Vol. 67, No. 5
345
The Development of Education in Dental Public Health in the United States of America* JOSEPH L. HENRY, D.D.S., Ph.D., Dean,t and
JEANNE C. SINKFORD, D. D.S., Ph. D., Associate Dean, § Howard University College of Dentistry, Washington, D.C., U.S.A.
The purpose of this paper is briefly to summarize the development of dentistry, dental education and the factors and forces which interplay related to the dental health of the public in the United States of America. There will be special focus on the developments of the last decade since they represent our current and future directions. Finally, some observations and recommendations will be made for your consideration related to dentistry and the development of the dental public health system in Finland. Circumstances preclude all but a surface skimming of historical events. Dentistry in the United States began in the colonial era and was a weak counterpart of dental practice in the mother countries of the several colonial groups. Dentistry, at this time, was practiced by a few physicians and surgeons, numerous mechanical barbers, and a surprising number of charlatans. The earliest documentable barber-surgeon giving attention to dental ailments was in 1639. From this time until the establishment of the first dental school in the world in Baltimore, Maryland in 1840, the practitioners were generally untrained, self-educated or recipients of apprenticeship training from an "established" practitioner. The degree of competency was almost totally dependent upon the motivation of the interested man. There were generally three types of practitioners *Read at the National Symposium on Dental Public Health at the Annual Convention of the Finnish Dental Society, March 30, 1974, Helsinki, Finland. tNow professor at Harvard University School of Dental Medicine, Boston, Mass. §Now dean.
during this period: a) a physician with interest in diseases of the mouth who apprenticed himself to an ethical practitioner; b) those without medical background who apprenticed themselves to a practitioner for a fee until both felt the student could practice on his own; and c) charlatans who posed as dentists and treated the trusting public without benefit of any exposure to the science and art of dentistry. The important work and publication of Pierre Fauchard, "Le Chirurgien Dentiste," the first complete work on dentistry, and "The Natural History of the Human Teeth," by John Hunter of England were outstanding contributions during this period. Their effect was felt directly and indirectly among the American dental practitioners. The years preceding the founding of the first dental school included the founding of the first dental society called the "Society of Surgeon Dentists or the City and State of New York," in 1834; the formation of the first national society, the American Society of Dental Surgeons in 1840; and the first dental journal, the "American Journal of Dental Science," in 1839. The emergence of dentistry as an independent and "organized" profession in 1840, with the establishment of the Baltimore College of Dental Surgery, was followed by several decades of confusion and uncertainty until Harvard University implemented a dramatic dental educational model. In 1867, Harvard brought the dental department into close affiliation with the med-
346
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
ical department and created the first university base for dentistry. Also, the one and later two year requirement for graduation from dentistry now became a three year requirement. Other universities in the U.S. followed the Harvard model.1-4 Attempts to effect the decline of private preceptorship by ethical practitioners was assiduously pursued from the time of the inception of Baltimore College of Dental Surgery. This effort met with little success. Finally, because of the infamous conditions related to the practice of many charlatans and quacks, regulatory laws for the practice of dentistry appeared in about 1868. All states had enacted dental regulatory laws before
1900.5,6 Unfortunately by 1900 most university based dental schools had disappeared leaving the proprietory schools to dominate the pro-
fession. From the time of the first association of dental schools in 1884 and the National Association of Dental Examiners in 1883 until the Gies Report in 1926, there existed a troubled era of conflict, internal strife, questionable standards and diploma mills. This occurred despite the appearance on the scene of giants like G. V. Black, John Oppie McCall, John Knutson, Balint Orban, Harry Sicher and many others.61 1 The trials and tribulations of these times are epically portrayed in books such as "Dental Education in the United States" by O'Rourke and Miner, The Gies Report for the Carnegie Foundation and "The Evolution of Dental Education" by John Gurley .2,4,5 Epochal events and publications during the period 1926 through 1964 swiftly produced the four year curriculum, educational reforms, disappearance of proprietary schools, and the development of standards for admissions, accreditation, and graduation. Of special interest were the publications: " American Association of Dental Schools Comprehensive Report on the Dental Curriculum" in 1935; Harner's "Dental Education Today" in 1947, and Hollingshead' s "Survey of Dentistry" in 1961 . 4, 12,13 Today all of the 58 operational dental
SEPTEMBER, 1975
schools in the U.S.A. are University affiliated and are under a single accrediting body and there is a national board and state and regional licensure examinations. There are roughly 118,000 dentists in the U.S.A. including approximately 18,000 dental students but not including auxiliaries and postgraduate dental students. The dentist to population ratio is now Ito 2,100.14 We are fortunate that federal funds are being directed toward health, education, research and dental health care. For 25 years the government has given direct support to dental research through the National Institutes of Health and the National Institute for Dental Research. The Armed Forces, Veterans Administration and United States Public Health Service have contributed significantly to educational research and to meeting dental service needs of the nation. Federal laws such as Title 5 of our Social Security Act provide for dental services for maternal and child age patients.15 Programs such as these are implemented at the state and local levels. The American Dental Association, The American Association of Dental Schools and the National Dental Association, as well as state and local dental societies have been our major lobbying organizations and have presented our dental health needs to congress for legislative deliberations.16 Discoveries resulting from research and by chance have had profound effects on the practice of dentistry and the pattern of the profession. Perhaps the most outstanding examples of these are: effects of fluoridation of public water supplies; the use of topical fluorides; the new focus on prevention and preventive techniques; discovery of "light touch" air powered drills; painless injection for local anesthesia and major efforts to control pain and anxiety; and even injections without using needles. 17,18 Since 1964 changes have been occurring so rapidly that their effects stagger the imagination! The advent of portable equipment instituted the practice of "bringing dental care" to the chronically ill, aged and homebound wherever they reside. The use of multiple auxiliaries in multiple operatory of-
Vol. 67, No. 5
Education and Dental Public Health
fices permitted practitioners to double and redouble their productivity.15,16 The advent of group and incorporated practices, peer review, neighborhood health centers, health maintenance organizations (HMOs), lie-down supine dentistry for patients with sit-down dentistry fir dentists, prepaid and third party dental insurance, "rediscovery" of the dental plaque, new focus on prevention and nutrition, pain control and the development of a national health scheme to provide health care as a right for all irrespective of economic status - all of these have had prodigious effects on the nature, scope and pattern of dental practice in the U.S.A. 1516 Of parallel and almost equal importance have been the discoveries resulting from research related to the etiology of dental disease, materials, and devices and treatment methodologies and modalities. These have led to the use of new adhesives, sealants, composite resins, plaque control and home care methods (including irrigators, sulcular brushes, disclosing wafers and fluorescent lights); and interdisciplinary approaches to treatment between the clinical specialty areas such as periodontics - prosthodontics; surgery and orthodontics; pedodontics and restorative. Also, the use of other professionals: engineers, psychologists, speech pathologists, geneticists, immunologists, and biochemists, to focus their expertise on orally related problems, is widespread in the U.S. today. 15,17 The entire treatment capability has been upgraded by the development of eight recognized dental specialties beginning in the mid-forties with oral surgery and ending in the mid-sixties with endodontics. Most U.S. specialty training programs are university and hospital based and require from one to three years of post-graduate training for board
eligibility. The intense focus on prevention of dental decay and periodontal disease has changed the morbidity of disease in Americans and has affected and will continue to affect the nature of dental practice. Anterior proximal decay has all but disappeared in many United
347
States communities. Routine loss of teeth and eventual edentulousness has been replaced by routine presence of teeth and the dwindling presence of the full denture patient. New attention is being given to growth and developmental problems, orthodontics and surgical orthodontics, speech and myofunctional therapy, transplants and implants, and the role of dentistry in hospital and neighborhood clinic settings. Major efforts are being directed toward altering the dental health delivery system through use of the health team and with a concept of total patient care. 15 These and other new developments promise a bright future and new directions for the profession of dentistry. An extensive bibliography is provided for those who wish to pursue the details of the development of dentistry, dental education and the development of the dental public health in America. However, our suggestion is that you look at us and other countries carefully. Your position is unique in that you have the advantage of the hindsight of the gains and the mistakes we and others have made. Therefore, you have the opportunity to avoid the pitfalls and the opportunity to include the good features of the various health care systems of the world. These systems should be embellished, refined and "tailor-made" to meet your own needs.18 In fact, you have the rare opportunity to create a model that may be utilized by many other countries of similar circumstances. We urge you to develop preventive oriented national health 'programs instead of a repair oriented system. You should press for a dental health officer in each province who would be charged with focusing the needs and quality of care for the citizens of his province. It is imperative that you begin to train specialists, increase your output and revamp the roles of your auxiliaries, and take a hard look at the educational program for and functions of your special dental laboratory technicians (legal denturists).19,20 You have a proud heritage upon which to build. Especially noteworthy is the recogni-
348
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
tion and training of women as equals in the profession. 19 Special efforts must be made to become a bonafide partner in rendering hospital dental service and with advice as needed to all who go to the hospital. Of even greater importance is that you should seek public health positions and opportunities according to your ability and not allow yourselves to be excluded from broad health opportunities because you are a dentist and not a physician. Let the Finnish indomitable spirit and determination become manifest in this area! Special commendation is richly deserved for the Committee on Dental Education (CDE) in Finland for their fine report in 1972. The report presented a thoughtful road map to better dental care delivery and better dental education for the people of Finland. We hope that you have endorsed and are actively implementing the recommendations of the committee.20 In summary, we should like to suggest that as you go forward with dental health service planning, special attention should be given to: 1) the development of a national health strategy which focuses on prevention and clearly delineates the health care priorities and includes the most efficient procedures for implementation; 2) the health delivery system should have a quality control component and should be available to all people regardless of age, sex, geographical locale, economic status, etc.; 3) major educational efforts must be directed toward changing the "barriers" toward the receipt of dental services through patient education and through availability of health professional personnel for all regions of the country; 4) the health educational system must include and provide for continuing and postgraduate educational requirements to maintain a high quality of care; and 5) research and other advances should be readily translated into improvements in diagnosis and treatment and in the elevation of the overall quality of health. In conclusion, the "Helping Hand of Howard" reaches out across the United States and to underdeveloped countries of the
SEPTEMBER, 1975
world. An International Dental Health Information Exchange should be implemented and facilitated so that the "Helping Hand of Howard" concept could be used as a helping hand for health for the people of the world. Such an exchange would allow us to cooperatively build on each other's strengths and avoid pitfalls which would impede progress toward advances in the quality of health for all people. LITERATURE CITED
1.
2. 3.
4.
5. 6. 7.
8. 9. 10.
11. 12. 13. 14.
ZAMBITO, R. F. History of the Development of the Four Year Curriculum in Dental Education, N. Y. State Den. J., 35:480-484; 1969. GURLEY, J. E. The Evolution of Dental Education. The American College of Dentists, Ovid Bell Press, Inc., Fulton, Mo., 1960. LEWIS, C. P. The Baltimore College of Dental Surgery and the Birth of Professional Dentistry, 1840, Maryland Historical Magazine, 50:268-85, 1964. GIES, W. J. Dental Education in the United States and Canada - Bulletin 199 - Carnegie Foundation for the Advancement of Teaching, D. B. Upike, Merrymount Press, Boston, 1926. O'ROURKE, J. T. and L. S. MINER, Dental Education in the United States. W. B. Saunders Co., Phila. and London, 1941. COLLINS, W. K. Dental Licensure and the Development of Dentistry in the United States. Jour. Amer. Coll. Dent., 40:41-53, 1973. SWEET, A. P. Dental Diploma Mills, Part I. The Problem. Dental Rad. and Photog., 35:82-86, 1962. SWEET, A. P. Dental Diploma Mills, Part II. The Problem Resolved. Dental Rad. Photog., 36:40-57, 1963. SWEET, A. P. Dental Diploma Mills, Part III. Foreign Reaction. Dental Rad. Photog., 36:57-68, 1963. FOLEY, G. P. Foley's Foornotes: A Treasury of Dentistry. Washington Square East Publishers, Wallingford, Penn., 1972. RING, M. E. Oddments in Dental History: The Bogus Dental Diploma for Sale, Bull. of the History of Dent., 20:76-78, 1972. HARNER, H. H., Dental Education Today, The University of Chicago Press, Chicago, Ill., 1947. HOLLINGSHEAD, B. S. The Survey of Dentistry - The Final Report. American Council on Education, Wash., D.C., 1961. Health Resources Statistics. Health Manpower and Health Facilities, 1972-1973, H.E.W., P.H.S., National Center for Health Stat., Rockville, Md., 20852, June, 1973. (Concluded on page 410)
410
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
islature cited him for unusual and extraordinary service in a special resolution. Our space will not permit an enumeration of his manifold
SEPTEMBER, 1975
professional activities and affiliations, but these have been most comprehensive and demanding. The Allens have two sons, Aris T., Jr. and Lonnie W. .
CRISIS INTERVENTION and ITS APPLICATION TO PATIENTS IN A CHILD PSYCHIATRY OUT-PATIENT CLINIC. VIOLET E. STEPHENSON, M.D. Clinical Assistant Professor of Psychiatry, Downstate Medical Center, State University of New York, Brooklyn, New York The facility here discussed is an out-patient Child Psychiatry Clinic, located in a University-Municipal hospital setting of a large city of the Eastern United States. Although specific catchment areas have been designated to the numerous mental health facilities, functioning on a lesser degree in this Borough, this outpatient clinic is somewhat unique in that it functions as the emergency room for children of the entire Borough. This role had to be assumed by this clinic, primarily because it is the only Child Psychiatry facility in the Borough with an inpatient facility for children up to, but not including the 16th birthday. This inpatient counterpart has merely 50 beds-14 female adolescent, 24 male adolescent, and 12 latency. When one considers that there are approximately 3,000-4,000 children evaluated per year, and that more than half the inpatient beds are invariably occupied by patients remanded by the court for evaluations, it immediately becomes evident that this outpatient clinic functions well, in spite of tremendous odds, in order to measure up to the expectations of the community, but more so, to the needs of the patients who seek help. With such a major responsibility, this clinic, over the years, continuously reviews and revises its evaluation and treatment modalities in order to better serve its patients. Of the many treatment modalities utilized by this clinic, Crisis Intervention has been selected as the topic for presentation and discussion. Since this clinic services children primarily of low socioeconomic backgrounds, the experience has been that there is a high incidence of failed appointments when these patients are assigned for long-term psychotherapy. After a careful evaluation of the cases, as well as the statistics, it became evident
15.
16.
17.
that a sizable number of the patients respond only until, in their estimation, the crisis which brought them to the clinic, has subsided. In addition to this type of self-limiting crisis intervention, the clinic very frequently must intervene and provide intensive intervention in instances in which patients need to be hospitalized, but because there are no available beds, these patients must be treated on an outpatient basis until beds become available, until they can be sent to a State Hospital, or until there is remission of symptoms. In this latter instance, the patients are followed with medication and supportive measures as indicated. The acutely psychotic retardate who has been functioning well in the community is also a very special area in which crisis intervention is required. This is so, because of the very limited inpatient facilities for the retardate and also because the State Hospitals are very reluctant to admit those retardates with I.Q.'s less than 52. In order to prevent the "dumping" of these children on the clinic's inpatient facility, the outpatient clinic must intervene until the patient and his family have surmounted the crisis. In summary, crisis intervention is presented, as it is applied in an outpatient clinic which services a very large population of children of low socio-economic background who present during periods of crisis. The various circumstances that demand this form of treatment are also presented. Emphasis is made on the fact that while in some instances crisis intervention is the best mode of treatement for the presenting patient, in other instances in which hospitalidation is the treatment of choice, crisis intervention is utilized because of the unavailability of hospital beds. In both instances however, the end results have been gratifying.
(Henry and Sinkford, from page 348) 18. WALKER, R. D. and C. L. SEVELIUS. PubDentistry in National Health Programs. Amerilic Dental Health Services World-Wide, Comcan Dental Association, 211 East Chicago Ave., mission on Public Dental Health Services, Chicago, Ill., 6061 1, Oct. 1971. Health Education and Welfare. Trends Annual F.D.I., 1964. 19. Dental Health in Finland. National Board of Supplement to Monthly H.E.W. Indicators OfHealth, Office of Dental Health, 00530 Helsinki fice of Program Analysis, H. E. W. Office of the 53 Finland, 1973. Secretary, Wash., D.C., 1963. DUNNING, J. M. Principles of Dental Public 20. Report of the Committee on Dental Education in Health, Harvard University Press, Cambridge, Finland - an Abridge Statement. Helsinki, Mass., 1970, 2nd edition. 1971.
345
The Development of Education in Dental Public Health in the United States of America* JOSEPH L. HENRY, D.D.S., Ph.D., Dean,t and
JEANNE C. SINKFORD, D. D.S., Ph. D., Associate Dean, § Howard University College of Dentistry, Washington, D.C., U.S.A.
The purpose of this paper is briefly to summarize the development of dentistry, dental education and the factors and forces which interplay related to the dental health of the public in the United States of America. There will be special focus on the developments of the last decade since they represent our current and future directions. Finally, some observations and recommendations will be made for your consideration related to dentistry and the development of the dental public health system in Finland. Circumstances preclude all but a surface skimming of historical events. Dentistry in the United States began in the colonial era and was a weak counterpart of dental practice in the mother countries of the several colonial groups. Dentistry, at this time, was practiced by a few physicians and surgeons, numerous mechanical barbers, and a surprising number of charlatans. The earliest documentable barber-surgeon giving attention to dental ailments was in 1639. From this time until the establishment of the first dental school in the world in Baltimore, Maryland in 1840, the practitioners were generally untrained, self-educated or recipients of apprenticeship training from an "established" practitioner. The degree of competency was almost totally dependent upon the motivation of the interested man. There were generally three types of practitioners *Read at the National Symposium on Dental Public Health at the Annual Convention of the Finnish Dental Society, March 30, 1974, Helsinki, Finland. tNow professor at Harvard University School of Dental Medicine, Boston, Mass. §Now dean.
during this period: a) a physician with interest in diseases of the mouth who apprenticed himself to an ethical practitioner; b) those without medical background who apprenticed themselves to a practitioner for a fee until both felt the student could practice on his own; and c) charlatans who posed as dentists and treated the trusting public without benefit of any exposure to the science and art of dentistry. The important work and publication of Pierre Fauchard, "Le Chirurgien Dentiste," the first complete work on dentistry, and "The Natural History of the Human Teeth," by John Hunter of England were outstanding contributions during this period. Their effect was felt directly and indirectly among the American dental practitioners. The years preceding the founding of the first dental school included the founding of the first dental society called the "Society of Surgeon Dentists or the City and State of New York," in 1834; the formation of the first national society, the American Society of Dental Surgeons in 1840; and the first dental journal, the "American Journal of Dental Science," in 1839. The emergence of dentistry as an independent and "organized" profession in 1840, with the establishment of the Baltimore College of Dental Surgery, was followed by several decades of confusion and uncertainty until Harvard University implemented a dramatic dental educational model. In 1867, Harvard brought the dental department into close affiliation with the med-
346
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
ical department and created the first university base for dentistry. Also, the one and later two year requirement for graduation from dentistry now became a three year requirement. Other universities in the U.S. followed the Harvard model.1-4 Attempts to effect the decline of private preceptorship by ethical practitioners was assiduously pursued from the time of the inception of Baltimore College of Dental Surgery. This effort met with little success. Finally, because of the infamous conditions related to the practice of many charlatans and quacks, regulatory laws for the practice of dentistry appeared in about 1868. All states had enacted dental regulatory laws before
1900.5,6 Unfortunately by 1900 most university based dental schools had disappeared leaving the proprietory schools to dominate the pro-
fession. From the time of the first association of dental schools in 1884 and the National Association of Dental Examiners in 1883 until the Gies Report in 1926, there existed a troubled era of conflict, internal strife, questionable standards and diploma mills. This occurred despite the appearance on the scene of giants like G. V. Black, John Oppie McCall, John Knutson, Balint Orban, Harry Sicher and many others.61 1 The trials and tribulations of these times are epically portrayed in books such as "Dental Education in the United States" by O'Rourke and Miner, The Gies Report for the Carnegie Foundation and "The Evolution of Dental Education" by John Gurley .2,4,5 Epochal events and publications during the period 1926 through 1964 swiftly produced the four year curriculum, educational reforms, disappearance of proprietary schools, and the development of standards for admissions, accreditation, and graduation. Of special interest were the publications: " American Association of Dental Schools Comprehensive Report on the Dental Curriculum" in 1935; Harner's "Dental Education Today" in 1947, and Hollingshead' s "Survey of Dentistry" in 1961 . 4, 12,13 Today all of the 58 operational dental
SEPTEMBER, 1975
schools in the U.S.A. are University affiliated and are under a single accrediting body and there is a national board and state and regional licensure examinations. There are roughly 118,000 dentists in the U.S.A. including approximately 18,000 dental students but not including auxiliaries and postgraduate dental students. The dentist to population ratio is now Ito 2,100.14 We are fortunate that federal funds are being directed toward health, education, research and dental health care. For 25 years the government has given direct support to dental research through the National Institutes of Health and the National Institute for Dental Research. The Armed Forces, Veterans Administration and United States Public Health Service have contributed significantly to educational research and to meeting dental service needs of the nation. Federal laws such as Title 5 of our Social Security Act provide for dental services for maternal and child age patients.15 Programs such as these are implemented at the state and local levels. The American Dental Association, The American Association of Dental Schools and the National Dental Association, as well as state and local dental societies have been our major lobbying organizations and have presented our dental health needs to congress for legislative deliberations.16 Discoveries resulting from research and by chance have had profound effects on the practice of dentistry and the pattern of the profession. Perhaps the most outstanding examples of these are: effects of fluoridation of public water supplies; the use of topical fluorides; the new focus on prevention and preventive techniques; discovery of "light touch" air powered drills; painless injection for local anesthesia and major efforts to control pain and anxiety; and even injections without using needles. 17,18 Since 1964 changes have been occurring so rapidly that their effects stagger the imagination! The advent of portable equipment instituted the practice of "bringing dental care" to the chronically ill, aged and homebound wherever they reside. The use of multiple auxiliaries in multiple operatory of-
Vol. 67, No. 5
Education and Dental Public Health
fices permitted practitioners to double and redouble their productivity.15,16 The advent of group and incorporated practices, peer review, neighborhood health centers, health maintenance organizations (HMOs), lie-down supine dentistry for patients with sit-down dentistry fir dentists, prepaid and third party dental insurance, "rediscovery" of the dental plaque, new focus on prevention and nutrition, pain control and the development of a national health scheme to provide health care as a right for all irrespective of economic status - all of these have had prodigious effects on the nature, scope and pattern of dental practice in the U.S.A. 1516 Of parallel and almost equal importance have been the discoveries resulting from research related to the etiology of dental disease, materials, and devices and treatment methodologies and modalities. These have led to the use of new adhesives, sealants, composite resins, plaque control and home care methods (including irrigators, sulcular brushes, disclosing wafers and fluorescent lights); and interdisciplinary approaches to treatment between the clinical specialty areas such as periodontics - prosthodontics; surgery and orthodontics; pedodontics and restorative. Also, the use of other professionals: engineers, psychologists, speech pathologists, geneticists, immunologists, and biochemists, to focus their expertise on orally related problems, is widespread in the U.S. today. 15,17 The entire treatment capability has been upgraded by the development of eight recognized dental specialties beginning in the mid-forties with oral surgery and ending in the mid-sixties with endodontics. Most U.S. specialty training programs are university and hospital based and require from one to three years of post-graduate training for board
eligibility. The intense focus on prevention of dental decay and periodontal disease has changed the morbidity of disease in Americans and has affected and will continue to affect the nature of dental practice. Anterior proximal decay has all but disappeared in many United
347
States communities. Routine loss of teeth and eventual edentulousness has been replaced by routine presence of teeth and the dwindling presence of the full denture patient. New attention is being given to growth and developmental problems, orthodontics and surgical orthodontics, speech and myofunctional therapy, transplants and implants, and the role of dentistry in hospital and neighborhood clinic settings. Major efforts are being directed toward altering the dental health delivery system through use of the health team and with a concept of total patient care. 15 These and other new developments promise a bright future and new directions for the profession of dentistry. An extensive bibliography is provided for those who wish to pursue the details of the development of dentistry, dental education and the development of the dental public health in America. However, our suggestion is that you look at us and other countries carefully. Your position is unique in that you have the advantage of the hindsight of the gains and the mistakes we and others have made. Therefore, you have the opportunity to avoid the pitfalls and the opportunity to include the good features of the various health care systems of the world. These systems should be embellished, refined and "tailor-made" to meet your own needs.18 In fact, you have the rare opportunity to create a model that may be utilized by many other countries of similar circumstances. We urge you to develop preventive oriented national health 'programs instead of a repair oriented system. You should press for a dental health officer in each province who would be charged with focusing the needs and quality of care for the citizens of his province. It is imperative that you begin to train specialists, increase your output and revamp the roles of your auxiliaries, and take a hard look at the educational program for and functions of your special dental laboratory technicians (legal denturists).19,20 You have a proud heritage upon which to build. Especially noteworthy is the recogni-
348
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
tion and training of women as equals in the profession. 19 Special efforts must be made to become a bonafide partner in rendering hospital dental service and with advice as needed to all who go to the hospital. Of even greater importance is that you should seek public health positions and opportunities according to your ability and not allow yourselves to be excluded from broad health opportunities because you are a dentist and not a physician. Let the Finnish indomitable spirit and determination become manifest in this area! Special commendation is richly deserved for the Committee on Dental Education (CDE) in Finland for their fine report in 1972. The report presented a thoughtful road map to better dental care delivery and better dental education for the people of Finland. We hope that you have endorsed and are actively implementing the recommendations of the committee.20 In summary, we should like to suggest that as you go forward with dental health service planning, special attention should be given to: 1) the development of a national health strategy which focuses on prevention and clearly delineates the health care priorities and includes the most efficient procedures for implementation; 2) the health delivery system should have a quality control component and should be available to all people regardless of age, sex, geographical locale, economic status, etc.; 3) major educational efforts must be directed toward changing the "barriers" toward the receipt of dental services through patient education and through availability of health professional personnel for all regions of the country; 4) the health educational system must include and provide for continuing and postgraduate educational requirements to maintain a high quality of care; and 5) research and other advances should be readily translated into improvements in diagnosis and treatment and in the elevation of the overall quality of health. In conclusion, the "Helping Hand of Howard" reaches out across the United States and to underdeveloped countries of the
SEPTEMBER, 1975
world. An International Dental Health Information Exchange should be implemented and facilitated so that the "Helping Hand of Howard" concept could be used as a helping hand for health for the people of the world. Such an exchange would allow us to cooperatively build on each other's strengths and avoid pitfalls which would impede progress toward advances in the quality of health for all people. LITERATURE CITED
1.
2. 3.
4.
5. 6. 7.
8. 9. 10.
11. 12. 13. 14.
ZAMBITO, R. F. History of the Development of the Four Year Curriculum in Dental Education, N. Y. State Den. J., 35:480-484; 1969. GURLEY, J. E. The Evolution of Dental Education. The American College of Dentists, Ovid Bell Press, Inc., Fulton, Mo., 1960. LEWIS, C. P. The Baltimore College of Dental Surgery and the Birth of Professional Dentistry, 1840, Maryland Historical Magazine, 50:268-85, 1964. GIES, W. J. Dental Education in the United States and Canada - Bulletin 199 - Carnegie Foundation for the Advancement of Teaching, D. B. Upike, Merrymount Press, Boston, 1926. O'ROURKE, J. T. and L. S. MINER, Dental Education in the United States. W. B. Saunders Co., Phila. and London, 1941. COLLINS, W. K. Dental Licensure and the Development of Dentistry in the United States. Jour. Amer. Coll. Dent., 40:41-53, 1973. SWEET, A. P. Dental Diploma Mills, Part I. The Problem. Dental Rad. and Photog., 35:82-86, 1962. SWEET, A. P. Dental Diploma Mills, Part II. The Problem Resolved. Dental Rad. Photog., 36:40-57, 1963. SWEET, A. P. Dental Diploma Mills, Part III. Foreign Reaction. Dental Rad. Photog., 36:57-68, 1963. FOLEY, G. P. Foley's Foornotes: A Treasury of Dentistry. Washington Square East Publishers, Wallingford, Penn., 1972. RING, M. E. Oddments in Dental History: The Bogus Dental Diploma for Sale, Bull. of the History of Dent., 20:76-78, 1972. HARNER, H. H., Dental Education Today, The University of Chicago Press, Chicago, Ill., 1947. HOLLINGSHEAD, B. S. The Survey of Dentistry - The Final Report. American Council on Education, Wash., D.C., 1961. Health Resources Statistics. Health Manpower and Health Facilities, 1972-1973, H.E.W., P.H.S., National Center for Health Stat., Rockville, Md., 20852, June, 1973. (Concluded on page 410)
410
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
islature cited him for unusual and extraordinary service in a special resolution. Our space will not permit an enumeration of his manifold
SEPTEMBER, 1975
professional activities and affiliations, but these have been most comprehensive and demanding. The Allens have two sons, Aris T., Jr. and Lonnie W. .
CRISIS INTERVENTION and ITS APPLICATION TO PATIENTS IN A CHILD PSYCHIATRY OUT-PATIENT CLINIC. VIOLET E. STEPHENSON, M.D. Clinical Assistant Professor of Psychiatry, Downstate Medical Center, State University of New York, Brooklyn, New York The facility here discussed is an out-patient Child Psychiatry Clinic, located in a University-Municipal hospital setting of a large city of the Eastern United States. Although specific catchment areas have been designated to the numerous mental health facilities, functioning on a lesser degree in this Borough, this outpatient clinic is somewhat unique in that it functions as the emergency room for children of the entire Borough. This role had to be assumed by this clinic, primarily because it is the only Child Psychiatry facility in the Borough with an inpatient facility for children up to, but not including the 16th birthday. This inpatient counterpart has merely 50 beds-14 female adolescent, 24 male adolescent, and 12 latency. When one considers that there are approximately 3,000-4,000 children evaluated per year, and that more than half the inpatient beds are invariably occupied by patients remanded by the court for evaluations, it immediately becomes evident that this outpatient clinic functions well, in spite of tremendous odds, in order to measure up to the expectations of the community, but more so, to the needs of the patients who seek help. With such a major responsibility, this clinic, over the years, continuously reviews and revises its evaluation and treatment modalities in order to better serve its patients. Of the many treatment modalities utilized by this clinic, Crisis Intervention has been selected as the topic for presentation and discussion. Since this clinic services children primarily of low socioeconomic backgrounds, the experience has been that there is a high incidence of failed appointments when these patients are assigned for long-term psychotherapy. After a careful evaluation of the cases, as well as the statistics, it became evident
15.
16.
17.
that a sizable number of the patients respond only until, in their estimation, the crisis which brought them to the clinic, has subsided. In addition to this type of self-limiting crisis intervention, the clinic very frequently must intervene and provide intensive intervention in instances in which patients need to be hospitalized, but because there are no available beds, these patients must be treated on an outpatient basis until beds become available, until they can be sent to a State Hospital, or until there is remission of symptoms. In this latter instance, the patients are followed with medication and supportive measures as indicated. The acutely psychotic retardate who has been functioning well in the community is also a very special area in which crisis intervention is required. This is so, because of the very limited inpatient facilities for the retardate and also because the State Hospitals are very reluctant to admit those retardates with I.Q.'s less than 52. In order to prevent the "dumping" of these children on the clinic's inpatient facility, the outpatient clinic must intervene until the patient and his family have surmounted the crisis. In summary, crisis intervention is presented, as it is applied in an outpatient clinic which services a very large population of children of low socio-economic background who present during periods of crisis. The various circumstances that demand this form of treatment are also presented. Emphasis is made on the fact that while in some instances crisis intervention is the best mode of treatement for the presenting patient, in other instances in which hospitalidation is the treatment of choice, crisis intervention is utilized because of the unavailability of hospital beds. In both instances however, the end results have been gratifying.
(Henry and Sinkford, from page 348) 18. WALKER, R. D. and C. L. SEVELIUS. PubDentistry in National Health Programs. Amerilic Dental Health Services World-Wide, Comcan Dental Association, 211 East Chicago Ave., mission on Public Dental Health Services, Chicago, Ill., 6061 1, Oct. 1971. Health Education and Welfare. Trends Annual F.D.I., 1964. 19. Dental Health in Finland. National Board of Supplement to Monthly H.E.W. Indicators OfHealth, Office of Dental Health, 00530 Helsinki fice of Program Analysis, H. E. W. Office of the 53 Finland, 1973. Secretary, Wash., D.C., 1963. DUNNING, J. M. Principles of Dental Public 20. Report of the Committee on Dental Education in Health, Harvard University Press, Cambridge, Finland - an Abridge Statement. Helsinki, Mass., 1970, 2nd edition. 1971.
