and lay groups. The bibliography and a copy of the questionnaire used in the survey conclude the study. CHAPTSB II REVIEW OF THE IITERATURE The summary of the various attitudes of the dental \ profession as presented below was compiled from opinions expressed by members of the American Dental Association principally in articles written for The Journal of the American Dental Association. Growth of dentistry since 1840. The progress of dentistry has taken place edmost entirely within the last one hundred years. Census figures regarding dentists are not available for periods prior to 1850, but it is estimated that by I84O, there were approximately 1,200 dentists. Most of them were located east of the Alleghenies in the larger cities, while the remainder were itinerant craftsmen travel ing from village to village. The federal census of 1850 lists a population of a little more than twenty-three mil lion, including 2,923 dentists. During the next fifty years, as shown in Table I, the population tripled itself, while in the same period the dental profession increased tenfold. By 1900, the ratio of dentist to population was one to 2,561. Twenty years later, it was one to 1,882+ and by 1940, one to 1,865. For ordinary purposes, this figure is usually quoted as one to 1,800. However, rapid as this growth has been, the supply of dentists has not kept abreast of public 13 TABLE I POPULATION, DENTISTS, AND RATIO OF POPULATION TO DENTISTS IN THE UNITED STATES, 1840 TO 1940* YEAR ■ ’ POPULATION NUMBER OP DENTISTS - , POPULATION PER DENTIST 1840 17,069,453 1,200 14,224 1850 23,191,876 2,923 7,934 1860 31,443,321 5,606 i 5,609 1870 39,818,449 7,988 4,985 1880 50,155,783 12,314 4,073 ' 1890 62,947,714 17,498 3,597 1900 75,994,575 29,665 2,562 1910 91,972,266 , 39,99? 2,299 1920 105,710,620 56,152 1,883 1930 122,775,046 71,055 1,728 1940 131,669,275 70,601 1,865 * Comparative Occupational Statistics for the United States. 1870-1940, and other publications, U. S. Bureau of the Census, Washington, 1943, cited by Lon W. Mgrrey, "Dental Personnel," The Journal of the American Dental Association, 32:131-44, February 1, 1945, p. 136. 14 appreciation and demand for service.^ There are many reasons for this increase in dental demands during the last fifty years. Various socio-economic factors, such as increased per capita income, urbanization, and Improved transportation have played a part, hut the principal reasons have been related to the profession, con sisting of the advances that dentistry has made in the biologic and technical fields and in the profession’s effort p to educate the public in matters of dental health. The hi^ proportion of young men rejected from selective service in World War IX because of dental defects^ awakened the country to a greater appreciation of the importance of dental health,^ and many men In service experienced for the ^ Lon W. Morrey, "Dental Personnel," The Journ^ of the American Dental Association. 32:131-34. February T." TMë: ^ Ibid.. p. 135. ® "Among the first two million men called for Se lective service, 20.9 per cent of the rejects were the result of dental deficiency. This percentage led all the causes of rejection in this group of men." "For every 100 men inducted into the Army, there have been 170 extractions and 740 fillings." Statement of Thomas Parr an, "Further Testimony from Hearings on Dental Research and Grants-In-Aid Bills, II," The Journal of the American Dental Association. 32:1146-47, September T7 TÜÎ5. ^ Margaret 0. Klem, "Medical and Dental Care In Prepayment Medical Care Organizations." The Journal of the American Dental Association. 33:330, March 1, 1946. 15 first time some of the benefits of dental attention. I. TSE DWTiL PROBLEM Despite the rapid growth of dentistry as a profession, and the fact that this country leads the world in that field, the majority of the people do not receive adequate dental care. The core of the dental problem centers In the marked disparity between dental needs and available dental service. There are many factors contributing to this imbalance, and these problems must be studied before any effective solution to the situation can be obtained. Nature of tooth decay. The first factor lies in the indiscriminate nature of tooth decay. Natural immunity applies to but a small segment of the population and few measures have succeeded In limiting the disease. Further more, the inability of the hard dental tissues to repair themselves allows destruction to proceed with the lesion usually Increasing in severity as time goes by. The number of affected teeth follows a consistent curve that rises sharply through childhood, the teens, and early adult life, flattens out somewhat at the age of thirty- five years, but continues to rise slowly as long as teeth are present.® 5 J. T. Fulton, "A National Dental Care Program: Presentation of the Dental Problem," The Journal of the Amerlcem Dental Association. 32:1244-45, October 1, 1945. 16 The effective treatment for handling the disease of dental caries is by some type of filling material to pre serve the tooth. Neglect to the point of necessity for extractions, with no subsequent replacement of teeth by artificial means often Increases the diseased condition of the oral cavity. This in turn creates a condition more complex in character because of this demand for mechanical replacement. ® More than nine of every ten children, by the time they reach the age of six, have one or more decayed teeth. At eighteen years of age, nineteen teeth, on the average, have become decayed and several extractions have been made. This continuing loss of teeth upsets the proper arrangement of those remaining, and predisposes to pyorrhea, a tissue disease which takes a heavy toll of the teeth remaining in adult life* Detailed information regarding the prevalence of dental decay among the entire adult population of the United States is limited, but available data Indicate a serious situation, with widespread need for care throughout the population. The approximate figures are given In Table XX. The accumulated unfilled needs, which tremendously in crease the extent of the problem, are also indicated by a ^ Leroy E. Knowles, personal interview, Los Angeles, California, April, 1948* 17 TABLE II OOmPARISON OF PRESENT DENTAL NEEDS OF ADULT POPULATION AND SERVICE RECEIVED TYPE OF SERVICE ACCUMULATED NEEDS OF ENTIRE ADULT POPULATION OVERALL AVERAGE NEED PER PERSON PRESENT SERVICE (YEARLY) Extractions 238,500,000 1.9 0.03 Fillings 632,000,000 5.0 0.4 Examination and Prophylaxis 125,000,000 1.0 0.03 Crowns and Bridges 39,500,000 0.3 0.04. Dentures 20,000,000 1 --- 0.2 0.01 Compiled from figures and chart in "Further Testimony from Hearings on Dental Research and Orants-in-Aid Bills, II," The Journal of the American Dental Association. 32:1142-49, September 1, 1945, p. 1147. 18 oomparlson between present needs and service received. The magnitude of the task presented, if attempts were made to catch up with this vast accumulation of dental needs, would be very great. It is estimated that eight hundred million hours of work would be required to do the job, not including the needed laboratory time."^ Dollar® states that the American public spent, in 1941, just over five hundred million dollars for dental care. Had this amount been evenly distributed over the adult population, the expenditure would have been approximately five dollars per capita. His survey indicated that the cost of restoring the average mouth to dental health would be approximately fifty dollars. This figure represented the initial cost of putting the average moutn in condition and did not represent an annual cost of keeping the mouth in repair. Therefore, the cost for initial care for the total population in 1941 would have been five billion dollars, while annual maintenance would amount to approximately one billion, staggering as this sum seems, when it was compared to what was spent for a limited list of luxury items that ^ Statement of Thomas Parran, "further Testimony from Hearings on Dental Research and Grants-in-Aid Bills, II," op. cit.. pp. 1144-45. ® Melvin L. Dollar, "The Present and Probable Future Role of Dentistry in American Society," The Journal of the American Dental Association. 30:1458-59, September 1, 1943. 19 same year, it was found that more than twenty-two times as much was spent for these luxuries as was spent for dented care (Table XXX). The evidence at hand suggests that annually, on the average, no more than 269 out of every thousand people 9 visit the dentist and that, despite the importance of regularity, the average lapse of time between visits is two and one-half years.Even the highest income and culture groups do not approach 100 per cent care.^^ Manpower shortage. A real problem is the shortage of dental manpower. In 1940, there was approximately one dentist to every 1,800 of the population, and it has been estimated that the present personnel of approximately seventy thousand dentists can furnish annual dental service to about twenty-eight or thirty million people, or to from one-fifth to one-quarter of the population. ^ S. D. Collins, "Frequency of Dental Services Among 9,000 Families, Based on Nationwide Periodic Canvasses, 1928-1951." Public Health Report. 54:629-57, April 21, 1939, cited by Fulton, op. cit., p. 1245. R. M. Walls, S. R. Lewis, and M. L. Dollar, Study of Dental Needs of the Adults in the United States (Chicago: American Dental Association, 1940), cited by Fulton, loc. cit. Collins, loc. cit.. cited by Fulton, cit., p. 1246. 12 Morrey, cit.. p. 135. 20 TABLE III * AMOUNTS SPENT IN THE- UNITED STATES IN 1941 FOR LUXURY ITEMS AND FOR DENTAL CARE LUXURY ITE3/Î AMOUNTS SPENT Automobiles $ 3,500,000,000 Tobacco 2,000,000,000 Liquor 4,000,000,000 Confections 600,000,000 Jewelry 500,000,000 Chewing Gum 100,000,000 Cosmetics 500,000,000 Flowers 153,000,000 Advertising of these items 160,000,000 TOTAL $11,000,000,000 For dental care $500,000,000 Melvin L. Dollar, "The Present and Probable Future Hole of Dentistry in American Society," The Journal of the American Dental Association. 30:1454-1463, September 1, 1943, p. 1459. 21 In a study made by the American College of Dentists, it was demonstrated that maintenance for adults would require more than two hours of dental service annually. The average length of time spent now is almost twice that amount due to the fact that many patients come who have had no dental care for perhaps four or five years. In order to provide the present adult population with the estimated two hours maintenance care each year, a staff of approximately one hundred and fifteen thousand dentists would be necessary, which is almost twice the number now practicing. It would also be essential that a complete program of dental care be given the children between the ages of three and fifteen, for should they reach adulthood with an accumulation of need, the whole vicious cycle would be started again. To provide this care would require the services of approximately twenty thousand additional dentists. Thus, even if all initial need was met, the maintenance care of the present population would require the services of approximately one hundred and thirty-five thousand dentists, and the unavail ability of dentists to perform this work makes the task utterly impossible in the near future. In order to meet the demand, the profession must Dollar, op. cit., p. 1460. Pit. zz expand.^® Enrollments in dental colleges have been held back in the past due to a lack of appreciation for dentistry and the high cost of dental education.^ Within the last few years, however, there has been an unprecedented interest in dentistry. The G.I. educational benefits have helped to remove the obstacle of cost, and have made it possible for many to receive the education that they could not have afforded without this government aid. Also, during the war, many men in service received dental care for the first time and now that they are back in civilian life, they want it for themselves and their families. This growing appreci ation of dentistry further increases the demand for service, and offers a wide field for those who enter the profession.^® The current demand for dental education has made possible the more careful selection of students and the resultant raising of standards.It has become evident, however, that the dental schools now in operation are not sufficient to accommodate all the desirable applicants, and before more students can be graduated, present educational facilities must be considerably enlarged.^® Loo, cit. I® R. W. Bunting, "Dental Education and the Future of Dentistry," The Journal of the American Dental Association. 34:581-82, May 1, 1947. Ibid., p. 583. Dollar, op. elt., p. 1461. 23 More equitable distribution of available manpower. The manpower situation is made more acute because of the un even distribution of available dentists. While the dentist- population ratio in 1940 was approximately one to 1,800 for the country as a whole, the distribution of dentists was by no means uniform.O’Rourke’s study reveals that, in 1940, the dentist-population ratio in the New England states was 1:1,674; in the Middle Atlantic states, 1:1,457; East North Central, 1:1,591; south Atlantic, 1:3,001; East South Central, 1:4,780; West South Central, 1:3,320; Mountain, 1:2,171, and Pacific Coast states, 1:290. O’Rourke writes: The apparent lack of correlation between dentist: population ratio and the population per square mile is doubtless brought about by many conditions. However, it is probable that the most significant influences are the geographic, agricultural or industrial character istics of the various regions . . . Mountainous area, desert, farms of large acreage cause unevenness in the population distribution. There fore, it is essential that analysis of states and geographic districts for the purpose of determining the accessibility of their populations to dental personnel include consideration of population distribution. Dentists will not tend to locate in remote or sparsely settled areas, and yet the total number of people living in such areas is considerable. Better roads and im proved methods of transportation have widened the area which a dentist may serve effectively, and this condition is very likely to continue. Therefore, it is expected that increased accessibility to sources of dental service may in the future increase the demands 19 Morrey, cit.. p. 135 24 upon dental personnel by many persons who reside in thinly populated eœeas.^® Dentists, like physicians and hospitals, have been concentrated in areas with sufficient population and wealth 21 to make their practice possible. It is natural for the urban areas which offer the greatest financial and cultural advantages to have the greatest number of dentists per unit of population.This tendency of dentists to congregate in the highly populated centers and in the Icœge cities is to the distinct disadvantage of the population in the smaller cities, villages, and rural areas. Cities in the United States with a population of over fifteen thousand have about half the population of the nation and more than 70 per cent of all the dentists. This does not mean that there is an excessive supply of dentists in the larger cities, but rather that there is a shortage of dentists in the smaller cities and rural areas.^ J. T. O’Rourke, "Analysis of Number and Distri bution of Active Dentists in the United States," The Journal of the American Dental Association. 31:1097, August 1, 104^, cited by Morrey, cit.. pp. 135-37. Thomas Parr an, "Dentistry in a National Heculth Program, " The Journal of the American Dental Association. 32:286, March 1, 19^45. Fulton, cit.. p. 1246. "Dental Health Goals, " Report of Council of Dental Health, The Journal of the American Dental Association. 33:903, July 1, 1946. 25 Soclo-economle factors. Socio-econoiaic status un questionably adds to the problem,and, if national health is to become an actuality, the service must be brought within the means of a greater number of people. In 1943, Dollar wrote that 46 per cent of the wage earners in the country earned less than one thousand dollars a year, and of the approximately forty-six million adults included in the families of such wage earners, only about seven million, or one out of seven, go to the dentist in the course of any one year.- Dollar stated that, since the whole problem cannot be solved at once, it should be broken down into its parts and those parts attacked that can be coped with successfully. He presented a very realistic approach by dividing the population into categories according to their dental status and considering the special needs of each. His classi fication is as follows: 1. There is a small group who can afford dental care and who get it. 2. There is an even smaller group who cannot afford adequate dental care, but, realizing its import ance, get it at a sacrifice. Fulton, loc. cit. Dollar, cit.. p. 1462 26 3. There is a large group who can afford adequate dental service, but, through ignorance, neglect it* This group includes many who think they cannot afford dental care, but, at the same time, find it possible to afford luxuries. 4. There is another group who can afford only emergency service, but cannot afford complete dental care. 5. Finally, there is that large group who cannot 26 afford any dental care at all. It is evident that the needs of each of these groups are different, and that any program, to be successful, must be adjusted to the particular group to be served. Some need only an educational program, some need financial assistance, and some need free service. The children can best be served through a dental maintenance program that will bring them into adulthood without an accumulation of dental need. An intensive study would reveal these needs, and, on the basis of such a study, the areas of most emergent need may be determined and programs designed to make the wisest use of the dental facilities now available. Simultaneously, long-term programs must be planned that will lead ultimately to the establishment of facilities Loc. cit. 27 adequate to meet the dental needs of our entire popula tion.^^ Ignoranoe of the value of. or lack of enthusiasm for. dental health. Making available facilities for care is not the end of the problem. Means must also be devised to see that the public makes regular use of the facilities. Availability of dental service would by no means assure their use.Fear would keep many from making use of the service, even if It was given without cost. The natural tendency to avoid pain, discomfort, or annoyance plays a definite and important role in the neglect of dental care.^^ Ignorance is certainly a factor, as is habit. Despite edu cational efforts, good dental health measures and the values accruing therefrom are still a closed book to many people.®® Before national dental health can be attained, then, it is necessary to face the problem of balancing dental services with a great volume of accumulated need, which is enlarged each year by the increment of new needs. This Ibid., pp. 1461-62. ^ Ibid.. p. 1462. Fulton, loc. cit. ®® V. D. Irwin and N. W. Wilson, "What Does the Lay man Know about Dental Health?" The Journal of the American Dental Association. 30:1088-91, July 1, 1943, cited by Fulton, loc. cit. 28 fact brings to light the other problems of manpower to furnish the service, of more equitable distribution of that manpower, of the necessity of developing a service that falls within the means of greater numbers of people, and lastly, of education to overcome man’s ignorance of the value of, or lack of enthusiasm for, dental health.®^ II. NSW FIELDS IN DÏNTISTRY Up to the present time, most of the dental care re ceived by the population in the United States has been offered through private dental practice. However, during recent years, in an attempt to reach greater numbers and give at least emergency treatment, various other methods have been tried. Prominent among these new fields in the profession are industrial dentistry and public health dentistry. Industrial dentistry. Industrial dentistry serves a group of individuals banded together for mutual benefit in a dental health plan.®^ The enactment of compensation laws by states and the realization by industry that an ailing or ®^ Fulton, Git.. p. 1247. F. F. Petty, "What is Necessary to Make Industrial Dentistry a Credit to the Dental Profession?" The Journal of the American Dental Association. 30:1426, September 1/ T543. 29 injured worker is a liability to eoonomio production have resulted in the expansion of this health service. Its lack of support in the past has been due to several con ditions. The resistance of industrial management to accept the responsibility and expense of installation and operation has been coupled with a lack of cooperation and skepticism of employers.®^ The United States Public Health Service has recommended that plants of five hundred or more employees have a full-time dentist and has suggested that smaller plants employ a part-time dentist, or collectively, perhaps, a full-time dentist. Physicians and dentists realize the potential ill- effect of sepsis of the gums and dental abscesses on the general health and the fact these conditions could, and probably do, seriously interfere with the worker’s efficien cy. However, exact records as to the prevalence of these disabilities are not available. If they could be provided. ® L. D. Heacock, "Industrial Dentistry as a Career," The Journal of the Amerioan Dental Association. 33:57, January 1, 1946. ®^ Petty, op. cit.. p. 1425. ®® Division of Industrial Hygiene, National Institute of Health, U. s. Public Health Service, Manual of Industrial Hygiene (Philadelphia: W. B. Saunders Company,“T943}, Ch. 6 "Denial Services," cited by G. W. Camalier and I. Altman, "Postwar Plans of Dentists in Service, V. Interest in Salaried Employment," The Journal of the American Dental Association. 32:1119,. September 1, 1945. they would probably remove one of the greatest handicaps to the establishment of industrial dental programs that would serve the best interests of all groups.®® There has also been a lack of support of industrial dentistry by the profession, due to the assumption that it must of necessity be of inferior quality. Due to the lack of support of organized dentistry, industrial dental pro jects have, in most cases, been only an adjunct to an industrial medical program, and were, therefore, limited in research opportunities and in the development of high 37 standards. There must be the application and maintenance of higher standards, under a new and greatly expanded plem, if industrial dentistry is to become acceptable to the dental profession. The administrative phases of the problem can be governed by economists and administrative experts, but the therapeutic phases must be formulated and supervised by men who are, through education and experience, qualified to 36 evaluate standards. The American Association of Industrial Dentists, ^ B. B. East, "Uniform Dental Records and Some of Their Uses, " The Journal of the American Dental Association, 30:1369, September 1, 1943. Petty, loc. Pit. 3® Ibid., p. 1427. 31 which is composed of those engaged or interested in dental programs in industry is developing standards of industrial dental practice. When these standards are agreed upon and adopted, industrial dentistry will have an opportunity to become uniform with other industrial health services. Industry could not attempt the colossal task of dental rehabilitation of all its workers, but industrial dental health programs can be augmented to provide remedial, pro phylactic and protective dental health service without in vading the field of restorative dentistry or assuming the 40 responsibility of dental rehabilitation. Dentistry and public health. The history of the public health dental clinic movement is an interesting one. Many of the first free dental clinics serving eligible children were started by dentists who volunteered their aid, and much of this work was financed by private health agencies associated with charitable institutions. This pioneer move ment started in the early part of the twentieth century, and received added impetus when the theory of dental focal in fection and its relations to systemic health was proved by Heacock, op. cit.. p. 58. E. Goldhorn, "Dentistry in the Industrial Health Program," The Journal of the American Dental Association. 32:1273, October 1, 1945. 32 clinical and laboratory observations.^^ The first dental clinics for children were established in the densely populated communities, because, as in other fields of organized health endeavors, all health hazards and con ditions of ill health are more apparent and diversified, and, consequently, become magnified in larger cities. In 1918, North Carolina became the first state to employ dentists on the state board of health, although by 1946, thirty-seven states promoted dental health programs. Federal health legislation can be divided into two classes: (1) that which attempts to develop a program at the federal level with complete federal control over ad ministration, and (2) that which attempts to develop at the state level by granting federal support in the form of funds. This grant8-in-aid system forms the basis for the Social Security Act of 1935.^® In 1919, the United States Public Health Service, the federal agency specifically charged with matters relating to M. J. Bosenau, Preventive Medicine and Hygiene (Sixth edition; New York: D. Appleton-Century Company, 1935), p. 1374, cited by L. A. Gerlack, "Standards of Dental Care in Public Health Programs for Children," The Journal of the American Dental Association. 35:171, Augusi 1, 1^4V. Loc. cit. ^® H. W. Oppice, "Past, Present and Proposed Federal Health Legislation," The Journal of the American Dental Association. 33:609-12, May 1, 1946. 33 the protection and improvement of the public health, organized a department dealing with dental problems. Another federal agency dealing with problems of health is the Children’s Bureau, created in 1912. It administers pro visions of the Social Security Act of 1935, dealing with maternal and child health services, services for crippled children, and child welfare services and providing for grants to states. An instance of federal grants to states for dental services is found in the Federal Emergency Belief Adminis tration of 1933. Dental care under the program was limited broadly to "emergency extractions and repairs," but in practice, the limitation of service depended on state or local definition. This legislation led to renewed national considerations of the problems of health and health service, and it gave the government and the professions their first practical lessons in designing programs for service for about twenty million or more of the population. The Farm Security Administration, another depression- bom agency, also dealt with problems of national health. It attempted to aid families to get medical and dental care by setting up country-wide group health services in co operation with local dentists and physicians. In most of the regions, dental prepayment programs were established. Few of the local plans were successful, although some 34 interesting data were aooumulated through the program on low income groups, rural needs, distribution of dental per sonnel in rural areas, and the need for relocation programs. Complete dental service for all the people is at present financially and professionally impossible and will be for many years to come. As yet, a dental health program for any community must be based largely on prevention, with concentration on adequate dental care for children so that in the next generation, the dental demands of the adult population will be lessened. There is a great deeil of work to be done in the field of public health as related to dentistry. "In 1941, the total amount for all health services was one hundred and nine million plus. Of this amount, 0.6 per cent was budgeted 45 for dental service." A comprehensive program could consist of: (1Î greater dental health education activities, (2) in vestigation of public health methods as applicable to dental health programs, (3) epidemologic studies of dental disease, and (4) experiments in dental care prevention and in dental ^ B. E. Lischer, "Public Dental Health in Dental Education," The Journal of the American Dental Association. 29:1201, JnlTT, 1942. Editorial, "Federal Aid in Public Health Den tistry," The Journal of the American Dental Association. 30:579, April 1, Ï943. 35 oare for children.^ The activities in dental health edu cation should include education for the lay people and classes on community health problems for dental students#^^ III. A NATIONAL DENTAL OARE PROGRAM Organized dentistry has always stood for the extension of service to the whole population. After the hearing on the proposed National Health Act in 1939, the National Health Program Committee of the American Dental Association worked out in detail a tentative plan for Dentistry’s participation in a national health program. Briefly, the plan recommends; (1) the utilization of existing social agencies for purposes of health promotion, namely, the health education service program of elementary and secondary schools, (2) the employ ment of the preventive functions of public health agencies in dentistry on local, state, and federal levels, and (5) the effective treatment and rehabilitation that are provided by private practice.^ A. 0. Grubbel, "Dental Services and Dental Per sonnel in state Health Departments," The Journal of the American Dental Association. 32:1288, October 1, 1945. Lischer, loc. cit. ^ J. B. Robinson, "The Problem of Dental Health Care for the American People, " The Journal of the American Dental Association. 31:526-27, April 1, 1944. 36 This must necessarily be thought of as a future, long-range program, for the setting up and working out of such a program is dependent on trained manpower and money and neither essential item is at present available in suf ficient quantity. However, such a program should strive to make avsdlable to the entire population, regardless of the financial means of any group, all essential preventive, diagnostic, and corrective dental services. Provision should also be made for the constant evalu ation of the effectiveness of the methods used in rendering the various services, and for maintaining standards satis factory to the public and the dental profession. The effort that is being made by the Dental Association in this direction is well spent, for statistics have shown how serious and widespread is the need for dental care throu^- 49 out the population. In June, 1945, a tentative chart of administrative organization of a national dental care program was prepared at the Institute of Dental Health Economics at Ann Arbor, Michigan. This plan is shown in Figure 1. This program provides for the utilization of local dental societies, with as much of the program as possible being carried out at a 49 V. D. Irwin, "Services to be Rendered Under a National Dental Care Program," The J ournal of the American Dental Association. 32:1247-48, October 1, 1945. FIGURE I ADMINISTRATIVE ORGANIZATION OF A NATIONAL DMTAL CARE PROGRAM* 37 Local Dentists Locàl Dental Health Officer COMMUNITY State Council on Dental Health Local Council on Dental Health Dental Health Education Program Local Dental Society State Dental Director A.D#A. Council on Dental Health U.8.P.H.8. District Dental Consultant Private Dental Society Public Service Program for Children and Adults Dental Consult ant U.S.P.H.S. States* Relations Division Field Representative (Dental) State Department of Health * R* C* Leonard^ "Administration of a National Dental Care Program^” The Journal of the American Dental Association* 32î 1254, October 1, 1945, 38 comsnmity level through these agencies under the supervision of the state and national associations. In areas where dental service is either lacking or inadequate, existing facilities would be augmented by clinical service sponsored by governmental agencies. This clinic service would cover only that portion of dental care that the local dentists could not themselves provide, and local dentists would have a voice in the direction of local clinical and dental health educational program. Local societies would be able to utilize the consultive advice of the state and national dental organizations.^^ Statement of goals* The Council on Dental HeeüLth of the ^erican Dental Association, in response to the request of the Senate Committee on Education and Labor, has made a summary of the goals to be borne in mind in the planning of 51 a national program. The following five points were in cluded : (1) The prevention of dental disease. Many of the causes of dental disease are at present unknown and the in creasing of knowledge of dental disease prevention and the ^ R. C. Leonard, «Administration of a National Dental Care Program, « The Journal of the American Dental Association. 52:1252. October 1, 1945. Report of Council on Dental Health, quoted in «Dental Health Goals,« The Journal of the American Dental Association. 33:900-903, July 1, 1946. 39 ability to apply new and proven preventive techniques will depend in a large measure on the support dental research receives. In previous years, such research has been con ducted by only a few properly trained workers under most unfavorable conditions. The difficulty in obtaining qualified personnel for dental research in the past has been due largely to lack of funds. Federal support of dental research would supply the financial means to initiate, stimulate, and accelerate investigations into preventive methods and other fields of dental service. (2} The control of dental diseases by the expansion of community dental health programs. Every community should support a comprehensive dental health program for children. The primary objective of these programs should be to prevent the accumulation of dental needs through a systematic plan of maintenance care in young age groups. The ccanmunity in all cases should determine the methods of providing care in its area. (3) The provision of additional facilities and uni form standards for dental care by making dental services ^2 be sure, in practice we have to resort to reparative methods because our knowledge of prevention is inadequate, but, in education, a growing number contend that if dentistry must continue to advance as a profession, it must accept prevention as a dominant objective.« Qqoted from Lischer. op. cit.. p. 1199. available in hospitals and health centers for inpatients and outpatients. (4) The recruitment of an annual enrollment of dental students equal to the capacity of all dental schools in order to increase the number of qualified dentists. (5) The adoption of measures to make dental practice in smaller cities and rural areas more attractive and re warding in order to procure a better distribution of den tists. More intensive recruiting of dental students from the areas most in need of dental services will help to solve this problem, for it is well known that dental students tend upon graduation to go back to their home areas to engage in practice.®^ The nature and prevalence of dental diseases pose some special probl@ms that cannot be solved by submerg ing dental problems in the large total of other unmet health needs. The fact that in 1941 only 0.6 per cent of the one hundred and nine million dollars budgeted from all sources for cooperative health work was allotted to dental health activities is a distinct case in point. This statement of the Council on Dental Health is important because it indicates once again the necessity of making some distinctions in the handling of dental diseases as a public health problem and points as well to the «Dental Health Goals,” loc. cit. Editorial, «Goals in Dental Health,” The Journal of the American Dental Association. 33:892, July 1, 1946. 41 essential need of earmarking funds for dental purposes. Until these things are done with specifically defined goals readily in view, the easy solution of endless emergency dental service as proposed by the current Wagner-Murray- Dingell bill will continue to receive much more attention 55 than it deserves. The three-point plan of the American Dental Associ ation. The American Dental Association has adopted three principles as being basic and fundamental in a dental health program for the American people.These three points are so integrally related in their influence in dental health that no dental program should be established without includ ing each of them in its proper relation. They are; (1) Research. Adequate provisions should be made for research which will lead to the discovery of the causes of dental disease, thus making preventive measures more effective and decreas ing the amount of dental disease in the country. (g) Dental Health Education. Dental health education should be included in all ibia. Formal statement of ^erloan Dental Association, «Testimony of American Dental Association at Hearings on National Health Bill, 8.545,« The Journal of the American Dental Association. 35:217-19, August ll, T947. 42 basic educational and treatment programs for children and adults, to bring a knowledge of present methods of pre vention and control to the attention of all the people. (3) Dental Gare. Dental care should be made available to all regard less of income or geographic location. Programs developed for dental care should be based on the prevention and con trol of dental diseases. All available resources should first be used to provide adequate dental treatment for children as the greatest amount of prevention and control can be accomplished in this age group. Efforts should be 57 made to eliminate pain and infection for adults. In order to express the attitude of the American Dental Association toward a national health program in a more practical way, and in order to insure the rights of the public and the profession in such a program, the House of Delegates approved eight basic principles, which were formulated by the National Health Program Committee. They were: (1) In all conferences that may lead to the formation of a plan relative to a (dental) health program, there must be participation by authorized representatives of the American Dental Association. (2) The plan should give careful consideration to: first, the needs of the people; second, the obligation of the taxpayers; third, the services to be rendered; and fourth, the interests of the profession. (3) The plan should be flexible so as to be adaptable to local conditions. (4) There must be complete exclusion of non professional. profit-seeking agencies. (5; The dental phase of a national health program should be approached on a basis of prevention of dental diseases. 43 An ideal clinic program for children. An ideal dental clinic program would provide complete dental clinic service for every child from the cradle to the time of graduation from high school. However, it is doubtful due to lack of finances or lack of personnel if there is a public dental clinic operating at the present time which is capable of giving complete dental service to the eligible children in its community. One must plan a scope of service that will be of good quality and which will include as many children as it is possible to serve with a curtailed setup. The insufficiency of budgetary allotments for dental clinics and the hi^ cost per dental operation are such that the services rendered must be spread comparatively thin at the (6) The plan should provide for an extensive pro gram of dental health education for the control of dental caries. (7) The plan should include provision for render ing the highest quality of dental service to those of the population whose economic status, in the opinion of their local authorities, will not permit them to provide such services for themselves, to the extent of prenatal care, the detection and correction of dental defects in children and such other service as is necessary to health and the rehabilitation of both children and adults. (8) For the protection of the public, the plan shall provide that the dental profession shall assume res ponsibility for determining the quality and method of any service to be rendered. Editorial, «Federal Aid in Public Health Den tistry, « The Journal of the American Dental Association. 30:578, April 1, 1943. 44 present time. The Low Income Group Gommlttee of the American Dental Association Council on Dental Health has recommended that complete treatment should he provided for preschool children and for school children in the lower grades with limited treatment given older children until a complete treatment plan for the younger age group has been put into effect. ”Xf teeth are saved for six-year old children, the number of emergencies in twelve-year old children will be reduced. Such pertinent points as eligibility for acceptance into the clinic, free clinical services rendered, establish ment of part-pay clinics and the extent of services rendered to individuals and families must be decided locally through the cooperation of all interested agencies. Each community's public health department has a policy of operation in L. A. Gerlack, «Standards of Dental Care in Public Health Programs for Children,« The Journal of the American Dental Association. 35:172-73, August 1, 1947. Gerlack calculated the cost per dental operation and the cost per injection in diphtheria immunization for one child was $0.17. Physicians generally agree that the initial diphtheria injection is usually effective for life. Comparatively, the cost per single dental operation, such as an extraction or filling, was $0.52 and an average of seven operations was required to carry out the original standard of dental service. Moreover, each child who has had complete dental care for one year will of necessity be forced to have at least a minimum of two dental operations in each year thereafter, at a cost of $0.52 per operation. Ibia.. p. 174. 45 eonjunetion with its welfare department, school board, council of social agencies and professional societies.^® At the present time, the need of dental care for children is far greater than the services rendered by public health programs, and the standards established for this type of service, while necessary, have to be fluid in order to fit into all kinds of programs. Limited budgets and inade quate dental personnel govern the amount of service given. The solution to the problem, although not impossible, requires long-term planning. It is necessary to keep the long-term perspective in mind and to continue pointing toward it. In this way, both the quality and the quantity of dental care administered to children in a public health program, regardless of limitations, will remain at a satis factory level and will make expansion less difficult when the occasion and the opportunity demand. Responsibilities for dental health. Under the third principle of its health program the American Dental Associ ation makes the statement that dental health is the res ponsibility of the individual, the family, and the community, in that order. When this responsibility, however, is not Ibid., pp. 174-75. Ibid.. p. 175. 46 assumed by the eommimity, it should be assumed by the state and then by the federal government. The community in all cases shall determine the methods for providing service in & p its area* It states further that the responsibility for pro viding dental care must be borne in the same manner as the responsibility for providing food, shelter, or any other essential of life. It is the American custom and tradition for the individual to attempt to supply these things for himself. If he cannot do so, the responsibility rests on the family, the community, the state, and the nation successively. If each assumes an equitable share of res ponsibility, the problem of better dental health in this country is on the way to solution.^^ Irwin, in a paper read before the Dental Health Section of the American Public Health Association in New York in 1944, enlarged upon this problem of responsibility.®^ He believes that responsibility for public dental health rests, in varying degrees, upon all health and educational Statement of American Dental Association, «Testi mony of American Dental Association at Hearings on National Health Bill, S. 545, « The Journal of the American Dental Association. 35:217, August1, 1947. Ibid., p. 218. 64 Irwin, 0£. cit., p. 1250, 47 agencies. Until a national dental care program covering the entire population becomes feasible, federal, state, and local communities must continue and increase their financial aid. It is especially desirable that state legislators be brought to a realization of the needs and benefits of dental health programs. Aid that has been given by both official and non-official agencies will need to be maintained and expanded. Schools will continue to make a valuable contri bution by motivating children to obtain needed dental care. Welfare agencies will supply essential aid by providing trained personnel to select persons eligible to receive free or low-cost reparative service. The Americein Dental Associ ation will make available the knowledge and experience of the organized dental profession while practicing dentists in public health work and in private offices will continue to be the key men in the whole program. Its success depends on their skill and knowledge, and they are, therefore, en titled to a large share in formulating the blue prints for any national dental care program. Parents, teachers, youth counselors, nutritionists, nurses, physicians— all who claim any interest in any phase of health or education— are concerned in the promotion of dental health. Finally, there are the men, women, and children who eæe the recipients and also (as taxpayers) the ultimate providers of public dental health service. 46 Sometimes, it is advisable to emphasize the responsibility of a certain group because of the special contribution that it can or should make to the total sum of dental health service; but the neatest success will be achieved if ser vice is recognized not as something to be handed down from a superior group to an inferior one, but rather as something that should be established, organized, and conducted by everyone for everyone*s benefit.®® IV. attitudes of THE AMERICAN DENTAL ASSOCIATION TOWARD THE WAGNER-MDRRAY-DINGILL BILL During recent years, various plans have been proposed for inaugurating a national health program which would be financed by federal funds and administered by a federal bureau. Studies have been made by the American Dental Association to determine the effectiveness of the proposed procedures and to determine professional and public opinion on centralized plans of administration. The Association has not endorsed these programs, for it has not felt that the high quality of care which has been established could be maintained and preserved under any of the plans thus far proposed.®® The Social Security Bill, ®® Loc. cit. J. B. Robinson, «The Problem of Dental Health Care for The American People,” The Joumetl of the American Dental Association. 31:528, April 1, 1944. 49 popularly known as the Wagner-Mirray-Dlngel 1 Bill, is the best known proposal. It is a plan for compulsory health insurance through the extension of the provisions of the Social Security Act. The program would be under the super vision of a national advisory medical and hospital council, with the Surgeon General of the United States Public He€ü.th Service as chairman. The Council on Dental Health studied the provisions of the bill, but opposed the particular plan outlined on the grounds that it violates the established principles approved by the Association as requirements for an acceptable national health program. Reasons for opposition to the bill. There are a number of important reasons why dentistry has not been in agreement with federal proposals for a national health pro gram. One has been the failure of those promoting legis lation, or of their technical advisors, to seek or to heed the advice of dental leaders in matters that affect the vital professional aspects of the problem. This does not mean that the American Dental Association wishes to dictate the terms of a national health program, but it does mean that the Association desires to participate in perfecting useful legislation, which, it believes, can be accomplished only through the utilization of the intimate experiences and the understanding of leaders in this special field. 50 A second point of disagreement is that all plans for federal control of health care so far proposed cannot, in their final analysis, operate in the ultimate best interest of the public* The American Dental Association places the public welfare at the head of its list of considerations for an acceptable national health program, and insists that the quality of the service to be provided be considered as of first importance in any legislation designed to increase the quantity of oral health care. The primary object of the dental profession is to prevent and control dental disease through the application of sound dental and public health objectives. The Wagner- Murray-Dinge11 Bill proposes to make emergency dental care available to larger groups of the population. This proposal involves a false concept in public dental health practice because if only emergency dental treatment is given, the problem of dental disease will be as great ten or fifty years from now as it is today. In contrast to this approach, the dental profession of this country supports the view that the problem can be solved through a coordinated program of disease prevention and dental care for children. The reasons behind this belief are that if the occurrence of dental disease cannot be prevented, efforts must be concentrated on Ibid.. pp. 528-29. 51 dental researoh; If service cannot be offered to all persons, the benefits of the plan must be limited to the age groups in which dental disease begins.®® The chief concern of the Wagner bill is to work out ways and means by which people can pay fop care. On the contrary, the Association believes that what is needed first is to achieve, as a nationwide basis, care that is worth distributing and worth paying for. The development of pre ventive dentistry, which, in the long run, is the only rational definition of «adequate dental eare,« has nothing to do with the principles upon which social insurance is ^ 69 based. Lastly, it is conceded that the less complex the organization, the more easily it can be adjusted to the changing or emergency needs of its members and the more effective it becomes in achieving its objectives. The Association insists that a fundamental of any health pro gram is its ready adaptation to local conditions. It is agreed by experienced health workers that the most Statement of American Dental Association, «Testi mony of the American Dental Association on Wagner-Murray- Dingell Bill, S. 1606,« The Journal of the American Dental Association. 33:746-47, June Ï, 1946. 69 C. L. Hyser, «A Proposal for Group Practice in Dentistry,« The Journal of the American Dental Association. :855, July 1, 1945. “ 58 ' effective health pregram is that which is organized on the local level, with final authority invested, as far as possible, in local administration, in order to ensure flexi bility in operation. It is the opinion of the Association that the needs of the people and the obligation to the tax payer cannot be competently met, and that the quality of dental service rendered and the effectiveness of the pro fessional worker cannot be achieved, by substituting a national health program such as those suggested as an alternative to a further and more adequate development of existing local and state health agencies. The American Dental Association believes that the Wagner-Mufray-Dingel 1 Bill does not take into sufficient account the unique and complex problem of providing adequate dental care. There has been a tendency to include dental practice and treatment under the categorical head of «medical service, « and while it is true that close cooperation between dental and medical practitioners exists in routine and special practice, it does not follow that the needs and pro grams of both professions are identical. There are specific facts about dental disease and dental practice that must be taken into consideration before an intelligent and long range program can be planned. Legislation that is well Robinson, op. cit.. pp. 589-30. 53 designed to meet medical problems and conditions is not necessarily as well adapted to meet dental problems which are quite different in nature, due largely to the prevalence of the disease. Because of the extremely high prevalence of untreated dental defects, it is impossible to apply the in surance principle. The insurance principle. According to Hyser, social insurance is based on the principle that Illness is a hazard, a calamity that does not come to all, and that it is pos sible to work out, on the law of avereiges, a scheme by which the money saved on those who are not ill can be applied to the care of those who are ill. Dentistry must include in the program provision for treating a disease that is almost universal. It is almost axiomatic that 95 per cent of our population suffer from dental diseases at some point or other in life; that an extremely high percentage need annual dental care; and that preventive dentistry is needed by all. The Association believes that compulsory health in surance for a majority of the population should not be established in this country without prelimineœy scientific experimentation involving less extensive groups of the See The Journal of the American Dental Association. 33:745-46, June 1, 1946. Hyser, cit.. pp. 855-56. 54 population and that it should not be established without directly facing the problem of expense, which should be clearly enunciated in terms of both cost to the individual and cost to the nation. The Association also feels that the right of the state to determine the methods of meeting its health needs should not be taken away and that a program as comprehensive as the one proposed should not be designed without seeking the official cooperation of all agencies and professions involved. Organized dentistry has sponsored instead two measures which provide for federal grants-in-aid to the states, and give states and communities the right, with broad limits, to determine their needs and programs for themselves. The two bills place the major emphasis upon prevention and control, and provide for research and experimental programs in dental health education and care. The Association feels that these bills will encourage the development of new dental resources to meet the problem and will make lasting contributions to dental health in this country. The American Dental Association has at no time ob structed reasonable efforts to improve the existing situation. See The Journal of the Amerloan Dental Association. 35:746, June 1, 1946. Ibia., p. 748. 55 It desires to see adequate dental health care made available to the whole population. But, having borne the responsi bility of advancing the quality of dental science and art to its high degree of usefulness, it feels a continuing res ponsibility for insuring dental health care of quality for all who require. Robinson, cit.. p. 530 CHAPTER III ATTITUDES OF SUBJECTS TOWARD DENTAL CARE This portion of the study was an attempt to compare attitudes of selected groups of lay persons toward some of their own dental experiences and toward some type of govern ment-sponsored dental program, to determine whether or not the subjects would choose to avail themselves of the denteO. care offered, and whether or not they would willingly support a government-sponsored plan. An attempt was made to discover differences in attitudes, and, where differences were found to exist, to discover various factors which may have been responsible for or may have affected these atti tudes. Distribution of subjects by income and source. The first step in making the study of the different lay groups was to make distributions of the subjects of the three groups by income and occupation, as shown in Tables IV and V. Of the 430 subjects who reported their yearly incomes, 31.38 per cent earned less than $2,000 a year, 44.41 per cent earned between #8,000-$3,999, 13.01 per cent reported theirs to be between $4,000-$5,999, while the remaining 11.14 per cent had an income between $6,000-$19,999. There was a notable difference in the distribution between the three groups, however. Of the subjects 57 > M îxj < En O o O g o m C O E4 § s g o to Ü4 0 1 I g P4 o < t D C O § . M ' 3 ' -P a m o Pi Q ) (U O O M C O C V 3 » o 02 00 02 C 3 Ï Î to ID P tD 00 f> P P u M C D o rQ t> to to ID C O C O e 00 P to P P M ï3 , m : p C O o 2 > c o C O O 00 ! J C D • • • • 1 Ü o 00 C O » t i o ' P - , o 1 ! n ■ Q ) rH 1 g; Ai M ! ^ Pi O m C D H " * C O 02 1 S to O P p 1 0 C V 2 P P 1 I m p 02 iD O' 0 O ID 02 (D Ü O 02 o H ^ ID O- ' pi O P Hi 02 P O (D iH M Ai 1 x4 Cc O (D O Hi o- £> 00 i s ! —1 P H ^ 02 P 0 rH P G O P 1 —1 05 ID 0 C O O 00 02 (D Ü O P H ^ to O- to Pi O to H* 1 —1 Q > rH g Ai o Pi E H 0 ) /A O lO P C O H < H < B to to O) ID to P 0 V p P S 05 05 Gi 05 05 05 Gi 05 05 o O) 05 05 05 O C O o • V P o C D o to ID 05 g; B * s 1 M o 02 1 1 1 o s g § : O H 0 o O o o I 3 P Pi o o o 1 O 1 C D o o o m , 1 P o ( —1 0 oT C O i p i < o ; TABLE V NUMBER AND PERCENTAGE OF 375 SUBJECTS BY OCCUPATION* 58 OCCUPATION TOTALS OFFICE CLINIC MISCELLMEOUS 1 ALL SUBJECTS MEN WOMEN TOTAL MEN WOMM TOTAL MEN WOMEN TOTAL MEN WOMEN Num' her f Per I cent Num ber Per cent Num ber Per cent Num ber * Per cent Num ber ► ! Per cent Num ber 1 Per I cent Num ber Per cent Num ber Per cent N\aml ber. Per cent Num ber • Per cent Num ber Per cent Num-1 ber Per cent All occupations 375 100 143 100 232 100 109 100 44 100 65 100 177 100 67 100 110 100 89 100 32 100 ' 57 100 I# Professional and related services 54 14.4 28 19.58 26 11.20 31 28.44 18 40,90 13 20 8 4.51 2 2.98 ■ ■ • i 6 5.45 15 16.85 8 25 7 12.28 II. Manufacturing and repair services 37 9.se ! 35 24.47 2 .86 7 6.42 7 15.90 a # 20 11.29 19 28.36 1 .90 10 11.23 9 28.12 1 1.75 III# Transportatio c ommuni cation, other public uti lities 13 ^3.46 11 7.69 2 .86 2 1.83 2 4.54 # # . # # # » 10 6.64 8 11.94 2 1.81 1 1.12 1 3.12 IV. Wholesale and retail trade 33 !s .8 22 15.38 11 4.74 10 9.17 8 18*18 2 3.07 13 7.34 10 14.92 3 2.72 10 11.23 4 12.50 6 10.52 V# Finance, insur ance and real estate 38 10.13 9 6.29 29 12.60 20 18.34 3 6.81 17 26.15 4 2.25 4 3.63 14 15.73 6 18.75 8 14.03 VI. Personal services 37 9.86 12 8.39 25 10.78 2 1.83 r — — 1 mm 2 3.07 33 18.64 11 16.41 22 20 2 2.24 1 3.12 1 1.75 VII. Government and military service 13 3.46 13 9.09 — I 1 1 1 .91 1 \ 1 |2.27 — mm 11 6.15 11 16.41 — 1 1.12 1 3.12 VIII. Industry not reported 150 40 13 9.09 131 1 ! 59.05 1 36 33.02 5 11.36 : 31 47.69 78 44.06 6 8.95 72 65.45 36 40.44 2 6.24 34 59,65 ♦ Based on classification used in U* S* Census, 1940# 59 receiving care in private offices, 12.73 per cent were in the under $2,000 ©roup, 40 per cent earned from $2,000- $3,999, 24.54 per cent earned between $4,000-$5,999, and 22.72 per cent had a yearly income over $6,000. A striking difference is shown when these figures are compared with those of the clinic patients, where 44.06 per cent earned less than $2,000, and approximately one-half of these earned under $1,000, while 46.30 per cent earned between $2,000-$3,999. Only a fraction over 7 per cent had an income of more than $4,000 a year. No one of the clinic patients had an income over #10,000.^ A noteworthy fact also is that included in the clinic figures were many men who were the wage earners of the family, while in the offices, single persons with no family responsibilities raised the per cent eige of that group. The miscellaneous group had approximately the same per centages as did the office group of distribution by income, except that in the divisions under $2,000 and $4,000-$5,999, it fell midway between the other two groups. A total of 375 persons, 143 men and 232 women, indi cated their occupations. A few noteworthy figures were shown in this report. The percentage of subjects engaged in Since the clinics from which the patients received dental care primarily serve patients of low income, it would be expected that none would have an income of 60 professional and related services was higher for office patients than was the total of the other two groups. The clinic group was noticeably low in the number of persons engaged in finance, insurance, and real estate, which in cluded stenographic and other office work, and was high for both men and women in the percentage engaged in personal and domestic services. Housewives were included in «Industry not Reported,” which accounts for the large number, 150 per sons, under this category. Gomparison of subjects as to frequency of visits to dentist, and the relationship of frequency of visits to income. There were 402 subjects who reported on the fre quency of their visits to the dentist, as shown in Table VI. Of these persons, 29.35 per cent stated they visited their dentist every six months, 32.08 per cent did so once a year, 10.19 per cent had check-ups every two or three years, while 28.35 per cent sought help only when in pain. There were striking differences between the habits of the office and clinic patients. Fifty per cent of the office clientele received attention every six months, while another 34.25 per cent sought-care regularly once a year. Only 8.33 per cent waited until they were in pain. By com parison, of the clinic subjects, only 22.22 per cent re ceived care every six months and 25.18 per cent were given attention once a year. Moreover, 39.25 per cent delayed 61 EH rfl Ph CD 5 : § : «p 0 (D Ü ë Ai O ; O r4 CD tO rH CVÎ ^ 5 CO co CO V O) o ' D- i • CVi co ; hH ! 0 tD M ! CD ÊH O O O) co LO CVi CD pc; CD i B lO to lO 1 —1 lO M tb 1 -1 0 1 —1 En S M CD M PD Q O P CVi co CO lO M 0 CVi 1 —1 co CVi O S 0) • • • é EH <4 Ü O CVi lO co G> O 0 o CVi CVi rH C<D CD M 0> rH En M S Ph M O n CD CD hP I ^4 i —1 M o Q) > ^ . rO tO o 00 CO S co co co iH iO & 4 - -a 0 iH O § s ÎH O # » p lO O CO S o 0 <Xi CO M M <D • • • S O O o D- GO G? M M U O m co M J O <D rH fx; O H4 Pi Ce, tx. «V Pc, P4 ÎX, M o Q) o O f) CO o CO 05 M S O i lO co m Pm 0 1 —1 ci> S < O Eh îs; CD p lO 00 O) lO m o EH 0 co o fH CO o Pd O 0) • • • • PC: Pc, M O O CJi CVi O CD M * ~ 3 ?4 o CVi co iH CVi Ai CD m 0> ( —1 EH tD Ph § M U • - 3 (D PQ < f) CVÎ CD Oi rH Pd O EH e O rH CVi îH M CD O 0 f —1 rH H m EH S CVi 0) O SI >4 m 0 H cd H CO A O % 0 S Xi cd 0 M CD P U eu •H ^Pc, Eh rH 0 cd H C ^ O M cd O 0) >s M CD p H y] iH pq M o 1 0 &i > Eh CD rH CVi O 62 care until they were in pain. in attempt was made to determine whether or not there was a relationship between the frequency of visits to the dentist and the yearly income. See Ta,bles VII and VIII. in the clinic group, the large percentage who went only when it became a necessity were in the under #2,000 a year group and this low income no doubt exerted an influence on their poor dental schedule. However, for the other income levels of this group and all of the categories of the other two groups, there appeared to be no relationship between amount of yearly income and regularity of dental habits. In the private offices, of the fifty-four persons receiving care every six months, the largest percentage, 31.5 per cent, had a yearly income of between #2,000-#3,999, while 64.9 per cent of the subjects going once a year were also within this income group. Five of the nine persons who sought care only when in pain were in the #4,000-$5,999 category, although no one earning more than #6,000 had fol lowed this plan. Thirty clinic patients had dental attention every six months. Thirty-three per cent of these and 59 per cent who received care once a year had an income which was under #2,000. However, a very significant fact was shown by the percentage of clinical patients who sought care only when in pain. Of this number, 63.2 per cent earned less than $2,000 TABLE VII FREQUENCY OF VISITS TO DENTIST AS RELATED TO YEARLY INCOME FOR 402 SUBJECTS, COMPARED FOR OFFICE, CLINIC, AND MISCELLANEOUS GROUPS, RECORDED NUMERICALLY 63 ALL SUBJECTS OFFICE CLINIC MISCELLANEOUS YEARLY INCOME Total 6 Mo# 1 Yr# 2-3 Yrs. irKln Total 6 Mo , 1 Yr# 2«*3 Yrs# Total 6 Mo. 1 Yr. 2-3 Yrs. l k % n All incomes 402 108 64 37 8 ! 9 1 135 30 34 18 63 159 34 58 15 52 Under $2,000 IIT 15 10 2 1 ! 2 68 10 19 6 33 34 4 15 3 12 #2,000 - 3,999 184 44 17 24 1 2 54 14 13 10 17 86 16 24 11 35 #4,000 5,999 55 26 11 6 3 5 11 4 2 2 3 19| 6 10 3 #6,000 - 9,999 33 17 12 3 2 2 2 14 4 7 1 2 #10,000 » 19,999 13 7 4 2 1 # ' 6 4 2 — TABLE VIII FREQUENCY OF VISITS TO DENTIST AS RELATED TO YEARLY INCOME FOR 402 SUBJECTS, COMPARED FOR OFFICE, CLINIC, AND MISCELLANEOUS GROUPS, RECORDED BY PERCENTAGES 64 YEARLY INCOME ALL SUBJECTS OFFICE CLINIC MISCELLANBOÜS Total 6 Mo. 1 Yr. 2-3 Yrs. I n “ M i n Total 6 Mo. 1 Yr. 2-3 Yrs. Total 6 Mo. 1 Yr. 2-3 Yrs. I % ^ i n All Incomes 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Under $2,000 29.10 13.8 18.5 6.4 12.6 22.2 50.4 33.3 55.9 33.3 62.3 21.4: 11.7 26.8 20 23.1 #2,000 - 3,999 45.77 40.7 31.5 64.9 12.5 22.2 40 46.6 I 38.2 55.5 32.1 64.1 47 41.3 73.3 67.3 #4,000 - 5,999 13.68 23.1 20.4 16.2 37.5 65.5 8.1 13.3 5.8 11.1 5.6 11.9 17.6 17.1 5.7 $6,000 « 9,999 8.20 16.7 22.2 8.1 26 ( i i c y , - ’ . 1*5 6<#6 mm mmwê 8*5 11.7 12.1 6.6 3.8 #10,000 19,999 3.23 6.5 7.4 5.4 12.6 -- 3.7 11.7 3.4 65 a year. In the laisoellaneous group, oomprised of persons who were not o ont acted at a time when they were seeking medical or dental attention, the majority of persons who had regular attention were In the #2,000-#3,999 bracket. The majority who waited until emergency treatment was necessary were also in this bracket. In contrast to the clinic cases, where the majority so doing were in the lowest income level. Of the six persons in the highest category, all received care at least once a year. Comparison of attitudes of subjects toward preference of private office or clinical care. Each of the subjects of the three groups, irrespective of where they were receiving dental attention at the time, was asked to check whether he would prefer private office or clinical care. Responses are given in Table IX. Of the 383 subjects who reported, 65.37 per cent preferred the private office and the remain ing 54.46 per cent chose clinical care* All but one of the patients (98.97 per cent) who were receiving care in private offices wished to continue doing so. Although all of the clinical group were receiving some type of clinical medical or dental attention at the time they answered the question, 39.15 per cent stated that they would prefer a private office. The per cent of office patients who preferred private care was significantly greater than the per cent of 66 g M 1 g M < ob > <5 M £h ffî S P4 M O p : O M P4 C O a O <t| M M) p : m M X o § M co co g 00 to M § m. m o * % C Q M H a O E-i H < î E- 4 O 6-* M < a 1 1 — 1 E - M O P î g ; O M G 1 P4 CQ O o M C <D ü <D PW o O r4 CD C V i £S O) ' CO o CQ W (D O to rH CQ €Q S £> e- H 0 S ■P iO ’ Q* c rH 00 a> • ü O : O) <D o U O co CD M <D iH % Ai •4 Pi O (D a c v j co CD s rH 00 CQ 0 C \ 2 rH a -p £> CO G Qi O Q • a ü O 00 rH M Pi O CD O <D r H I M Ai f V , f X| Pi O (D P 00 £ > • rH S O) Gi 0 a p> O CD co 0 CO EH m • O ü o lO ' 4 * M Pi o CD CO * -3 (D rH © Ai CO Pi 0) ^4 rO CO rH CQ S 00 lO CO < 0 CO CQ rH 0 1 —1 d) 03 CQ P> ü <D 0 • r H > 0 0 • f H « r H CO P» Pi rH M *H Oi ü O 43 5 O P> Pi < 0 Pi Eh P 03 <D ü CD M < i M Pi ‘ H P i (D &H ^ rH 0> P, (D Pi Eh O S? rH Pi P i 0 03 <4 EH O <4 Ai O Ai ü 67 ollnic subjects who wished to change to private practice as indicated by the extremely hl^ critical ratio of the difference of per cents between patients of the two groups. The critical ratio was 9#94, which indicated that there was no possibility that the results obtained could have been due to chance. Some of the comments written in the question naires are pertinent. Two Of the statements made by clinic patients follow: I think clinics are a wonderful thing as long as they are run in all honesty and sincerity. However, if graft is allowed to creep in then the whole objective is lost. Many times Doctors and Dentists lose that individual patient attitude and treat the patient like so many cattle. I’ve had this experience with Doctors as I was raised in an orphanage. I’ve heard the same complaint from men in our armed services and of Doctors of Corporations. I think school Doctors and Dentists are different because everyone loves a child and therefore has more patience and sympathy. However, even un interested, unsympathetic dental and medical care is much better than none at all.^ The trouble with clinic service is one sits for about four hours, wait every time one goes. And too many times we haven’t the time to do this. Actually I have been unaware that such services were available, or would have taken advantage of them long before this.® The statements of the miscellaneous group corres ponded closely with those of the office patients; 97.86 per cent stating they preferred private care. ^ Clinic subject. Number 0-17. ® Clinic subject. Number K-49. 68 A comparison of attitudes of subjects toward quality of care. Attitudes of 421 subjects regarding the quality of care that they felt they were receiving were charted. See Table X. It was found that over half of all the patients, 59.38 per cent, believed their care to be excellent; 28.26 per cent felt it was adequate; 2.61 per cent considered it to be inadequate; and 9.73 per cent did not know. One of the differences in attitude between the patients in private offices and clinics was that a smaller percentage of the latter classified their quality of care as excellent: 74.10 per cent in the offices believed this to be the case as compared to 52.72 per cent in the clinics expressing this attitude. A significantly greater per cent of office patients than clinic patients considered the quality of care excellent. The critical ratio of this dif ference in attitude was 3.77, indicating that the difference was not due to chance. Also, a greater percentage in the clinics, 15.90 per cent, were unsure of the quality of attention they received; 1.78 per cent of the office patients expressed a similar feeling. Ninety-five per cent of the miscellaneous group were satisfied with their care. A comparison of past experiences of subjects as to postponement of care due to cost. Of the 452 subjects who reported regarding the postponement of dental care due to cost, 59.51 per cent stated that they had postponed care for 69 X s E - t M O C e * 0 1 o s co EH O g m 0) co N E t4 O to g 0) EH j — i EH < i I g Ai 0 < M 1 g g •p O C- CQ CD CO 0 to O rH 0) Q ) • o Ü O £> i> rH M S h O lO CO : % 0 H 3 A, h4 0 M 0 O CD rH cO rH > 4 i CO H 00 ID co ; 1 —1 0 +3 CQ 00 00 O 0 £> «H rH Oî 0 • • # ü O CQ CD CO lO o U O lO CQ rH H 0 iH Ai h4 U O 0 rO O tû CQ I> LO B CQ rH to CO 0 CQ rH % -P O CQ i> 00 0 rH to O 0 • • « • ü O rH CQ 1 —1 M 0 O £> CQ O 0 M Ai &4 0 O 0 .0 CQ CO CO CQ S r4 00 CQ 0 0 co ! -P 00 to rH CO ÊH i 0 CO CQ CD O O i 0 * • # . # M i Ü O CD 00 CQ 0> ha 1 0 i O ID CQ m 0 r4 0> Ai to ! U i •4 - i 0 <4 ! 0 r4 O CD H H ËH ; B 1 CQ m rH rH O 0 ; CQ rH EH ; e; 1 1 0 O 0 nd 0 0 ^ ! o -p p P O •H 0 0 0 0 ÎH •P 0 P 0 M Eh P I —1 0 Cf M 0 rH 0 0 p • - 3 0 ü‘ — <4 rH O 0 0 0 M X 0 O oy < M <4 M O 70 this reason. This is shown in Table XI. The remaining 40.48 per cent answered negatively. It was found that the clinic group had the highest percentage of persons who had delayed treatment because of the expense involved. This was the case with 69.01 per cent of the total of 255 subjects. The per cent of clinic patients who had postponed dental care due to cost was sig nificantly greater than the per cent of office patients who had done so for this reason, as indicated by the high cri tical ratio of 4.54. The results of the office and miscel laneous groups were very similar, with 45.94 per cent of the 111 of the office clientele and 48.85 per cent of the miscellaneous group answering in the affirmative as to postponement of care due to cost. Qomparison of subjects from offices and clinics with regard to their evaluation of attitudes of dentist. The majority of subjects also expressed favorable impressions in evaluating the attitude of the dentists from whom they received ceœe, as shown in Table XII, page 72. Many of the subjects checked more than one of the descriptive words, and a total of 476 responses were polled. "Friendly” was the attitude most frequently chosen, with 42.45 per cent of the total number of patients checking this response. "Interested” was second highest with 51.30 per cent. "Pro fessional” was checked by 17.64 per cent. Only 8.59 per 71 n X I CO A> s 3 -P 0 0 Ü $H 0 A o o rH CO 00 9 to H rH to 0 U M 0 O 0 CD CQ CO w CO xM M 0 m O +3 rH 00 0 O CD < m 0 EH o Ü O CD d % A3 to o F h O CD to Ixi A< M 0 rH O 0 îz; A . &, Eh § 0 Fh O O CÎ3 o 0 M 0 LO D CD Eh ^"3 CO 8 . 0 J> o ;s; m a 0 CQ rH W 5 o N CO M CQ <4 -p to O LO 0 0 o> o A, 0 0 #, Eh M Ü O to m ÎH o M S h O ■ -Qt to o PQ to o 0 H cu M M A 1X4 o 8 &4 U &H EH o o 0 A: « 0 H rH O w o <4 H A to CD î> Pn 0 rH M 2Î Eh pq o <4 M 0 CO LO 4-P I —1 GO M < M Eh 0 LO 'QT Pd 0 O 0 • Eh O M Ü O CD d CO CO ^-3 0 O to o m 0 iH o o § A o M SU M EH 5x4 0 AÎ Ü4 0 CQ CD to m O EH s lO CD 00 Pj O 0 ■QL CQ rH X o EH % fxj EH 0 0 CO > > P <4 0 Cd 0 At 0 0 0 O U 0 Ü EH o cd o 0 g 0 O P 0 0 o H ra C P a <0 O A M 0 0 o 0 P 0 ^ fx, eg 4J 0 P ra 0 o o < Ü O O Ü O Rj A, o rH 0 A P 0 A EH cd M—3+3 —"3 0 CO -p 0 œ 0 0 P S h O o 0 O 0 0 O cd A EH CO CO 0 o 72 rH t - H X g EH g c i 3 a M I 0 <4 Eh C O M Eh 1 A O CO M g EH I —I Eh EH <4 g 0 M Eh <4 1 P rH O' to to 0 to to to £> 0 • Ü o CQ CO to £> O 0 o •Qt CQ rH M 0 fH sz; ; A 0 S h CO o 0 o rO - Q L P P CQ M B P CQ CD CQ rH a 0 CQ A M Ss? 0 . O 0 P O rH to 0 Q 0 EO t> CQ O P 0 T O <4 O O CQ to P CQ tH p3 SH O CO iH rH CQ O 0 rH M n A TO o M 0 0 A F4 A O 0 0 A a CQ £> to to lO P O B 0 % CO rH D- to CO •rH P P o C d g to p 0 O { > CQ 0 M 0 6 0 to to P 0 to to 0 . • • a P ÊH Ü O CQ rH JN lO CQ o o su o CO rH A M A 0 iH O s CO Gd A A 0 0 to 0 O 0 0 to CQ P £> A <4 i E> O ■O’ 00 CQ rH 0 O icH o 0 % CQ H M * EH p to M 0 CO F 4 g; EH O o to S A H to E H 0 M % KD 0 A 0 •W P Ü to 0 rH 0 A P Cd P XÎ O • r H tj 0 A 0 O P 0 O c d 0 W P >3 P 'H 0 0 TO P Cd rH m ra O 0 P P nd 0 ra CQ A O EH rH 0 0 0 0 C m 0 h - C d 0 0 < + H 0 •H E p ♦H P o A • 0 0 EH o 0 s u B 0 0 <4 Eh A M A M M TO I 73 cent expressed dissatisfaction, and felt that their dentist was either impersonal or indifferent. When a comparison was made of the evaluations of office and clinical groups, certain differences were noted. The same percentage, 42 per cent, believed the attitude of their dentist was friendly, although a slightly greater per centage of office patients felt their dentist was also interested. Of the clinic patients, 7.45 per cent felt that the attitude of their dentist was impersonal, while 4.76 per cent believed him to be indifferent. None of the private patients checked indifferent, although 2.74 per cent evalu ated their dentist-patient relationship as impersonal. A comparison of attitudes of subjects toward the present cost of dental care. From the reports given by 371 persons, it was shown that the majority of them believed they were paying a fair amount for their dental care, see Table XIII. When the attitudes of the total number were tabulated, it was found that over 60 per cent felt that the fees were fair. While only 1.34 per cent believed they were paying too little, a little over one-fourth felt they were paying too much; 11.85 per cent of the subjects did not feel they were able to judge. When the total number of persons was broken down into the three classifications as to source, it was found that there was little difference in attitude among the three, 74 M M X I C Q <4 Q M O O n % j—1 A ) o <4 EH S A M O O M C O A A A A 03 O O O E h S @ C O O o A co O A 0 ) EH C O O A B EH M O <4 C O A A M • “ 3 A A m A A A O C O C O i M rH S I O - 60 g H co M m o O A A» E H EH A H o E h A Eh A <4 A co 03 A a 43 0 0 Ü 0, 0 A 0 0 H 1 t t CO CQ CO co 0 A cô CQ CQ CQ * £> A U A 0 O A CO 1 10 CQ iO co E 00 1 10 CQ M 0 g % 43 CD A CD 0 0 cp CD t —1 CQ 0 • » Ü 0 CQ 10 Ht i> O 0 0 10 CQ A M 0 rH :s A A 0 O 0 A CO 10 sM A CQ 8 00 0 H* A 0 iH A 05 43 CO CQ A 00 0 03 O- H" 00 0 • « 0 0 60 CD A A 0 0 CO CQ O 0 A ! —1 rv. A A ÎH O 0 A CQ A to 0 A B 0 CO A 0 A B CO 43 o* H* A EH 0 CO 60 1 —1 00 O 0 • • A ü 0 A 0 CO A 0 0 CO CQ A m 0 A A A co F h A 0 A A CO £> EH S 0 CQ CD 'H o 0 co CQ Eh S: 0 A 43 A 43 ü CQ A 0 A 0 A B "A U 0 0 A 0 O 43 0 w 0 0 A 43 < + H A 0 A 43 M O 43 bû bO C E S 0 0 0 0 A EH A A 0 A — CO 1 —1 >3 >5 0 >3 0 O rH cd Cd B Cd 0 O <4 A A cd A n 75 except in one instance. There was a notable difference in the number of clinical patients who did not know how to judge the cost of their dental care; 17.2 per cent were in this category, as compared to 5.88 per cent from the offices and 7.22 per cent from the miscellaneous group. With this exception, the attitudes of all three groups followed closely the distribution for the group as a whole. Suggestions were made that fees should be controlled so that all could have good care. Comments of two clinic patients are quoted as illustrations. Large family with modest means should have opportunity to pay for dental service in installments. Several fill ings for each child in one month is a terrific strain on a limited budget— especially these inflationary days.^ Consider the fellow who can and one who can’t. Give the person who has a small income a chance to retain a fair health status by pricing his fees within his in come ... In other words help those who need.® Â coTOari son of attitudes of subjects toward a govern ment dental plan, if individuals were free to accept or reject the service, and the relationship of income to these attitudes. The subjects were asked to give their attitudes concerning a provision for dental care by the government, with compulsory individual wage deductions, if individuals ^ Clinic subject, Number 0-16* This subject supported six children on an income of #2,130 a year. ® Clinic subject. Number M-115. 76 were free to accept or reject the service. Three hundred and seventy-nine responses were obtained, as shown in Table XIV. It was found that of this total number, 73.35 per cent would favor such a plan, while 26.64 per cent would oppose it. When the subjects were classified, variations in attitude between the groups were noted. There were 104 office patients and it was in this group that there was the smallest percentage who favored the plan, with 59.61 per cent registering approval and 40.38 per cent opposing the proposition. The largest percentage favoring the proposal was found emong the clinical patients, where 84.51 per cent favored the plan. The miscellaneous group differed from the private group by approximately 5 per cent, with 64.19 per cent favoring the adoption of a plan under government sponsorship. The total number of subjects was then classified according to income and a comparison made of the attitudes of the subjects of different income levels, as shown in Table XV, page 78. Interesting results were obtained when this was done. It was found that although all but one in come category had a majority favoring the proposal, there was a relationship between the amount of yearly income and attitudes toward the plan. Of the total number of subjects, 73.35 per cent had 77 O g H M O W A A A A to a E h S O M M M *- 3 C Q m g è A C O o A < CD C Î J 0 3 î> Q 60 C Q M A > H O M m M A B A 1 — 1 g A > ■ A M M g; O O X <4 A to A M M M A A t-3 E h C O A 2: <4 EH M S <4 S M • V A O o M M M > > S O A f — I Ü J g A O < 4 EH A § o W g M M A O A A E h A O CO O H A E h A A ÊH W J H O E h O E h <4 <4 +3 A O CQ 0 A CO A 0 # . O Ü O H* A A U O D A 3 0 A H A Fh A . 0 O A 1 —1 CQ 03 to S CD UD CQ H 0 ïz; 43 60 A 0 A 0 • • O O ■H A o F4 O CO A M 0 : —1 % A A 0 o 0 A "H O B A A A 0 «H A A A A 00 0 to A 0 • • Ü O , CD O W 0 O A 'H O 0 A M A A A 0 O 0 A CQ CQ S O A 0 A A A A 'H CO 0 A A A 0 • • 1 —i Ü O A A O 0 O £> CQ A 0 A A A <4 0 0 A A CD 00 A A G ï> £>• O <4 0 A 60 CQ A 0 0 0 0 A A A A A A A 0 ËH A 0 C Q 4 0 O O ÊH A > A Eh O 0 A <x i En A O 78 S E -t KO <4 e# o M M m CO 03 <4 CQ 03 <4 i> nQ P i A ÎH &H 0; m H o > M X 05 Eh P i Pi Â M O > i 8 Pd <4 M O S o o 5: 0; O A M ÎH CO § D EH M E h O < ÊH 43 g C H* A A A g ^ o> A CQ CO rH A CQ ^ <4 Ü • * _ mJ 0 A 03 • Q L CQ A A CQ A 0 CQ A CQ A A A gH A C3 r r ^ W S X t M O 0 1 - 3 J> 0 m <4 rÛ 1 —1 A rH 00 CQ 03 î = > A B 0 CQ rH 1 rH CQ 0 05 rH 43 g a A A A A i A A 0 A H 00 1 A £ > ^ <4 0 •- • ' M) F h A 0 A î> A A CQ A 0 P- CO 0 A i A Eh A O A A O ÎH • ; » “D > * 0 m <4 f * CO CD ! 00 ! —1 i > 03 A B D - 00 .'CQ i A CQ CQ 05 0 ; CQ rH CQ 43 , EH C O 0 A 0 0 0 - O : 0 ; 0 0 u 0 0 0 0 ! 0 0 PQ 0 H rH rH rH iH rH A KO J h 0 < A 03 03 A i A A A Eh B , E> 1 0 A -A A rH O 0 : A H rH ! ' E r * % '■"'tr*' 03 1 03 03 ! 03 03 M 03 03 ; 03 0 03 03 ; 03 03 O CQ 0 #\ « N m rH 1 O 0 0 A A : 03 05 a «\ 1 M : 0 CQ i ■ 1 i 1 ; H ü - ^ 0 ! c 0 0 i 0 0 1 i-j •H F h 0 ; . 0 ; .0 i 0 i pd 0 0 .0 0 M rH rcS . - 0 % 0 1 —1 % a CQ i A rH ÎH <4 Î C 3 4#: 4» ^ ' i 4# : 79 favored and 26.64 per cent had opposed the proposal, ^ong the persons having an income under $2,000 a year, there was an increased percentage in favor of it, for 80.73 per cent voted in the affirmative and 19.26 per cent in the negative. In the grcup earning between $2,000-$3,999, 75.15 per cent favored it, and, as the yearly income rose to $4,000-#5,999, the percentage was lowered to 67.85 per cent. This differ ence of opinion widened among the $6,000-$7,999 group, with 63.65 per cent in favor of and 36.36 per cent opposed to the proposition. The consensus of opinion went in the other direction among the persons with an income of $10,000-$19,999 a year, where 43.75 per cent favored such à plan while 56.25 per cent were opposed to it. When the results of the attitudes of the subjects of each of the three groups, office, clinic, and miscellaneous, were tabulated, other significant facts were observed, as given in Table XVI. There was only one instance in all the distributions where there was a greater number of people opposed to than there was in favor of the plan, and in this case, the difference was small. In the office group, among the persons of the #10,000-$19,999 income level, four favored the plan while six opposed it. In all the other categories, the majority of subjects favored the suggested proposal. The largest percentage in all cases who favored and who opposed the issue were in the #2,000-#3,999 group, into which group 80 TABLE XVI ATTITUDES TOWARD A GOVERNMMT PLAN AS RELATED TO YEARLY INCOME, AS REPORTED BY 379 SUBJECTS FROM OFFICE, CLINIC, AND MISCELLANEOUS (mOUPS YEARLY INCOME ALL SUBJECTS OFFICE CLINIC MISCELLANEOUS TOTAL FAVOR PLAN OPPOSE PLAN TOTAL FAVOR PLAN OPPOSE PLAN TOTAI. FnOk ÿUM 0PF0ÔE ÿïM Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent ; Num ber Per cent Num ber Per cent Num ber Per cent Num ber [■Pei--- ! cent All incomes 379 100 104 100 62 100 42 100 194 100 164 100 30 ICO 81 100 62 100 29 100 Under #2,000 109 28.76 12 11.52 7 11.29 i 6 11.90 81 41.76 70 42.68 11 36.66 16 19.76 11 21.15 6 17.24 #2,000 - 3,999 165 43.53 39 37.50 : 25 40.32 14 33.33 96, 48.97 80 48.78 16 50.00 31 38.27 19 36.53 12 41.37 #4,000 - 5,999 66 14.77 27 25.96 16 26.80 11 26.19 16 8.24 12 7.31 4 13.33 13 16.04 10 19.23 3 10.34 #6,000 - 9,999 33 8.70 16 15.38 i “ 16.12 6 14.28 2 1.03 2 1.21 — 15 18.51 9 ! 17.30 : 6 20.68 #10,000 - 19,999 16 4.22 10 9.61 1 I 4 6.46 6 14.28 — - — - -— — 6 7.40 3 5.76 1 ^ 10.34 81 the majority of the total number of subjects also fell. The reason most frequently mentioned for favoring the plan was that such a program would provide more adequate care for the low income groups. Several mentioned the bene fits to children that would be available and their comments are herewith quoted. I’m very thankful that we as a family can now pay our own way. Throu^ reading and P.T.A. work I have heard and learned how many less fortunate children and adults there are who cannot pay for their dental work, and I myself as a girl had to go to a clinic. I feel that if some dental service was worked out, where a person would have confidence in the doctors of such an organization, by them being able to offer good doctors, where the organization would be supported by taxes so as to get away from the charity idea& I believe with a sincere effort for perfectly kept teeth for everyone as an objective ralïher than a conflict between private den tists and "group dentistry," everyone would stand to gain. 5 It’s not a question of being satisfied; it’s a ques tion of economics. I am not satisfied with many things I support. I am thinking of the average citizen, not of myself, of the heavy financial burden of taxes and I had inadequate care while attending University (U.C.L.A.) and due to this neglect, I lost four teeth. I went to a "cheap" dentist that believed in doing all his work for each patient within a half hour period. This was in 1940 . . . Anyway, the fillings didn’t hold too well, and with further neglect (no money), these particular teeth had to be extracted three to five years later. Now I can afford excellent dental care, but how about those who can’t?© ^ Office subject, Number A-11. ^ Office subject. Number B-S. ® Office subject. Number A-19. sa I think it’s a great idea, especially when it comes to children. Their teeth should he checked every six months, or at least once a year. Then if and when you did go to the dentist the trouble would be minor. A small amount in taxes would prevent a lot of cavities, and save the next generation from having false teeth.^ Subjects who were not in favor of the proposal also made comments explaining their attitudes. One of the prin cipal reasons for opposition was the feeling that existed that the quality of care would not be as high under such a plan as it would be in private practice. One office patient made this comment: I don’t feel dental care would be as efficient following such a plan. I think it would be fine for the needy, but for those who can afford it I think there should be private dentists for their choosing. However, a clinic patient who favored the plan ex pressed the following view: I feel it would depend entirely upon the type den tists chosen for this work and how they were supervised. I believe a conscientious man would do his work well in either a private office or a clinic. Whereas a dis interested dentist would be a poor operator in his own office as well as a clinic. Because a man has a private office, he is not necessarily a dependable, honest dentist— I think strict supervision and management would be indicated in a government clinic or agency.H Many of the subjects emphasized the desirability of freedom in the choice of the dentist to do their work. The Q Government clinic subject. Number J-6. 10 Office subject, Number B-31. 11 Clinic subject. Number 0-3. 83 following quotations are indicative of this attitude. Preceding questions answered no as I wish to choose my dentist. If allowed to choose my professional doctor would not mind having the government set the pay ments for service . . .12 I like to choose my own dentist . . . All I care about is a good and skilled doctor, dentist, nurse or any professional person plus a certain personality that makes me feel a "PEBSON . . .13 Others felt that a group insurance plan or some form of credit arrangement would be preferable to the plan sug gested. Two statements are quoted. I would still want to go to dentistal agency only if the best dentists were there. If all dentists were in this plan, as Blue Cross, it would be very agreeable to me. However, I wouldn’t want to substitute quality for price saving.1^ A dental plan is needed, especially by improvident persons. Perhaps something handled by Insurance Com panies. Above all it would have to be agreeable to the Dentists themselves, or the service would be inferior.^® Comparison of attitudes of subjects toward making use of the service, and the relationship of income to these attitudes. The subjects were asked if, in the event that a government program of dental care was put into effect, they would choose to make use of the service offered. Three Office subject. Number A-28. Office subject. Number B-40. Miscellaneous subject, Number 1-33. Office subject, Number A-29. 84 hundred and sixty responses were obtained. See Table XVII. Of this number, 61#58 per eent stated that they would make use of the service, while 38.61 per cent said that they would not. The attitudes obtained from the three different groups vary considerably. Of the ninety-four office patients, only 29#8 per cent stated that they would want to avail themselves of such dental attention, although 59 per cent had said that they would approve the inauguration of such a proposal. Of the clinic patients, 81 per cent would favor using the service, which was a slightly smaller percentage than that which favored the plan. The miscellaneous group was almost equally divided on the question, although a majority of 64.19 per cent had favored the inauguration of the system. The critical ratio between the attitudes of office and clinical subjects toward making use of the service was ex tremely high— 8.68, and this figure indicated that the per centage of clinic patients was significantly greater than office patients. Some comments indicate a number of reserva tions regarding both approval and use of a government plan. The following quotation is more or less characteristic of this attitude. It is impossible to give a categorical answer to some of the questions pertaining to dental insurance and national health programs. That some such scheme will be put into effect appears inevitable. It is probably the only solution to the problem of adequate dental care 85 M s i H 03 |Z> 0 M 1 M O 03 1-4 +3 a 0 o F4 0 Cd O O r4 CQ m f4 0 î 0Î to O lO to m to M O 4-> ËH H C CD rH 0: De 0 • . • M De Ü O s —1 CD A O O ÎH O CO rH M 0 H ÊH S 0 Cd 0; O M Dl Cd 1-3 ÎH S Ce CD O 0 05 o «9 to CD LO CO cd s CD lO to S ÊH cb 0 r4 rH > o M 03 0: tÎ3 hs 0» m O rx. 0> M 0 00 CQ o CQ 0: Q) • • <4 Ü O CD O N O M ÎH O CQ D- CO to ,-3 O 0 1-4 0> to g n Pr* Cd CÎ5 ÎH 03 d 0: m M O 0 M S f) 00 to X o S CD CQ to M O 0 â EH Cd s .05 a O CL, # % -P 00 rH M o 03 0 to to Pd M M 0 • • o 0i M Ü O rH 00 ÊH 03 M O 0 O to to <4 h3 % 0 H 03 o M Cd &D C*3 rh O O <4 0 10 n 0 EH > h3 d) O rH CD H Cd 1-3 G to « CQ to EH M <4 0 to CQ rH ÊH 03 05 0 C Q 0 03 © •PI W C O o| 1 Q 0 0 0| 0 Î 0 Ü Ü j E-H rH "0 "H -H M a S rH t> H > 1 B ■p 0 0 0 0 1 EH O O 0 O 0 1 <4 ÊH 0 B: ra 86 for the masses of people in the low income bracket. My opinion regarding any particular plan would depend upon the specific provisions of that plan. Whether I should make use of such a plan would depend upon how well it seemed to be working. If, upon investigation, the plan gave evidence of functioning efficiently, then I should avail myself of its services providing I could no longer obtain the services of the dentist who is currently caring for my teeth or some other particular dentist recommended to me by my present dentist.^® The 560 subjects were classified according to income and a comparison was made of the attitudes of the subjects who made up each income group. See Table XVIII. Of the total number, 61.38 per cent had stated that they would be in favor of making use of the government service. It was found that there was a relationship between yearly income and the desire to make use of this type of service. The largest percentage in favor of it was found in the first group, where 76.85 per cent expressed a favorable attitude. In the second group, 65.46 per cent felt likewise, while in the #4,000-#5,999 category, the percentage fell to 53.84 per cent. For the remainder of subjects, the majority took the opposite attitude, and among persons with an income from #6,000-f9,999, only 36.66 per cent would make use of the plan, while none of the fourteen persons in the highest bracket who responded expressed a desire to have such care, should it become available. Office subject. Number B-1. 87 W O M > 03 m EH O M S <4 A EH CO 05 M A A O EH 01 £0 ! > l M m S 05 A Pi M M £h M > Pi ? —1 O O M > ô â X I k , 01 M O w M PQ CQ S <4 A O Eh o Gb 05 0 M M X H A A m H § o O Ei EH CQ s M EH A <4 A A Eh M 1 —1 Pi <4 M O O A M ^ A > hJ 0Q 4 - 5 a 0 ü 0 0 A A CD cô to A cô CQ to A A A A A i A A CO . A O o 1 —1 ixj A w to o CQ 0 O ^ 0 A M A CD lO l> r j i CD TfL B to B CO CQ A CQ A A A A A A 4 - 5 0 00 A A A M 0 co 00 00 A r O O ü • « ' • • « 1 A M 0 A «3 to A A 1 ^ A >• 0 CD O A A A A A Ai M A A CQ o CO 0 O ^ 0 A M A A A CD 00 A 1 Eh 03 B CQ 00 CD CQ 1 —1 I A PS CQ 1 A to 4 - J Eh C O 0 A ü O O O O O o A 0 O o O O O o PQ 0 A 1 —1 A A A A A CQ Ah “ A 0 <4 A O CD A CQ O • QI EH S A O A A A A o PS CO A A E h A * CD CD CD CD CD CD W CD CD CD O CD CD CD CD O CQ O • S A o 0 o A A CD A S 1 ( —I o CQ 1 1 1 ü O H s i O O O O A • fH 0 O O O o 0 O O o rH nJ • V # % o M A C CQ A A ÎH <4 A 88 Only twenty-eight of the ninety-four office patients (29.8 per cent) had stated that they would choose to use the dental care offered. When the office subjects were distri buted according to income. It was found the largest per centage who stated that they would care to use the service were in the #4,000-15,999 income group, as stated in Table XIX* Although this Income group comprised only £7.7 per cent of the total office subjects, 43.9 per cent of those office patients who were favorable to the plan were in this income bracket. The large majority in all income categories of the clinic group had stated that they would want to make use of the service. The largest number of these subjects earned between $2,000-#5,999 a year, and the largest percentage of those who favored as well as those who opposed came from this bracket. This distribution was also true in the ease of the miscellaneous group. A comparison of attitudes of subjects toward payment of taxes for care, and the relationship of income to these attitudes. The comparison between the attitudes toward making use of government care and those toward the payment of taxes for such care provided certain specific differences It was found that although only 29.8 per cent of the patients of private offices had stated that they would care to change dentists if a state program was initiated, 32.98 89 TABLE XIX ATTITUDES TOWARD MAKING USE OF GOVERNMENT DENTAL SERVICE AS RELATED TO YEARLY INCOME AS REPORTED BY 379 SUBJECTS FROM OFFICE, CLINIC, AND MISCELLANEOUS GROUPS OFFICE i CLINIC MISCELLANEOUS YEARLY INCOME ALL SUBJECTS TOTAL WOULD USE SERVICE WOULD NOT USE SERVICE TOTAL WOULD USE SERVICE WOULD NOT USE SERVICE TOTAL WOULD USE SERVICE WOULD NOT USE SERVICE Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent All incomes 360 100 94 100 28 100 66 100 193 100 168 100 35 100 73 100 35 100 38 100 Under #2,000 108 30 10 10.6 3 10.7 7 10.6 83 43 71 44.9 12 34.3 15 20.6 9 25.7 6 15.8 $2,000 - 3,999 156 43.3 34 36.2 11 39.3 23 34.8 93 48.2 73 46.2 20 57.1 29 39.7 15 42.9 14 36.8 $4,000 - 5,999 52 14.4 26 27.7 12 43.9 14 21.2 16 7.8 12 “ 7.6 3 8.6 11 15.1 4 11.4 7 18.4 $6,000 - 9,999 30 8.3 16 17 2 7.1 14 21.2 2 1 2 1.3 ——— 12 16^ 7 20 6 13.2 $10,000 - 19,999 14 3.8 8 * 8.5 — 8 12.1 — — 6 8.2 i" xa.8 90 per oent were willing to be taxed to support sueh a program. See Table XX. On the other hand, although 81.9 per oent of the clinical patients had expressed a desire to receive dental attention under the proposed plan, 53.96 per oent were willing to pay taxes for it. The critical ratio of the difference of per cents between the office and clinical sub jects who were willing to be taxed for dental care was 3.37. This indicated that the per cent of office patients willing to pay taxes was significantly greater than the per cent of clinic subjects who would willingly do so, and indicated that this difference in attitude between the two groups was not due to chance. The following quotation indicates this attitude. I believe there are plenty of people that could afford to contribute to the government yearly for this cause, but we poor are far too poor to contribute at When the subjects were classified according to in come, it was found that althou^ 76.85 per cent of the group earning under #S,000 a year wished to make use of the govern ment service, 54.9 per cent favored paying taxes for it, as indicated in Table XXI, page 92. In the next bracket, of the 63.46 per cent who wanted the service, 44.17 per cent favored taxation. The 53.7 per cent in the #4,000-$5,999 Clinic patient, Number M-14. 91 E - i I E4 o % i —1 M Pm Pm O pd CO w Pi > o 53 O Pi O o îi, Pg pc; to c!> o E-* to Pm O W o to *"3 M m % X p) < < CO hP} EH o M <£> O O to to E4 >4 3 g; m w n a M < < Eh P* p : # % o o O p. M pi M 25 pH M O to O E-* < to N § O E - i HH E4 Ë - 4 c* CO § 4^ C 0) O fe Ph o o 1 —1 to o> tô ' lO to o d f, M <D O rO to to o CO S o to M P3 53 4^ to tO C CD O (D • • Ü o to to o 5h o lO , M (D M g; Pi P3 o C t > Xi CD 02 o- B CD O GO H H 4J CD H G CD O <D • • Ü O CV2 O M Sm O to to o CD iH M Pi Pm U O CD ,o O CM LD s CD to to G 53 4-) to to to G CD o M (D • • M O O to to O ! h O rft LO .Sî CD 1 —1 M Pi rK < Pc CD X 02 o 02 .4 B to o- CD <t{ G to r4 iH z; X CO X eü M ce 4^ « 4^ Î3 CD EH rH U CQ M c c 5 O O &H 4J > A E h O CÜ A <£ Eh Pi O 92 M S I I O z: g g 1 2 « CO < o EH § n CO E h 0 1 CO 05 i> to 3 M E h Pi 0 1 ■P J G to 03 C V 2 03 to rH H M m o O CO C V 2 o £> <4 X Ü • i P h CO to tô to 02 to E h ^ 0 IQ to to CO O C5 % % Pm Pi M O P i Npi 0 CO O E h a 02 to rH to CO 02 o > z: s 03 03 02 rH rH K < N G rH Eh Cm S z; C Î Ï p g G *> CO CO M 0 03 03 I —1 E> 03 02 Pi O • » • O EH CO P i to ■ s t * co H* ^ R N 0 to to CO rH Pi P i M << 0 CO Pi Cm o to 02 03 rH 02 o o e o- to I> 02 rH w G i —1 Eh z; CO p Eh G O 0 M Ü o o O O O O P i o o o o O O m 0 rH t - i rH f —1 rH rH 5 Pi CO *4 P i 0 S a 02 (M to Hi 03 H* e to O to to 02 j H o G CO rH 'rH EH z; 03 03 03 03 03 03 03 03 03 O 03 03 03 03 O 0 o # \ rH o 0 o CO to 03 z s rv 1 M o CQ 1 1 1 o • i € 0 : O G O o O o i4 *H P i o o o o 0 o o o M r4 •G o iH G 02 s j T to rH < j z > 95 income bracket who wanted the care were willing to have deductions made for it, as were those in the next higher category. Two of the twelve persons with an Income over #10,000 a year voted in favor of taxation, although they had stated previously that they preferred to have their dental . work taken care of elsewhere. The one instance among the office patients where the highest percentages of the number of subjects who were in favor of this tax was in the #4,000-#5,999 group, as shown in Table XXII. This group comprised £6.8 per cent of the total number of office subjects. However, 40.6 per cent favored the tax and 43.9 per cent had previously said they would make use of the service. The first income bracket of the miscellaneous group contained 20.8 per cent of the total number of subjects, but it was found that of those persons registering approval, 87.7 per cent were at this income level, while in the high est bracket, which comprised 7.9 per cent of the total, only one person (2.7 per cent) favored the added assessment. In the other categories, the percentage of those favoring pay ment followed rather closely the distribution of patients in those income levels. The following quotations illustrate these attitudes. A dental clinic would be fine but I can*t see getting involved in paying more income tax when possibly there would be little need for care. I would rather contribute TABLE XXII ATTITUDES TOWARD PAYMENT OF TAXES FOR GOVERNMENT DENTAL CARE AS RELATED TO YEARLY INCOME AS REPORTED BY 379 SUBJECTS FROM OFFICE, CLINIC, AND MISCELLANEOUS GROUPS 94 ALL OFFICE CLINIC MISCELLANEOUS - SUBJECTS TOTAL FAVOR TAXIOPPOSE TAX TOTAL 1FAVOR TAX OFPOSE TAX TOTAL FAVOR TAX OPPOSE TAX lahRhl INCOME Num ber Per cent Num ber Per cent Num ber 1 Per-: cent Num ber Per cent Num ber Per cent Num ber Per cent Num ber Per cent Num-| ber Per cent Num ber Per cent Num ber Per cent All incomes 362 100 97 loo 32 100 1 65 100 189 100 102 100 87 100 76 100 36 100 40 100 Under $2,000 102 28.2 10 10.3 . 3 9.4 7 10.8 76 40.2 43 42.1 33 37.9 16 20.8 10 127.7 6 15 $2,000 - 3,999 163 45 38 39*2 11 34.4 27 41.5 95 50.3 46 45.1 49 56.3 30 39.5 16 41.6 16 37.5 $4,000 - 5,999 54 14.9 26 26.8 13 40.6 13 20 16 8.5 11 10.8 5 5.7 12 15.8 5 13.9 7 17.5 $6,000 - 9,999 29 8 16 15.5 4 12.5 11 16.9 2 1.05 2 2 - - 12 15.8 5 13.9 7 17.5 $10,000 - 19,999 14 i 3.9 8 8.2 1 3.1: 7 10.8 ! — “I — — 6 7.9 1 2.7 5 12.6 95 to a dental olinic than he overtœed.^® I believe that a large number of people would have dental oare under federal government plan who need it and who postpone oare otherwise. I am a person who sets aside a certain amount of money without being forced to do so. I am not in favor of the plan because I do not want withholding tax taken from my income when I don’t feel that I would want to use the services I’d paid for— only to go to a private dentist and pay again. I feel that such a plan could not operate as efficiently as a private concern. The dentist would no doubt try to do his work better in order to "keep” his patient in a private off ice. 3-9 I feel we are taxed enough already and for those who are unable to pay for their own dental services can be taken care of by clinics. I feel by government control the average dentist would not do nearly as conscientious work as by his own private practice.^0 Distribution of subjects who expressed willingness to pay specific amounts in deductions. After a summary was made of the percentage of patients in the office, clinic, and miscellaneous groupw who would favor taxation to support the proposed plan, an attempt was made to determine the specific amounts that the subjects would be willing to pay by means of wage deductions. See Table XXIII. They were asked to check if they would pay up to two dollars, five dollars, or ten dollars a month. It was found that in the Clinic subject. Number 0-7. 1 Q Miscellaneous subject. Number 1-29. Miscellaneous subject. Number 1-30. 96 M M M M S I g C Î 3 z; M O g O o <*î KO et 0 M 1 iH iH (M ü, 0 1 Z M O M A* O S O z; co o M EH 0 1 Z: M 03 ÊH {aj Zî Pd z> ^ o o m < EH z ; o M M ^ Gc. Z: M pd O M 03 03 03 03 M M Z Pd CÎ3 55 O M Ai B: B p Eh 03 O Eh O EH M Z: V-O M m EH Z> X 03 M g ü ÎH 0 Al CO O O) iO to co .• D- lO O g G Z rH Ü co to CO to iH î> to o S M > Ph ^ g < Q O o CO Eh g to iH to 00 H od O G) • TM rH (M < o Eh A* ï*« O m EH 0 G 0 o 03 •H 0 03 Ü G W KO G 03 Z Eh 0 1 — t Ü3 O bO 0 O iH z ; M 03 Ü •H ■ 0 M Ea 'H G ü h-3 m ! — 1 «H •H 0 ^4 z> rH «H rH •H 1 —4 03 < O C3 S: 97 first two groups, the percentage of those specifying the amount they would pay exceeded the percentage of those who had stated they would be willing to be taxed. This situ ation was not so in the ease of the miscellaneous group. Of the office patients, 32.98 per cent had favored a wage deduction, but 34.54 per cent indicated the maximum amount they would be willing to pay. Of the clinic patients, 53.96 per cent favored the tax, while 57.46 per cent indi cated the specific amount they would be willing to be assessed. In the third group, of the 53.96 per cent who had approved the tax, 44 per cent responded to this question. Because of the small totals for the different items, the numbers instead of percentages were used. On the thirty- eight office replies, thirty indicated willingness to pay two dollars a month, seven were willing to pay five dollars, and one person would pay ten dollars monthly. In the clinic group of 136 subjects, 113 checked two dollars, while twenty- three stated they would pay five dollars a month. Thirty- seven in the miscellaneous group answered, and the distri bution was as follows: twenty-six were in favor of a two dollar deduction; ten persons were willing to pay five dollars; and one subject stated that he would pay ten dollars monthly. The distribution according to income is given in Table XXIV. A comparison of attitudes of veterans and non-veterans 98 0 8 KO S 1 KO E h 0 M 1 rH r H (M ë i § o M PH 0 Z <JÎ 1 g to Z KO § hH EH 0 1 z; ( H CQ Eh Z 5 O O H P t , M 0 M È Ph g KO KO 1 Z M t —I i O o z; M o Eh a a M § o o o <4 M 0 Eh a 1 I § ÎX l KO a o rH J —1 1 1 iH 1 1 1 I 1 1 0 w 1 IfD o rH CM CO co (M 1 1 CM 3^©î to <M to CO iH CM CM ë C3 H4 (H (d ■p» o Eh i> KO CD D- rH ÏN iH o M a *4 o O rH 3^r, 1 1 1 1 1 I 1 1 1 1 1 lO 4# CO (M £> iH ; H H 1 1 CM CO rH f-H CM lO O LO ; O iH rH ! I f4 c t i 4-> O Eh CÛ CO rH 03 LO H* to H iH (M 1 ! 1 8 IH O rH iH 1 1 rH 1 1 1 1 1 1 lO 4#: O 1 1 CO CM CM 1 fe ■ O (M O CO CO rH O rH (M 1 1 rH cd 4-3 o EH CG CO CO 00 rH CM rH ■ s j r rH CQ ♦4 ÊH <4 O Eh m 1 + 3 G G 0 0 PH O O O rH o ! —1 co co rH 03 Ü rH CO D- 03 O a eh m a KO S G G 0 a rû rH rH (M o £ > 03 03 g O H (M N o o a 1— i X B 0 0 G O O G "r4 rH ] —1 < O O O CM G 0 G a 03 03 03 CO i o O o oT 03 03 03 LO 1 O O o 03 03 03 oT 1 O o o t c T 4# 03 03 03 03 rH 1 O O O C D rH 99 toward government oontrol of oare. The last comparison that was made was one between the attitudes of veterans and non- veterans included among the subjects toward government con trol of dental care, as given In Table XX?. Three hundred and fifteen responses were obtained. Sixty-three of this number were from veterans. Of the sixty-three, 52.69 per cent favored government control while 47.61 per cent opposed it. Among the 252 non-veterans who answered, 42.85 per cent stated they would prefer care under such control, while the remaining 57.14 per cent were not in favor of such a plan. For the group as a whole, 44.76 per cent answered in the affirmative and 55.23 per cent in the negative. The critical ratio of the difference of per cents between the veterans and non-veterans favoring government control was 1*37. This ratio indicated that the difference in attitude between the two groups was not sufficiently great as to eliminate the factor of chance. Comments of subjects illustrating both attitudes are quoted below. In four years of Naval experience during the last war I benefitted a great deal from Navy dental care— since that type of organization is definitely controlled by a government agency, I see no reason to suppose that the same fine type of dental and medical cafe could not be attained through a government agency for the benefit of civilians. In other words-^I’m definitely in favor of some plan whereby adequate dental care can be offered to the general public at a reasonable expense.^1 ^ 21 Office subject. Number B-20. 100 I i ÊH I g O 0 ÊH KO 1 E h g I % g 0 < KO 1 O CO M f = » 5 ÊH < g 8 El g P U KO <u> G . 1 1 0 Bz; rÛ <M 00 H» B o G iQ o Hi z G (M rH rH Z +3 o> rH G CD CD 0 co ü O C v i £> z G O to Hi 0 rH 8 PH EH G A3 0 > X to to o B CD to CO G Z +3 CD to G £> (M CO 0 . • EH Ü O lO O G O lO A3 0 rH PH m Z > G KO 0 iO rH Hi X rH Hi f> h J B to rH rH i 4 G <4 Z rH rH O O G G 4 3 4 3 G KO ■ G O 0 O O *G o G 4 3 + 3 4 3 <H — > KO + 3 t > o A3 + 3 O bO Q c6 bD Z> 0 ËH rH G CO M «S O O EH + 3 > a, EH O cd A o 1 EH A. O 101 I have had very satisfactory dental care in the Navy, at no cost and very imsatisfactory experience with civilian dentists at high cost since d i s c h a r g e .22 In the service the majority of fellows preferred their private dentists to those the army provided, who seemed to have no personal interest or care whether the job was done too well. I feel such a plan as outlined would be similar.22^ I believe that dental work should be made available to all, because there is nothing so painful as a tooth ache, but on Navy checkups we found the dentists would sometimes not recommend work because they were already too busy . . .24 I should want better oare myself if it operated as plans have operated in the past and as I have been told the government dental care offered to service men’s families operate . . .25 A summary of the attitudes expressed in the question naires is given in the following chapter. po Govermaent clinic patient. Number J-2. Miscellaneous patient. Number H-9. Office subject. Number B-39. Miscellaneous subject, Number C-27. CHAPTER IV SCMMARY AND CONCLUSIONS As was stated In Chapter I, the first purpose of this study was to discover the attitudes of selected groups of lay people toward some of their own dental experiences. Many differences in attitudes were found to exist between the subjects when they were considered as a single group and when they were divided into the office, clinic, and miscel laneous categories. There was also a variety of opinions among the members of each of these three groups. I. SUMMARY Reports of subjects concerning regularity of dental care. The study showed that among the subjects who reported, the office patients were more regular in their visits to the dentist than were the patients of the clinics, and that a larger percentage of the service received by the clinic group was solely of an emergency nature. Amount of yearly income appears to be a factor influencing this condition, for 60 per cent of those who sought care only when in pain belonged to the lowest income category. However, with the exception of this particular group, there appeared to be no relationship between yearly income and regularity of dental habits. On the other hand, almost 70 per cent of the clinic 103 patients and almost half of the remaining subjects stated that they had, at some time, postponed dental care due to cost. Attitudes toward private versus clinical care. It was found that 65 per cent of all subjects favored care under private practice. All but one of the ninety-eight patients (98.97 per cent) who were receiving care in private offices wished to continue doing so, and 39 per cent of the subjects from the clinic group stated they would prefer a private office. Attitudes toward quality of oare. When asked their opinions of the type of care they were receiving, a majority of persons felt it was excellent or adequate. A larger per centage of office patients (74.10 per cent) as compared to clinic patients (52.72 per cent) classified their care as excellent. An appearance of indifference on the part of their dentist was noted by almost 16 per cent of the clinic group, as compared to 1.78 per cent of the office subjects and 4.49 per cent of the miscellaneous group. The majority of subjects also expressed favorable impressions in evaluating the attitude of the dentists from whom they received care. Over 40 per cent felt the attitude to be one of friendliness, and 31 per cent felt that their dentist was also interested. Only 8.59 per cent expressed 104 dissatisfaction. When a comparison was made of the evalu ations of office and clinical groups, it was found that although the same percentage, 42 per cent, believed that attitude of their dentist was friendly, a slightly larger percentage of office patients felt he was also interested. A larger percentage of the clinic patients felt they noted an impersonal attitude than was so in the case of the office subjects. Indifference was checked by 4.76 per cent in the clinic and by none in the office grouping. Attitudes toward cost of present dental oare. Of the 371 persons who expressed attitudes toward cost of present dental care, over 60 per cent felt that fees were fair. Of the remaining persons, approximately 25 per cent felt they were paying too much. There was little difference in atti tude among the three groups. The highest percentage of subjects who did not know how to judge the cost of their dental care was found in the clinical group (17.2 per cent). Also, there was a slightly lower percentage of persons in this group who felt they were paying too much. Attitudes toward a government-sponsored dental pro gram. The plan submitted to the subjects of this study was one with dental care provided by the federal government, with individual wage deductions, and including provision for voluntary acceptance or rejection of the service. When the 105 attitudes of the subjects were tabulated, it was found that almost three-fourths of the total number were in favor of such a government plan. When the subjects were classified, variations in attitude were noted. The clinic group registered the strongest approval, with 84.5 per cent voting in the affirmative, while the office patients had the small est percentage, although favorable responses there reached 59.6 per cent. Amount of yearly income appeared to be an influencing factor. For every bracket for the total group, as the in come rose, the responses in favor of the government plan lessened. They range from 83.7 per cent among persons earn ing under #2,000 a year to 43.75 per cent among subjects with an income between #10,000-#19,999 yearly. The reason most frequently mentioned for favoring the plan was that such a program would provide more adequate care for the low income groups, particularly the children. One of the prin cipal reasons for opposition was the feeling that the quality of c€0*e would not be as high under such a plan as it would be in private practice. Attitudes toward making use of government dental care. As the plan provided for voluntary acceptance or rejection of the service, an attempt was made to determine whether or not the subjects would want to avail themselves of the ser vice. The majority of all subjects (61.38 per cent) stated 106 that they would wish to do so, although percentages ranged from 29*8 per cent among office patients (59 per cent had approved the inauguration of the program) to 81 per cent among those in the clinics* Previous dental experiences appeared to he a factor affecting these attitudes. There was also a relationship between the amount of yearly income and the attitudes expressed. As the income increased, the desire to make use of the service decreased. Percentages ranged from 76.85 per cent among subjects earning under $2,000 a year to 36.6 per cent among those with an income between $6,G00-$9,999 and 0.0 per cent in the bracket of over $10,000 a year. Attitudes toward payment of taxes for government dental care. Another of the aims of this study was to deter mine whether or not the subjects would willingly support a government plan. Of the total, 46.96 per cent were willing to do so. It was found that a slightly larger percentage of office patients would willingly support the plan than would care to use it. The reverse was true in the case of the clinic patients, for while 81.9 per cent had expressed a desire to receive dental attention;under sueh a plan, 53.96 per cent were willing to pay taxes for it. Income appeared to be a factor affecting these atti tudes, for as the amount of income rose, the willingness to support the plan through taxation increased. In the lowest 107 income groups, approximately 22 per cent more persons wanted to use the care than wished to pay taxes for it. The per centage of persons earning between #4,000-$9,999 who wanted to receive the dental care were willing to pay for it, while two of the twelve persons with an income over #10,000 voted in favor of taxation, although none in that group would prefer government-sponsored care. Attitudes of veterans and non-veterans toward government-controlled care. An attempt was made to deter mine whether or not previous experience with government controlled dental care would be an influencing factor in the development of attitudes toward the suggested plan. The attitudes of veterans and non-veterans were compared. Comments which were made by the veteran subjects indicated that their previous experiences with dental care in the armed services was an influencing factor, but the favorable and unfavorable reactions to such care were almost equally divided. There was a greater difference in attitude among the non-veterans with 42.8 per cent favoring and 57.1 per cent opposing government control. Attitudes of dentists toward need for care. The second purpose of this study was to discover the attitudes of the professional group as revealed largely in their publication. The Journal of the American Dental Association. 108 The American Dental Association has long been aware of the deplorable dental conditions in the general popula tion, and has been working on the improvement of these conditions. The core of the problem is the great imbalance between dental needs and available dental service. There are many factors which serve to make this a most difficult problem to solve. The prevalence of tooth decay with the great volume of accumulated need for care and the inability of the hard dental tissues to repair themselves make the task one of great magnitude. The manpower shortage presents another problem, for there are at present only enough den tists to furnish dental service to about one-fifth to one- quarter of the population. The situation is made more acute by the uneven distribution of available manpower. Dentists have tended to congregate in the highly populated centers, although there is not an excessive supply of dentists in the larger cities. This tendency has worked to the distinct disadvantage of the population in the smaller cities, villages, and rural areas. Other problems, such as dental health education and the necessity of developing a service that falls within the economic means of greater numbers of people must also be worked out before national dental health can become an actuality. A program of national dental health sponsored by The American Dental Association. The American Dental Association 109 has set up a long range plan for Dentistry’s participation in a national health program. The goals of the program are greater knowledge of dental disease prevention, control of dental disease by the expansion of eommunity dental programs, capacity enrollments in all dental schools, and a better distribution of dentists in rural areas. The dental health program of the American Dental Association is based on three principles which are felt to be basic and fundamental for any dental health program. They are (1) research, (2) dental health education, and (3) dental care. Until the time in the distant future when the entire population can be given attention, it is felt that the greatest strides can be made by concentrating what facilities and manpower are at present available on the children, for it is with them that the greatest amount of preventive work can be accomplished. The Association feels that dental health is the res ponsibility of the individual, the family, and the community, in that order. However, when the responsibility cannot be assumed by the community, it should be assumed by the state and then by the federal government, but the community in all cases should determine the methods of providing service in its area. Importance of the local community in a program of dental health. It is felt that as much of this program as 110 possible should be carried out at a coiamunity level by the local dental societies with the expansion of local health programs. In areas where dental service is either completely lacking or inadequate, that portion of dental care that the local dentists could not themselves provide could be covered by clinical service sponsored by governmental agencies. The local societies would have a voice in the direction of the local clinical and educational programs, and would have access to consultive advice by the state and national dental associations. Opposition to a federally sponsored program. The Association feels that such a plan based on the utilization and expansion of local agencies is preferable to any federal government program of dental care that has been so far pro posed. Opposition to the proposals suggested to date has been principally on the grounds that under such proposals a high quality of care could not be maintained, largely be cause of the emphasis on emergency work, with inadequate provisions for means to improve the dental health of the population by early care and other preventive measures. II. CONCLUSIONS The condition of dental health of the nation’s people indicates the need for some form of dental care program. This need is well recognized by both professional and lay Ill groups. The differences of opinion between the groups deal with the manner in which the problem can best be solved and how such a program can best be carried out. The manpower shortage for this tremendous task of dental rehabilitation and maintenance presents the most serious problem, and the uneven distribution of available manpower has made the condition even more acute in some areas. Meanwhile, exist ing dental schools are turning away hundreds of applicants who desire a dental education. Sufficient numbers of den tists cannot be trained until educational facilities are expanded, and this should be done as soon as possible to take care of the large numbers who would like to enroll. At the present time, there are many states that do not have a dental college within their boundaries, and frequently these states are the ones where the poorest dental conditions exi st. Work in the field of dental research and dental health education is in initial stages. Effective preventive measures cannot be initiated until more is known concerning the causes of dental decay. There is a need for trained personnel and adequate facilities for dental research. Next is the problem of dental care for the low in come groups. The fact that a majority of the persons who responded to the questionnaires favored the inauguration of such a plan would seem to indicate that they recognized its 112 need. There were, however, significant differences in attitudes between the different groups. The higher income groups expressed a willingness to support such a plan, although as groups they did not care to use it. This sense of responsibility was not felt by the lower income groups, where many persons wanted to avail themselves of a service for which they did not wish to pay. Differences were also found between office and clinic patients. The office patients showed little desire to use the government service yet almost 60 per cent favored the establishment of the program and almost one-third were willing to be taxed for it. On the other hand, over 84 per cent of the clinic patients favored the plan and would use the service, but only 53 per cent were willing to be taxed. Many of the subjects made reservations regarding their endorsement of the proposals. The importance of pro fessional ethics was stressed. It was felt that the plan would have to be agreeable to the dentists or the service rendered would be of an inferior quality, and many of those persons opposing the plan did so for this reason. On the other hand, it was argued that a truly conscientious man would do equally good work under a government plan or in his own office. Most of the subjects preferred a private office. They believed that a more personal interest was shown there 113 than in the clinic. One patient expressed the attitude when she said that she liked a dentist who made her feel like a person. Suggestions were made for some form of dental in surance as a plan patterned after Blue Cross in preference to the proposed plan of government-sponsored care. From a comparison of lay and professional points of view obtained in this limited study it would seem to be true that there is a definite disagreement as to the desirability of a government sponsored dental program. As pointed out above, 73.35 per cent of the total sample of lay persons favored some plan of government-sponsored care, whereas the professional organization, through The Journal of the American Dental Association, expressed definite opposition to such a program, and has offered one of its own* This limited study did not inquire into the possible reason for this difference, which might well be investigated by further research. It is not evident whether or not the majority opinion of lay persons favorable to a government-sponsored plan represents a trend in popular attitudes, that is, in a demand for more service from the government. On the other hand, the study does not indicate whether or not the American Dental Association is aware of popular attitudes which may or may not be similar to those discussed in this brief study. 114 Again, the need for further research is indicated. 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Klem, Margaret 0., "Medical and Dental Care in Prepayment Medical Care Organizations," The J ournal of the American Dental Association. 33:330-49, March 1, 1*546. Knutson, John W., "Appraising the Dental Health Program," The J ournal of the American Dental Association. 29 ; 643- 55, April, 1942. Leonard, Richard C., "Administration of a National Dental Care Program, " The Journal of the American Dental Association. 32:1251-55, October 1, 1945. Lisober, B. 1., "Public Dental Health in Dental Education," The Journal of the American Dental Association. gÔTlK'ë-12Ü 27”JÛÎÿ 1, 1942. McCall, John Oppie, "Methods of Payment for Dental Care," The Journal of the American Dental Association. 33:998-1004, August 1, 1946. Morrey, Lon w., "Dental Personnel," The Journal of the American Dental Association. 32:131-44, February 1, 1945. Oppice, Harold W., "Past, Present and Proposed Federal Health Legislation," The Journal of the American Dental Association. 33:609-19, May 1, 1946. Parr an, Thomas, "Dentistry in a National Health Program, " The Journal of the American Dental Association. 32:285-88, March 1, 1945. ; Petty, F. F., "What is Necessary to Make Industrial Dentistry a Credit to the Dental Profession?" The Journal of the American Dental Association. 30:1418-27, September 1, 1943. "Recommendations for Experimental Prepayment Dental Plan," The Journal of the American Dental Association. 32:194-98, February 1, 1945% 120 Robinson, J. Ben, "The Problem of Dental Health Care for the Amerioan People, " The J ournal of the American Dental Association. 31:524-31, April 1, 1944. Scherer, W. H., "Dentistry, International and National, Present and Postwar," The Journal of the American Dental Association. 32:289-97, March 1, 1945. "Summary of the New Wagner-Murray-Dingell Bill," The Journal of the American Dental Association. 33:240-42, February 1, 1946. "Testimony of the American Dental Association on the Wagner- Murray-Dingell Bill (s.1606)," The Journal of the American Dental Association, 33:743-54, lune 1, Ï946. "Testimony of the American Dental Association at Hearings on National Health Bill," The Journal of the American Dental Association. 35:216-21, August 1, 1947. APPENDIX 122 QPESTIQNNAIRE The following questions are being submitted to you to enlist your aid in determining the nature of people’s atti tudes coneerning dental care and the financing of such care. This study is being made by a member of the Southern California Dental Association who is a graduate student in the Department of Sociology at the university of southern California. We will greatly appreciate your help. Please do not sign your name to this document as we do not need to know the identity of those who assist us. Thank you very much for your cooperation, Billyanna Niland What is your occupation?_______Your age? Sex Male Female Married? Yes No___ Number of dependents___ Is your mate a dependent? Yes No How many dependent daughters?___ How many dependent sons?___ Others___ With regard to dental care, do you yourself, go to the dentist: Every six months ; Once a year ; Once every two years ; Once every three years ; Only when in pain . Have you ever gone to any of the following dental clinics: Free clinic: Yes__ No_Part-pay: Yes No , A dental college clinic : Yes No If you have ever gone to a dental clinic, were you satisfied? Yes No Why did you leave? _____ . . Would you go againT Yes N^o ' " Check which you prefer: Dental clinic Private office Do you consider the care you are receiving at present to be Excellent Adequate Inadequate Don’t know__ Do you feel that the attitude of your present dentist is Friendly Interested Impersonal Professional____ Indifferent 123 Please cheek your total yearly income (combined income of husband and wife, if married) Iftider #1. OOP Between #1,000-1,999___, #2,000-3,999 , #4,000-5,999 6,000-7,999___, 8.000-9.999 10,000-19,999 Over #20,000___ How much did you spend for yourself and family for dental care in 1944___, in 1945___, in 1946_^ ? Do you feel that you are paying: Too little Fair amount , Too much Don’t know Are you a veteran of World War II? Yes No_ Have you ever postponed dental care because of cost? Yes No Would you favor a plan whereby the federal government would provide dental care for everyone, funds to be provided by a withholding tax? Yes Nc^__ Would you favor such a plan if the individual is free to accept or reject the service? Yes No___ Would you vote for such a plan? Yes No __ Would you make use of such service? Yes ¥o___ Would you favor paying higher taxes for it? Yes No Would you pay up to #2 a month #5 a month a month Do you think you would be satisfied with the dental services supported by a government agency? Yes No___ Do you think you would be satisfied with the dental services controlled by a government agency? Yes No Any comment that you would care to make on the subject will be greatly appreciated _____________ ^ ____</u>

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Asset Metadata

Creator Niland, Billyanna (author)

Core Title A comparison of the attitudes of selected groups toward the provision of dental care by the federal government with compulsory individual wage deductions, including provision for voluntary accept...

School Department of Sociology

Degree Master of Arts

Degree Program Sociology

Degree Conferral Date 1948-06

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health and environmental sciences,OAI-PMH Harvest,social sciences

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c39-401091

Unique identifier UC11313329

Identifier EP65668.pdf (filename),usctheses-c39-401091 (legacy record id)

Legacy Identifier EP65668.pdf

Dmrecord 401091

Document Type Thesis

Format application/pdf (imt)

Rights Niland, Billyanna

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA