University of Southern California Dissertations and Theses

Orthodontics: A new field in public health

(USC Thesis Other)

Orthodontics: A new field in public health

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content ORTHODONTICS: A NRW FIELD IN PUBLIC HEALTH A Thesis Presented to the Faculty of the School of Social Work University of Southern California In Partial Fulfillment of the Requirements for the Degree Master of Science in Social Work by Dorothy Marian George June 1936 UMI Number: EP65550 All rights reserved INFORMATION TO ALL USERS 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. Dissèrtâion Publishing UMI EP65550 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 This thesis, w ritten under the direction of the candidate’s Faculty Committee and approved by a ll its members, has been presented to and ac cepted by the F aculty of the School of Social W ork in partial fu lfilm e n t of the requirements fo r the degree of MASTER OF SCIENCE IN SOCIAL WORK Dean Faculty Committee Chairman ACKNOWLEDGMENT The writer welcomes this opportunity to thank sin cerely the many professional and lay persons interested in orthodontics, whose cooperation and guidance made this study possible. The writer is indebted to them for personal inter views, letters and literature re: orthodontics. The large number who contributed to the study makes it difficult to acknowledge by name. The bibliography lists many of those who replied by letter or consented to be inter viewed. Dr. I. Eugene Gould, of the Pasadena Hospital Dispens ary, by opening the histories and facilities of his orthodon tic clinic, and by instruction and advice, aided materially in the preparation of the study. Miss Alice Kratka^ Medical Social Worker at the Pasadena Hospital Dispensary, Miss Linda Mitschke, Agent under the California Crippled Children's Act, and Hazel Merrick, D. D. S., of the Los Angeles County Health Department are particularly thanked for their helpful contri butions. TABLE ÛE CONTENTS CHAPTER PAGE I. THE SUBJECT OE THE STUDY, DEEINITIONS OE TERMS USED, AND METHODS EMPLOYED IN THE INVESTIGA TION . . . . . . . . . . . . . . . . . . 1. Statement of the problem ...........1. The importance of the study. . . . . . . . . . 2. Définitions of terms used. . . . . . . . . . . 2. Methods used . . . . . . . . . . . . . 4. II. THE PREVALENCE OE DENTAL MALOCCLUSION AMONG AMERICAN CHILDREN, AND ITS RELATION TO DENTAL AND GENERAL HEALTH. . . . . . . . . . . 6. The relation of malocclusion to dental health . . . . . . . . . . ........ . 11. The relation of malocclusion to general health 12. III. CONTRIBUTORY AND CO-EXISTING FACTORS IN MALOCCLUSION . . . . . . . . . . . . . . . . . 15. Etiology of malocclusion . . . . . . . . . . 15. The influence of heredity. ..........18. Pre-natal conditions . . . . . . . . . . . . . 20. Diet and the influence of the endocrine glands ................................21. CHAPTER Z>AGE III. CONTRIBUTORY AND CO-EXISTING FACTORS IN MALOCCLUSION (CONT»D) Posture and malocclusion ...........26. Diseases which may he a factor in malocclusion The relation of nose and throat obstructions to malocclusion . . ^ . . . . . 28. The teeth as causative factors . . . . . . . . 29. Habits and malocclusion. . . . . . . . . IV. INTERVIEWS ELICITING THE SOCIAL AND PSYCHOLOGICAL RESPONSES OF ORTHODONTIC PATIENTS . .......... 40. V. THE PSYCHOLOGICAL AND SOCIAL ASPECTS OF THE PROBLEM. ...... ............. ...... 81. The psychological aspects..................81. The social aspects ..............89. VI. DIFFICULTIES ENCOUNTERED IN PROVIDING FOR ORTHODONTIC TREATMENT AND SOME EXISTING TREATMENT PROCEDURES ..........96. Expense and time involved in orthodontia treatment, . . . . . . . . . .......... ..96. Necessity to cooperate during treatment. • . . 98. Lack of cooperation in clinical treatment. . . 99. The small number of qualified orthodontists, . . . . . . . . . . . . . . .101. Existing clinical facilities inadequate, , , .102. CHAPTER PAGE VI. DIFFICULTIES ENCOUNTERED IN PROVIDING FOR ORTHODONTIC TREATMENT AND SOME EXISTING TREATMENT PROCEDURES (CONT'D) Treatment under California Crippled Children*s Act .. .. ... ... .. 108. VII. PROPOSED METHODS OF ATTACKING THE ORTHODONTIC PROBLEM. ........ ....... 115. Trends toward socialization of treatment. . .......... 117. Health insurance as a means of solving the treatment problem. . . . 121. Prevention of malocclusions. . . . . . . . 123. Methods of preventions 1. dental care for children. ....... 127. 2. education ........ . . . . . . . . 128. a. in the school system . . . . . . . . 129. b. of the lay public ..............130. c. of the health professions. ..... 132, VIII. FINDINGS AND SUGGESTIONS ...............136. BIBLIOGRAPHY.............. 143. 1 . CHAPTER I THE PROBLEM AND DEFINITIONS OF TERMS USED During the past fifteen years great progress has been made in research and practise in the medico-dental field of orthodontics.^ But, so far as this investigator knows, no attempt has hitherto been made to assemble facts and authori tative opinions regarding the wider social aspects of the orthodontic problem among American children. Statement of the nroblem. This study is primarily concerned with children of school and pre-school age who require orthodontic supervision or treatment, and particular ly with children from the low income masses of the population whose parents, under existing conditions, are unable to pur chase such supervision or treatment from practising ortho dontists in the competitive dental market. The study is only incidentally concerned with the medical and dental as pects of orthodonticsj the inclusion of such data below is for the comprehension of the complex nature of the problem, and of the factors which must necessarily enter into plans for treatment and prevention on a large scale. The study ^Harvey D. Stallard, D. D. S., personal interview, San Diego, April 7, 1936. 2 . is by a lay student. It is made in the interests of the lay and professional individuals and groups who plan and organize public health work for children. It endeavors, also, to assemble and present some of the facts and factors related to the incidence and causation of malocclusions. The importance of the study. The orthodontic problem has for the most part been studied from the technical point of view. Estimates of the high incidence of malocclusions among children imply that the problem has a social as well as a technical side. Further evidence of the existence of a social side to the problem is the difficulty of obtaining orthodontic treatment for poor children because of their poverty; and the apparent presence of psychological and social / consequences of facial deformities related to malocclusions. The fact that oral hygiene, the public health or preventive aspect of dentistry, is already well developed in progressive communities, suggests that prevention of malocclusions might be a next step in public health dentistry. If so, a study of the social facts of the problem, will be useful. Definitions of terms used. In this study the principal terms used may be understood to have the meaning given them by Dr. James David McCoy, in his volume, * * Applied Orthodontics*. 3 . Orthodontics t Orthodontics may he defined as that science which has for its object the prevention and correction of dental and oral anomalies • * . . Further, . . • . • the writer feels that the problems confronting us and the scope of the field embraced justifies the conclusion that orthodontics is a study of dental and oral development ; it seeks to determine the factors which control growth processes^to the end that a normal Tunctional and anatomical relationship of these parts may be realized, and aims to learn the influences ne cessary to maintain such conditions vrhen once establish ed.^ Malocclusions When normal growth processes are disturbed to the extent that the teeth, dental aréhes, or jaws exhibit deviations from the normal, a dental or oral anomaly is established.3 Dento-facial deformity: .... are dealing with dento-facial deformities which, in character, are complex morphological devia tions, including not only the teeth and alveolar pro cess, but extending beyond these boundaries, involving the jaws, and, in many instances, some of the external features of the face.^ Normal function: All organisms and their parts are subject to varia tion, and the teeth and jaws are not exempt from this phase of growth, but vary as do other parts of the body. These variations occur around a certain average mean which we call the normal. This is a standard of a functional, as well as an anatomical"nature whicE is not rigidly fixed ^James David McCoy, M.S., D.D.S., F.A.C.D., Applied Orthodonticsj(Philadelphia. Pa.: Lea and Febiger, 1935. Fourth edition.) Sibid., p. 37. 4lbid., p. 38. 5Ibid.. p. 36. 4 . Procedures used in the preparation of the study. The investigator found it necessary to employ varied procedures in the collection of material. They may he summarized as follows t 1. A study of orthodontic literature, especially of the more recent periodical literature, and of other literature in the public health and health insurance fields, which might particularly apply to public health organization of preventive and corrective pro grams. This procedure of study was supplemented throu^ correspondence and interviews with orthodontic authori ties and other interested and informed persons. 2. The collection of significant data and authorita tive opinions on the incidence of malocclusions among children. 3. The collection of data on some outstanding dental clinics at present giving orthodontic treatment. 4. Personal observation and investigation of the procedures employed in a welfare clinic and a dental school clinic, 5. Compilation of selected case histories of malocclu sion patients, each with investigator*s analytic comment. 5 . 6. Correspondence and interviews with authorities in the orthodontic field, with a view of obtaining their most recent conclusions regarding a possible solution of the orthodontic problem. 6 . CHAPTER II. THE PREVALENCE OF DENTAL MALOCCLUSION AMONG AMERICAN CHILDREN, AND ITS RELATION TO DENTAL AND GENERAL HEALTH Accurately checked estimates of the incidence of malocclusion among American children are difficult to ob tain. The United States Department of Public Health in a communication to the investigator, under date of March 16, 1936, by R. C. Williams, Assistant Surgeon General, states, *. . . you are advised that the survey of dental needs which is now being published will give an estimate of malocclusion which exists among school children. This publication will not be available for about two mohths*. One available report, valuable because of its well organized plan, the thoroughness of examinations, and the classification of children according to school grades^ and also noting the presence or absence of speech defects, is the survey of the St. Louis Dental Society, an illustrative table from which is quoted below.1 ^Committee on Public Dental Education of the St. Louis Dental Society for 1934, Report and Dental Survey in the St. Louis Schools. (Issued by the St. Louis Dental Society.) p. '35. 7 . REPORT OE THE COMMITTEE ON PUBLIC DENTAL EDUCATION OE THE ST. LOUIS DENTAL SOCIETY FOR 1934 Malocclusion (Final Total of all Schools Examined--White and Colored) Normal Speech Total Normal Mal- Per cent Mal Grades examined occlusion occlusion occlusion \ Kinder 6301 5091 1210 19.2 garten 12286 8041 4245 34.5 First 11323 5691 5632 49.7 Second 10073 5100 5973 59.2 Third 10862 5184 5678 52.2 Fourth 10434 4967 5467 52.3 Fifth 9900 4645 5255 53.0 Sixth 9666 4424 5242 54.2 Seventh 8320 3760 4560 54.8 Eighth 585 236 349 • 59.6 Ungraded 6993 2653 4340 62.0 Ninth 5555 1915 3640 65.5 Tenth 3840 1190 2650 69.0 Eleventh 3044 950 2094 68.7 Twelfth 207 105 102 50.7 Ungraded 2637 965 1672 63;4 Vocational 817 493 324 39.6 Teachers* % College Defective Speec * * Kinder 343 261 82 23.9 garten 312 480 332 40.8 First 574 266 308 53.6 Second 598 262 336 56.1 Third 427 201 226 52.9 Fourth 348 144 204 58.6 Fifth 244 103 141 57.7 Sixth 262 99 163 59.0 Seventh 266 109 157 59.0 Eigth 246 149 97 39.4 Ungraded 308 92 216 70.0 Ninth 286 90 196 68.5 Tenth 202 63 139 68.8 Eleventh 115 31 84 75.0 Twelfth 6 4 2 33.3 Ungraded 12 4 8 66.6 Vocational 2 2 Teachers * College 8 . It should he noted that in the above survey the occlusion of the teeth were checked to determine any devia tion from normal position or relation, and only those with anatomically correct relations were classified as normal. The finding of the survey was that 51.4^ of the children examined had malocclusion. Other estimates place the incidence of malocclusion at a much higher figure. One writer states his belief that oral deformities rank next to dental caries in incidence, and that at least twenty millions of American children are in need of orthodontic care.^ This high estimate is based upon an investigation conducted by the late Professor Forrest H. Orton and Dr. B. E. Lischer of 2,928 students entering the University of California at Berkeley, California, in August, 1930. The investigation discovered that, *. . . .less than five per cent had anatomically correct, unmutilated dentures*.^ Another writer believes that children are in need of orthodontic service in the United States, and he is sure the number is not growing less.4 %. E. Lischer, D.M.D., “Orthodontic Education*, International Journal Orthodontia. Vol. 21, No. 6, June 1935. p. 512. ®IMd., p. 512. 40uy 8. Millberry, D. D. S., “An Adequate Course of Instruction in Orthodontics*, Dental Cosmos. (May 1930). 9 . The report, “Twenty Years of a School Dental Program in Peoria**, by D. Carroll Smith, D. D. S., supervisor of the dental department of the Peoria, Illinois, public schools, states that an inspection of 5,578 children from kindergarten through to the fourth grade revealed fifteen per cent in need of orthodontic treatment.^ There is no further comment in the report, so it is not possible to determine if the low incidence reported is the result of a long time preventive program practised in the schools for twenty years. Senior students from the New York University School of Dentistry, in December, 1930, examined 178 members of the Boys* Club of New York City. The ages of the boys ranged between twelve and seventeen years. Of the group examined, ninety-eight had abnormal occlusion.6 A dental inspection of public school children in Oyster Bay, Long Island, during the winter of 1930, revealed that of tv/o hundred and seventy one pupils, 26.59^ required orthodontic treatment.? Oyster Bay is a wealthy suburban district, and its residents have higher average incomes than most other American communities ; moreover, this inspection 5The Committee on Community Dental Service of the New York Tuberculosis and Health Association, Health Dentistry for the Community, p. 26. (University of Chicago Press, Chicago,1935) ®rbid., p. 56. 7Ibid.. p. 13. 1 0 . was made before the financial depression influences had been operating long enough to cause dental neglect among the children of such a community. The conclusion to be reached from the foregoing admittedly meager data, is that dental malocclusions among American children are undoubtedly very numerous. But just how numerous it is impossible to say until more comprehen sive and accurately checked estimates (such, perhaps, as the survey of the United States Public Health Service now in process of publication) are available. Surveys of the incidence of malocclusions among the British population have been made which indicate that it is widespread in that country. The eminent authority. Sir Arthur Keith, made an estimate respecting the British popu lation in the Huxley Lecture of 1923. In this lecture he stated that disturbance of growth which shows itself in “contracted jaws and irregularity of the front teeth* oc curred in about one-third of the whole population. In 1924, in the Dental Board Lecture, he stated that *at least twenty-five individuals in every hundred will have a gross disturbance in the growth of their palates, or in eruption of their teeth”.® ®J. G. Brash, M.G., M.A., M.D., The Aetiology of ___________Malocclusion of the Teeth. (London: The Dental Board of the United Kingdom, second impressioî), p. 19 1 1 . These estimates of malocclusion incidence in this country and Britain indicate a serious problem. The rela tionship of malocclusions to dental and general health is known to be intimate. Therefore it is a medical-dental pro blem of considerable importance. The relation of Malocclusions to dental health. Crooked and crowded teeth, such as the usual malocclusion case presents, predispose the individual to dental caries and gingivitis.9*10 it is difficult, and in some cases im possible, for the child with a maloccluded mouth to proper ly clean his teeth; moreover, he has not the incentive a child with a healthy mouth has to care for his teeth. The consequence of lack of care, or of teeth so crowded as to prevent care, is that food accumulates between the teeth and around the gums, and the development of pockets and ca vities are inevitable. Many dental authorities believe that pyorrhea in later adult life is a common sequela of malocclusions in c h i l d h o o d . ^ " 1 9 Stillman and McCall in their textbook on Periodontia discuss malocclusion of the natural teeth as one 9b . E. Lischer, D.M.D,, “Orthodontic Education”, International Journal Orthodontia. Vol. 21. No. 6. June. 1935. pT3l2T lOwyj^g Education of the Dental Patient”, Reprinted from Dental Digest. Copyright 1933. 1 2 . of the primary factors in the etiology of peridontia because of the mechanical irritation resulting from malooclusions.il They further state that tissues whose functions are chiefly mechanical are influenced most markedly by mechanically injurious agencies.1^ Dr. Walker believes that, “The loss of this tooth (first permanent molar) which occurs so frequently in early childhood is a predisposing factor to malocclusion in later life, and is probably the most prolific cause of pyorrhea*.13 The relation of malocclusion to general health. There is ample evidence that dental malocclusion may have a direct effect upon the general health and well being. The relation ship between dental caries (encouraged by malocclusion) and mouth infections and health is well known even by the layman of this generation. But besides this rather indirect con nection between malocclusion and general health, the indivi dual with malocclusion is very frequently unable to properly masticate his food. Frequently he cannot eat certain foods which are necessary to avoid diet deficiency. Malnutrition and indigestion are frequently the direct result of malocclu sion. llpaul R. Stillman, D.D.S., and John Oppie McCall, A.B., D.D.S., A Textbook of Clinical Periodontia. (New York; The Macmillan Company, 192^. p. 50. l^rbid.. p. 5. Impersonal Correspondence letter from Dr. Alfred Walker, New York City, January 18, 1936. 1 3 . Dr. Alfred Walker, in a letter to the investigator, comments as follows: Some physicians and others in the field of public health service recognize that malocclusions may jeo pardize health. Certain types of malocclusions place the individual very definitely in the crippled class. As a matter of fact, these types may be more serious in their consequences than some other bodily deformities, 14 Jerome H, Trier, D.D.S., in discussing this question of general health and malocclusion, writes: As for his general health, the child will be liable to any ill effects that might result from the improper chewing of his food (which is inevitable when the teeth are not in alignment), and although these ill effects often take a long time to occur, every parent will want to spare his child even the possibility of developing poor digestion and the consequent discomforts and ill ness that attend it,15 Some authorities believe that malocclusion may fur ther jeopardize the child*s normal health by interfering with normal respiration,1® These authorities emphasize the importance of respiration without breathing through the open mouth and relate incorrect breathing habits to nose and throat obstructions and diseases. Ludwick stated that “no child can expect to grow into a strong healthy adult if he is deprived of a proper functioning occlusion or has a den- 14personal correspondence, Letter from Dr. Alfred Walker, New York City, January 18th, 1936, 13jerome H, Trier, D.D.S., “The Meaning of Orthodontia”, Mouth Health Quarterly, p. 6. Vol. 4, No. 3, July-October 1935 16 C. F. S. Dillon, M.S., D.D.S., personal interview, March 16, 1936, 1 4 . tal deformity which interferes with normal speech or respi ration.”1? And again, Brusse said: The rhinologist cannot correct mouth-hreathing in cases of this type, and if abnormalities of this class are not treated orthodontically, proper aeration is lacking, with a possibility of later sinusitis. It is universally agreed by rhinologists that the requisites for the preservation of healthy sinuses are proper aeration and ample drainage.18 There is even evidence regarding the relationship between malocclusion and deafness. Crittenden, discussing oral deformities associated with impaired hearing, quoted authorities who found that the relationship of mandible with maxillae which in some cases may be due to “malposed teeth permitting malocclusion*, may effect the hearing,^9 The effect of malocclusion upon mental health is dealt with in a later chapter of this study. 17paul G. Ludwick, D.D.Sé, “Orthodontia— Its Relation to Health and Society”, International Journal Orthodontia. Vol. 21, No. 9, September 1935. p. 864. ^®Archie B. Brusee, D.D.S.% “Orthodontics as an Aid to the Rhinologist”, International Journal Orthodontia. Vol. 21, No. 7, July 1935. pp. 646-647. . ^9i,ouis M. Crittenden, D.D.S., “Oral Deformities Associated with Impaired Hearing”, Dental Cosmos, p. 591-2 Vol. LXXIV, June 1932. 1 5 . CHAPTER III. CONTRIBUTORY AND COEXISTING FACTORS IN MALOCCLUSION. The etiology of malocclusions as determined by scien tific research, is for the most part unknown. The develop ment of the face and jaws is one of the most complex and intricate presented to the student of growth and develop ment processes. It is essential to realize that malocclu sions are related to the growth and development of the body as a whole. Brash, who made a study of dental irregularity and malocclusions based on present scientific findings, found that: “In general it (scientific opinion) now tends to con sider the problem as a whole one which can be solved only on wide biological lines.He stated further that most of the data on this subject was so incomplete that many of his conclusions cannot be taken as final.^ The findings on this subject of the White House Con ference on Growth and Development of the Child were: On the whole, the cause of malocclusion of the teeth is still a riddle. That malocclusion of the teeth i s intimately related to development is quite clear. But the kinds of disturbances in development which affect J. C. Brash, M.C., M.A., M.D., The Aetiology of Irregularity and Malocclusion of the Teeth.fThe Dental Board of the United Kingdom, London, Second Impression). p. 245, ^Ibid.. o. 246. 1 6 . occlusion of the teeth are not known, (discussing de velopment of the head) . . . the magnitude and com plexity of the problem may be appreciated. It is, therefore, obvious that the problem as a whole has scarcely been approached and that its solution depends upon further and more exhaustive investigation and re search.^ They (the teeth and jaws) are mutually dependent structures and part of the bony skeleton. Clinically it is of the utmost importance to realize that their de velopment is guided by the same general laws which go vern that of the skeleton. The structure and condition of the teeth are delicate and reliable indicators of an adequate provision of many of the materials necessary for normal growth and the maintenance of good health of the whole body.4 Development is a single name for many complex pro cesses and the development of the human face, jaws and teeth, like the development of the body as a whole, is influenced by factors affecting the pace at which growth or differentiation is taking place.5 Dr* Delabarre indicates that he takes the long time biological concept of the problem in his statement: Science tells us that function determines form. Ap plying that to malocclusion, function must be interpret ed in the broadest sense to include all the functions of the body, since they are all concerned in growth and development in varying degrees of influence according to their physical and physiological relationships. A wholly efficient function therefore results in the form most desireable for the organism. Conversely a poorly functioning unit will have a less desirable form. There fore malocclusion must be the end-result of malfunction.6 3The White House Conference on Growth and Development of the Child. (The Century Company, New York - London, 1933f. p. 243. 4lbid.. p. 156. 5Ibid.. p. 132. 8prank A. Delabarre, D.D.S., “Orthodontia and Dentistry for Children*, International Journal Orthodontia. Vol. 21, No. 9, September 1935. p. 881. ~ 1 7 . Dr. Rogers and Dr. Baker also have a biological concept of the problem of malocclusions and emphasize the effect of the functional activity of the muscles. Rogers stated: .... in the early stages of life, the development of functional elements continues until certain structures have attained a state of practical usefulness. From this point, then, it is necessary for the further develop^ ment, and that the ultimate form and structure depehd on the nature and degree of function the individual is able to bring into use. Structural development never achieves its proper form unless function is performed in such a way as to produce it.® Orthodontics, which is based on science, and is an art in practice, has noted the relationship between certain phenomena and the presence of malocclusion. It has therefore attempted to eliminate those factors which might be harmful to the patient. Orthodontists* by study and observation, have determined the existence of conditions, some or all of which may be contributory factors. On the harmfulness of some factors, there is a consensus of opinion on the.part cf practicing orthodontists, A further argument to support the attempt of the orthodontists to eliminate harmful factors, is that their recommendations, if carried out, will promote the health and development of the child as a whole even though they may not be able to prevent malocclusions. ®Alfred Paul Rogers, D.D.S., “The Place of Myofunc tional Treatment in the Correction of Malocclusion*, American Dental Association. Vol. 23, No. 1. January 1936. p. 66. 1 8 . The influence of Heredity. Orthodontists agree that the hereditary factor influences the occlusion of the teeth.^**^^ The relation between this factor and the influences of en vironment in determining malocclusions is subject to debate and further study.But hereditary and congenital factors are believed responsible for supernumerary teeth, missing teeth, over-adequate and inadequate material for tooth forma tion, and the individual glandular balance which directly affects the formation of the jaw and boney structure and the eruption and shedding of the deciduous teeth. Grouch finds that the growth and shaping of the face and jaw are influenced by inheritance from both parents, and the extrinsic environmental factors. He discusses studies which have been made showing the inherited likenesses in shape and size of jaws in family lines, particularly the royal families.At birth and during the early years of life, the jaws are plastic, and respond to outside pressures, which leads some orthodontists to conclude that too much ^Russell Marsh, L.D.S., “Orthodontics and Common Sense”, International Journal Orthodontia and Dentistry for Children, June 1935. ' ” ' Tyler Haynes, B.S., D.D.S., “Development of Teeth and Jaws”, International Journal Orthodontia. Vol. 21, No. 11, November 1935. ~ . llPrank M. Casto, D.D.S., “Orthodontia and the General Practioner”, International Journal Orthodontia, Vol. 21. No. 9. September 1935. p. 805. ' l^S. Stuart Crouch, D.D.S., “Heredity”, Ibid. June 1935. p.527. 1 9 , importance must not be given the hereditary factor in shap ing the jaws. On the influence of the hereditary factors, the White House Conference on Growth and Development of the Child in discussing research on this subject based on study of identical twins, quote Detlefsen's findings that "the reserablences in form, position and occlusion of teeth and resemblences in the forms of the dental arches of identical twins may be attributed to influences which are due to heredity and not to environment."^^ They also quote Goldberg, who analyzed the casts of the dentitions of fifty pairs of twins, "that all the ex trinsic factors are relatively insignificant compared with the intrinsic factors in the production of m a l o c c l u s i o n . In the summary of the chapter, the statement is made that t Heredity plays a part, though an uncertain one, in the development of the teeth. Familial resemblances in the shape of the teeth, jaws, and face are presumably due to heredity, but the quality of the structure and the development depend largely on nutrition.15 Brash in his study of scientific data and opinions ^^White House Conference Report on Growth and De velopment of the Child, (The Century Company, Hew York and London, 1933), p. 145. p. 146. I S l b i d . . p . 172. 2 0 . on malocclusions found that "such evidence as we have of the inheritance of face and jaw form, • • • • all points to the genetic constitution of a primary factor".16 This investigator believes that Brash not only con cludes that the genetic factor in determining malocclusions has the weight of the existing research, but that it will continue to be considered a primary factor in the findings of future research on etiology of malocclusions.1? Pre-natal conditions. Certain pre-natal conditions, which science is unable to prevent, predispose the child to developing malocclusion. These embryonic conditions include: Pressures on foetus during uterine life, harelip, cleft pa late, abnormal frenum labium, and accident to the pregnant mother. Deficiency and constitutional disease may affeot cell growth and glandular functioning with consequent effect upon the development of bones of the face. Untreated syphilis in the pregnant mother— which should be immediately detected and treated before or during pregnancy may cause missing teeth. Birth injuries are responsible for some malocclusions.18 16j. c. Brash, M.C., M.A., M.D., The Aetiology of Irregularity and Malocclusion of the Teeth, [The Dental Board of the United Kingdom,^London, second impression), p. 244. p. 246. l^This paragraph is an interpretation of interview with Dr. I. Eugene Gould. 2 1 . Adequate pre-natal care of the expectant mother should include a diet rich in calcium, phosphorous, and vitamins to supply the needs of the embryo, and correction of any endocrine unbalance so that these dietary elements may be a s s i m i l a t e d . 19 White House Conference found that "the quality of the teeth seems, however, to be more a matter of proper assimilation of food-stuffs and of an adequate supply of tooth-building material on the part of the mother during pregnancy, in as much as both the temporary and permanent teeth are in process of formation during this period.*20 Relation of Diet and Endocrine glands on malocclusions. There appears to be a complex and intimate relationship be tween vitamins and hormones, and it therefore seems logical to discuss these factors together. Orthodontists treating malocclusions recommend a diet rich in minerals and vitamins, and seek the cooperation of the pediatrician in correcting endocrine disturbances, believing that these measures will assist the child to develop normally, and may assist ortho dontic treatment. However the evidence on the relation of diet and endocrines to the development and treatment of 19m . Evangeline Jordan, D.D.S., "Operative Dentistry for Children", Dental Items of Interest. Vol. 46, December 1924, Chap. XIV. p. 885. ^^The White House Conference Report on Growth and Development. (The Century Company, Hew York and London, 1933), p. 159. 2 2 . malocclusions, is conflicting and probably insufficient to warrant the formation of definite scientific concepts. Brash, after a wide survey of scientific evidence, stated t There is evidence of widespread "defective nutrition" in the populations among whom irregularity and malocclu sion are prevalent; but the evidence is inconclusive that the form of the jaws and the position of the teeth are directly related to nutritional factors.21 Vitamins and hormones have a special relation to growth in general and to the growth of the skeleton in particular. When these produce pathological condition of bone or clinically recognisable signs and symptoms, and other general disorders of growth, of unknown origin but often strongly hereditary, they may all be accompa nied by changes in the facial bones with incidental ir regularity and malocclusion of the teeth. There is, ■ however, no evidence in support of speculative opinions that common irregularities and malocclusions may be due to such causes in the absence of other characteristic signs.22 The White Conference Report found: Pathological conditions are surmised but not proved to be a cause (of malocclusions). Glands of internal secretion are suspected. So is nutrition. In fact, the association of malocclusion of the teeth and arti ficial feeding in infancy is found in 80 per cent of more than a thousand children examined. However, more extensive investigations of the problem are needed to ascertain the truth.23 The problem of the growth and development of the C. Brash, M.C., M.A., M.D., The Aetiology of Irregularity and Malocclusion of the Teeth, '('The' Dental Board of the United Kingdom, London, second impression), p. 244, ^^Ibid.. p. 244. 23gp. cit.. p. 146. 2 3 . bodily structures and the process of calcification in bones and teeth is highly complicated and largely un solved. But there are some facts which prove rather conclusively that variations in nutrition produce effects on the physical growth of the body as a whole. The development of specific organs and structures, such as the teeth, can be so modified by varying the factors governing nutrition that retardation and abnormalities are produced.24 It seems essential to good teeth that there should be on hand an adequate supply of the chief building materials, calcium and phosphorus, and that they should be present in the right proportions, that is about two parts of calcium to one of p h o s p h o r u s .24 Howe believed that a diet deficient in one or more of the vitamins was responsible for the irregularities in the arrangement of teeth which have been occurring in 85 per cent of the children of the United States for the past two decades and continue at the same high per centage at the present time. These irregularities in dicate an arrest or abnormality in the growth and develop ment of the maxillary bones and m a n d i b l e s . 25 Among children, narrow vaulted arches and protruding teeth are often thought to be a result of bad habits such as thumb sucking and mouth breathing. Among the animals on diets which produce the same narrow vaulted arches, mouth breathing occurs. Although these habits may accentuate such conditions, because of the muscular stresses involved which can distort softened rachitic bone, all of the experiments in animal feeding indicate that a diet deficient in certain elements is the funda mental cause.26 In scurvy the dentine remains uncalcified, or softens after its formation. Adenoid tissue is perceptibly thickened. Irregularities of the second teeth occur be cause of the retardation in the development of the jaws. ' S4i-bid.. p. 161. 25lbid.. p. 165. 2Glbid.. p. 167. 24. During periods of malnutrition, the growth of adenoid tissue which often occurs will tend to close the narrow nasal passages, making it impossible to supply the body with sufficient oxygen except by mouth breathing. We again appear to be dealing with a result rather than a cause of malformations. .... Keith, from anthropolo gical measurements and Brash, from his feeding experi ments, also came to the conclusion that irregularity of the teeth is the result of a lack of proper growth and development of the maxilla and mandible.2? Mellanby also finds that the chemical qualities of diet are of much greater signigicance than mechanical qualities in assisting normal development and calcifica tion. Even from the point of view of exercise of the jaws, the consistency of the diet is of relatively less importance than its chemical make-up. A diet containing ample fat-soluble vitamins, even if soft and pappy and involving no mastication in itself, permits of normal growth in which the muscle tone and physical activity of the dogs are normal.28 Oppenheim found that diet as it is related to ortho dontic treatment and distinct from orthodontic causes, was not important: "The contention, however that diet might be of paramount importance to the progress and final result of orthodontic therapy is by no means supported by clinical observation."29 Disturbances in endocrine balance and metabolism affecting the growth and development of child, may be con tributory factors in malocclusion. Dr. Grant finds suffi- 2?Ibid.. p. 167. ^^Ibid.. p. 168. ^^Albin Oppenheim, Vienna, "Critical Review of the Publications of J. A. Marshall", International Journal of Orthodontia. Vol. 21, Ho. 8, August 1935. 25. oient proof of "the profound influence of the endocrine glands on growth and development. So complicated is the endocrine system that it is sometimes impossible to tell which gland is the primary cause of some developmental error, as the glands affect each other . . . ."30 The endocrine glands which are known to effect the structure and development of the skeleton are the pituitary, thyroid, parathyroid and gonads.31-32 The peculiar glandular constitution of an individual may be inherited; and glandular balance, or lack of it, may be intimately related to the hereditary factors of malocclusion. The human jaw, with which the orthodontist must work, is built according to the specifications of the glandular system. The statement is made in the Report of the White House Conference that "hypothyroidism and various forms of marasmus in infancy very powerfully retard facial growth and predispose to defects of adjustment."33 Any imbalance or unbalance of the glandular system 30t. a . Grant, D.D.8., "Relation of the Endocrines to the Teeth", InternatiOnal Journal Orthodontia. Vol. 21, Ho. 9, September 1935. 3^Dr, I. Eugene Gould - Interview. 32Herbert A. Pullen, Transactions Panama Pacific Dental Congress. Vol. 2, 1915. p. 21. ^3white House Conference Report on Growth and Develop- jrent of the Child. (The Century Company, Hew York - London, 1933). pp. 117-118. 2 6 . is found to create, a • . greater general tendency to react unfavorably to otherwise harmless stimuli"*34 These varying reactions, as well as the eruption and shedding time of the teeth are dependent on the stimulation of the ductless glands.35 Posture and malocclusion. Many of the children treat ed for malocclusion have posture defects. The chart compiled from a study of patients at the Pasadena Hospital Dispensary, pa'ge ; ' 3 9 shows a high incidence of posture defects among die se Orthodontic patients. The tendency of these two types of abnormality to exist in the same individual may not be chance association. The quality of skeletal bones and the quality of the muscular tenacity are factors in each condition, and it may be presumed that the quality of bone or muscle will not vary in the same individual although located in various parts of the same body. The White House Conference report found that: They (the teeth and jaws) are mutually dependent struc tures and part of the bony skeleton. Clinically it is of the utmost importance to realize that their develop ment is guided by the same general laws which govern that of the skeleton. The structure and condition of the teeth are delicate and reliable indicators of an adequate ^Albin Oppenheim, Vienna, "Critical Review of the Publications of J. A. Marshall", International Journal of Orthodontia. Vol. 21, Ho. 8, August 1935. 33jerome H. Trier, D.D.S., "The Limitations of Ortho dontia", International Journal Orthodontia. Vol. 21. Ho. 9, September 16, 1935. p. 817. 2 7 . provision of many of the materials necessary for normal growth and the maintenance of good health of the whole body.36 The relation between bodily growth and malocclusion of the teeth has been more carefully examined. It has been found that retardations and acceleraticns in the bodily growth are often found in association with op posite effects upon the differentiation and occlusion of the dentition. Thus, among certain groups of child ren, the tall ones are late in erupting their teeth. But when teeth erupt late they are, in turn, found to be in close association with wrong position and mal occlusion.37 Poor posture may indicate that the bones of the skele ton respond abnormally to pressures. Orthodontists, recog nizing this fact, commonly refer such posture defects for orthopaedic treatment, such treatment to be undertaken prior to or along with the orthodontic treatment. Diseases which may be a factor in malocclusion. The diseases which particularly effect changes in bone may be serious factors in causing malocclusion. These diseases include rickets and tuberculosis.38-39 The last named dis ease sometimes causes the early loss of deciduous teeth, which itself is an important factor in causing malocclusion. (Mote the conclusions of the White House Conference quoted under the section on nutrition, pages ‘ 23 and 36%ite House Conference Report on Growth and Develop ment of the Child, (Mew York and London;The Century Company.) p. 156. 37lbid.. p. 146. Dr. I. Eugene Gould - Interview 39jerome H. Trier, "The Limitations of Orthodontia^ . International Journal Orthodontia. Vol. 21. Mo. 9, September 1935. p. 817. 28 . The relation of nose and throat obstructions to malocclusion. A large proportion of orthodontic patients have, or have had, nose and throat obstructions. It is recognized that nose and throat obstructions commonly cause mouth breathing, already noted as an important causative factor in malocclusion.40 But further, the malocclusion itself frequently causes deformity of the bones forming the nasal passages, thus obstructing the normal air flow, and encouraging a further growth of adenoid tissue, or even causing sinusitis.41 A vicious cycle is thus initiated, and it is often impossible to permanently correct one con dition without correcting the other.41 Dr. Rogers wrote: We are all perfectly familiar with case operated upon by the rhinologist when removal of the nasal ob struction, adenoids and tonsils, has not been followed by the beneficial results promised. In the case of individuals who have failed to receive the hoped for results, the muscles will be found to lack tone and de velopment. Proper systematic exercise alone will be found to do more than any other thing to produce har monious development.42 It will be noted that among the children receiving ortho dontic treatment at the Pasadena Hospital Dispensary (see Chart) some of the patients have had to submit to tonsillec- 4ÛHerbert A. Pullen, Transactions Panama Pacific Congress. Vol. 2, 1915. p. 21. 4lArchie B. Brusse, D.D.S., "Orthodontics as an Aid to the Rhinologist", International Jouinal Orthodontia, Vol. 21. Mo. 7. July 1935, 42Alfred P. Rogers, "Exercises for the Development of the Muscles of the Pace", Dental Cosmos, Oct., 1918. p. 862. Vol. LX, Mo. 10. 29. tomies and adenoïdectomies prior to or during treatment, and in several cases more than one operation was necessary on the same child. Contrary to the opinions held by most orthodontists is the statement of Brash that "there is no satisfactory proof that the presence of adenoids, the diminution or ab sence of nasal breathing or the constant habit of mouth- breathing can affect the form of the jaws or the position of the teeth in any of the ways that have been suffested,"43 (Also note the discussion of the White House Con ference quoted on page 24^ under the section on nutrition). The teeth themselves as factors in malocclusion. The position of the teeth in their relation to the other teeth, and the premature loss of teeth, are recognized as important causative factors in malocclusion. These causes are the particular concern of the dental profession. The spread of knowledge among practising dentists of the prin ciples underlying malocclusion causation and treatment, and the increase in the facilities for children's dentistry, are expected to eradicate many harmful dental practises. J. C. Brash, M.C., M.A., M.D., The Aetiology of Irregularity and Malocclusion of the Teeth, (London, The Dental Board of the United Kingdom, second impression), p. 16. 30. The deciduous teeth perform a very important func tion in preparing the jaws for the coming of the permanent teeth.44 They should he protected against caries and early shedding. It has been estimated that thirty seven per cent of dento-facial deformities are due to the premature loss of deciduous teeth.45 Heretofore, the care of deciduous teeth has been commonly neglected by parents, due to the general belief that since the second teeth will be forthcoming, the pri mary teeth are of little importance.45 The Committee on Community Dental Service found that in Oyster Bay, Mew York, the kindergarten children showed the fewest mouths in good condition: . . . .an indication of the general tendency not to seek dental care for the deciduous teeth, even in a community where parents are in general well informed as to the health needs of their c h i l d r e n . 46 This Committee further states: "It is agreed and fully accepted by dentists that 44b , E. Lischer, D.M.D., "Orthodontic Education," International Journal Orthodontia. Vol. 21. Mo. 6. June 1935. p. 512. 43^, McClure Patterson, D.D.S., "Observations on the General Practise of Juvenile Dentistry", International Journal Orthodontia, 'Vol. 21, Mo. 6, June, 1935f. ' 46The Committee on Community Dental Service of the Mew York Tuberculosis and Health Association, Health Dentistry for the Community, (University of Chicago Press,” "1935). p. 9. 31. the first set of teeth .... are just as important as the second set, or permanent teeth. The period of life when the child is served by the temporary teeth is the period of greatest physical development and growth. At that time the teeth fulfil a most important function in nutrition as well as in the formation of the jaws and face.4? When the permanent teeth replace the deciduous set it is important that the normal position in the dental arch be m a i n t a i n e d . 4 8 - 4 9 Any loss of individual teeth as a re sult of caries, abscesses or accident may endanger the nor mal occlusion. The spaces left by the removal of teeth should be retained by artificial r e p l a c e m e n t s . 50 The teeth which are basic in the development and maintenance of the normal arch are the first molars. Unfortunately, these teeth, which are so essential to a normal mouth, are peculiarly subject to decay and imperfections. The widespread inci dence of dental caries, and the lack of treatment facilities for large numbers of the nation's school children, make the 4?loc. cit., p. 9. McClure Patterson, D.D.S., "Observations on the General Practise of Juvenile Dentistry", International Journal Orthodontia. Vol. 21, Mo. 6, June, 1935^ ^^Berth Holman, "Two-Year-Old make Friends with the Dentist", Child Health Bulletin. Vol. X, Mo. 3, May 1934. p. 98. 30"The Education of the Dental Patient", Reprinted from Dental Digest. Copyright 1933. 3 2 . loss of these — and other -- teeth a serious causative factor in malocclusions. The White House Conference stated; If, . . ., the first permanent molars are permitted to decay and are lost there is a permanent defect in growth with failure of adjustment which demands ortho dontic attention.31 Among the many reasons advanced for such changes in occlusion, there is no doubt that one at least is valid, and that one is the injudicious extraction of teeth. The extent to which extraction was resorted to among these children was appalling (Hebrew Orphan Asylum, Mew York City, in 1920) and the number of cases where the disturbance in occlusion was definitely traceable to mutilation of this sort was rather great. This is suffi cient reason to believe that, with proper dental care, the percentage of the normal in the group would have been even higher*32 The St. Louis Dental Society in its report of 1934 regarding dental conditions among the St, Louis school child ren its survey examined, states, that a total of 30, 234 de ciduous and 28,808 permanent teeth were found missing from the children's mouths, and comments that this premature loss of teeth, ". . . . is a forerunner of a deformed mouth . . . makes these facts all the more a l a r m i n g . "33 The presence of too many or too few teeth, misplaced teeth, and similar anomalies, usually the result of heredity 3^The White House Conference on Growth and Develop ment of the Child, (Mew York and London; The Century Company.) p. 117. 5 2 l b i d . . p . 1 4 5 . S^Committee on Public Dental Education of St. Louis Dental Society for 1934, Report and Dental Survey in the St. Louis Schools, (issued by the St. Louis Dental Society). p. 31. 33. are factors in malocclusion. But such cases are too few in number to be regarded as an important percentage of the total Improper dental treatment, as well as its lack, may be considered a cause of malocclusion. Cavities which have been filled without thought of the occlusion, or the loss of the cusp form due to wear and not properly replaced by fillings and inlays, may interfere with occlusion, and com mence a process which may eventually result in facial de formity. In this respect, Frederic T. Murless, Jr. observe^ The effects of deforming influence of worn and carious deciduous and adolescent teeth may be averted by means of prophylactic orthodontia as expressed in accurate restoration of the individual teeth.34 The White House Conference finds that the eruption time of the teeth may affect the occlusion: Mellanby has recently reported experiments which show, among other things, that there is a relationship between the state of nutrition and the eruption of teeth.35 It has also been observed, however that when dental retardation is associated with disturbances in the se quences of eruption, the incidence of malocclusion of the teeth become extremely high. The cause of this dis turbance is not yet entirely clear.35 Moreover, a tooth may erupt rapidly at the beginning and slow up at the end, and vice versa. These accelera tions and retardations undoubtedly have some relation to ^4prederic T. Murless, Jr., "Address", International Journal Orthodontia. Vol. 21, Mo. 10, October 1935 . ^^The White House Conference on Growth and Develop ment of the Child. (The Century Company, Mew York - London, 1933), p. 152-153. 34. 56 the occlusion of the teeth. Habits g^nd malocclusions. As we have seen from the quoted opinions of Brash and the ^i/hite House Conference, the effect of habits on malocclusions is still a contro versial subject in science, because of the lack of suffi cient scientific evidence that habits are causative factors. Some habits, however, are well established by research evidence, as being, if not causative, then important contributing factors. Practicing orthodontists generally believe that ha bits are related to malocclusions, and that harmful habits must be corrected before treatment can be successful. There fore they believe that the nature of the harmful habits should be widely understood so that those who contact young children will be watchful that thqy do not develop. A habit which practicing orthodontists believe to be particularly harmful is one in which the individual is accustomed to exert pressure, usually by hand, against the jaws and the bones of the face. This pressure may be applied when sleeping face down, or with the face pillowed on the arms, or other hard object, so that the weight of the hand 35. is transmitted to the bones of the face and jaws. It may be applied by leaning the head on hands or arms while read ing. The bones of the face and jaws are weak and plastic during the first years of life. Unbalanced pressure con sistently exerted against these bones below the level of the eyes and in front of the ears is harmful to occlusion.37 The pressures exerted by practise of these habits may register a force of ten or fifteen pounds.37 This is in contrast to the maximun pressure of six ounces which can be produced by orthodontic appliances under the ideal con ditions of the laboratory.37 it is obvious that orthodontic appliances can have little success in malocclusion cases unless harmful pressure habits are broken. Dr. Harvey Stallard states, regarding the influence of pressure upon malocclusion, "Any small force unchecked by an equalizing reaction will in time damage o c c l u s i o n . "38 Pillowing habits are usually formed in very early life, and are difficult to break. They commonly do the most serious damage before the sixth year, when the bones are most plastic and occlusion not yet well established.38 37Dr. I. Eugene Gould - Interview* 38jjarvey Stallard, D.D.S., "Etiology of Crossbites and Gothic Arches", The Dental Cosmos. Vol. 65:1181, 1923 3 6 . Pillowing habits in children should be prevented from the early months of the child's life. It is natural for a new born child to sleep on its back with its arms above its head; the back of the skull is hard when compared with the bones of the face, particularly at early age. Placing a child in a harness is a common method of breaking a bad and establishing a new and non-harmful sleeping habit. Dr. Harvey Stallard, who has done much research on the relationship between the habit and the resulting de formity,/ finds that ". . . • the more fixed the habit, the more pronounced the corresponding malocclusion."59 Dr. Stallard believes that what he terms "slouchy sleeping postures" lead to the development of bad pillow ing habits during sleep. The results of these pillowing habits are much more serious to a child breathing with open mouth, because the closed jaws would have more power to withstand the pressures pushing against them during sleep. Dr. Stallard makes the following observation on proper sleeping postures: So far as the denture is concerned, many different postures may be assumed in bed, providing not too • permanent pressure be applied to the face, the child breathes through the nose, keeps the hands and arms away from the face and sleeps without a pillow. It p. 1191. 37. is best to make the child lie straight on the back, then on one side, then the other, pillowing always on the cranium, health permitting. Children should never pillow their faces upon anything nor rest their cheeks upon their hands during the d a y . 60 Mouth breathing, as already noted, is a contributing factor in the cause of malocclusion. Aside from being the result of nasal obstructions, mouth breathing may also be caused by disuse or incorrect use of muscles of the face. The muscles of mastication and expression must be properly exercised to obtain normal facial development. One method of obtaining this necessary exercise is to provide the child with hard food beginning with the second year of life. The mastication process stimulates the growth of normal j a w s . 61-63 Breast feeding of the infant also helps the develop ment of these important muscles.62-63 Brash did not find evidence to support the theory that normal growth and development of the jaws is influenced by the development of the muscles of mastication. GOIbid.. p. 1195. G^Herbert A. Pullen, Transactions Panama Pacific Dental Congress. Vol. 2, 1915. p. 21. 6^m . Evangeline Jordan, D.D.S., "Operative Dentistry for Children", Dental Items of Interest. Vol. 46, December 1924. Chap. XIV. p. 888. ^^Lawrence W. Baker, "Influence of the Forces of Occlusion on Development of Bones of Skull", Transactions Panama Pacific Dental Congress. Vol. 2, 19.5. p. 106. 3 8 . The form of the jaws, their relation to each other and the position of the teeth in them correspond to their "function" in the general sense of evolutionary adaptation.64 The alleged influence of disuse of the jaws owing to the quality of modern diet has been greatly exagger ated, and there is no reason to believe that their act ivity has fallen below the minimum required for normal growth.65 (Mote also the White House Conference findings discussed under the section on nutrition, page » Sucking habits which are unrelated to feeding are definitely harmful to occlusion; the sucking of lips, and of other objects including clothes, thumbs, pacifiers, nipples of empty bottles, biting the nails, lips, and other like habits, are all factors in producing abnormal facial development. Jerome H. Trier estimates that thumb sucking, alone, is the direct cause of about two per cent of the cases seen in any orthodontic practise.66 The White House Conference noted that: A high correlation has also been found to exist be tween certain forms of malocclusion and some sort of sucking habit such as thumb or finger sucking. While there is presumably some causal relationship ih this 64Tbe White House Conference on Growth and D< ment of the Child, (Mew York - London: 1933) p. 12 GSlbid.. p. 245. GGjerome H. Trier, D.D.S., "The Limitations of Ortho- dontia". International Journal Orthodontia, Vol. 21, Mo. 9, September 1935. p. 817. SOME FACTS AND FACTORS COMPILED FROM A STUDY OF 28 PATIENTS RECEIVING ORTHODONTIC TREATllENT AT THE PASADENA HOSPITAL DISPENSARY ·~-~------+-----:--~---,---...,....--~----<~-L----..l...-...--L----L---...J..·~--'-~·-_,._- ---L.--~~~_,__---1..~--~------ ·---------·--_..,-._ F.9___,;:..........i'Ma....ll..-.:.: _1_ .... ~.._..J...l ..... il!L3-· ,_;i.......e;~2---· .... FL9-1tl7_ ~3 : t__: -ft-rf-f-· .... ;~o.____M~11._; ... ,--=~=s·---~--~ ..... ;:_1-:_:::;;~~~~F"""1_2 __ · .,...!._4_ ... ~ __ 1 ______ !_1 __ ' .... !_~o -,'.!. f if==~ -t- i9 1 ;s ;' ~4 '.- ' ! i , , i i , ' i i . I r I 1 -='R"-'~~,_,~~~~o ... r_om""®~l""'1§""'0~'-"s-_t:a __ t_u_s_~~---_-_-_-_-----1-.:!:.*-.:...'._~*:__"-1, ....::.*._...;.j __ -"-j · ___ !_--J~---- ! u___\ _* . .:...·-.... ' __ ....;! ________ , ___ , ____ '!'.__ ___________ ,·~-J-J.1; ~ •, * :.', * 1--*----*-rl _!__._I . ~- lll! __ :..l.{. - I I * * * * _L ___ ,:_ __ 1.__.:_ I * i * * I * * * I -t- R 1 . f @if: r. I I ' ,I ·----i----·--"-----"-----;.,----t--r- I -+----- __ __..I 1 1 ~~e __ 1 ___ e_·~•-~'-"-'~-.__~-------------+--------~--~......::__:*::.._.....;..i ___ ~---~r--_._• - , , --·--~--~---~-~*-------------' -- L__. -· . . .---- , I i ' ! : I : I I 1 I I l 1 I l Family : . l : 1 I , 1 lIQ.r.mal - * * * ! * * * L L---,-----11 --------'-----1--·---'-'--:i:.*-----·*---..,...--*=----' ---*·---.....!.---+T------*'---·--.._-,'-·---!..~_;___._J_ .. : I _..JL_J__ __ l-f' - .Q.ep<arated ·------1--------·---.:--------r----·""7"·--------:--·---'-!.-l...-:!:*--i.______ * · · L._ ' ' , l * I .ll~_, __ ..__ ___ , __ __._ I _JU...!.35.. ---·.,------!.__ __ _..,., _________ : ___ ._....;._ _______ , _____ __,I i • : ! I I .N.o..._~_r_eMn..._~-----------·---'-=:~--::-2~---~---=~3==~==~~=::-_;,~----~---~2=~==~=~·-...fi..____2..__~--~-~3---'·--=-3~-:-1=-~--3;;_ __ M2 __ ~•l4t~··.--_.1.__~~2'-----::!2 ______ ~·~=~-~ 1 · ~-~l__g - 6 J___ I i ! I I ; J I I I I I ~D~e~n~t~a~l~R~e~s~u~l~t•s ______ _,_ ________ ...J-_____ ~nli.-----------~--------J------~'--r'--<l..--~~G--G•=-----·~G,._ _____ ~-.w;..n _____ ~,----------~~----~Gt.---~GL· ____ G~··---J. ______ :i~_f_--l_JL_~ ___.F. ____ _::._i~_l_ _ __L __ ~~.QD~t+-9n off ~ha~endts _______ --t..,_ ____ --'niL.--'------~··~~----'N~a.._~·--r-· ... y.__, .. _.··;:~;;,:--+-·i-G-~---Ye~ ·.-...1'.~v-o--:~FN_o_~:-N-o __ ..._~Fii--....:.--N-o__.1 ___ N_o _____________ -"G---~E~·----'=Gi;,__;L__E_L ____ :__G__l.---F__;..-._f-_l __ :e_j_ ____ l __ ~.QJ,1.e;;a ion o c 11 t:!. !:11-... ,., _ .. a , _:. Np No NQ No • No -...E..J.. 1 __n.._1 -~-..l!. I p i I I I I I ' I Habits , ! ; i i 1 , · ! l i i 1 1 1 ]'t)rrP.r.t Fil P.An; "'"' '-T"' '-T"" u.. lir" TIT... 111 0 * ' * * : , * ! * * * *, * * * ! i Jllo 1 No ! Na . ....__ .... N .... o_.,__ ~Ji~a~n~d--~~ .... r~~~§~§~u~r~e""--'o~n~._..,f~a~c~~..__---·-·----iJ-.-*!!----.!!*:__ __ *~-----.!*~---------.:--~~,._~----~'~--------:""""---~'----~'--~*__.'_. ______ *~..,.----------·--------------' ----+--* l i i * i * ! * ~"R~: ....... - t~.·:-- ,·~"'"'-:au.· "'l.l.' ~1'-lF:~U:.!:;C!;t.'.i;i, ,,..""';·~ "'"'..__ _____ -1--·------------.J*L_:__.!.*_'~ _____ ..;.! ---------- ! i * ; 1 ! L i i __ _j__·-4--- Swa llowing 1 * • -L...:-·-"'*-'"-1 -=*c..~--.,...~---7--~*1:--~-z*-,_.:*1:...-..----·....:i*:.._------~--.4-!. _ _J_ ; ]3.iting and lickin.o- of 1ins * * * *-"1., _______ .._1 ___ ..._ __ • ____ , ___ ..__ _ _. ________ , _____________ _,:_, __ .. 1 ___ .:..i _ _L __ 1 * ! * ~T~o~n~g~u~e::-'"h~a~b~i~t~§"!--------·--------1~------------_,..----------___;l;-"*:.......----~l----'---....:*c.._~--~~*--·....,--"*'---'------~*"-------~---·-----·----------~----~·_.i__: ' l , 1 .Mm.l.th breathing ... * * * l-------'-- ·----·---__J·------------------------------- i r------, ----:--r--r Use of myt;1ical_instr-"u~m=.::e.:.:nJ:...t~s:.:-_ __,, ________ ~---..;._----·'---·- : . , ' , ' ~Wh~;~·s~~t:~1.;·~n·~~:-=--------------f-·----------------------_;_--Jl .. ~*.--~--1---~-------_::::_-.~---~'-·---*-·--'-~---.-*===,======-:::.-=.-,,_-_-~*::.:.:::::::::::.:::::::::::.::::~1:::.:.:.::.:::+. 1 ----~ l , llo ttle be&bv * * y *--l--.J__·_·,_i -~---- .... --L..--"----L-·---'----...,.._--...__, _ __.. ____ ..._1 _ __.1 __ ....:1...--------· ----· __ --,--T _:l""~ ... ~ ... ~ .... t-Y _________________ L-L. • . ' I • : • ~ ; i T i _ _,_ __ ! ! ! __._ __ L l Father ------~----------ll 1 : ---- ' i-___,. __........,_..._...._~----~~-------------1-,..------------------·-'-~*!__ ____ J-,----~-- I·--~-~----------------·,__-------------------------------------.~---'·---_,..----~-.---..;.'----.....;- ~~.Q~~~~~~~~· ~~:~1~~~~~ae~e~d~i~c:-::-:-::-:-=~~~---~----l__:L.. __ _r_ ____ .z. _ _j~--__]t__~!!:_Jj---------1~-------·-------;,------,--------------~------'----------------------l t ' .~i~ _ _. _ _..__ __ _,._....._ l ~ 1i' F F p F I I : i p :_L. ____ +-L ·~ F F ' ~E~x~e~r~c~i~s~e._.s..._.pil"r._e~s ... c .... r_..i""'b~e...::dr:__ ____ --t-.:?:*---,..~*~-...!.*------·-*:_ __ J-·--·----------·-----P Q ._ • .._..._;F:_;_ G Q; F _, ... F __ _,F,__ _ __,,,G,_ ________ ,--lll*'--!..--*---.'.• __ ,. .L-; "ProP''l"~FIR • G ,1 : * i * ' ..._.lo--W.~~w.!--------------------f-----Jl..-----------------~--------~~,------·---""'~-·-------..:.--:-'----------------a~*-----------'----------<--..f_ G i ---~-+--__J_ G Respiratorl Condition l •21 ~1-----~,·--~-----~F~----~F-~'-------,----~-----------, l i 1 I J I I T" & A, Date of 2.:E,eration 130 ! 135 135 '32 I , •23 ; ~ ! i i 1 i l , 1 Other difficul tv . .-....;..o..;;...;.=----1-·-:..!~--+,---~!.!!------...:.!~-........... •28 .· •28 •24 ' 135 l ' 1----'11--· --1.3J....;. ____ . __ -+---..,.---+-.ll3....L- --..--..--_.;:.;.;::.::.-=-:;.::.~::.::..~---------l-~l~.-~,----~2~.__:.---------~3~·~·-----~•~3-2_,..~•~2~4L---------•---,-'•2~9, __ ,~3Q~·-'-_.-~_.__--"-~-----~-~-'----''~~9--------~-....-·-------~--__l_~ i ! I ; * f Medical Condi" ti'ons 1· ' [-·-------~.__-:----'-; __..fS,__. _ _a,_ __ _,__ _____ :- 7 '-··-·------·---·--------*-- i l--T--l Malnutrition ' * : I 1 I I j Other ;---·----·-----~_:::*-~------·--------:__j i ' ; ' , ' 1 ~--+·----------- 1 --..... ..L---f--+----- ---------------------------J--....... ..,.....----~~~---"----L.' --~oL----·-----------·--..i..--------_;.----'------------------"-------·------------------1.-----i·----------'·------l-----_._----------L-- '-. ____ [__ ___ _._,~9,___,_, __ __..._ .~~--~ 10~ ........ ~~.._----..!.~---------.:.....----i.-.---i.----.:._ __ __ I LEGEND G good F fair P poor 1. Hay fever 2. Deflected pinus 3. Difficult breathing 4. Submucus septum 5. Growth in nose 6. Sinus trouble 7. Adenoids recurrent; deviated septum 8. Indigestion; very thin 9. Miss:l.hg teeth 10. Frequent colds; preventorium care; possible endocrine disturbance; teeth late in developing; finger nails defective. 39. association, it is not quite certain which is the cause and which the effect, 7 These habits may seem small and trivial for the most part, hut they commonly accompany the beginning of ortho dontic c o n d i t i o n s . 6 B Moreover, these little harmful habits cause other malfunctions and establish other harmful habits, and eventually a whole complex of habits and causes develop. The factors of growth are dynamic and interrelated. It is essential to correct the little harmful habit before it widens its sphere of influence and an entire group of ab normal processes are set up to prevent the normal growth and development of the face and mouth. 67The,White House Conference on Growth and Develop ment of the Child, (Mew York - London: 1933)p. 146. 6^Dr. Frank M. Taylor, February 10, 1936. 4 0. CHAPTER IV. INTERVIEWS ELICITING THE SOCIAL AMD PSYCHOLOGICAL RESPONSES OF ORTHODON TIC PATIENTS Interviews with children and young persons who have suffered facial deformity related to malocclusion and case, history materials have been obtained to see what light these interviews and materials might shed on the social and psychological problems of the handicapped patients. The investigator sought interviews with patients of various ages, personality types, and social and economic backgrounds. In most cases the subjects of the interviews were children and young people who have received, or are receiving, treat ment at the Pasadena Hospital Dispensary. In these latter cases, the investigator, after obtaining clinical data, visited the subjects* homes and interviewed the parents, and, whenever possible, the subject himself. With the exception of Case 6, page 68 , the inter views presented in this paper seems to be a fair sampling of the responses which might be characteristic of ortho dontic patients. Because these histories indicate non- pathological responses for the most part, they do not in dicate extreme divergence from the norm of behavior. They may not therefore be particularly helpful for a psychological study of personality reactions. The case histories which 4 1 . are discussed in psychological and orthodontic literature present more valuable materials for this latter study be cause they illustrate clear cut and serious behavior changes. The patients whose case histories are discussed in the following pages, are receiving or have received ortho dontic treatment, and their facial deformaties have been corrected or are in the process of being corrected* For most of the patients, the improvement in facial appearance began in the early years of adolescence so that there was little opportunity for them to develop abnormal psychological behavior reactions to their logical conclusion. The find ings of psychologists and psychiatrists respecting abnormal or pronounced behavior changes related in Chapter V may assist the student in an understanding of factors or possible factors influencing the behavior of the patients here dis cussed. 42 Case H i s t o r y 1 . James C._____ It appeared that James had been an active boy who was not given to introspection* Probably he did not dis tort his analysis of his past by unduly dwelling on and reliving childhood experiences and feelings. At the present time he is making good adjustment and finding his place in society. Although James had a serious facial deformity, both he and his mother agree that this handicap did not prevent him from getting along with the other children. They d o not feel that it interfered with his social adjustments* In direct contradiction to their belief is the statement of the Dispensary staff who remembered James, that his den tal condition pronouncedly affected his behavior. The "nervousness" of the patient which was one of the reasons for his referral to the Dispensary, and which improved se veral months later, may have indicated a behavior reaction to his dental deformity. James may have been sensitive to his deformity, so sensitive that he refused to consciously admit it. His unusual resentment against wearing glasses may be, in part, an unconscious resentment against his malocclusion. 4 3 . That a boy as interested in activities and as un reflecting as James should have been interested in the re actions of his classmates and the neighborhood children who had orthodontic problems, suggests that James thought about these problems. Further evidence of his considera tion of these problems is his statement that at the time treatment is begun, the child is usually too young to ap preciate the value of treatment; and anyway girls would be more sensitive to dental deformity than boys. He recognized also the vocational handicap of facial deformity resulting from malocclusion. 4 4 . Case History 1^. Hame: James C. Age : Twenty-one years in 1936. Malocclusion: Protruding upper teeth, narrow jaws. Pronounced facial deformity. Family data: James’s family belong to the skilled laboring class. They are American folk with good standards, and are not highly educated people. Father worked in a nursery in 1932 and earned $3.50 wages by the day. James has two younger sisters. The family paid $22.00 rent for a frame bungalow in a nice neighborhood. The home was well furnished and com fortable. The father had no savings, but carried a small amount of life insurance. Physical condition before treatment: Mother stated that Jimmie was ’ ’puny, humped over and sickly* when she took him to the Dispensary. He was thin and his condition so poor she does not know what would have become of him if he had not received treatment. Mother said his dental de formity was ’ ’terrible**. Clinical data: - March, 1924 Referred by school because of trouble with his eyesight. Further complaint that patient was nervous and has a poor appetite. 4 5 . June, 1924 Tonsillectomy. Cod Liver Oil prescribed. Julyy 1924 Patient less nervous. Orthodontic record: School grades good, work recommended. Habits: mouth breathing, bites nails and tongue, leans on hands while reading, incorrect sleeping posture. Bolts food. A little nervous. Psychological condition before treatment: Mother stated that Jimmie had always gotten along well with people. She did not think that he had any diffi culties or behavior problems as a result of his deformed mouth. Dispensary supervisor remembered Jimmie well although many years had elapsed since his treatment. She stated that before treatment Jimmie looked like a half-wit and was very self-conscious and retiring because of his dental condition. Physical condition after treatment: Mother stated that Jimmie immediately improved and gained weight after his tonsillectomy. He continued to improve during orthodontic treatment. At the present time he is well and strong and his teeth are normal. He is a good looking young man and has no facial deformity. Social activities since treatment: Mother stated that Jimmie did well in high school. 4 6 . He was interested in dramatics and took part in several of the plays. At the present time he is apprenticed in an electrical shop and his *boss* reports he is doing very well. He will probably finish his apprenticeship before the regular term. He attends night school to help him with his work. Jimmie has a girl, a good girl. They expect to be married in the summer. He attends church regularly and frequently leads in prayer, and conducts the young people’s meetings. The mother said that Jimmie is very proud of his appearance and thankful that he had his teeth treated. Both the mother and father were very sincere in their apprecia tion of the treatment given by the Dispensary to their son many years previously. Interview with James : ”Ho, the looks of my teeth didn*t bother me when I went to school. Ho one called me names about my teeth. Anyway, if they did, 1% the kind of guy that would take it as a joke and laugh it off. Oh, I’m just a regular guy. Sort of guy that does things and doesn’t care how he looks. **I always got through my classes, just ordinary work, but anyway, I am through now. I pitched in 3rd grade, ran in track later, but had to quit it in 8th grade because I 4 7. tore the ligaments in my chest. At Tech (technical high school) I ran again and played tennis. Hever could play football or basketball because of my glasses, I held some offices in my class room, but never class offices. Just average guy, I guess. ’ ’Glasses are a real handicap. Sorry if I spoil your story but my glasses worried me three times as much as my crooked teeth. Kids used to call me *four eyes*I Started in school with glasses, and never could play ball. I felt it was the greatest handicap any fellow could have. Wonder ed why I had to have it. And even now, I wouldn’t go with any girl that wore them. Just wouldn’t do it. ”I didn’t care at all about my crookêd teeth when I began to get them straightened. Did it because my mother wanted it. Didn’t never ask her to do it for me. Some times after treatment my teeth would be sore to bite on and I could only drink milk and soup for several days at a time. *Fo, I didn’t complain. I’m the kind of guy who just takes it. Just thought I had to, and didn’t think there was anything else I could do about it, ”I’d be the saddest guy in the world if fl had crooked teeth now. Sure I appreciate them now, but I said I didn’t then. I wouldn’t go with a girl who had them, and I wouldn’t expect her to ga with me. But when you are young, you don’t 4 8 . notice them. Anyway, girls would he more self-conscious, it would mean more to them. • ’People with crooked teeth look dumb all right, sort of cracked, I knew some boys who had them, who worried about it. One worried all the time and wanted to have his straighten ed --he was the kind of a guy who had to have every hair on his head in place. *0h, I remember another boy who had treatment at the time I did. Why don’t you see him, he is a big shot now at Junior College. But I bet he feels the same as I do about it. • ’The girl living across the street from me wanted her’s straightened when she saw me start. But she never got it done. How she is twenty-six and she’s getting them done. I remember another fellow, he worried a lot about it. He started to get his done, but only kept the bands on six months. Eis teeth went back crooked again when he took the bands off, ”0h, I appreciate having straight teeth now, but it’s different now, I know you can’t hold some jobs if your teeth are crooked, I was a salesman for a while, couldn’t have done it with crooked teeth. ••Do you know what. If my teeth were crooked now, I would have them all pulled out. Ho, I wouldn’t bother to have them straightened. 49. **If I were writing that paper, I would say when you are young, you don’t notice it — anyway, girls would notice it more. Sorry can’t help you more with the paper, you ought to write about glasses. I could sure tell you how glasses bothered me. ”But now it’s different. I would give a million to have straight teeth if my teeth were crooked.now.* 5 0 . Case H i s t o r y 2 , Hame: Robert H._____ Although Robert was nine years old at the time treat ment for malocclusion was begun, he and his mother realized that his dental condition was a handicap. Robert noticed that his school-mates called him names. His mother felt that he was beginning to be self-conscious because of the condition. The fact that this small boy begged his mother to begin his dental treatment, and that he has cooperated to the best of his ability with the orthodontist during treat ment, suggest that the child was sensitive to and suffered because of his dental deformity. 51. Case H i s t o r y 2 . ^ Hame: Robert H. Age: Eleven years in 1936. Malocclusion I Protruding upper anteriors, narrow jaws, lower front teeth too high* Without correction the facial deformity would become pronounced. Family data: Robert’s home is a neat frame bungalow in a good working class neighborhood. Robert’s father is an ice delivery man; in good months he earns as high as $150.00, but much less in poor months. The mother is a very intelligent woman who has provided a very attractive home for her husband and two children. Both children show evi dences of exceptionally good care and training. Clinical data, physical: June, 1934 Robert’s general condition good. Tonsils had been removed. Had slight scoliosis, kyphosis and pronated feet. Posture exercises and corrective shoes were pre scribed, January, 1935 Posture good. Ho further need of exer cises except for feet, which are improv ing. Clinical data, psychological; Hoted as habits related to the malocclusion, incorrect sleeping, hand pressure on face, lip biting, mouth breathing. Robert was a bottle baby. Robert was conscious of his looks and very eager for treatment. He promised to take the responsibility on himself of correcting his harmful habits; this promise he has faithfully kept. 52. Robert’s story (from interviewer’s notes): *I’m awful glad I’m getting my teeth done. The doctor says they’re coming along fine. Yes, sometimes they hurt, but I don’t care. The kids don’t make cracks. Anyway, I don’t care. Say there was a colored girl at school -- she wasn’t so hot either — big and fat; and she used to call me "Gopher Mouth!” All the kids wanted to see my bands, and I let some of them, but I didn’t let her, you bet I* Mother’s statement: "I think the treatment has helped Robert. I realize that he needed it, he was beginning to be self-conscious. He seems brighter and happier now; more active in playing than he used to be. I know the children’s teasing used to hurt him, although he never would say anything. But he wanted to begin the treatment very much, and when we had to put it off because of financial reasons, he kept begging and begging for us to arrange it. Robert never complains about the braces although sometimes they hurt him very much. Some times after a treatment he can’t eat solid food right away, and his mouth hurts so that he cries. But he never complains. We are all so glad it is being done.* 5 3. Case H i s t o r y Name: Dr. John 8.______, dentist and oral surgeon. In this case, there is a difference of opinion be tween the orthodontist who treated the patient, and the patient, as to the effect of malocclusion on the social re lations of the patient. The orthodontist, who had known the patient for many years and was his friend, believed that the patient dreaded group contacts because of consciousness of dental deformity and speech defect. The patient believed that he did not suffer any social disadvantage because of his condition. However, he admitted that he was always self- conscious and did not smile, but he minimized the importance of these responses. He unfairly compared the handicap of malocclusion with the serious disfigurements resulting from hare-lips and accidental injuries. There are indications that the patient was sensitive to his dental condition to a greater extent than he was will ing to admit. First, he refused to have X-rays taken at the completion of his treatment, saying that he did not want to know the amount of damage to his teeth which might have re~ suited from treatment. And when he had the X-rays taken later, he did not show them to the orthodontist. He seemed unwilling to face unpleasant facts and to cooperate with the orthodontist. Second, he seemed unduly criticaland wary of 54. orthodontists and orthodontic treatment. Third, he has had a defensive attitude toward his orthodontic treatment and its results. Also he has been defensive toward the problems of facial deformities. Taking into account the patient’s professional ex perience and training, and his questioning attitude toward orthodontics accomplishments, his belief in the value of ortho dontic treatment for children is impressive and convincing. 55. Case H i s t o r y 3 . Hame: Dr. John S._____ , dentist and oral surgeon. Age: about thirty-seven years at time of treatment. Interview with orthodontist who treated patient: Dental condition: Upper teeth markedly protruded over lower jaws. Lower teeth had fallen out as a result of lack of function. Patient had decided to have upper teeth pulled out. This would not have solved his dental problem because of the shape of his dental arch which was not normal and would not have held dentures. Because of the seriousness of the condition, orthodont ist offered to treat him without any promise of success be cause of his age. Physical and psychological condition: Patient had a marked deformity which was noticeable and made clear enunciation difficult. He avoided speaking at professional meetings and dreaded teaching his classes. He was highly nervous, embarrassed about his speech difficulty, and discouraged and disgusted with his dental troubles. Treatment : Treatment extended a year and a half with marked im provement in the position of the jaws. Treatment was not com pleted. Patient was difficult because of nervous temperament 56. and professional knowledge of complications which might en sue. At the end of this period, orthodontist asked for an X-ray to discover if any root absorption had taken place dur ing treatment. Patient refused to have X-ray, saying that it was the first time in his life he had felt like speaking be fore anyone and he didn’t care a damn if there were no roots left. Interview with patient: Patient said emphatically and many times that correc tion had lessened his self-consciousness. "Before treatment I had always been conscious of my teeth and appearance. I feel better how. "I think the ordinary layman does not think so much about dental defects. But of course, I work with oral surgery and therefore am more conscious of my own teeth. I have a long upper lip which hides my teeth and I don’t think they were noticed much. Since my treatment, my friends have said that I look better, but I don’t think they have paid much attention to it. But anyone who works with teeth, would no tice any unusual condition immediately. It’s much more im portant to them. "Malocclusions are definitely a minor deformity". Then the patient showed pictures of hare-lips, and other extreme facial deformities and facial injuries which 57. he considered major deformities, saying that a hare-lip in an adult is a real deformity. "I never avoided speaking before groups or worried about teaching my classes, but I was self-consciouS before groups. What did it make me do^ Well, I didn’t smile, so my teeth would not show. Of course, my teeth were not bad. "Do you know what is the most important thing in life? Health, and you can have health without teeth, I have a book here telling about it, if you would like to see it. When the interviewer mentioned the theory advanced by Dr. Louis E. Bisch that malocclusions were a serious con tributing factor if conditions were present which had created an inferiority complex in the child, the patient enthusiasti cally agreed with the theory. "That fellow really knows something. There is a lot in that theory — add dental deformity to an inferiority complex, and then you have something!" "Are you asking me whether I think orthodontic treat ment for adults is good? I certainly don’t know, but it’s right for the kids. I would like to see all children with malocclusions have them corrected. There is a moderate amount of pain connected with the treatment, but it would be worth it for the children. I would not hesitate to have a child’s teeth corrected, knowing that there is pain 5 8 . connected with it and that they have to be restrained to some extent to break their bad habits, "Anyone conscious of a defect feels better when it is corrected, that’s evident. It’s like having the end of your nose cut off, you would want it corrected. "The orthodontists are inclined to overemphasize the importance of correcting malocclusions. I don’t believe the ordinary person is sold on it. But the educated classes are and demand treatment for their children. Watch out for the enthusiastic orthodontist. They are like school teachers, they think their services are indispensable to all of us. And don’t believe them when they say that they can prevent as much of it as they claim. You can’t believe everything they say, by any means. "As for me, I may have my teeth pulled out yet. I did have X-rays taken of my teeth, but I haven’t shown them to my dentist. "But don’t forget, it makes you feel better if your teeth look right." 59. Case H i s t o r y 4 . Fame: Ruth Â._____ The orthodontist who treated Ruth explained that she had had feelings of inferiority and isolation due to her serious dental-facial deformity before treatment. During and after treatment Ruth "blossomed out" and seemed to find herself. She felt so grateful and happy about these changes in herself and for the interest of the orthodontist in her development that she wanted to share her happiness with others and help them to find themselves. Realizing the value of a developed personality, she wanted to help others attain this end and even considered becoming a social ser vice worker. The investigator wrote Ruth and asked her if she would write in simple language, if possible in the words and thoughts of her childhood, of her behavior and feelings before and during orthodontic treatment. Her analysis is her reply to this request. In her letter accompanying the analysis, Ruth expressed her desire to help any study which would assist children afflicted as she had been. In her letter, Ruth mentioned an inhibition which prevented her from remembering the incidents and problems of her adolescence. This inhibition is significant. It is probably an unconscious defense to protect the child against 6 0 . painful experiences. While this same inhibition may or may not be active in the patients who deny that dental-facial deformity causes them difficulties in social relationships, it plays an important role in the lives of many children and adults handicapped by crippling deformities. Ruth is a sensitive introverted person who possesses the skill necessary to express her feelings adequately. Even without graphic illustrations from her childhood, her letter is valuable. It indicates the depth of her feelings and her joy in developing her personality unhampered by fears and feelings of inferiority. Ruth may have expressed the feelings of other patients who lacked her ability to express their thoughts, or of pa tients whose experiences are buried in the unconscious mind. 6 1 . Case H i s t o r y 4 . Fame: Ruth A. , University student. Age: twenty years old. Dental condition: Crowded teeth, with upper teeth protruding over lower jaw. Orthodontic treatment began when patient was fourteen years old. This material was prepared by Ruth for this study to assist us in understanding the reactions of the dentally handicapped individual. One paragraph of her letter accom panying the material is quoted. Reading over this horrible attempt I am overwhelmed with its inadequacy. I no soomer began its composition, though, before I encountered an unsurmountable difficulty which still confronts me. I cannot, it seems, recall for expression incidents and problems of my adolescence. To you I owe the uncovering of an inhibition so strong that I cannot imagine why it has not been more evident in the past. It is difficult to analyze and express the complexity of feelings and attitudes that handicap the child in need of orthodontic treatment. Certainly I, for one, felt always a sense of physical inferiority because of unsightly appearance of my teeth; a feeling that the rude jokes and remarks of my associates did not serve to alleviate. Even a child far less sensitive than I could not have helped but react to this unhappy situa tion by erecting a defensive barrier against these jibes. Unfortunately, this barrier, formed by suspicion and distrust, is far too frequently extended to those who should be nearer and shuts them out too. Without under standing and a sympathetic recognition and correction of these problems, they begin to grow, and, coupled with the difficulties of adjustment that adolescence always presents, they cause one to withdraw further from his associates and thus lose even more of their respect and regard. Lacking faith in one’s physical attractiveness, accustomed to give ground before one’s more presentable 6 2 . companions, provides a fertile field for the growth of the seeds of 'bitterness and antagonism. Given orthodontic treatment the transformation is truly great. Aside from the more obvious cosmetic values that accrue from the correction of malocclusion, there are other changes of less immediate evidence, perhaps, but far more deep-seated in their signigicance. Bodily health, for example, is aided and advanced by improved mastication, and hence, better digestion. A general im provement of the whole body structure soon follows, lend ing further impetus to growth and development. With an increased confidence in one’s personal ap pearance is born a feeling of equality; and a sense of potentiality and opportunity replaces the former feel ing of impotence and hopeless dejection. Greater effort and, seemingly, greater ability are soon evident. Social activities, too, receive more notice and bring more satis faction. And securing more and more poise and assurance, gradually one loses the old idea of not fitting and as sumes instead a sense of harmony and comradeship, of be longing to the group and contributing to it. Having achieved this, I find myself no longer hindered by the thought that my future will be handicapped by a deformity; the fear that such a mishap may prevent my recognition in any profession I choose to follow no longer torments me. Instead, I have a confidence in the present and the future, a greater faith in my own ability, and, conse quently, I achieve more. It is impossible, however, to attribute these develop ments solely to the mechanical correction of a deformity. Even as I enumerate them I realize how tremendous a part was played by my orthodontist in their production. He it was who provided the understanding and interest, the inspiration for my own efforts at making myself worthy of the new "me" to be created. A sense of harmony and beauty that extends far beyond the mechanical exactitude required to cause the teeth to occlude properly allowed him to take a case that presented not only the difficulty of maloccluded teeth in a bone tissue old enough to be very well set, but also the problem of missing teeth, and give to this unattractive mouth and face a harmony of feature and contour that it could never, otherwise, have known. I cannot describe the delight that such a change occasions; to find myself gradually becoming more and more presentable, to see my acquaintances accepting 63. me more readily, to feel the inward urge to enter and enjoy the new fields now open to me -- how can I en compass all the immeasurable joy of this in words? To be sure, I am not so beguiled by this delight not to realize how infinitely far I am from my goal, A normal appearance, first requisite to a normal life, I have obtained, but too late to allow me to attain .that state with the ease that my companions living normal lives have reached it. Could this correction and the first impetus toward normalcy have come at an earlier age how much more rapid and natural might have been my progress! But to have the miracle of orthodontia open the gate to a new life and draw from the dark shadows outside one more bewildered and tormented child, that is a gift worthy of any sacrifice to obtain. 64. Case H i s t o r y 5 . Fames Keith B._____ As a young boy, Keith realized the vocational handi cap of malocclusion to the attainment of his ambition. But he never mentioned his reasons for wanting his teeth straighten ed at the Dispensary, and the Dispensary staff did not know that malocclusions prevented the acceptance of a candidate at Annapolis,- Keith’s family have unusual standards of moral conduct, and value cultural and intellectual attainments far more than material goods and comforts. Keith is a sensitive, intelli gent boy with a serious approach to life for one of his age. Although he is shy and does not talk about himself, he has shown by his cooperation in the orthodontic treatment that the correction of his malocclusion is important to him. It was unusual that so many of the relatives of the patient realized that malocclusion was a serious handicap and wanted to help him financially so that he might receive dental care. 6 5 . Case H i s t o r y 5 . Fames Keith B*_____ Ages Fifteen years in 1936. Malocclusions Protruding upper teeth, narrow jaws, very noticeable. Family datas Keith’s father, an Australian by birth, is extremely strict in his family discipline. The mother is intelligent, and very kind in her attitude towards the child ren. There are eight children. Keith is the second child. The father is a writer on economics. He earnings run from seventy-five to ninety dollars a month. At times the family has fallen behind in their rent, but the landlady has been willing to wait for payment. Keith is a good pianist. He does not go in for ath letics for fear of injuring his hands — as he once did in a game. The mother says that Keith is exceptionally good in mathematics. His ambition is to go to Annapolis and specialize in radio communication. Keith’s mother and father and several of the rela tives have long been interested in correcting the child’s malocclusion. They have realized that Keith’s future would be greatly handicapped unless the correction were made. But financial reasons kept them from having it done. Finally, the father’s sister came to California and made the necessary 66. financial arrangements out of a small legacy left her. All of the adult members of the family are keenly aware of the importance of the treatments, and hope to be able to continue them as long as necessary. Clinical data, physical: 1935 Greatly enlarged tonsils and adenoids, advise tonsillectomy. Septum deflected and large. Breathing space small on right side. Orthopaedic: posture fairly good. Pediatrics: tall, lanky, "recent growth", but no indication of endocrine disturbance. Clinical data, psychological: 1935 The habits noted as contributing to condition were thumb suching until child entered school, and biting lips. Keith was a bottle baby. Keith was not particularly self-conscious about his condition. The interviewer was unable to see Keith personally. The mother’s statement (from interviewer’s notes): **I am so thankful that Keith is getting his teeth straightened at last. Indeed, we all are, Keith most of all. He has wqnted it done for years, ever since he learned that he couldn’t get into Annapolis with teeth like his. Of course we have always planned to have it done — but times have been so hard. "I know Keith is better and happier in every way since his treatments started. He never complained about the other children teasing him, but I know they did. I’ve heard them 67. call him "Gopher" and "Snipper-Snapper". He would take it as a matter of course, hut I think it hurt him all the same. "Keith is very much interested in what they do to him down there. He finds it all out from the dentist. When they put new things on his teeth he is tickled, because it means he is making progress. Why, just to show you how he feels - — he hates to wear a tie. He never wears one to school. But before he goes down to the dispehsary he bathes, puts on his best clothes, and actually puts on a tie. Just the minute he comes out of the dispensary -- off comes the tie!" 68. Case H i s t o r y Name : Helen ÎT._____ Helen displayed an extreme reaction to her dental deformity which might have had tragic consequences. She was sensitive, an adolescent girl, the type of patient who suffers intensely from an unattractive face. Being called names "by her play-mates made her more unhappy and at an early age she began to withdraw from group contacts. Her suffer ings must have been intense to drive her to attempts at end ing her life. That she became a normal happy girl after treatment indicates that her facial appearance was a dominant factor in conditioning her behavior. 6 9 . Case H i s t o r y 6^ Hamet Helen H. _ Dr. Spencer Atkinson gave the following information about this patient: One day a tall fine looking physician brought his thirteen year old daughter to him for consultation. She had a pronounced overbite of the lower jaw, and had been treated for seven years for the condition. When Hr. Atkinson said that he did not believe that he could improve her condition, tears came to the eyes of the physician. Hr. Atkinson took the father aside. He explained that his daughter was an only child and his wife and he were wrapped up in her happiness. She had always been a bright and happy child. She was musical, playing the violin well. But during the past few years, she had become extremely self-conscious about her appearance. Other children were calling her names; she had been called "Jumber-jaw**. Be cause of her awareness of her appearance, she refused to play with other children, and would not play her violin be fore anyone. She was losing interest in her school work. Twice during the past year, she had attempted suicide. Realizing the seriousness of the child's behavior. Hr. Atkinson undertook to treat her, but could not promise successful results. After a year and a half of treatment. 70. the position of her jaws improved remarkably. She was like a different person. She became her former self, happy and interested. She returned to her violin playing, and recent ly took part in a school program before a large audience. 71. Case H i s t o r y %. Name : Ray P._____ Ray is a sensitive youth with a serious dental de formity which markedly affects his facial appearance. Ray admitted that he was self-conscious because of his appear ance, but felt sure that his social relations had not been affected by his appearance. This statement is difficult to believe. The dispensary social worker, orthodontist and the dental assistants agreed that Ray was unusually timid and seemed to have feelings of inferiority. The explanation of Ray's statement may be complex. It is possible that he would not permit himself to realize consciously the misfortune of his appearance. Possibly be cause he has never had a normal appearance, he may not know how to compare and judge the disadvantages of his condition. Or he may not be able to express his feelings, because he is not normal in appearance at the present time. Another possible explanation is that because he was twenty-one years old when treatment was begun, he may not change his psycho logical make-up and overcome his inferiority mechanism. Perhaps it will be impossible for him to have the reactions of an unhandicapped individual. The part that a strongly developed religious nature coupled with intense missionary zeal may play in Ray's 72. personality development and reactions, is difficult to as certain, but it probably has an important influence. 73. Case History %. Fame: Ray P. _ Age: Twenty-three years in 1936. Malocclusion: Protruding upper teeth, narrow jaws, upper jaw too far forward. His teeth only occluded in three places. His lower teeth struck the roof of his mouth and formed a hard callous which was usually very sore. All of his teeth were loose with pyorrhea. The facial deformity was very noticeable. Family data: Ray's mother died when he was a very small child. The father remarried; in 1935 the father died, after a long illness of tuberculosis. Ray has five brothers and sisters, most of them older than he. The fa mily is very poor and has always had difficulty in getting along; sometimes they have had welfare aid. The father was a house painter, and Ray has learned and follows this trade. Ray is regarded as an exceptionally good craftsman; he does volunteer work for the stage sets of the Community Play House. Ray has been the chief support of the family since the fa ther's death. Whenever able, he has contributed ten per cent, of his earnings to the Dispensary for his dental treatments; but at times he has been able to contribute no more than ten cents a visit. Since boyhood Ray has been very religious. 7 4 . Clinical data, physical: December, 1931 Deviated septum, enlarged tonsils. January, 1932 Tonsillectomy. February, 1932 Submucus resection. September, 1932 Orthodontic examination, disclosing pronounced malocclusion and advanced pyorrhea. Orthodontie noted: **Irregular teeth, deformed face unless corrected, al ways mouth breather, unable to chew properly and appearance will be handi cap in struggle for existence*. Contra indications to treatment: Ray's advanced age and under par physical condition. Clinical data, psychological: The dispensary social worker noted that Ray was the oldest patient accepted for treatment at the Dispensary, and that his acceptance was due not only to his malocclu sion being a decided health problem, but also because his pronounced deformity imposed a severe handicap in Ray's struggle for existence. The social worker's chart note con cerning Ray states, "Psychological problem -- pronounced inferiority feel ing due to facial deformity. Timid, uncertain in speech and approach. Gets work by great effort." Although the treatment is not yet completed, Ray's facial condition shows vast improvement. He no longer has a pronounced facial deformity, and his lower teeth no longer strike the roof of his mouth when he masticates. He is very grateful for the treatment, and has made real personal 7 5 . sacrifices to obtain and continue it. Ray told the interviewer that he had always been self- conscious. However he felt sure that this self-consciousness did not interfere with his getting along with other people. He said he had always been able to get along with anybody, and had made friends easily. But he had worried about his teeth and prayed for many years that something could be done for them. He had prayed before he ever knew of the Dispensary. Ray is now attending the Southern California Bible School. He has had a definite "call" to be a missionary in Borneo. He is very happy and confident about his work and future. 7 6 . Case H i s t o r y 8 . HaineÎ Clifford H._____ The following case history was obtained the re cord of the Probation Department. Unfortunately the record did not describe the boy's behavior problems. The Los Angeles Supervising Dentist remembered this case and recall ed that Clifford was called names by the other children. His unfortunate appearance, which affected his social re lations unfavorably, was a major reason for seeking dental care for him. That the only recommendation of the Juvenile Hall after its examination of Clifford was for "dental care", is significant. The record shows several attempts to secure orthodontic treatment for him, although to provide ortho dontic treatment would have been expensive for the county. When a way to provide treatment was finally agreed upon — authorized by the Crippled Children's Act — , the boy had left the state so that the value of dental treatment as a means of improving the boy's behavior will not be known. This case indicates the difficulty of providing orthodontic treatment to seriously handicapped children de pendent on county relief. 7 7 . Case H i s t o r y 8 . Hame: Clifford H. ward of Juvenile Court. Ages Born September 27, 1913. All information was secured from report of Probation Department. Family backgrounds Report of Division of Outdoor Relief, Department of Charities to Referee, Juvenile Court, December 27, 1924s Father, "ne'er-do-well* and deserted family. Mother, "inordinately fond of dancing". Both parents untruthful; . . . The key to the mother's existence was a quest for pleasure at any price. Mother later remarried and deserted her children. The background and home environment of the children was as discouraging as could possibly be, . . . The mother's love of pleasure stands out as their most dominant charac teristic. There are no really vicious tendencies, but fun and play is their one aim in life. They recognize no author ity which interferes with this program. We have not been able to keep them in any one place long till word is received from the Caretaker demanding that we remove them. They will not mind, they will not study, they are impudent and will do nothing but play. In that sense they are incorrigible. About a year ago Mrs. took Clifford for adoption but is returning him for reasons enumerated. November 2, 1925s Clifford made ward of the Court. He is without parent or guardian. Child no vicious tendencies, but fun and play are the one aim in life and has an I.Q,. 91. October 23, 1925s Preliminary Report of Juvenile Hall. Ages eleven In good physical condition. Teeth neglect. Throat, glands, thorax, abdomen negative. Puberty pre. I.g. 91%, low average normal. Ten year vocabulary. General information poor. Poor writer. Talkative, rather nervous. Good attack, agreeable, cooperative. 78. Recommendations; Dental care. Reports of Mr. King, Superintendent, Strickland Homes May 5, 1926s Clifford has been in the Home six months and he is making a good adjustment and has shown a decided improvement. December 11, 1926s Gives a good report for Clifford. Clifford likes the home very much and makes good school re ports. June 25, 1927s Clifford is one of his finest boys and wishes him to remain with them until he graduates. January 26, 1928s Very proud of Clifford; that he is certainly a credit to their school. They class him among their very finest boys. He will graduate from the eighth grade in June, . . . October 3, 1929s Court Report as to welfare of the boy in free homes The boy was placed in the free home of . He has been getting along splendidly there. He is in the second year of high school, worked during the whole vacation, earn ing money enough for his clothes and to pay something on his board. May 9, 1930s This boy is now sixteen years of age. In March 1929, placed in free home of . After being there several months,,he got trace of his mother somewhere in the East and left 'this home and has left the state, and at that time is beyond jurisdiction of the Court. Case dismissed by Court. Dental and Health Record October 25, 1926s Record notes that "Took up matter of having teeth straightened with Dr. Grey at Dental College." Dr. Grey sent written statement of the cost. Statement turn ed over to Mr. Holland. November 22, 1927s Asked Board of Supervisors allow ance additional $10.00 month to be paid Strickland Home dur ing time this boy's teeth need care and also that Board authorize expenditure of $45.00 for two appliances needed. The request was ordered placed on file. (Signed; W. H. Holland) January 26, 1928s Mr. King, Strickland Home, reports: Clifford is in splendid health except that he is- made very uncomfortable and self-conscious by his crooked teeth. This matter has been taken up with Mr. Holland and through him with , Supervisor of Oral Hygiene of Los Angeles County 7 9 . Health Department who is trying to make arrangements to have. Clifford's teeth straightened. August 3, 1928s Hearing to submit to the Court the facts, testimonials and recommendations of various persons interested in the care of Clifford in the hope that necessary arrangements may be made to take care of this boy's crippled condition under the Crippled Children's Act. A letter in the file on this case, from Mr. King, Superintendent of Strickland Home declared this boy to have developed into a fine boy, that he has been very successful in his studies and his manners have improved greatly. He states, however, that owing to his facial deformity he has been under a disadvantage in that the boys have called him different names in referring to his deformity and this has caused him to be somewhat backward in reasonable development both socially and physically. Report from the County Health Office under the signa ture of _____, Supervisor Oral. Hygiene Sections and also letter from _____, Supervisor of Dental Section of Oral Hygiene, advised the necessity of correcting the crippled condition of this boy's dental arch both from a physical standpoint and mental affect that this correction will have on the boy. November 27, 1928s Petition for Amended Certificate of Superior Court, stating Clifford, 14 years old and a physically defective and handicapped person in need of ortho dontia surgery only. September 29, 1928s Letter from _____, Supervisor Oral Hygiene Section of County Health Departments You will remember that Judge Scott signed an order for Clifford, a ward of your department, to have orthodontia work done under the "Crippled Children's Act". It appears from the copies of the correspondence received by this office that the order did not specify orthodontia, but simply said dental work. . . The Board of Supervisors has set aside a sum of money, to use for the care of children under this Act. It will be necessary . • , to have this order or a certified copy with Dr. _____ letter stating the price for which he would do the work for Clifford to present to the Board of Supervisors so they would authorize that amount from this fund for that pur pose. . . . it would do much good for publicity purposes if we could have a picture of Clifford and Judge Scott as they appeared when Clifford shook hands with the Judge and thanked him for his interest. . . . 80. Can we rush this thing through very soon? We have already been working on it for over a year and poor Clifford will be losing courage pretty soon, I fear. 8 1 . CHARTER V . THE PSYCHOLOGICAL AND SOCIAL ASPECTS OF THE PROBLEM aspects of dento-facial deformity related to malocclusiont The behavior problems among people, particularly children, who have dento-facial deformities related to mal occlusions have been quite extensively studied by psycho logists and psychiatrists. Many forms of problem behavior may be conditioned by dental deformity. These manifesta tions range from disobedience, stubbornness, aggressiveness, exhibitionism, secondary rages and tantrums, to outright delinquency.! With one exception, the cases studied in Chapter IV did not display these tendencies save perhaps in embryo. I. S. Wile, in discussing individual reactions to dental malpositions, observes, that they include, . . .such important responses as stiff necks, chorei form movements, tics of the head and neck, marked fatiga bility and lack of interest in things in general. Occa sionally one notes tantrums, lack of self-control, pug nacity, depression and marked psychotic disturbances, carrying with them much disagreeableness in social re lationship and failure in social position.% !l. S* Wile, M.D., "The Relation of Teeth to Behavior of,Man", Mouth Health Quarterly. Vol. 2, No. 4, July 1933.pp. 5-16. %Ibid.. p. 15. 8 2 . (Case 6, page 68 , displayed extreme depression). A human being lives and acts as a whole.3 Any bodily defect will affect his mind and personality, and, vice versa, a mental abnormality will affect his body. The teeth are a very important part of the body mechanism, largely governing, as they do, the taking of nourishment into the body, and also, from their position, largely determining the individual's appearance to his fellows.4 Consequently, the teeth react positively upon the personality, and materially influence both the inner and the social life of the individual. They (the teeth) are inherently factors in man's individuality. They constitute one of his instruments for contact with his environment and one of the parts of his organization that expresses some of his capaci ties in reaction. In man the service of the teeth is not wholly physiologic; it is in a large measure es thetic.^ Dr. Wile further believes that every reacting, re sponsive individual is aware of his own appearance, his ex pression, his speech and his*dental difficulties, and that practically every person possesses an instinctive pride in ^Ibid.. pp. 5-16. W. Patry, M.D., "What Has Psychiatry to Offer the Dental Hygienist?", Dental Cosmos. Vol. 74, No. 11, November 1932. ^Qp. cit.. p. 15. 8 3 . a good appearance. If a child or adult is conscious of beautiful teeth, he is pleased and confident in his good appearance* he smiles easily, and feels gay and free. The smile is of importance in social contacts; it promotes good feeling between the individual and the people he meets. (Case 3, page 55 ; the patient stated he did not smile and was self-conscious, but he felt it did not interfere with his social relations.) The person with a deformed mouth usually fears to in dulge in easy and natural facial reactions. Either he will not smile naturally and thus expose his deformity, or he will smile in a restricted and artificial manner, or he will not smile at all, and will convey to others an impression of sullenness, and of harboring anti-social feelings.^ Unfor tunately, mankind readily assumes that ugly appearance and ugly thoughts and acts are inter-related. The adult or child having a dental deformity, and conscious that his appearance is less attractive than his fellows, tends to withdraw from contact with them. (For example. Case 6, page 68; patient refused to play her violin before audiences.) He becomes self-conscious, reticent, lacks self-assurance, and may become pronouncedly melancholy 3Jerome H. Trier, D.D.8., "The Meaning of Orthodontia*!, Mouth Health Quarterly. July - October 1933. Vol. 4, No. 3, p. 6. 8 4 . over his belief that he possesses less personal value and fewer personal assets than other people.? He may feel in ferior and inadequate, even feeling "... resentment of self, with selfVaccusation and self-rejection. These may become tendencies toward self-isolation and during adolescence in terfere with normal social relations."8 (Case 7, page 71 ; Ray admitted self-consciousness, but denied any social handi cap because of it.) The abnormal behavior growing out of this sense of inferiority may become more serious, even developing into delinquency or neurosis. "All abnormal or anomalous dental development tends to undermine emotional stability".9 Dr. C. M. McCauley, orthodontist at the Los Angeles Orthopaedic Hospital, told this investigator that he be lieved, from his experience, that crippled faces are more difficult for patients to endure than crippled bodies. He daily treats patients for dental deformities who also have orthopaedic deformities. He explained that while crippled limbs can often be hidden or disguised, a crippled face can ?Kermit E. Khudtzon, D.B.S., "Dental Defects and Mental Hygiene", Mouth Health Quarterly. Vol. 4, No. 3, July - October 1935. p. 10. ^Jerome H. Trier, D.D.S., "The Meaning of Orthodontia", Mouth Health Quarterly. Vol. 4, No. 3, July - October 1933. p.14 Sibid.. p. 15. 8 5 . not be hidden, and attracts immediate attention. That facial deformity is an active factor in causing inferiority feelings to develop in the sufferer is a matter of observation.10 The reason is thus stated by Dr. Louis E. Bisch, . . . if there is an organic defect in any part of the anatomy, there is likely to be a compensatory re action in the brain. The mind would show an over-de termined adaptability to the physical defect, the cause being an attempt on the part of the mind to bring the entire body back into as complete harmony as possible. In other words, in an orthodontic case, with every malformation of the jaw there would be bound to be a psychic correlate . . . The child with this disfigurement of the mouth, and consequently of the face knows that this makes him in- 'ferior to others; but this conviction does not necessa rily start an inferiority complex going. In order that this may occur, the mind, one might say, must be psychically ripe for it . . . (but) the likelihood is strong that the majority of your (ortho dontic) patients are harboring inferiority feelings . . .Ü In discussing malocclusion cases referred to his psychiatric clinic for "nervousness". Dr. Eric Kent Clarke remarks, Dental malformation and other conditions centering about the teeth have occurred in sufficient numbers to make us feel that this very important part of the pic ture should never be neglected. The most frequent part in our experience that the teeth may play is in appear ance and that self-consciousness which the patient may !0j. A. Salzmann, "The Face as a Factor in Health and Life", International Journal Orthodontia. Vol. 21, Ho, 8, August 1935. ÜDr. Louis E. Bisch, M.D., Ph. D., "Relationship of the Inferiority Complex to Orthodontia", Dental Cosmos. Vol. LXX, July 1928. pp. 697-698. 86. develop over the appearance of the teeth • (in discussing a case of difficult behavior problems in a girl of twelve, Dr. Clarke adds, page 6) I feel that we would have made no headway whatever in the re-education of this child without the dental treatment. . . . (and in his summation Dr. Clarke further adds, page 8) In all these cases there are many other factors at work beside the dental condition and yet in each I feel that the dental condition played a part of sufficient importance to definitely influence the life course of each of these individuals. The waiting room in an orthodontic clinic is a good place in which to observe the outward differences in at least some of the children having maloccluded mouths from normal children. This observer noticed the under-par physique of the children waiting in the Pasadena Hospital Dispensary. Some of them may have been tall and lanky, but they seldom appeared to be husky and robust. They were an orderly set of children; waited their respective turns patiently and quietly. Like most crippled children, they were sensitive and alert to the reactions of others to their deformaties. The investigator has interviewed a number of these patients, both children and young adults. Generally they appeared to be sensitive personalities whose behavior had been effected by their dental deformities. In many cases the patients declared and honestly believed that the !2journal American Dental Hygiene Association (September, 1931), pp. 3-8. 8 7 . deformity had not interfered with social relations even when their present behavior indicated the inhibiting influences of the condition. Their common technique (if the word may be used) is to deny any social difficulties consequent upon their appearance, in the hope that the denial will cause their appearance to be unnoticed by their social groups. But almost all of them, adolescents as well as young child ren, will endure the discomfort of orthodontic appliances without thought of discontinuing treatment; and very often without any complaint. Dr. Willis A. Sutton, Superintendent of the Atlanta, Georgia schools, is an educator who has long realized the relationship between health and educational progress. Some years ago an experiment was made in one of the Atlanta schools to determine the relationship between mouth health and attendance and scholarship in the school. With the aid of a dentist, a hygientist and a visiting nurse and teacher, the children's mouths were placed in good condition. He states that the improvement in attendance resulting from this dental program was "around 15%". In promotion and scholarship the record was even better. Dozens of children who had been failing in practically all of their work, were promoted and went rapidly on their way through the grades. Taking this experiment as a basis for the entire city, it was conservatively estimated that if the mouths of the children in Atlanta could be kept in A-1 condition it would save on an average of from five to ten per cent 88. of the children's time in school. Because of Dr. Sutton's interest in dental health and experience with an advanced dental hugiene program, his advice was sought regarding malocclusions and the social, medical and psychological consequences resulting therefrom. He wrote: Your letter of March 17th with reference to "Ortho dontics, A Hew Field in Public Health Work" is certainly interesting to me. My statement with reference to re lationship between oral hygiene, dental health, behavior and school attendance and scholarship I think is just about as strong as I can make it, and I am very happy for you to use it. However, I will state that we have not had the opportunity to go into the whole field of orthodontia or malocclusions, but if you wish, you may use the following statement: The fact that children's teeth are out of line and need orthodontic treatment must impress even the untrained layman with the seriousness of the consequences that occur in the mental development of a child. If one will use as an illustration the fact that we have a regular stride, and then for a limited time are forced to step but half that stride, one must realize how thoroughly disorganized our mental life becomes and how nervous and irritating such a procedure is. The same thing is certainly true with reference to our teeth. If our teeth are supposed to fit into certain other teeth and certain grooves that are connected with certain nerves, and if these teeth fit into other grooves, and the nerves of those teeth are out of harmony.with the tooth with which it comes in contact, this incessant and eternal grind and wear upon the nervous system must be very dangerous for children. I am thoroughly convinced that the straightening of children's teeth, that the getting of the mouth in the proper position, that the increasing of the size of the arch and the work which goes on under the general name of orthodontia has a very definite relationship to the mental hygiene, to the nervous condition, and to the 89. physical development and growth of any child.13 Dr. Will G. Sheffer, orthodontist treating patients under the California Crippled Children's Act, at San Jose, California, thus describes some of the psychological and social handicaps accompanying malocclusions, and their re moval by orthodontic treatment. Socially, orthodontic treatment under the Crippled Children's Act has been most successful in this County. We have watched patients who were misfits socially, who would not even go to school because of the frightful condition of their mouths, develop into splendid examples of young manhood and young womanhood. Patients who could not stay in a reception room with other patients because of facial deformities and odor of the gums, putrid from lack of occlusion and malfunction, have changed to be leaders in school classrooms and on athletic fields. The sincere "thank you's" and letters we receive from the rehabilitated patients make our work more enjoyable. It is regrettable that more children with such handicaps cannot receive orthodontic treatment. The social aspects of dento-facial deformity. The social consequences to the individual of a facial deformity resulting from maloccluded teeth may be even more harmful than the physical and dental disorders that frequently re sult from this condition. Indeed, facial deformity directly affects three of the four fundamental wishes or desires of !3personal correspondence, April 1 4 , 1 9 3 6 . Atlanta, Georgia. !^Personal correspondence, letter from Will G. Sheffer D . D . S . , January 2 4 , 1 9 3 6 , San Jose, California. 90. the human being, (first) the desire for recognition, (second) the desire for security, (third) the desire for response. These concepts are based on the classification of T h o m a s .!5 Facial expression, or lack of it, the beauty and symmetry of the face, and, often, the speech of the individual, are largely determined by the shape of the teeth and jaws. The most serious behavior problems, frequently with later social consequences, occur in the children who, because of malocclusions, have faces which lack normal expression, and suggest mental deficiency or anti-social pugnacity. Be fore treatment, the appearance of the children in cases 1, 4, 6, 7 was of this unfortunate character. Many types of malocclusion cause the mouth to hang open. Normally, the mouth is closed. The muscle of the lips, obicularis oris, is a circular muscle which is the point of origin of many of the facial m u s c l e s .!G When the mouth habitually hangs open, these facial muscles do not develop to their normal length. The result is that the muscles of expression are shortened, and the chin has less chance to develop becoming pinched and puckered. This result makes it impossible to !5william I. Thomas, The Unadjusted Girl,(Boston: Little, Brown and Company), 1931, !^Alfred P. Rogers, D.D.S., "Exercises for the Develop ment of the Muscles of the Face"} Dental Cosmos, Vol. LX, No, 10, October 1918, p. 857. 9 1 . adequately or naturally express emotional or character re actions, because of the misshapen and mal-developed facial muscles.17 People as a whole habitually base their judgment of individuals upon facial appearance and expression. Often a person suffering from malocclusion is generally thought to possess defective mentality, when, in reality, he is only unable, because of his deformity to properly express his feelings.18 Speech is dependent upon proper spacing between the teeth, and the coordination between tongue, lips and teeth.19 Malocclusion directly affects this coordination, and is re sponsible for a large per centage of speech defects. How common these speech defects are is indicated by the statement of Dr. J. A. Salzmann, ". . . . it has been estimated that almost 26,000 children in New York City public schools alone have speech defects. Many of these defects are without doubt l?Dr. Prank M. Taylor, February 10, 1936. l^Alfred P. Rogers, D.D.S., "Exercises for the Develop ment of the Muscles of the Face", Dental Cosmos. Vol. LX, No. 10, October 1918, p. 857. l^ira S. Wile, M.D,, "The Relation of Teeth to Be havior of Man", Mouth Health Quarterly, Vol. 2, No, 4, July 1933. p, 14, ' 9 2 . directly due to dental irregularities . . ."^0 Facial appearance, expression, and fluency of speech all directly influence the individual's ability to earn a living. Indeed certain careers, such as the stage, politics, and other professions which require public appearance and public approval, are almost automatically closed to people suffering from easily observable dento-facial deformities. There are many other callings, including practically all of the vast service professions and trades which require con stant contact with the public, where dento-facial deformity opposes a serious obstacle to success. The report of the St. Louis Dental Society, indicates that in this respect school teachers may be indirectly and partially selected on the basis of normal occlusion. Among white children, the peak of malocclusion is reached in the High School groups, 73.7 being recorded in the 12th grade. The drop in per centage to 43.4 in the Teachers' College is interesting. The probable explanation for this is that the facial deformities resulting so frequently from malocclusions, have elimi nated many with malocclusion from preparing for teach ing positions. Note that no person with defective speech was listed in the Teachers' College.21 The office of the Surgeon General of the United States A. Salzmann, D.D.S., "The Face as a Factor in Health and Life", International Journal Orthodontia.Vdl. 21, No. 8, August 1935. "" ^^Committee on Public Dental Education of St. Louis Dental Society for 1934. Report and Dental Survey in the St Louis Schools. (Issued by the St. Louis Dental SocietyTT 93. Array states in a letter to this investigator that array regulations take account of properly occluding teeth in hoth commissioning and enlisting men. (Case 5, page 64 ; this case illustrates a vocational handicap.) The importance of this field of work to the children and youth of this country is reflected in the require ments for entrance to the West Point Military Academy, which requirements include, other than those of a healthy mouth and teeth, that of properly occluding teeth. Several candidates are disqualified each year on malocclusion alone, as well as facial deformity. One of the requirements for enlistment in the Army as a soldier is that the teeth of the candidate for en listment shall occlude properly. Eo actual statistics as to the number disqualified for this reason are avail able, but no doubt the number is considerable.22 The literature of orthodontia contains many dramatic life stories reflecting the changes in personality and per sonal prospects which follow the correction of serious mal occlusions. Marriages not infrequently follow upon the conclusion of treatment. One case worth noting is that of a patient at the clinic of the University of Southern California, who completed her treatment on Saturday, and married on the following Monday. On the basis of pain and suffering alone dento-facial deformities exact a cruel price. All of us inevitably react to facial deformity. Children are brutally frank in their 22personal correspondence, a letter from the office of the Surgeon General, United States Army, by Prank P. Stone, Colonel, Dental Corps. 9 4 . reactions, conmionly labelling their more unfortunate fellows by such descriptive names as *Goofy*, ^Gopher Mouthand ^Snipper-Snapper*’, and thus singling out the cripples for distinction. Popular cartoonists, knowing the common reaction, have capitalized it in their drawings, and most of us are used to laughing at the inanities of Andy Gump, or at the ferocity and stupidity of prize-fighter *^mugs**. The author of **Alice in Wonderland” contributed perhaps unwittingly, an excellent character study of changed personality and be havior due to malposition of teeth in his portrayal of the Ugly Duchess.^^ (Most of the cases discussed in the previous chapter complained of being called names by their class mates.) The final consequences of dento-facial deformity are frequently social in character and expressed in the social waste resulting from undeveloped potentialities, thwarted ambitions, and personal sufferings of large numbers of people having preventable or correctable malocclusions. Dr. P. 1. Patry thus states the case:”A skilled ortho dontist can often prevent untold misery, unhappiness and 23Kermit P. Khudtzon, D.D.S., ’ ^Dental Defects and Mental Hygiene”, Mouth Health Quarterly. July - October 1935, Mol. 4, Ho. 3, p. 10. 9 5 . even social and economic failure, as well as physical and mental disorders, hy timely intervention.^24 And Frederick T. MurHess, Jr., speaking from the same viewpoint, observed: ”As a constructive and corrective measure, orthodontia ranks with the educational system it self in its beneficent influence upon the future of the child afflicted with a facial deformity.”25 24p. L. Patry, M.D., ”What Has Psychiatry to Offer the Dental Hygienist?”, Dental Cosmos. Toi. 74, Ho. 11, Hovember 1932* p. 1105. 25prederick T. Murrlless, Jr., ”Address”, Internation* al Journal Orthodontia. Vol. 21, Ho. 10. October 1935. 96, CHAPTER V I, DIFFICULTIES EHCOUHTERED IH PROVIDIHG FOR ORTHODONTIC TREATMENTS AND SOME EXISTING TREATMENT PROCEDURES The expense and time involved in orthodontic treat ment. The cost of treatment and the time required to change abnormal function and growth into normal occlusion consti tute one of the major difficulties in the present orthodontia picture, and, undoubtedly, if the orthodontic problem were to be included in public health planning and functioning, this difficulty would still be serious, though in a less degree. Most orthodontists hesitate to estimate the time re quired for treatment. But on the average the time required is more than one year. The treatment itself is divided into, first, active treatment, when appliances and exercises are moving the teeth and^jaws, and, second, passive treatment, when retention appliances are keeping the teeth and jaws in the position obtained during active treatment. The time re quired for passive treatment is likewise a long one, usually over one year. Even after these long periods of active and passive treatment are terminated, it is frequently advisable for the orthodontist to see the patient at intervals to be sure the occlusion is being maintained. 97. An estimate, made by the senior students of the New York University School of Dentistry, of the time required to correct the abnormal occlusions of ninety-eight boys in a New York Boys Club was twenty hours per person per year, two and a half years for each boy, or a total of forty-nine hundred hours.^ Another time estimate is that of Jerome H. Trier, D.D.8., writing in the Mouth Health Quarterly for July- October, 1935. ”The average orthodontic treatment takes from two to two and one half years. There are cases that can be completed in six months, and. others that require three or four years.”2 Dr. C.F.S. Dillon states that at the University of Southern California Dental Clinic the average time consumed in orthodontic treatment is eighteen months. He estimated the average cost of competent orthodontic treatment at $400.00 or more. He stated that the charges have been very much reduced during recent years* It is evident from consideration of these elements ^The Committee on Community Dental Service of the New York Tuberculosis and Health Association, Health Dentistry for the Community. (Chicago; University of Chicago Presÿ, 1935. p. 56. 2jerome H. Trier, D.D.S., ”The Meaning of Orthodontia”, Mouth Health Quarterly. Vol. 4, No. 3, July - October 1935. p. 7. 9 8 . of time and cost that orthodontic service today is necessar ily restricted almost entirely to patients whose families belong to the more fortunate, income groups. The cost of orthodontic service places it generally far beyond the reach of the masses of the population* The necessity for cooperation between the orthodontist. the patient, and the patient*s family during the period of treatment. Unlike diseased tonsils, which can be removed by surgery, or immunity from certain contagious diseases, which can be quickly conferred by simple injections, the correction of malocclusions depends in large measure upon the coopera tion of the patient and his family with the orthodontist.% In orthodontia one cannot pay one’s money down and demand certain results. Orthodontic treatment is a joint under taking of practitioner and patient. Many orthodontists re fuse to accept a case for treatment unless one or both of the patientas parents are convinced the treatment is necess ary and are willing to cooperate to insure its success. This cooperation involves the willingness of the child to protect his appliances and keep his teeth clean, and, much more diffi cult and usually requiring the assistance of parents, the correction of the habits which have contributed to the mal occlusion. This cooperation insofar as habit correction is %. F. Cole - Mathews, L.D.S., "The Time Factor in Orthodontics”, International Journal Orthodontia. Vol. 21, No. 9, September 1935. p. 821. 9 9 . concerned must continue throughout life. Dr. Alfred Paul Rogers, writing in the American Dental Association Journal, remarks. No case of malocclusion should he thought of as com pleted, irrespective of the method used in obtaining tooth position, unless there have also been instituted methods of myofunctional nature having for their purpose the establishment of a harmonious relationship between the dental arches, together with coordination, balance and the development of tone in all the muscle groups re lated to facial development.^ The lack of cooperation in clinical treatment. A major difficulty encountered during orthodontic treatment, both in private and clinical practise, is the tendency of parents or patients to stop treatment as soon as the patient’s mouth begins to look normal. This bettering of appearance may occur comparatively soon after treatment begins, and long before it should stop. This premature discontinuance of treatment appears to be particularly prevalent among clinic and charitable cases. It is also extremely difficult to obtain the necess ary cooperation from this class of patients. Dr. Spencer Atkinson, in an interview with the investigator, stated that in his belief only a small proportion of charity patients were sufficiently appreciative of orthodontic treatment to ^Alfred Paul Rogers, ^Exercises for the Development of the Muscles of the Face”, American Dental Association Journal. Vol. 23, No. 1, January 1936. p. 68. 1 0 0 . give the orthodontist the necessary cooperation. Dr. C. F. S. Dillon stated that this lack of cooperation was also present at the University of Southern California Dental Clinic. He stated that of some forty children treated hy him at an insti tution, only five per cent of the cases resulted successfully, due to lack of cooperation. The cases sent hy the County Welfare Department to his clinic rarely are completed, because of loss of interest by patients or their parents. Many orthodontists believe that the intensive coopera tion necessary in successful treatment can not be expected from unintelligent parents, and that most parents who require charity for such treatment are unintelligent. Their inability to obtain this cooperation leads them to believe that clinical care of orthodontic eases will always be difficult, and, per haps unsatisfactory. In passing, it may be noted that the same complaint of lack of cooperation is made by orthodontists in the cases of children of very rich parents who generally leave the coopera tion problem to be solved by servants. It should also be mentioned that, so far as the investi gator could learn, in the treatment of these cases cited above no medical social worker, or other person trained in liason work, was ever employed to explain the cooperative need to the parents and educate them to giving it. 1 0 1 . The small number of qualified orthodontists. There are approximately one thousand recognized orthodontists in the United States at the present time. It is a debated question within the dental profession as to how much orthodontic treatment should be given by the general practitioner. Webb Waldron, in a popular arti cle, states that in addition to the thousand orthodontists, some 22,000 general practitioners do some teeth straighten ing, and that of this number only six per cent have studied orthodontia.5 This lack of qualified orthodontists to meet the needs of the estimated fifty per cent of American school children constitutes a serious problem. B. E. Lischer, states in this connection. The orthodontic Directory for 1932 lists 890 ortho dontists who are engaged in practise in the United States, and practically all of them are located in the large cities, which comprise only 36 per cent of the population. Several inquiries, which have been imde to determine the number of dentists in general practise which include the treatment of anomalies in the services they render, reveal that 50 per cent do so. Specialists are unanimous in contending that to be able to render such services efficiently requires adequate training and education.& Waldron, ”About Face”, Readers’ Digest. Vol. 28, No. 167, March 1936. p. 89. ^B. E. Lischer, D.M.D., ’ ’Orthodontic Education”, Inter national Journal Orthodontia. Vol. 21, No. 6, June 1935. p. 513. 102 Exi s t ing clinical facilities are inadequate. The literature and reports of orthodontic clinics commonly stress the fact that the need for orthodontic treatment far exceeds the ability of the clinics to give it. A study of dental clinics in the United States made in 1930 gave the following figures and data on the practise of orthodontics in clinics. Number of clinics giving orthodontia in 1950 Type of clinic Number Per cent of total number of clinics of each type Health centers 8 8 Hospitals 20 15 Industrial 11 18 Schools 14 8 Total 53 11 In the dental-sohool clinics in 1930, of 1,469,023 treatments, 2,574 were for orthodontia. It is surprising to find that 8 out of the 95 (health center) clinics include orthodontia in their program ... Out of the 218 chairs reported by health center clinics, 52 each offer orthodontia. Clinics with three chairs or more offered orthodontia in 12 per cent of cases. Out of 136 hospital clinics, 20 or 15 per cent gave orthodontic treatment, and had 65 chairs for the purpose or 21 per cent of the chairs. Industrial dental clinics in 18 per cent of the 62 clinics, or 11 clinics gave orthodontic service.? ^Miriam Simons Leuck, ”A Further Study of Dental Clinics in the United States”, (Chicago: The University of Chicago Press, 1932^ 1 0 3 . The Annual Report of the Dental Department of the Peoria Public Schools for 1934 - 1935 lists, ”Pupils with malocclusion -- 806? pupils with orthodontic treatment in progress -- 76.”8 It must be remembered that Peoria has an outstanding preventive dental service which has been a part of its school system for twenty years; it also operates a dental dispensary service for school children who can not pay fees to private practitioners. Undoubtedly Peoria meets the orthodontic needs of its school children better than most other communities; yet the per centage of treatment to known need, as quoted above, indicates that Peoria is unable to fully cope with its orthodontia problem. Prom St. Louis, which made the extensive survey of dental needs among its school children, in 1934, Dr. C. W, Brandhorst reports in a letter, Prom the survey report you will notice we were anxious to establish an Oral Hygiene department in the school system of St. Louis, but that has not materialized up to the present. The best that we have been able to do so far is to utilize the municipal clinics for render ing dental services to the indigent children. However, this is strictly reparative work and very little atten tion is given prevention of malocclusion. We are at the present time attempting through the Medical Dental Service Bureau, to arrange for orthodontic o Annual Report of the Dental Department of the Peoria Public Schools, 1934 - 1935. C. Carroll Smith, D.D.S. 1 0 4 . services for the low income group, but anything that we may work out, I am sure will hardly scratch the sur face.* The Porsyth Dental Infirmary for Children, in their twentieth annual report, show one instance of clinic expan sion to meet orthodontia needs. The report, of January 1935, states that 48 orthodontia cases were accepted during 1933 - 1934. “The staff has undergone a gradual increase. At the present time it consists of twenty men who are caring for two hundred and fifty cases.“10 The annual report of the Rochester Dental Dispensary for 1935 shows 389 orthodontia eases under treatment, and the disbursement for orthodontia of $14,465.95. It is planned to greatly extend the activities of this department as soon as operators may be trained for this particular work. At the present time there are 389 cases under observation and treatment .... The splendid results obtained in this department are most gratifying.il Dr. H. J. Burkhart, director of the dispensary, in reply to the query of the investigator, “What proportion of children need orthodontic treatment in your community?”, writes, “It is a difficult question to answer. In my opinion 9 Personal correspondence, Letter from Dr. 0. W. Brandhorst, St. Louis, March 12, 1936. l^Twentieth Annual Report of the Porsyth Dental Infirmary for Children, January 1935. llRochester Dental Dispensary, Annual Report. 1935. 105. about 25 per cent of the children need orthodontia,”12 Dr. John Oppie McCall, Director of the Murry and Leonie Guggenheim Dental Clinic wrote to the investigator that his clinic did not give orthodontic service. He fur ther stated regarding clinical orthodontia in New York City, There are several clinics giving fairly low cost orthodontic service in New York, notably the Ortho dontia Departments of the dental schools of New York University and Columbia University .... The Dewey Post Graduate School of Orthodontia also has a low cost service. A few of the hospitals give orthodontic ser vice on the same basis. No free orthodontic service is given in New York.13 The University of Southern California Dental School Clinic may be accepted as a fair average example of this type of clinic. It gives orthodontic treatment to between eighty and ninety patients. Ninety new patients are treated annually. It charges $30.00 for the first month of treat ment, and $10.00 monthly thereafter. These charges do not quite cover all the costs of materials and overhead. This clinic does not attempt to make a profit from its fees. Some dental college clinics do make charges in excess of costs of treatment. In an interview. Dr. C. P. S. Dillon stated that the 12personal correspondence. Letter from Dr. H. J. Burkhart, Director, Rochester Dental Dispensary, March 11, 1936 Impersonal correspondence, Letter from Dr. John Oppie McCall, Director, Murry and Leonie Guggenheim Dental Clinic, New York, March 16, 1936. 1 0 6 . selection of cases is based upon the following points, first, the practibility of the case for treatment, and its value as a teaching case; second, the treatment is limited to patients who can not afford to pay the fees charged for private treatment. No social service investigation super vises the admissions. The patients are usually referred by dentists who state they are unable to pay for private dental care. The obvious disadvantages of this clinic form are that first, its facilities are limited as to the number of patients treated, second, its basis of selecting patients is to obtain desired teaching material rather than to meet the social, dental and medical needs of the applicant, third, trained social workers are not provided to obtain the vi tally necessary cooperation of the patient’s parents during the long period of treatment, fourth, the charges, although low, make the service prohibitively costly to many who need it. The privately endowed clinic performs useful service, but the numbers of its patients are dependent upon its fi nancial resources. The Pasadena Hospital Dispensary Clinic is a good example of this type of clinic, which gives free, or partially free, service. The Pasadena Dispensary Clinic is a Community Chest organization. The orthodontist is paid 1 0 7 . a nominal fee by the Community Chest, and gives three morn ings each week to the clinic. It is necessary for the fa milies of the children treated to pay for the materials used in the treatment; this cost is usually about $75.00. Patients who can pay more are permitted to do so. Although the clinic does not keep a record of the number of patients receiving orthodontic treatment, the Dis pensary authorities state that the clinic facilities are in adequate to meet the needs of Pasadena children* A medical social worker supervises the selection of patients, and care fully explains to parents and to older children the need for cooperation to insure successful results from the treatment. A class including some dozen young children and their mothers has been formed in which the orthodontist explains the con sequences of harmful habits to occlusion, and the necessity to discontinue such''habits. This class is an effort to effect a saving in time and overhead costs by group rather than individual instruction. It is a new venture, and as yet no statement can be made as to its efficiency. The disadvantages of this type of clinic are, first, the sharply limited facilities and funds available for the service, second, the rendering of the service on a welfare basis with the larger part of the cost met by private gifts or Community Chest funds, third, treating children in a 1 0 8 . clinic which also renders general health services to the indigent. There is another type of health and dental service, organized for middle class patients on a part pay basis. Examples of this type organization were the San Diego Health Service and the Pasadena Central Health Service. The last named organization has ceased to operate, but many similar organizations are functioning throughout the country. They are, in most cases, an effort to meet depression needs, and are apt to be short lived. The Pasadena Central Health Service during its existence, and even on its part pay basis of treatment, was able to care for less than one third of the orthodontic cases which applied for treatment. Even a cursory examination of the field will convince one that the existing clinical facilities for meeting ortho dontic needs are inadequate. The large majority of children who need the service cannot obtain it. The free, or largely free, clinics are very few in number, and can treat only a small percentage of those needing treatment. The charges in the dental school clinics, even though below costs, are still so large as to make the service quite prohibitive to the low income classes. Treatment under the California Crippled Children’s Act Some counties in California have included dental cripples 109. under the state Crippled Children’s Act. This act provides that the counties, under the supervision of the state Board of Health, shall provide medical care and necessary appliances, transportation, etc., for crippled children under eighteen years whose parents or guardians are residents of the county and unable to provide for this care wholly or in part. A petition for the child meeting these requirements is filed in the Superior Court of the county of residence, and the judge may issue a certificate which determines what sum, if any, the parents can pay to the court for the care. The county pays the remaining costs. Santa Clara County has eared for the largest number of dental cripples mostly by means of orthodontia under the provisions of this Act. Dr. Charles L. lanne, of the Sana torium Division, Santa Clara County Hospital, states in a letter to the investigator, There have been fifty certified cases in this county under the Crippled Children’s Act. The total cost per child averaged from $400.00 to $500.00, a very high cost as you will note. This is not including incidentals. The treatment is rather prolonged and requires trans portation to the medical center, that is, the U. C. Den tal School. This duty is often imposed on a social worker if the mother is employed, or if the mother is required to lose time from her work. This item cannot be estimated but amounts to a considerable sum. The criticism is that most cases have been certified for cosmetic reasons although our department has been trying to be fair with the tax-payer and consider only serious masticatory impediment cases. . . . We have been criticized for spending too much money for other than 1 1 0 . physical defects. That the treatment of malocclusion under the Crippled Children’s Act is generally unsatisfactory is the opinion of Dr. Will G. Sheffer, a Santa Clara County orthodontist who has treated patients under the Act. In a letter to the investigator, he states, Psychologically, the orthodontic treatment adminis tered in Santa Clara County under the Crippled Children’s Act may he considered successful so far as the few pa tients receiving the treatment are concerned. But the large number of families asking for treatment but being refused, produces a serious hopelessness of attitude to ward State Aid on the part of all concerned. In order to better explain this attitude, may I illustrate by tracing the procedure in obtaining and gran,ting ortho dontic treatment under the Crippled Children’s Act? The teachers recognize that certain children in the class room would do better work if their dento-facial deform ities were corrected. The school nurses in turn recog nize these handicaps and recommend that the parents take the children for advice about orthodontic treatment. The parents go to the orthodontists who, in about one half hour’s time, explain the deformities and advise treatment. The cost of treatment seems prohibitive so the school nurses, knowing the social status of each fa mily, express hopefulness in receiving treatment under the Crippled Children’s Act. The actual number of child ren needing orthodontic treatment in Santa Clara County is 60 or 65 per cent. Each school nurse reaches between three and five thousand students. The better informed the nurse is about dento-facial deformities, the more de formities she will recognize and the more children she will refer for advice about orthodontic treatment. The most observant nurse orthodontically we have, refers for advice about treatment about-fifteen or twenty per year. Others about ten or five a year. This is recognizing only .005^ of the deformities in one instance and about Personal correspondence. Letter from Dr. Charles L. lanne. Sanatorium Division, Santa Clara County Hospital, San Jose, California, January 20, 1936. 1 1 1 . .002^ in the others. Still other nurses will not re cognize the existence of dento-facial deformities at all or who, if they do recognize them, will not do any thing about it because of the hopelessness of obtaining treatment under the Crippled Children’s Act. When these few referred cases do return to the offices of the orthodontists, they are again told of the import ance of the children’s receiving treatment and sent to the County Health Officer for certification. Organized criticism of the expenditures of County funds has ap parently put a stop to the expenditure of money for ortho dontic treatment under the Crippled Children’s Act. Not long ago, we witnessed the exasperating circumstance of having an administrator of the law pass judgment on the physical fitness of the patient. Orthodontic treatment was refused because the patient looked plump, yet only the distal of the second permanent molars occluded, the rest of the mouth being in a most extreme malocclusion. At the present time, the physical fitness of the patient is still the determining factor in granting a recommenda tion for certification for orthodontic treatment. But the physical inspection is given by a county physician. In the past year over a hundred such recommendations by orthodontists to the County Health Officer have been made. No new certifications for Orthodontic treatment have been granted for the past two years. . . . The orthodontists of the county made a special fee for treatment under the Crippled Children’s Act, This fee is just a little above the cost of handling these extreme cases. At present, there is a rumor among the county physicians and nurses that each orthodontist in Santa Clara county is receiving over $6000.00 a year for treatment of children under the Crippled Children’s Act. At the present time the expenditure to orthodontists for all the State Aid Orthodontic treatment in the county is less than $300.00 a year. Thus you see that orthodontic treatment under the Crippled Children’s Act as adminis tered in Santa Clara County is far from satisfactory. As a solution to the problem of taking care of these handicapped children, we are just about .0008^ efficient. For we are treating less than one out of every thousand children needing orthodontic treatment. Unfortunately, the only dento-facial deformities that have been recognized under the Crippled Children’s Act are so extreme that complete corrections are impossible 1 1 2 . even though treatment were continued for many years. Some cases are so extreme that the extraction of permanent teeth has been resorted to in order to shorten the period of treatment. Like in our average practices, many of these State Aid Children come for the adjustment of their retaining appliances for years after the cases have been closed financially. AH orthodontists have many of their good paying patients fail to meet their financial obliga tions before completion of their cases so that they hesi tate before inviting an entire practice of the indigent type patient.15 It will be seen from the foregoing that the California Crippled Children’s Act, as at present administered in this county does not provide a solution of the orthodontia pro blem. But an extremely small per cent of malocclusion cases applying for aid under the Act receive it. Moreover, the de cision as to the need of the applicant of treatment, at least in Santa Clara County, rests with a lay person, the judge, and a medical man, the county physician, and not with the dental specialists who have examined the applicant and re commended treatment. At the present time, Los Angeles County is treating its first orthodontic case under the provisions of the Crippled Children’s Act. The new policy of this County will be to accept orthodontics as a “crippling defect” under the law providing the child is first diagnosed in the Los Angeles ISpersonal correspondence, Letter from Dr. Will G. Sheffer, Orthodontist, San Jose, California, January 24, 1936 1 1 3 . County General Hospital Crippled Children’s Clinic hy the clinic oral surgeon and an orthodontist. Determination of the “crippling defect" is a matter for medical and dental opinion, and only definitely handicapped children will he accepted under the provisions of this Act. A further limita tion is that the dental deformity must he susceptible to successful orthodontic treatment. Unlike Santa Clara County, Los Angeles County has set up its own organization for meeting the provisions of this law. It is therefore unnecessary to petition the Superior Court and fulfil the many complicated regulations attendant on that form of procedure in Santa Clara County. Los Angeles County has established its own administrative procedure, and possesses its own clinic for diagnosis. Arrangements have been made with the local Orthodontic Society for the treat ment of the accepted cases. The Los Angeles County will pay the orthodontist treat ing the child under this Act, $150.00 anually, payable in four installments. The Society of Orthodontists have select ed a panel of their members whom it can recommend and who are willing to accept these cases for treatment. The names of the orthodontists are drawn from this panel in rotation and with regard to the location of the dentist’s office and the residence 1 1 4 . of the child. l^Interview with Ruth Cooper, Director, Social Service Department of Los Angeles County General Hospital, April 6, 1936, 1 1 5 . CHAPTER V I I . PROPOSED METHODS OP ATTACKING THE ORTHODONTIC PROBLEM The fact that great numbers of children have mal occlusions which require orthodontic correction while pov erty prevents their receiving the needed treatment has caus ed many orthodontists to cast about for new methods of attacking the orthodontic problem. Being closest to the problem the orthodontists are most aware of the need, and of the inadequacy of present facilities and procedures to meet it. Illustrative of this awareness, and of the atti tude of at least one orthodontists’ organization toward the problem, is the following excerpt from the President’s Ad dress to the American Society of Orthodontists assembled in convention in St. Louis, Missouri, in April, 1936: SOCIALIZED ORTHODONTIA: The practice of our specialty during the past thirty years has been passing through its incubation period, a transition during which time its workers have been occupied religiously in the quest of scientific improvement and dispatch of treatment. Spectacular advance has been the reward. Notwithstanding now that the work has emerged and established itself on a high plane of endeavor another problem appears upon the horizon of orthodontic progress, plainly not so simple of solution as is the methodical step-by-step advance in technique which has occurred in the past, from year to year. Rapid change is taking place in the economic and social life of America and it is now no longer doubt ed that all departments of practice must meet the health requirements of the new social concept. This new order means that health services will be made available in the long pull future for all of the people, the same as is 1 1 6 . education for the children of all of the people. In this transitional movement, orthodontists realize that wheels must he put into motion as rapidly as possible within the organization itself for the extension of ser vice to reach wider brackets of the people, and this is as it should be. In the presidential address of Presi dent Waugh presented to this organization just one year ago in New York, he emphasized this point: “If we be lieve in the importance of orthodontic service as an essential health measure, and if the true professional concept be adhered to then the duty to the children of the nation is plain, and the utmost effort must be bent toward making all dental services available to all who need them.” It was pointed out that the physical benefits of this work be not confined to the fortunate children alone, and it was recommended that a socio-economic committee be appointed by the Executive Council of the American Society of Orthodontists to study the problem and to suggest ways and means to attain this end. The fore going recommendation exemplifies the highest traditions of all health service, upheld throughout the world, as set forth in the oath of Hippocrates. It emulates the tradition of all medical practice that the servant of physical ills shall use his utmost skill with every pa tient, no matter what may be his biological character istics or in what stratum of society he is born.l The foregoing does not represent an isolated instance of orthodontists’ interest in community sponsored extension of their particular health service to the masses of the population now unable to obtain it. Recent orthodontic literature and discussion is replete with acknowledgments of the need of such an extension, and suggestions as to how ^Dr. H. C. Pollock, “The President’s Address to the American Society of Orthodontists”, (35th annual meeting, St. Louis, Missouri, April, 1936) p. 7. Obtained by investi gator through correspondence with Dr. H. C. Pollock, St. Louis, Missouri. 1 1 7 . it should he obtained and administered. The socialization of orthodontic treatment. If the burden of correcting dental malocclusions in children whose parents are unable to afford private service is assumed by the public, it will involve large expenditures of public funds. But there is no other purse big enough to provide the known needed care. Moreover, it may be urged that the social saving, as expressed in the avoidance of illness, economic failure and personal and social maladjustment by those accepting the service, would in the long run repay society for the sacrifice. Many authorities on orthodontia agree that public funds should finance organized community efforts aimed at the correction of malocclusions.2 But most of them differ as to the best form which such organized efforts should em ploy. Dr. Harry E. Kelsey, who has written extensively on the subject of orthodontia in the public health service,/be lieves that because of the cost and time required for treat ment, “All the more, therefore, has it become a matter which can only be adequately taken care of by service supplied by 2w. R, Dinham, D.M.S., “A Discussion of the Clinic Plan as Applied to Orthodontics”, International Journal Orthodontia. Vol. 19, 1933. p. 4047" 1 1 8 . the community or the state.*3 Dr. Kelsey favors community or state free clinics, and compares a free clinic system with the free public school system as supplying a necessary civilized need. But he recognizes that such a system will not prevent the occur rence of malocclusions. There will still be malocclusion in spite of universal health service and our best efforts, but it is reason able to suppose that the amount of malocclusion may be greatly reduced as well as the complexity of many of the cases, and therefore, there will be a diminution in the amount of time required for their treatment.4 Concerning this phase of the problem. Dr. John Oppie McCall, Director of the Murry and Leonie Guggenheim Dental Clinic, wrote the investigator, Regarding suggestions for organizing orthodontic ser vice for the children whose families are in the low in come classes, I will say that this should parallel in scope and method the organization in the community for care for other severe physical defects in children. If a community provides, either on a free or part pay basis, for the correction in the orthopedic field, correction of severe sight defects, etc., provision should also be made for the correction of severe mal occlusions. Under the heading of severe malocclusions, I would place those that are deforming to the extent of constituting a severe psychological hazard or a probable handicap in seeking employment and those that inhibit speech or masticatory function to a severe or dangerous %arry E. Kelsey, D.D.S., P.A.C.D., **The Public Clinic as a Measure of the Cost and Value of Universal Health Service**, International Journal Orthodontia. Vol. 19, Ho. 4, April 1933. p. 428. %arry E. Kelsey, D.D.S., P.A.C.D., «Place of Ortho dontia in the Impending Wider Health Service#, Journal Amer ican Dental Association. Vol. XXI, Ho. 3, March 1934. p.390. 1 1 9 . extent. This will involve securing the interest of medical men or philanthropists, or both, in the problem on the broad basis of an appreciation of community re sponsibility toward cases of extreme physical handicap.5 Dr. Guy S. Millberry, Dean of the University of California Dental School, at San Francisco, writing in the Pacific Dental Gazette, states his belief. For patients of the second group (those who have to be cared for), I believe a government service, supple mented by private philanthropy, is best. This service should be divided into a relief service for indigents and children, who would not otherwise receive it, and a part pay service for those who, through some form of contributory plan, could pay the costs.* Dr. L. M. Waugh believes that the dental needs of the indigent should be provided for by public taxation, and that a system should be instituted which woixLd give thorough den tal care to all children from the second year. He thinks this dental service could be supervised by either Boards of Health or Departments of Education. He thinks there should be «truant officers for health# who would see that the child ren received systematic dental attention. Dr. Waugh believes that this work could be done in their own offices by private practitioners who have volunteered to give low cost service 5john Oppie McCall, D.D.S., Director, Murry and Leonie Guggenheim Dental Clinic, Hew York City. Personal correspon dence, letter of March 16, 1936. ^Guy S. Millberry, D.D.S., Dean of University of Cali fornia Dental School at San Francisco, «The Outlook for Dental Practise#, Pacific Dental Gazette. January 1933. p. 10. 120. 7 under official supervision. Dr. Guy S. Millberry stresses the importance of the school dental clinics because, . . . they are organized to prevent or inhibit the decay and premature loss of teeth. Further, they pre sent the best opportunity that we have for the dissemina tion of information that will aid in achieving this goal; and they constitute the best existing agency for dental health education in America.8 The experience of Peoria, as reported by Dr. G. Carroll Smith, contra-indicates the use of school clinics for ortho dontic treatment. After several years of effort in regard to orthodon tic procedure for the indigent in connection with school dispensary service it seemed to us that orthodontic pro cedure is contra-indicated in the school dental dispens aries. . . . the net cost is prohibitive. It could not be expected of a board of education to finance procedures of this type.9 It will be noted that Dr. Smith’s objection is based upon cost. But if orthodontia were accepted as a public health service, obviously special provision of funds would be made for treatment. But the question as to whether clinic organization. M. Waugh, D.D.S., «Address#, International Journal Orthodontia. Toi. 21, Ho. 10, October 1935. p. 905. ^Guy S. Millberry, D.D.S., «Effective Public Dental Clinics#, Journal American Dental Association. Toi. XVIII. April 1931. p. Vël: ' 9C. Carroll Smith, D.D.S., «Public Dental Health», op. cit.. Toi. XIX, Ho. 12, December 1933. p. 127. 1 2 1 . or some other method of providing treatment, would he best, should, this investigator feels, be left to the authorities to debate and determine. The investigator believes that the type organization chosen to administer such a service is not nearly as important as the quality and interest of the personnel selected to perform the service. Any system would be ineffective if its personnel were uninterested in its success or antagonistic to its philosophy or objectives* An obstacle to the successful extension of orthodontics as a public health service might very well prove to be the individualism of orthodontists and allied professional con freres themselves. Health insurance as a means of solving the treatment •problem. Many health authorities believe, that in the not distant future health insurance will become a part of the already instituted American social security program. In such an event the treatment of orthodontic deformities might very well be included within its services because of the close relationship, already discussed in this study, between malocclusion and general health and well being. The authors of Health Dentistry for the Community, be lieving that compulsory health insurance may be instituted in America before long, have this to say regarding dental care under such a regime. 1 2 2 . Such laws, if properly drawn to avoid the evils of politics and bureaucracy, would seem to present the most feasible method to provide maximum amount o-f dental care ^ for all groups in the population not at present able to obtain this care. . . . laws equitably drawn, capably and honestly administered so as to provide dental care for the masses of our population with justice to the dental profession, would seem to offer the solution. It will be necessary to have plans for complete den tal care for children go hand in hand with any success ful health insurance system.10 These authors admit that the cost of such complete dental care for children would be very large, but they be lieve that this cost would be more offset by the saving . . . from reductions in absences from industry and from school and from other resources, which an improved general health would effect. . . . Dental disease, because of its wide occurrence in the community and because it is responsible, directly or indirectly, for an extraordinary amount of illness and loss of time from school work and gainful occupation, presents a problem that is both social and economic. To bring it under control community planning is necessary; in this respect it compares with malaria, typhoid, and tuberculosis.il Great Britain and Germany are the two countries in which health insurance has so far received its greatest de velopment. In Great Britain dental service is the most com mon form of extra benefits declared by prosperous health 10The Committee on Community Dental Service of the Hew York Tuberculosis and Health Association, «Health Dentist ry for the Community (Chicagoî University of Chicago Press, 190lF*p. 58. lllbid.. pp. 58 - 61. 1 2 3 . associations. In 1930, 10,500,000 insured persons in England and Wales were eligible for dental benefits, but only one in ten actually received it, at a total cost of 12,100,000.12 In Germany six thousand, or three fourths, of the German dentists are employed by various sickness funds.13 But in neither country has anything but emergency service, describ ed as simple and essential treatment, been given under the health insurance systems. Heedless to say, no orthodontic treatment has been given under existing insurance systems. If America were to include orthodontia within its proposed health insurance system it would be a pioneering adventure. The prevention of malocclusions. Orthodontists, them selves, are not agreed upon the possibility of successfully instituting programs, at the present time, designed to pre vent the occurrence of malocclusions. The difference of opinion is caused by the admittedly obscure etiology of the subject. The weight of orthodontic authority voices the opinion that the etiology of malocclusion is still, for the most part, unknown.14 Some few authorities believe the knowledge of causative factors to be as yet too uncertain to 12percy Cohen, The British System of Social Insurance (Hew York: Columbia University Press, 19327 pp. 31-32. l^Barbara Armstrong, Insuring Essentials (Hew York: MacMillan Company, 1932) p. 357. 14See Chapter III, 15-39, above. 1 2 4 . justify large efforts toward prevention. Typical of this attitude, is the response of Dr. H. C. Pollock, President of the American Society of Orthodontists, 1935-1936, to a query by the investigator, “Answering your question about Etiology — personally I do not think we have sufficiently accurate information in regard to this subject of etiology to begin public propaganda on it.“15 Dr. Robert H* W. Strang, of Bridgeport, Connecticut, also believes that the causes of malocclusion are still too obscure and unknown to justify expectations of successful results from public programs. My own personal feeling relative to the preventive field of orthodontia is somewhat negative, because the primary etiological factors which lead to the defects of growth and development are so deep-seated and hidden that they are not possible to eliminate or improve, with our present knowledge of metabolism. Those causes which we see active when the cases are brought to us are se condary to these most important underlying influences and while we can modify these secondary etiological fac tors to a great extent by educational efforts and by so doing stabilize the results of our treatment to a reason able percentage of success, yet success in prevention cannot come by efforts directed towards these secondary factors. It must aim to eliminate the primary ones.16 Dr. Strang’s contention, of course, is that such ISpersonal correspondence, Letter from Dr. H. C. Pollock, St. Louis, Missouri, May 4, 1936. ^^Personal correspondence. Letter from Dr. Robert H. ¥. Strang, Bridgeport, Connecticut, March 23, 1936. 1 2 5 . causative factors as habits, generally regarded by ortho dontists as primary factors in the development of malocclu sion, are not primary factors, and that preventive measures against them will not materially lessen malocclusion inci dence. But, in opposition to this attitude, can be cited the declared opinions of many other acknowledged orthodontic authorities, and of many practising orthodontists who base their conclusions upon experience as well as text, that pre vention is possible and publicly supported preventive pro grams are desirable* These authorities generally believe that in prevention lies the solution of the orthodontic pro blem.!? They also are generally agreed that successful pre ventive measures can be inaugurated and continued on the necessary vast scale only by public sponsoring and the use of public funds. But whatever the cost of a preventive pro gram it would in the long run be much less than the cost of treatment of the vast number of malocclusions which are of the preventable type. Dr. L. W. Waugh, in his presidential address at the thirty-third meeting of the American Society of Orthodontia, 17 Prank M. Casto, D.D.S., «Orthodontia and the General Practitioner#, International Journal Orthodontia. Vol. 21, No. 9, September 1935. p. 808. 1 2 6 . said: “By early recognition of factors which predispose to malocclusion, and by their proper care the general dental practitioner can prevent the need of perhaps 35 to 50 per cent of corrective (orthodontic) treatment."18 Harvey Stallard, D.D.S., of San Diego, in an inter view with the investigator said that in his opinion. Ninety percent of malocclusions can be prevented by education of mothers, nurses and the children. This education need not necessarily be done exclusively by the public schools; in fact the public school education comes too late in the life of the child to prevent. More than 60^ of all malocclusions starts in children before they are of school age. Malocclusion is a de formity which begins and is begotten in tender i n f a n c y . !9 Dr. Spencer Atkinson, in an interview with the in vestigator, said. Seventy-five per cent of malocclusions are prevent able. A dental hygienist devoting full time to the prevention of malocclusions would save parents and the community an inestimable amount of money. Staggering amounts of money are spent on straightening crooked teeth, and three fourths of that money could be saved by prevention in cases where the given anatomical con dition is n o r m a l . 2 0 Even Dr. Brash, the noted British scientist, states that while we may believe the generic origin of irregular ity and malocclusion to be uncertain, it does not follow M. Waugh, «Address#, International Journal Ortho- dontia. Vol. 21, No. 21, October 1935. p. 905. ^^Personal interview with Harvey Stallard, D.D.S., at San Diego, California, April 7, 1936. ^^Personal interview with Spencer Atkinson, D.D.S., March 16, 1936. 1 2 7 . that “. • .prevention becomes an impossible ideal . . . nor that a scientific basis of orthodontic treatment and prevention cannot be found.«21 Methods of prevention, (l) dental care for children. The first and most direct means of preventing preventable malocclusions is to provide children with early and continu ous dental care. Dr. Harvey Stallard, in interview, dis cussed the problems of providing dental care for children; At the present time a very small percentage of child ren in the United States receives any dental care, as judged by the children of the rural communities, where about receive occasional relief care. There is not enough money available through taxes to correct the mal formations and restore lost dental tissue caused by caries in a neglected and uninformed public. The res ponsibility of keeping a people should rest with the people. Providing too much correction through taxation would shift the responsibility of keeping well to the agencies of government. It would also provide a large fund for laymen and politicians to feast upon at the expense of the taxpayers and the people’s health. Children who are regularly under the care of pedia tricians seldom have dental caries, but are apt to be afflicted by malocclusion rather characteristic of the practice of pediatricians. The malocclusion is charac terized by a narrow Y-shaped maxillary arch and a nar row mandibular arch in a retruded jaw. Pediatricians produce through their system of instruction and care a child with a beautifully contoured occiput but with a narrow repressed face. The people who swaddled produc ed through their maternal care a flat back head but a 2!j. C. Brash, M.C., M.A., M.D., The Aetiology of Irregularity and Malocclusion of the Teeth (The Dental Board of the United Kingdom, London, Second Impression) p. 246* 128. fully developed face in their infants,22 John Oppie McCall, D.D.8., in his letter to the in vestigator, stated. As regards prevention of malocclusion, the situation is much simpler technically, although it still involves the awakening of community conscience in regard to physic al handicaps among the under-privileged. It consists of providing continuous dental care for each child from the age of two until at least fourteen, so ■diat there shall he no inhibition of masticatory function from un cared for dental caries. This will cut down the number of cases of malocclusion tremendously, although it does not guaranted that the severe malocclusions mentioned above will be among those eliminated. It constitutes our best hope, h o w e v e r . 23 Methods of prevention. (2) education. Aside from providing continuous dental care for all children, the pre vention of malocclusions involves the dissemination of an educational program comprehensive enough to make all classes of the population orthodontia conscious. Like the task of providing children with dental care, the preparation and administration of such a program would be so huge a task that the investigator believes only governmental agencies could properly handle it. Such a program would include educational services 22personal interview with Harvey Stallard, D.D.S., at San Diego, California, April 7, 1936. 23per8onal correspondence. Letter from John Oppie McCall, Director, The Murry and Leonie Guggenheim Dental Clinic, New York City, March 16, 1936. 129. of all kinds, addressed to all classes of people, and co ordinated by whatever ultimate public authority would be behind the program. a. Orthodontia education in the school system. An important part of an educational program designed to pre vent the development of malocclusions would be carried on within the school system as a supplement to dental care. This would involve first of all the instruction of teachers in orthodontic problems, particularly habit problems, so that they, in turn, could pass on the instruction in a man ner suitable to the age of their classes. Dr. Spencer Atkinson, in interview, expressed the belief that about half of the number of malocclusions are developed by children after they enter school. They lean on desks, and on their hands, in the class room, as well as continue other bad orthodontic habits they have already f o r m e d . 2 4 Dr. C . P . S . Dillon, in interview, said it might be found necessary to change the construction of the pre sent school desk to a construction which would permit easy adjustment to the size of each individual child.25 24personal interview with Spencer Atkinson, D.D.S., March 16, 1936. 25personal interview with Dr. C. P. S. Dillon, March 16, 1936. 1 3 0 . In cases where oral hygiene programs have been ac cepted by school systems, such programs could be expanded to include the orthodontia educational work. Dr. Harvey Stallard has recently proposed an oral hygiene and educa tional program to the San Diego Board of Education, and fur ther proposed that this program be correlated with a county wide educational program for adults who would not be reached by the school service, but could be reached by activities of the County Health Department. He believes that: In cases where oral hygiene programs have been ac cepted by school systems, such educational programs could naturally include the prevention of malocclusion, caries and gingival infections. It has not been proved that the providing of public correction and public administration of therapies has decreased the incident of disease or improved the health services. A usual result is obtained in countries adopt ing socialization of dentistry in which the standards of dentistry decline, the dentists obtain for fees only what is left in the funds when hot exhausted by admin istrative costs, hospital expense, medical service, etc., and in the end the people would be better off if there were no dentists at all. On the other hand, if we suc ceeded in preventive education, we would not need den tists and the people would be bettered. The presence of dentists in a Society only proves that the preventive educational program has failed. b. Orthodontia education of the lay public. The pro blem of educating the lay public as to orthodontic facts and needs would have to be solved in a way that would achieve a two fold objective; first, convince the layman that mal occlusions should be prevented or treated, and second, convince 1 3 1 . him that as citizen and taxpayer he i s willing to spend money for such a purpose. All forms of appeal, including formal instruction and indirect and informal instruction through all methods of publicity might be employed to instill in the public mind a consciousness of orthodontic needs. The oral hy giene programs already employed by many health and school departments, notably by the Los Angeles County Health De partment, the Bridgeport, Connecticut, Health Department, the Peoria, Illinois, public schools and the Atlanta, Georgia, public schools, might be profitably studied during the pre paration of an orthodontia educational program. Dr. Harvey Stallard, in interview, suggested that certain kinds of commercial advertising and publicity, such as that conducted by business organizations in the milk and cheese industries, might be utilized for orthodontia educa tional purposes. He also expressed the opinion that along with the enlightenment of the lay mind, the solution of the problem might indicate regulatory measures upon foods offer ed the public, because of the intimate relation between diet and dental disease.^6 26personal interview with Harvey Stallard, D.D.S., at San Diego, California, April 7, 1956. 132. c. Orthodontia education of the health professions. Along with public and child instruction, a balanced pre ventive educational program should include provisions for the orthodontia education of health workers and practition ers both in the medical and the dental field. Orthodontics has developed its research and tech nique immensely during the past fifteen years, so much so that Dr. Harvey Stallard, in interview, expressed the fear that creating a public interest in and knowledge of ortho dontia might result in so fast increasing a demand for or thodontic care that specialists could not be trained quick ly enough to meet the need. The general practitioners in the dental profession, particularly the older members, should be reached by the orthodontia educational program to the extent that they will understand how to protect against the premature loss of teeth, how to make repairs that restore the original form, how to properly diagnose malocclusion and know the value of early treatment. The medical man should be able to give sound ad vice to parents concerning malocclusions, and understand their relation to general health. Dr. Harvey Stallard, in interview, made the point that for preventive purposes, the physician and orthodontist should work together, particularly in cases where endocrine disturbance is known. 133. The pediatrician and obstetrician should both possess a comprehensive knowledge of orthodontia, particularly of the causative factors in malocclusion, so they can actively cooperate in prevention, and, when necessary, treatment. At the present time there seems to be no connecting link be tween obstetricians, child specialists and orthodontists, and one is needed. Habit training, it is generally conceded, should be gin very shortly after birth. Pre-natal instructions to prospective mothers on child rearing should include adequate instruction as to the relationship of habits to malocclusion. One prominent and well trained obstetrician with whom the investigator discussed the sleeping habits of infants and their relation to the orthodontic problem, expressed dis interest, and the opinion it was “a lot of hooey#, and that anyhow it was a pediatrician’s and not an obstetrician’s problem. This attitude, the investigator believes, is quite general on the part of medical men towards orthodontia. The obstetrician leaves the responsibility for this problem with the pediatrician. But very few mothers in the United States can afford the luxury of a pediatrician. The best chance, frequently the only chance, the mother has to learn about habits and malocclusion is during her consulta tions with the obstetrician before the baby comes. 134. Dr. Guy S. Millberry notes this fact in an article in the Pacific Dental Gazette, One good opportunity then, is to educate the obste trician and the nurse, who are in closer contact with the mother during the antepartum period than any other professional groups. That these persons need counsel is borne out by a statement in the report of the White House Conference, 1930, dealing with prenatal and mater nal care, viz. Most of the dental supervision and advice, if given at all, comes from the physician without proper consulta tion with the dentist.2? Along with the orthodontia education of the practi tioners instruction should be given to other workers in the health field, including social workers and nurses, both in public health and in private work. This investigator believes that social workers and public health nurses are in a very special manner the liason between the practising professions and the people, particu- larly the great masses in the low income and indigent groups. No other classes of health workers are so well able to per form missionary health work. In a widespread preventive program, such as is here suggested, their work would be par ticularly important because they are the persons upon whom would naturally fall the responsibility of seeing that child ren of pre-school age received the necessary dental care, and 2?Guy S. Millberry, D.D.S., “Objectives in Public Dental Service#, Pacific Dental Gazette. September 1931. 135. of instructing mothers as to malocclusion facts. 1 3 6 . CHAPTER V I I I . PINDINGS AND SUGGESTIONS The modern progressive attitude toward children’s problems is to seek an understanding of the child as a whole, as a personality integrating physical, psychological and social factors of growth and development, rather than to limit the understanding within the arbitrary bounds of med ical and social specialty practise. This wider view of the subject is particularly applicable to a consideration of the orthodontic problem since, as we have seen above, malocclu sions may, and do, affect children physically, psychologically and socially. And the wider view is necessary to any scien tifically organized quest for a solution to the problem, since such a quest would depend upon the correlation of in quiries in varied fields of research. For the orthodontic problem is not entirely, perhaps even not primarily, a dental problem. Our inquiry into the causative and contributory factors in malocclusion (Chapter III) revealed that the etiology was as yet largely unknown; but that malocclusion was known to be related to the growth processes, to the functioning of the glands of internal se cretion, and to nutrition; and also that, in the opinion of many orthodontists, habits, though they may not be primary 137. factors of causation, were extremely important contributory factors. It may be argued that since causation is obscure or unknown the time is not yet ripe for preventive programs on a large scale. But many orthodontic authorities (Chapter VII) believe that the time is ripe for the launching of pre ventive programs, and that the larger the scale of such pro grams the better. In this connection a similarity may be pointed out between the orthodontic problem and the cancer problem. The etiology of cancer is also unknown. But preventive educa tional programs designed to make the public cancer conscious and reduce the mortality from the disease have been success fully carried out. The stimulated public interest has in turn stimulated laboratory research. The result in the gen eral health field has been a gain -- a vast amount of human suffering has been avoided, and large numbers of cancer vic tims, responding to the information in the preventive pro grams, have sought medical aid early enough to permit their lives being saved. In like manner, the investigator believes, the public interest in the orthodontic problem could be aroused, and this interest would in turn stimulate research into causes. It is true, malocclusion is not a life or death matter like 1 3 8 . cancer, but we have seen that in its extreme form it can cause psychological maladjustments and social wastes of a serious nature (Chapters IV-T), and its indicated high in cidence, and its known relation to dental and general health, (Chapter II), combine to make it an important health problem. The fact that possibly one half, or more, of American school children have maloccluded teeth, and that malocclusion is importantly related to the growth and well being of the child, (Chapters II-IIl), would seem to justify preventive measures which would have behind them an important body of orthodontic opinion. (Chapter VII) It must be kept in mind that malocclusion prevention includes needful dental treatment and continuous dental super vision of children. (Chapter VII) This does not mean treat ment and supervision by orthodontic specialists necessarily; it means that the dental needs of the child be supplied, thus possibly averting serious malocclusion development. It means the spreading of orthodontic knowledge among"the gen eral practitioners in dentistry, and among health workers whose interests touch child dentistry. It means the growth of a wider concept of dental service both inside and outside the dental profession. Dr. Guy S. Millberry, writing in the Pacific Dental Gazette for September, 1931, has aptly defined this wider 1 3 9 . concept : With one hundred per cent of all the people above the age of three years needing some form of dental service periodically; with health and welfare organi zations discussing the dental problem; with banks and insurance companies, industries and industrial workers, churches and schools, undertaking to solve it or some aspect of it, dental service becomes more of a social than a professional problem.! This study, in its survey of existing facilities for giving orthodontic treatments, revealed their inadequacy to meet the need, both clinically and socially. (Chapter VI) The need is so widespread and the costs of treatment so high, that only public funds could fully meet it. (Chapter VII) If we agree with the many authorities quoted above as to the intimate relationship between orthodontic problems and den tal and medical health and social well-being it would seem intelligent to accept and act upon the concept of dental service as a social problem, and provide necessary social measures for its solution. At this writing Federal funds are becoming available for various child welfare movements, including funds specif ically appropriated for the treatment of crippled children. It is suggested that the definition of crippled children might be widened to include dental cripples; and, perhaps !br. Guy S. Millberry, «Objectives in Public Dental Service#, The Pacific Dental Gazette. September 1931. 1 4 0 . even more important, potential dental cripples. Orthodontists generally are alive to the social pro blem involved in the practise of their specialty. At the 1936 convention of The American Spciety of Orthodontists the consciousness of this problem caused the appointment of a committee to study the socio-economic phases involved in treatment. But these orthodontists are working alone. It is suggested that other groups of children’s specialists, and public health workers and planners, could profitably give attention to the orthodontic problem, and correlate and supplement the findings of the orthodontists, as well as work toward securing public support for a constructive program for meeting the problem. During the progress of this study, the investigator endeavored to ascertain through correspondence with dental clinic and health authorities throughout the country if any where any organized efforts were being made to meet the ortho dontic problem. Replies to the queries were universally neg ative. Some clinics, such as the Rochester clinic, the Forsythe clinic and the Pasadena Hospital Dispensary (Chapter VI) are providing such orthodontic service as limited funds and facilities permit. But nowhere, so far as the investi gator could discover was any organized effort being made to provide orthodontic care on the broad social base of service 141. given when and where needed. Typical of the replies receiv ed is that from Dr. H. G. Pollock, president of the Ameri can Society of Orthodontists, and editor of the Internation al Journal Orthodontia; he wrote that he did not know of any organization which was endeavoring to meet the orthodontic problem, either in the preventive or the treatment fields.2 Dr. Ella Oppenheimer, Children’s Bureau, United States De partment of Labor, replied. In response to your recent letter, I regret to tell you that I do not know of any organization which is giv ing special attention to orthodontics as a public health problem. Dental hygiene work has long been a part of the health program of many public schools, especially in the larger cities, and possibly a certain amount of orthodontic work is done, or arrangements made for it.3 The investigator believes that the findings of this study disclose the orthodontic problem in the United States as being of sufficient size and importance in terms of num bers involved and social values concerned to justify its in clusion within the public health service, and to indicate that the lines of attack upon the problem which offer the best chance of success are those discussed above (Chapter VII) which envisage a publicly sponsored and supported pre- ventive-treatment program on as wide a scale as possible. ^Personal correspondence. Letter from Dr. H. C. Pollock, St. Louis, Missouri, April 29, 1936. 3personal correspondence. Letter from Dr. Ella Oppenheimer, Children’s Bureau, United States Department of Labor, January 29, 1936. 1 4 2 . The authors of the volume. Health Dentistry for the Commun ity, describe their study in words which the investigator feels apply particularly to the present study, “It is not the intent of this study to suggest a specifi c plan, but rather to delineate existing conditions and to utilize them as a basis for the statement that a comprehensive plan for socialized dental service is urgently needed.“3 ^The Committee on Community Dental Service of the New York Tuberculosis and Health Association, Health Dentistry for the Community. (Chicago: University of Chicago Press, 1935) p. 66. BIBLIOGRAPHY 1 4 3 . BIBLIOGRAPHY A. BOOKS Armstrong, Barbara, Insuring the Essentials. New Yorks Macmillan Company, 1932. Brash, J. G., M.C., M.A., M.D., The Aetiology of Irregularity and Malocclusion of the Teeth. London; The Dental Board of the United Kingdom, second impression. Cohen, Percy, The British System of Social Insurance. New Yorks Columbia University Press, 1932. The Committee on Community Dental Service of the New York Tuberculosis and Health Association, Health Dentistry for the Community. Chicago; University of Chicago Press, 1935. The Committee on Medical Care for Children, White House Conference on Child Health and Protection, Health Protection for the Pre-school Child. New York - Londons The Century Company, 1931. Dillon, Charles Frederick Stenson, The Evolution of Ortho- dontic Diagnosis. Etiology, and Treatment. Master’s Thesis, University of Southern California, 1933. Epstein, Abram, Insecurity, A Challenge to America. New York; Harrison Smith and Robert Haas, 1933. Leuck, Miriam Simons, A Further Study of Dental Clinics in The United States. Chicago; University of Chicago Press, 1932. McCoy, James David, M.S., D.D.S., F.A.C.D., Applied Ortho dontics. Philadelphia; Lea and Febiger, 1935, fourth edition. Stillman, Paul R., D.D.S., and McCall, John Oppie, A.B., D.D.8., A Text Book of Clinical Periodontia. New Yorks The Macmillan Company, 1922. Thomas, William I., The Unadjusted Girl. Boston; Little, Brown and Company, 1931. 1 4 4 White House Conference on Child Health and Protection, Growth and Development of the Child. Part II, Anatomy and Physiology. New York - London: The Century Company, 1933. B. REPORTS AND PAMPHLETS Committee on Public Dental Education of St. Louis Dental Society for 1934, Report and Dental Survey in the St. Louis Schools, (issued by St. Louis Dental Society. Cripple Children’s Act of the State of California, Chapter 590, Department of Public Health, fCalifornia State Printing Office, Sacramento, 1931). The Education of the Dental Patient. Why Construct a Bridge? '^Reprinted from Dental Digest, Copyright, 1933). Twentieth Annual Report of the Forsythe Dental Infirmary for Children, January, 1935. The Murry and Leonie Guggenheim Dental Clinic Annual Report. 1935. Annual Report of the Dental Department of the Peoria Public Schools, 1934-1935, C. Carroll Smith, D.D.S. Monthly Report of the Dental Department of the Peoria Public Schools, December 1935, C. Carroll Smith, D.D.S, Santa Clara Valley District Dental Association, pamphlets entitled Orthodontia ; Growth and Development of the Teeth; and Children’s Dentistry; 1935. Smith, C. Carroll, D.D.S., A History of the Mouth Hygiene Movement in the Peoria^Public Schools, August 1926. Rochester Dental Dispensary Annual Report, 1935. Rogers, James, Better Teeth, (The United States Department of Interior, Bureau of Education, Health Education, No. 20, 1927. 1 4 5 . C. PERIODICALS Baker, Lawrence W., "Further Evidence of Influence of the Forces of Occlusion on Development of Bones of Skull". Transactions Panama Pacific Dental Congress, Vol. 2 (1915). Bisch, Louis E., M.D., Ph D., "The Relation of the Inferior ity Complex to Orthodontia", Dental Cosmos. Vol. LXX (July, 1928). Bonney, Thos. C., D.D.S., "Facial Deformities". Mouth Health Quarterly, Vol. 4, No. 4 (October - December, 1935%* Brusse, Archie B., D.D.S., "Orthodontics as an Aid to the Rhinologist", International Journal Orthodontia, Vol. 21, Ho. 7 TJÜly, 1935)'. Cale-Mathews, G. F., L.D.S., "The Time Factor in Orthodontics", International Journal Orthodontia, Vol. 21, No. 9 Casto, Frank M., "Orthodontia and the General Practitioner", International Journal Orthodontia, Vol. 21, No. 9 September, 1935). ' Cartwright, Frank S., M.S., D.D.S., "Orthodontia -- Save and Sane", International Journal Orthodontia. Vol. 21, No. 8 (August, 1935%% Childs, W. B., D.D.S., "The Value of Orthodontia as a Health Service", International Journal Orthodontia. Vol. 19, No. 2 (February, 193377 Clarke, Eric Kent, M.D., "The Mental Hygiene of Dentistry", Journal American Dental Hygiene Association, (September, 1931). Coryell, Hubert V., "New Mouths for Old", Good Vol. 101, No. 4 (October, 1935). Crittenden, Louis M., D.D.S*, "Oral Deformities Associated with Impaired Hearing", Dental Cosmos, Vol. LXXIV (June, 1932). 1 4 6 . Crouch, S. Stuart, D.D.S., "Heredity", International Journal Orthodontia. Vol. 21, No. 6 (Junej1935)* Dean, J. Camp, D.D.S., "A Consideration of the Economic Treatment of Deciduous Teeth", International Journal Orthodontia, Vol. 20, No. 1 (January, 1934)7 Delabarre, Frank A., D.D.S., "Orthodontia and Dentistry for Children", International Journal Orthodontia, Vol. 21, No. 9 (September, 1935J7 Dewey, Martin, "A Public Health Talk", International Journal Orthodontia, Vol. 11, No. 5 (May, 1925)♦ Dinham, W.R., D.M.D., "A Discussion of the Clinic Plan as Applied to Orthodontia", International J ournal Ortho dontia, Vol. 19 (1933). Grant, T. A., D.D.S., "Relation of the Endocrines to the Teeth", International Journal Orthodontia, Vol. 21, No. 9 (September, 19357*1 Haynes, W. Tyler, B.S., D.D.S., "Development of Teeth and Jaws", International Journal Orthodontia, Vol. 21, No. 11 %Nbvember, 1935)7 Holman, Bertha, "The Two-Year-Olds Make Friends With the Dentist", Child Health Bulletin, Vol. X, No. 3 (May, 1934). Jordan, M. Evangeline, D.D.S., "Operative Dentistry for Children", Dental Items of Interest, Vol. 46, No. 10 (October, 1924) Vol. 46, No. 11 (November, 1924); Vol. 46, No. 12 (December, 1924). Kelsey, Harry E., D.D.S., F.A.C.D., "Place of Orthodontia in the Impending Wider Health Service", Journal American Dental Association, Vol. XXI, No. 3 (March. 1934). ' "The Public Clinic as a Measure of the Cost and Value of Universal Health Service", International Journal Orthodontia, Vol. 19, No. 4 {April, 1933). Kemple, Frederick C., "Observations on a Few Problems of Orthodontia", International Journal Orthodontia, Vol. 21, No. 7 (July7 1935). 1 4 7 . Siudtzin, E. P., "Dental Defects and Mental Hygiene", Mouth Health Quarterly, Vol. 4, No. 3 (July - October, 1935), Langdon, L. Russell Marsh, L.D.S., "Orthodontics and Common Sense", International Journal Orthodontia, Vol. 21, No. 6 (June, 1935)7 Iiischer, B.D., D.M.D., "Orthodontic Education", International Journal Orthodontia, Vol. 21, No. 6 (June, 1935). Ludwick, Paul G., D.D.S., "Orthodontia -- Its Relation to Health", International Journal Orthodontia, Vol. 21^ No. 9 (September, 1935). Book Review of "Applied Orthodontics" by David McCoy, Inter national Journal Orthodontia, Vol. 21, No. 10 (October, 193577 Millberry, Guy A., D.D.S., "A University Curriculum for Graduate Orthodontics", Journal American Dental Association, (July, 1927]7 "The Outlook for Dental Practice", Pacific Dental Gazette,(January, 1933). "The Minimum Basic Training for the Practice of Medical Specialties Including Dentistry, American Dental Association Journal, (September, 1927). "An Adequate Course of Instruction in Orthodontics", Dental Cosmos, (May, 1930). "Objectives in Public Dental Service", The Pacific Dental Gazette, (September, 1931). "Effective Public Dental Clinics", Journal American Dental Association, Vol. XVIII (April, 193177 Moore, George, R,, D.D.S., "Case Anterocclusion Treated at an Early Age", International Journal Orthodontia. Vol. 21, No. 10 [October, 19357#* Murlless Frederic T., Jr., "Address", International Journal Orthodontia. Vol. 21, No. 10 (October,1935). 148. Nelson, A. Alfred, D.D.S., "The Aesthetic Triangle in the Arrangement of Teeth", Journal National Dental Assoc iation, (May, 1922). Oppenheim, Albin, Vienna, "Critical Review of the Publica tions of J. A. Marshall", International Journal Orthodontia, Vol. 21, nO. 8 (August, 1935). Patry, P. L. M.D., "What Has Psychiatry to Offer the Dental Hygienist?", Dental Cosmos, Vol. 74, No. 11 (November, 1932). Patterson, R. McClure, D.D.S., "Observations on the General Practice of Juvenile Dentistry", International Journal Orthodontia, Vol. 21, No. 6 (june'J 1935)7 ” Porter, Lowrie, J., "Possible Orthodontic Assistance in Mutilated Cases in Conjunction with or in Preparation for Prosthetic Restorations", International Journal Orthodontia, Vol. 21, No. 10 (October, 1935). Pullen, Herbert A., "Control of Overbite", Transactions Panama Pacific Dental Congress, Vol. 2 [1915)7 Robertson, T. M., B.S., D.D.S., "Root Movement and Bone Development", International Journal Orthodontia, Oral Surgery and Radiography, Vol. XI, No. 9 [September, 1925)7 Rogers, Alfred Paul, "Exercises for the Development of the Muscles of the Face with a View to Increasing Their Functional Activity", Dental Cosmos, Vol. LX, No. 10 (October, 1918). "Exercises for the Development of the Muscles of the Face", American Dental Association Journal, Vol. 23, No. 1 (January, 1936)7 Salzmann, J. A., D.D.S., "The Face as a Factor in Health and Life", International Journal Orthodontia, Vol. 21, No. 8 (August, 1935). Sperber, I. J., "Dental Deformities and Mental Hygiene", Psychiatric Quarterly, Vol. 4, No. 3 (July, 1930). 1 4 9 . Smith, C. Carroll, D.D.S., "Correlating Dental Health Instruc tion with the Modern Public School Program", Inter- national Journal Orthodontia, Vol. 20, No* 1 (January, 1934). ~ "Teaching Mouth Hygiene in Schools", Journal American Dental Association, Vol. XXXI, No. 7 (July7 1934). "Public Dental Health", International Journal Ortho dontia, Vol. XIX, No. 12 (December, 1933)7 "Why Dental Health Education in Public Schools", International Journal Orthodontia, Vol. 20, No. 2 (February, 1934). Stallard, Harvey, D.D.S., "Etiology of Crossbites and Gothic Arches", The Dental Cosmos, Vol 65, 1181 (1923). Steadman, G. B., D.D.S., "Orthodontia as Preventive Dentistry", American Dental Association Journal, (August, 1928). Taylor, H. B., "A Visual Presentation for the Patient of the Importance of Dental Service", International Journal Orthodontia, Vol^ 21, No. 11 (November, 1935). Trier, Jerome, H., D.D.S., "The Limitations of Orthodontia", International Journal Orthodontia, Vol. 21, No. 9 (September, 1935). "The Meaning of Orthodontia", Mouth Health Vol. 4, No. 3 (July-October, 1935). Waldron, Webb, "About Face", Readers’ Digest, Vol. 28, No. 167 (March, 1936). ------- --- Waugh, L. M., . "Address", International Journal Orthodontia, Vol. 21, No. 10 (October,19357. Wile, I. S., M.D., "The Relation of Teeth to Behavior of Man", Mouth Health Quarterly, Vol. 2, No. 4 (July, 1933). Willett, R. C., D.M.D., "Surgical Orthodontic Correction of a Macro-mandibular Deformity", The International Journal of Orthodontia, Oral Surgery and Radiography, Vol. XII, Ho. 10 (October, 1926]. 1 5 0 . Wilson, Harris, R. C., "Mouth Hygiene for Cleveland School Children", International Journal Orthodontia, Vol. 21, Mo. 10 (October, 1935). D. OTHER SOURCES Personal Correspondence of the Author: Brandhorst, 0. A., D.D.S., St. Louis, Missouri, March 12, 1936. Burkhart, H. J., D.D.S., Director, Rochester Dental Dispensary, March 11, 1936. Dickie, Walter M., M.S., Director, State of California, Depart ment of Public Health, January 15, 1936. Edwards, Thomas C., Manager, National Health Council, New York City, January,17, 1936. Gottwerth, Sylvia, Associate Editor, American Mouth Hygiene Association, Minneapolis, Minnesota, February 27, 1936. Hill, Lilliam B,, Chief, State of California, Department of Education, Bureau of Mental Hygiene, Sacramento, March 3, 1936. Hunt, Mrs. Josephine P., Librarian, American Dental Associa tion, Chicago, December 9 and March 12, 1936. lanne, Charles L., M.D., Santa Clara County Hospital, San Jose, California, January 20, 1936. Komora, Paul 0., Associate Secretary, The National Committee for Mental Hygiene, New York City, February 15, 1936. McCall, John Oppie, D.D.S., Director, The Murry and Leonie Guggenheim Dental Clinic, New York City, March 16, 1936. Millberry, Guy S., D.D.S., Dean, University of California Dental School, San Francisco, December 3, 1935. Malloch, Archibald, M.D., Librarian, The New York Academy of Medicine, New York City, January 20, 1936. 1 5 1 . Miller, I* Frank, D.D.S., Pittsburg, Pennsylvania, January 22, 1936. Oppenheimer, Ella, M.S., United States Department of Labor, Children’s Bureau, January 29, 1936. Pollock, H. C., D.D.S., Editor International Journal Ortho dontia, St. Louis, Missouri, April 29 and May 4, 1936. Sheffer, Will C., D.D.S., San Jose, California, January 24, 1936. Smith, Barry C., Director, The Commonwealth Fund, New York City, January 14, 1936. Stone, Frank P., Col. Dental Corps, United States War De partment, February 14, 1936. Strang, Robert H. W., D.D.S., Bridgeport, Connecticut, March 23, 1936. Sutton, Willis A., Supertintendent of Schools, Atlanta, Georgia, April, 1936. / Russell, Helen B., Russell Sage Foundation, New York City, January 16, 1936. Walker, Alfred, D.D.S., New York City, January 18, 1936. Williams, R. U., United States Treasury Department, Public ^ Health Service, Division of Sanitary Reports and Statistics, March 16, 1936. Interviews : Atkinson, Spencer, D.D.S., Pasadena, California, March 16, 1936. Bronson, Earl, D.D.S., University of Southern California Dental College, December and January, 1935 - 1936. Cooper, Riith, Director, Social Service of Los Angeles County General Hospital, April 6, 1936. Dillon, F. S., M.S., D.D.S., University of Southern California Dental College, March 16, 1936. 1 5 2 . Gould, I. Eugene, D.D.S., Pasadena, California, interviews throughout period of investigation, 1935-1936. King, E. J., former Superintendent, Strickland Home, Los Angeles, April 10, 1936. Kratka, Alice, Social Worker, Pasadena Hospital Dispensary, frequent interviews, 1935-1936. McCauley, C. M., D.D.S., Los Angeles Orthopaedic Hospital, February 7, 1936. Merrick, Hazel, D.D.S., Los Angeles County Health Depart ment, December, 1935, January and March, 1936. Mitschke, Linda, Agent for State of California, Department of Crippled Children, January 3 and March 17, 1936. Rumset, Earl W., Los Angeles Probation Department, April 1, 1936. Sattler, L. R., D.D.S., Los Angeles, March 20, 1936. Stallard, Harvey D., D.D.S., San Diego, April 7, 1936. Taylor, Frank M., D.D.S., Pomona, California, February 10, 1936. Van Euskirk, Guy, D.D.S., Los Angeles, January, 1936.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

The role of the psychiatric social worker in psychiatric hospitals and clinics

PDF

A study of changes in services of All Nations Foundation as affected by the neighborhood's ecological changes

PDF

Factors associated with truancy in juvenile delinquency cases

PDF

Social service on a locked ward in a state mental hospital

PDF

Mental illness in adult males: Impact on fathers

PDF

The State Relief Administration social worker: an analysis and survey of the educational background, professional training and experience, and functions of one hundred social workers in the State R...

PDF

A study of the Los Angeles medical agencies providing care for certain classes of low income groups

PDF

The impact of alcoholism on the family: A study of interaction within six families, their attitudes and feelings towards a father who is alcoholic

PDF

An analysis of the community's use of the Los Angeles Bureau of Social Work of the California State Department of Mental Hygiene as demonstrated by request for information and referal service

PDF

A community's use of a mental hygiene clinic: A statistical study of one hundred and fifty-five cases referred to the Long Beach Mental Hygiene Clinic

PDF

Physical factors involved in injuries to California Highway Patrol motorcycle officers

PDF

Differential function of public health nursing and medical social work in the Los Angeles County Health Department

PDF

Short service in a children's outpatient psychiatric clinic: A follow-up study

PDF

The social implications of delay in sanatorium placement for tuberculosis; a study of a group of cases in Los Angeles County

PDF

Hospital care for home patients

PDF

Requests for re-study at a children's psychiatric clinic

PDF

Factors affecting readiness of leave patients in using after-care services as seen in initial interviews

PDF

Legal aspects in the development of health maintenance organizations

PDF

Social service on a transition ward and a maximum security ward in a state mental hospital

PDF

U.S. Children's Bureau: An account of legislative history of its establishment

Asset Metadata

Creator George, Dorothy Marian (author)

Core Title Orthodontics: A new field in public health

School School of Social Work

Degree Master of Science

Degree Program Social Work

Degree Conferral Date 1936-06

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

Tag health and environmental sciences,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c39-338823

Unique identifier UC11313243

Identifier EP65550.pdf (filename),usctheses-c39-338823 (legacy record id)

Legacy Identifier EP65550.pdf

Dmrecord 338823

Document Type Thesis

Format application/pdf (imt)

Rights George, Dorothy Marian

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