COMMUNITY DENTAL 
SERVICE 
Michael M. Davis, Jr. COMMUNITY DENTAL 
SERVICE COMMUNITY DENTAL 
SERVICE J 
DENTAL NEEDS AND DENTAL FACILITIES 
WITH SPECIAL REFERENCE TO A DENTAL 
PROGRAM FOR CHICAGO 
BY 
MICHAEL AIL DAVIS, Jr., Ph. D. 
CHIEF OF THE SERVICE BUREAU ON 
DISPENSARIES AND COMMUNITY RELATIONS OF HOSPITALS, 
AMERICAN HOSPITAL ASSOCIATION 
ASSISTED BY 
MARY C. JARRETT 
CHICAGO 
1922 COPYRIGHT 1922 
BY 
MICHAEL M. DAVIS, Jr. FOREWORD 
As stated in the opening paragraph, page IX, this 
survey was conducted by the undersigned, at the request 
of Mr. Julius Rosenwald of Chicago, under the auspices 
of the Service Bureau on Dispensaries and Community 
Relations of Hospitals of the American Hospital Asso- 
ciation. The material was gathered during the months 
of February, March and April in 1921. The style in 
which it is presented is influenced by the fact that it 
was a report of a survey rather than a formal treatise on 
the subject. In preparing the report for publication, the 
original form has not been changed except by a few slight 
verbal alterations, and no attempt has been made to revise 
the subject matter up to date. 
Michael M. Davis, Jr. 
New York City 
March 1, 1922 
VII INTRODUCTION 
Recognizing the great importance of adequate dental 
care for the promotion of health, particularly among 
children, Mr. Julius Rosenwald conceived the idea that 
a study should be made of the facilities and organization 
for dental care in some of the large cities of the United 
States which have done the most in this direction; as a 
foundation for suggestions for a program towards the 
provision of more adequate dental facilities for the people 
of Chicago. He requested the author to make the study. 
The resulting Survey has included intensive studies 
of the dental facilities provided for the public in the cities 
of Boston and Rochester, which among the large com- 
munities of the country can show the most advanced 
developments; somewhat less intensive studies have been 
made in Bridgeport (Connecticut), New York, Detroit, 
Cleveland, Philadelphia, and in Chicago; correspondence 
with cities of one hundred thousand population or over 
and with a few smaller communities in which dental 
service was known to be especially developed has been 
carried on; dental service in a selected number of leading 
hospitals and dispensaries has been studied; interviews 
with representative dentists, health officers, educators 
and others, have been held. Examination has been made 
of the literature on the subject of dental care in its com- 
munity relationships, and a number of selected titles are 
included in the bibliography. 
The list of the author's obligations would be a long one. 
Grateful acknowledgment is made to Miss Mary C. 
IX X 
INTRODUCTION 
Jarrett of Boston, for her intelligent and efficient assist- 
ance in the study of the community relationships of 
dental institutions and services, and in analyzing and 
assembling material; as well as to Miss Josephine Cole- 
grove for assiduous secretarial aid. The study would 
have been impossible without the advice of many pro- 
fessional men, among whom mention must be made of 
Dr. Thaddeus P. Hyatt, Dr. Alfred C. Fones, Dr. Arthur 
D. Black, Dr. Harvey J. Burkhart, Dr. Harold DeWitt 
Cross, and Mr. Abraham Flexner. TABLE OF CONTENTS 
I. Kinds of Dental Service. 
Dentistry a Branch of Medicine ... 1 
Dental Needs of Children 3 
Cleaning 5 
Extracting, Filling, Treating .... 5 
Relations of these Services .... 6 
Orthodontia 7 
Oral Surgery 8 
Preventive Dentistry 9 
Dental Decay and Nutrition . . . . 10 
Summary 12 
Dental needs of Adults 14 
II. Dental Facilities. 
Dentists 17 
Dental Quacks 19 
Dental Hygienists 20 
Dental Schools 24 
Dental Clinics 26 
Infirmaries 26 
Hospital and Dispensary Clinics ... 28 
Industrial Clinics 30 
Public Health Clinics 31 
School Clinics 31 
Independent Local Clinics 33 
Special Dental Institutions .... 34 
III. Dental Facilities and Dental Practice. 
Private Practice Based on Curative Work . 35 
Payment of Dentists 37 
Summary 37 
XI XII 
TABLE OF CONTENTS 
IV. Dental Facilities in Relation to Dental Needs. 
Supply of Dentists Inadequate .... 39 
Financial Aspects-A. Adults .... 40 
Financial Aspects-B. Children ... 41 
Summary of Resources 44 
V. Dental Service in Various Cities. 
Boston 46 
Forsyth Infirmary 50 
Boston System as a Whole 56 
Cleveland 60 
New York 62 
Various Other Cities 69 
Detroit 73 
Bridgeport 75 
Rochester 79 
Chicago ■ . 85 
VI. Tonsil and Adenoid Work. .... 89 
VII. Principles of a Community Dental Program. 
Dental Policy 99 
Relations to Education and Research . . 102 
Organization 104 
VIII. Recommendations for Chicago .... 107 
Appendices. 
A. Bibliography 117 
B. Dental Clinics in Hospitals and Dispensaries . 119 COMMUNITY DENTAL 
SERVICE 
CHAPTER I 
Kinds of Dental Services 
To a large number of persons, dental care still means 
nothing more than the relief of pain and the preservation 
of the chewing apparatus. This is true even among many 
dentists themselves, as well as among the lay public. 
Dentistry a Branch of Medicine. Only very gradually 
has a new conception spread. The dentist has been 
thought of as the mechanic of the mouth. An entirely 
different conception is necessary for any adequate under- 
standing of the dental needs of a community and of the 
ways of meeting them. Dentistry as a recognized pro- 
fession is about a century old; dentistry in its modern 
conception is hardly a generation old. Within this brief 
recent period the connections between dental trouble 
and disease have been so developed as to transform the 
conception of dentistry from a kind of mouth mechanics 
to a branch of medicine. This transformation in point 
of view has been brought about by the convergence of a 
number of forces. The discovery that a number of con- 
stitutional diseases may be caused by root abscesses has 
aroused among medical men an unprecedented interest 
in the care of the teeth. The development of X-ray 
technique has provided a tool whereby the condition of 
1 2 
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the teeth and the presence or absence of foci of infection 
may be determined with an accuracy formerly unthought 
of. The prompt and sometimes dramatic cures of rheu- 
matism, of heart disease, and of other serious or painful 
afflictions, as a result of treatment of the teeth, have 
aroused active interest among the laity. The relation of 
bodily' nutrition to the growth and decay of the teeth 
has been studied in recent years by students of dietetics 
and metabolism and by medical men, and has further 
emphasized in the minds of leading dentists and physicians 
the medical relations between mouth conditions and 
general physiology. 
Again, from another angle, medical inspection in public 
schools, as it has become more widespread in recent years, 
has revealed a startling amount of dental defects. Still 
more recently the examinations made for the military 
draft stirred the country by their revelations of the great 
prevalence of many physical defects, particularly of the 
teeth. 
Finally, actual demonstrations made by a few public 
spirited dentists and health workers, notably Dr. Alfred C. 
Fones of Bridgeport, of the benefits of dental prophylaxis 
among children, have convinced a certain proportion of 
the dental and medical professions and a certain section 
of the general public, that practical accomplishments are 
possible for a not unreasonable expense. 
With the advance in the preventive idea in dentistry, 
more and more effort has been made to reach children of 
the younger ages. So far as adults are concerned, the 
public has become more receptive to the idea of pre- 
ventive dentistry, because modern discoveries in local 
anaesthesia have made dentistry almost painless, and 
because infection at the roots of the teeth has been KINDS OFJDENTAL SERVICES 
3 
demonstrated as a cause of ill-health. Fear of pain has 
been removed and at the same time a popular conviction 
has dawned that bad teeth may cause illness. 
The dental and medical professions have been brought 
much closer together by the discovery of the relation 
between oral sepsis and systemic disease. The interest 
of the physician in dentistry has been greatly stimulated 
for this reason. On the other hand, the dentist's interest 
in medicine has been enhanced by his growing realization 
of the significance of mal-nutrition as a cause of dental 
disease. 
Dental Needs of Children. Children and adults present 
different problems in dentistry because of differences in 
the kind of dental work required and also in the means 
for getting it done. With children the emphasis is upon 
prevention, upon cleanliness, nutrition, and the formation 
of habits of oral hygiene, and all treatment of dental 
diseases should be subsidiary to this main purpose. With 
adults dental work must be largely curative, consisting in 
repairing or replacing diseased teeth, relief of pain, and 
removal of infections that cause systemic troubles. Oral 
hygiene has value, of course, for the adult, and its bene- 
fits have been effectively demonstrated; but it is of 
paramount importance to the health of the child during 
the years of growth. If the teeth are kept in order up to 
the age of twenty-five, and habits of dental hygiene are 
established, there is likely to be little serious trouble from 
them throughout adult life. 
There is considerable diversity of opinion among mem- 
bers of the dental profession as to the frequency of 
various forms of dental disease and defect, the relative 
frequency and weight of various causes in the production 
of dental disorders, the best methods of dealing with 4 
COMMUNITY DENTAL SERVICE 
community needs in dentistry, and the amount of time 
required for the different types of treatment. However, 
there is substantial agreement upon the main issues of 
the problem of mouth hygiene in relation to public health, 
which has been tersely stated recently * by Dr. Edwin N. 
Kent, Supervisor of Mouth Hygiene, Massachusetts 
Department of Public Health, as follows: 
Dental Disease and General Health. 
"1. Dental caries (tooth decay) is the most prevalent of all 
human diseases, being found in a progressing stage in the mouths 
of at least 95 per cent of our school children. 
2. Deleterious systemic effects from this almost universal 
disease come about mainly through the three local results 
immediately following its ravages:- 
(a) A crippled chewing machine, with its working tools 
wholly or partially destroyed, cannot do the work for which it 
was intended. The first act of digestion is many times entirely 
eliminated. 
(b) Cavity pockets in the extensively decayed teeth found 
in the mouths of a large percentage of our school children form 
ideal incubators for the proliferation of bacteria, many millions 
of which are hatched, mixed with food, and swallowed daily. 
(c) The abscesses appearing at the end of tooth roots, follow- 
ing death of the pulps, resulting from extensive caries, may 
cause rheumatism, endocarditis, neuritis, nephritis, arteriosclero- 
sis and other serious systemic disturbances. 
3. Eighty per cent of all dental disease may be prevented 
by proper home care of the mouth and regular operative treat- 
ment by a dental practitioner who understands and follows the 
principles of preventive dentistry. 
4. Ninety per cent of our school children do not use a tooth- 
brush daily, and many of these are not financially able to obtain 
necessary professional treatment." 
* Mass. Dept, of Public Health Monthly bulletin, The Common- 
wealth, Sept.-Oct. '20. Mouth Hygiene Number. KINDS OF DENTAL SERVICES 
5 
Cleaning Children's Teeth, (a) The first step in dental 
work for children is cleaning the teeth. Practically 
every child needs to have its teeth thoroughly cleaned 
and polished periodically by a dentist or dental hygienist. 
Nine-tenths of the children in our schools do not brush 
their teeth daily, and therefore need this initial treatment 
badly. An unclean mouth helps to produce dental caries 
and provides soil for harmful bacteria. Even with proper 
daily brushing, the teeth require this prophylactic clean- 
ing at intervals. Dentists have different opinions as to 
how often it should be done. Some say four or six times 
a year (Hyatt). Others say that after the initial cleaning, 
with proper diet and care, later cleanings are relatively 
unimportant (Kent); and that one cleaning a year given 
to all the children of a grade would be worth more than 
two cleanings a year for half the number (Cross). The 
most prevalent opinion seems to be that two cleanings a 
year are required (Black, Burkhart, Tones). 
These prophylactic cleanings are now usually given to 
children for the first time when they reach school; but 
they should begin when the child reaches the age of three 
years. The Forsyth Infirmary set aside a week recently 
for the Baby Hygiene Association of Boston to bring young 
children. In Rochester, parents are encouraged to bring 
children of pre-school age to the Dental Dispensary. 
Extracting, Filling, Treating, (b) Cleaning the teeth 
alone is not enough, for 75 to 95 per cent of school children 
have dental caries. The diseased teeth must be extracted, 
filled, or treated. Children of the first five grades in 
Bridgeport, when the dental work began there, were found 
to average seven cavities each. It is estimated that 20 
per cent of all the teeth of school children are in a state 
of decay. These decayed teeth are the cause of poor 6 
COMMUNITY DENTAL SERVICE 
mastication, abnormal growth of the jaw from improper 
chewing, tooth-ache, infection from the bacteria bred in 
the mouth and swallowed, and greater liability to disease. 
As a rule only about a third of public school children are 
found ever to have been to a dentist. 
About one child in a hundred in the ordinary school 
will have an ulcerated tooth, indicating a condition of 
infection at the root of the tooth that may cause serious 
injury to the general health, rheumatism, or heart disease. 
Relations of these Services. The relative amounts of 
the three kinds of corrective work above mentioned 
(extracting, filling, and treating) are found to vary within 
fairly wide limits, depending in the first place upon the 
dental policy which is followed, and in the second place, 
on the degree to which the children's teeth have been 
previously neglected. For example, as regards extracting, 
at the Forsyth Infirmary the number of fillings in one 
year was over two and a half times the number of ex- 
tractions. The same ratio is found at the Rochester 
Dental Dispensary.- In the New York City school clinics 
for the last two years there have been many more extrac- 
tions than fillings. The figures of the experimental clinics 
conducted by the Association for Improving the Condition 
of the Poor in a district of New York show in two months 
nine times as many fillings as extractions. 
Prophylactic treatments have come into use for the 
prevention of caries, such as a little silver nitrate put into 
fissures that are likely to develop decay. Treatments to 
remove the tooth pulp (or nerve), if it has been injured, 
are more or less frequent according to the judgment of the 
dentist as to whether it is expedient to extract or to treat 
the tooth. Some dentists consider that more benefit 
can be secured to a greater number of children by extrac- KINDS OF DENTAL SERVICES 
7 
tions, which take relatively little time, than by treatments, 
which are time consuming. The necessary treatments 
these men would say, amount to less than half as many 
operations as filling and extracting. As an illustration of 
variations in dental policy in this matter, it was found that 
at the Rochester Dispensary in one year the treatments 
given were one and one-half times as many as the fillings 
plus the extractions, while at the Forsyth Infirmary 
there were only one-sixth as many treatments in a year as 
fillings and extractions together. 
Orthodontia, (c) Irregular development of the teeth 
presents a large problem to the dentist. The normal 
arrangement of the teeth may be interfered with by a 
number of causes, among which are prenatal growths 
affected by poor condition of the mother; lack of proper 
nutrition in infancy; habits of mouth breathing and 
thumb sucking. Any lack of the nourishment necessary 
to the growth of the teeth, or of vitality to give the jaws 
the exercise they require, may cause irregular teeth. 
The extent of this defect and the degree to which it 
impairs health is a matter upon which varying opinions 
are at present found among dentists. 
A special branch of dentistry, orthodontia, has been 
developed to deal with these conditions. The general 
practitioner in dentistry is apt to think that the ortho- 
dontist overrates these troubles, but all dentists recognize 
that numerous orthodontic defects may cause serious 
injury to health. One estimate puts it that 80 per cent 
of American children have crooked teeth (Delabarre). 
Another is that 80 per cent would be benefited by treat- 
ment while 35 per cent require it to prevent serious 
impairment of physical development (Waugh). In 
Detroit among about 48,895 school children examined, 8 
COMMUNITY DENTAL SERVICE 
2,478 were reported to need orthodontia. An examination 
of 500 children in a school where all the children had 
received dental treatment not later than the third grade 
showed only two serious cases of orthodontia (Cross). 
The causes of irregularity can be detected by a skilled 
dentist before disturbance of the arrangement of the teeth 
is noticed. It would therefore be desirable that every 
child be seen not later than the age of five by a dentist 
with some training in orthodontia. It is believed that a 
very large proportion of these defects could be prevented 
by the present knowledge of the dental profession if the 
defects were discovered early. 
The consequences of irregular teeth are inefficient 
chewing, leading to difficulties of digestion and nutrition; 
greater liability to decay among the irregular teeth, as it 
is more difficult to keep them clean; often pyorrhea, 
resulting from the over-use of some of the teeth; impacted 
teeth bound in the jaw. The specialists believe that the 
mental attitude and capacity of the child are seriously 
affected by crooked teeth. If the teeth are not growing in 
their normal positions, there is a slight nervous irritation, 
too slight to be distinguished as pain, but so constant that 
it finally produces a nervous strain, which may appear as 
irritability, restlessness, St. Vitus dance, or even more 
serious mental disorders. 
The treatment of the child for any considerable ortho- 
dontic defect requires an average of thirty hours a year 
for two or three years by a trained specialist (Waugh). 
If properly done, the child will not suffer pain from the 
treatment. 
Oral Surgery, (d) Surgical treatment is required for a 
variety of conditions that occur in children, and should 
receive attention in early life. This includes operation KINDS OF DENTAL SERVICES 
9 
upon adenoids and tonsils, deviated septum, cleft palate, 
hare-lip, necrosia, osteomyelitis, and tumors of the jaw. 
At the Forsyth in a year among 23,881 children, there were 
57 cases of oral surgery (requiring 273 treatments), ex- 
clusive of the tonsil and adenoid operations. 
The extent of the need for tonsil and adenoid operations 
is a matter under investigation in a number of places at 
the present time, and will be discussed at some length 
elsewhere in this report. The subject is not essentially a 
part of dentistry, but the condition of the nose and throat 
is closely related to the care of the teeth. 
Preventive Dentistry, (e) Prevention of dental disease 
depends upon two factors, cleanliness and nutrition. The 
relative importance of these two measures is a matter of 
debate, and present knowledge of the cause of weak or 
decayed teeth is not sufficient to make a definite state- 
ment. The growth of the teeth is only one phase of the 
growth of the child's body. The teeth require special 
nutritive elements, and there can be no doubt that there 
is a close general connection between the condition of the 
teeth and their rate of decay, with the general nutrition 
of the child. The question is not one of the existence of 
the connection, but of its degree, and of the specific factors 
that are involved. 
For example, one specialist estimates 95 per cent of the 
problem to be a matter of nutrition and 5 per cent of 
hygiene (Howe). Since bacteria reappear in the mouth 
five minutes after asepsis, the lowered resistance to the 
tooth to infection is regarded as the primary cause of 
dental disease (Cross). Another dentist believes that 
70 to 80 per cent of dental caries will be prevented through 
a systematic program of oral hygiene in the public schools. 
Still another view holds that hygiene without opportunity 10 
COMMUNITY DENTAL SERVICE 
for fillings in a dental clinic is not of great value and that 
the dental clinic should come first and the training in oral 
hygiene second. 
Dr. Percy Howe, head of the Research Department at 
the Forsyth Infirmary, has made a study of the growth 
and decay of teeth in guinea pigs, which leads him to the 
opinion above noted. He has come to at least the tentative 
conclusion that food is the determining factor in tooth 
growth and tooth decay, and moreover, that the essential 
point is the presence or absence of certain vitamines in the 
food. He is now at work endeavoring to test this con- 
clusion, and to ascertain the particular vitamine or 
vitamines which are most concerned. In this view, there 
may be an ample supply of necessary chemical elements 
for tooth growth, but without sufficient supply of the 
necessary vitamine or vitamines, the body does not make 
use of the available food material for tooth building. 
Another element is the mechanical effect of food, 
manifested first by the exercise given the jaws in chewing, 
and second by the cleansing effects of the coarser foods 
upon the teeth. Certain kinds of food promote this 
automatic cleansing, and also require chewing. Some 
foods promote a free flow of saliva, which helps chemically 
in dental prophylaxis. Whole wheat bread and hard 
biscuits, for instance, serve both the purpose of affording 
mineral constituents and also of exercising and cleansing 
the teeth. Fruit after the meal, particularly the apple, 
affords one of the best natural methods of keeping the 
teeth clean. 
Dental Decay and Nutrition. There is much discussion 
among dentists and physicians interested in this subject 
as to the degree to which sugar can be held responsible 
for tooth decay. Many hold sugar to be one of the chief KINDS OF DENTAL SERVICES 
11 
factors. According to Dr. Howe's present belief, sugar 
is of little direct influence in promoting caries, although 
the eating of large quantities of sugar is likely to mean 
deficiency in tooth forming elements in the diet, so that 
decay results indirectly from the sugar. 
The great importance of the character of the food upon 
the teeth seems conclusively proved by the healthy teeth 
of savage and semi-savage peoples. Among 18 children 
of a savage tribe in the Philippines,* a typical sample, 
89 per cent of the teeth were sound, and in another bar- 
barian tribe 93 per cent of the teeth of the children were 
sound. Italian children of the rural districts brought up 
on coarse foods and little sugar arrive in this country 
with clean strong teeth, which very soon break down 
with the new diet. 
The prevention of dental disease among children should 
begin with prenatal care. Insufficient and improper 
nourishment of the mother during pregnancy is particular- 
ly bad for her teeth, and if the mother's teeth are dis- 
eased, the development of the child may be interfered 
with. The movement for prenatal care should give atten- 
tion to this dental aspect. 
Perhaps the question of the relative influence of 
mechanical cleanliness and of bodily nutrition is one more 
academic than practical, for both mechanical cleanliness 
of the teeth and good nutrition are obviously desirable. 
Preventive dentistry for children should clearly include 
all aspects,-(1) the cleaning of the teeth, (2) instruction 
of the child in mouth hygiene, (3) instruction of the child 
(and the parent) as to diet, (4) attention to general 
hygiene. 
*"Oral Hygiene and Public Dental Service in the Philippine 
Islands." Louis Ottofy. Transactions of 6th International Dental 
Congress, 1914. 12 
COMMUNITY DENTAL SERVICE 
The dental needs of children may be summarized 
according to the following procedure. The first three 
items cover the preventive aspect. 
1. Periodic dental inspection. 
The child should be seen by a dentist at the age of two and 
twice a year thereafter. The first teeth, so commonly neglected 
on the ground that they are not permanent, are in reality of the 
greatest importance, for nutrition is more easily disturbed and 
has a more serious effect on development in early childhood than 
at any time later. 
The first permanent teeth, the six year molars, should receive 
particular attention, as they are the main reliance for chewing. 
Early neglect of the teeth causes the loss of a large percentage 
of first molars. The Public Health Service reports 25.8 per cent 
of over 7,000 children examined and had lost one or more; and 
among over 6,000 children from 6 to 17 years, of the six year old 
children 14.3 per cent had carious first molars; of those 11 years 
old, 54 per cent, and of those 16 years old, 58.7 per cent had 
molars either carious or missing.* 
School inspection of children's teeth should wherever possible 
be made by dentists. 
2. Systematic Instruction. This should be given to 
the child, and certain phases must extend to the parents. 
It must take three forms: 
A. Instruction in mouth hygiene, including tooth brush drills. 
The most important means of education in mouth hygiene is 
the personal talk of the dentist or dental hygienist with the child. 
It has been said that 75 per cent of the value of the prophylactic 
cleaning is the education that the child receives in the care of its 
teeth. Time must be allowed for this important part of the 
operation. Talks to groups of children and tooth brush drills in 
the schoolroom are important, and may be conducted by teach- 
ers, school nurses, or dental hygienists. To the older children, 
stereopticon lectures have been used successfully. Literature 
and lectures for parents are a great help. The personal instruc- 
* "The Fate of the First Molar." Harry B. Butler. U. S. Public 
Health Service Reports, March 4, 1921. KINDS OF DENTAL SERVICES 
13 
tion in the children's home by school nurses, public health 
nurses, and visiting teachers is a large factor in educating parents. 
B. Instruction in diet. To make this effective, it must often 
take practical as well as academic forms. The parents must 
often be shown how to purchase and prepare the needed foods 
for the child, and for the whole family. Some of this instruction 
to parents can be transmitted through the child, but sometimes 
it must be given directly to the parent by a dietitian in the home. 
This field of work lies outside dentistry proper, and falls within 
the province of the pediatric clinic or the nutrition class. Not a 
little of it has been taken care of in tuberculosis clinics, but by 
whomsoever done, its dental relations need to be understood and 
emphasized for the sake both of the child's teeth and of the child 
as a whole. 
C. Instruction in general hygiene. This again may be given 
partly by the dental clinic or its agents, but obviously reaches 
still further beyond the special field of dentistry. 
It is apparent that a completely worked out dental 
program must be part of the general public health pro- 
gram, if it is to be soundly based and broadly successful. 
3. Tooth Cleaning. This must be done partly by the 
dentist and the dental hygienist in the clinic or office, 
and partly by the child himself with his own toothbrush 
at home. Of course part of the instruction in oral hygiene 
above mentioned is the method of using the toothbrush, 
but what is even more important, is the habit of making 
use of it at least twice a day. 
4. Dental Repairs, including so far as necessary: 
a. Extraction 
b. Filling 
c. Treatment 
d. Orthodontia 
e. Related medical and surgical work, such as the removal 
of diseased tonsils and adenoids, or medical or surgi- 
cal treatment for other defects or diseases which have 
a demonstrable relation to the child's general condi- 
tion and to the particular problems of its teeth. 14 
COMMUNITY DENTAL SERVICE 
Dental Needs of Adults. Ideally, if present scientific 
knowledge could be completely applied and complete 
dental care and all known preventive measures be pro- 
vided for a population from earliest childhood up, the 
dental needs of children and adults would be nearly the 
same. There would of course be greater emphasis among 
children upon the educational, dietetic, and orthodontic 
features. From the practical standpoint, however, the 
dental problem now presented by the adult differs sharply 
from that of the child, to a degree that is more than 
difference of emphasis. The adult generally comes to the 
dentist with serious dental defects already developed. 
The need of repair is usually so urgent that it dominates 
the dental situation. The outstanding immediate need 
mostly leads to dental repair rather than prevention. 
The filling of cavities is essential to health, and it is 
estimated that adults have on an average five cavities 
each to be filled. The filling of small cavities would pre- 
vent much of the decay that later results in extraction. 
On the other hand many extractions are made necessary 
by the improper filling of cavities that have gone far in 
decay. 
The recent studies of the relation of abscesses at the 
roots of the teeth to various bodily diseases has increased 
the demand for extractions. The amount of dental service 
required for adults whose teeth have been neglected in 
the way of filling and extracting only (without considering 
for the moment the substitution of artificial teeth and 
oral surgery) is of overwhelming volume. One hundred 
per cent of adults need dental care. In the British Army 
in a new draft, 6.5 operations were required per man. In 
the South African war 2,450 men were invalided home for 
dental disease at a cost of £100,000. KINDS OF DENTAL SERVICES 
15 
Mention has already been made of the special need of 
dental care for pregnant women. The British Royal 
Commission on Dentistry* stresses the importance of 
dental care for expectant and nursing mothers, saying 
that they should 11 perhaps more than any other section 
of the community" have their teeth put in good condition. 
Curative Work for Adults. Crown, bridge, and plate 
work is needed to some extent by nearly 100 per cent of 
the adult population. The restoration of partly destroyed 
teeth and the replacement of extracted teeth is desirable 
in practically every adult case; but it is a question how 
necessary to the health it may be to restore or replace 
teeth, depending upon the number of teeth involved and 
their importance to mastication, and also upon whether 
their loss is disfiguring. In public health dentistry only a 
small part of this form of treatment would be possible 
because of its relative expense, and extraction would be 
resorted to in most cases. 
A complete set of false teeth is required for a small 
proportion of adults, not over 2 per cent. 
Oral surgery for adults, exclusive of extractions, is 
comparatively rare, not over one per cent requiring it. 
In those cases which do need it, however, it is often of the 
greatest importance to the patient that it be performed. 
Much dental work required by adults is closely asso- 
ciated with medical and surgical treatment which is 
needed because of other diseases. Patients in hospitals 
for various disorders are found to have bad teeth and 
root infections, which may be closely connected with 
conditions which brought them to the hospital, and which 
* Great Britain, Royal Commission on Dentistry. Report of 
Committee to Investigate the Practice of Dentistry, 1919. Dental 
Cosmos, Vol. 61, 1919, pp. 525-605. 16 
COMMUNITY DENTAL SERVICE 
therefore urgently need to be dealt with; or the condition 
of the teeth is revealed when the patient is examined in 
the hospital, and should be given attention even when 
not demonstrably connected with any systemic condition. 
Patients in a dispensary or in the care of private 
physicians at their offices likewise manifest a wide variety 
of medical troubles which are connected with dental decay 
or other disorders of the teeth. A distinct proportion of 
dental work for adults now arises as result of diseases 
which the patient did not himself suppose had anything 
to do with his teeth, but which upon study by the phy- 
sician in his office, the clinic, or the hospital, show their 
connection with mouth conditions. CHAPTER II 
Dental Facilities 
Facilities for meeting dental needs may be divided into 
five classes: 
A. Dentists 
B. Dental Quacks 
C. Dental Hygienists 
D. Dental Schools 
E. Dental Clinics of Various Types. 
A. Dentists. An estimate furnished by the National 
Dental Association states that there are approximately 
57,000 registered dentists now in the United States, but 
an authoritative article by Dr. H. E. Friesell,* estimates 
the number in 1919 as only 44,000, which would make the 
number today, 1921, only about 45,000. In 1920 there 
were no graduating classes in the dental colleges of the 
country because in that year the length of the course was 
changed from three to four years. In 1923 it is estimated 
that there will actually be 800 less dentists in the United 
States than in 1920, owing to higher standards for entrance 
requirements now being introduced in the dental schools. 
The combination of a reduction of students due to the 
war and the further reduction due to the lengthening of 
the course has created a particularly serious scarcity of 
dentists at the present time. It is difficult for the dental 
infirmaries to keep their staffs up to full strength. 
* Journal of American Medical Association, Vol. 75, No. 19, 
November .6, 1920, page 1247. 18 
COMMUNITY DENTAL SERVICE 
It will be observed that the present number of dentists 
in the United States in proportion to population is about 
one dentist to 2,400 persons. The proportion to popula- 
tion among different states varies widely. Figures dating 
from 1917 show that there was the following proportion 
of dentists to population in a few typical states. 
State 
Dentist 
to Popula- 
tion 
California 
1 
1296 
Massachusetts . 
1 
1346 
Illinois 
1 
1614 
Connecticut . 
1 
1650 
Iowa .... 
1 
1765 
Wisconsin 
1 
1817 
Kansas 
1 
1871 
New York 
1 
1980 
Pennsylvania 
1 
2194 
South Dakota 
1 
2400 
Alabama . 
1 
3177 
Texas 
1 
3654 
South Carolina . 
1 
3700 
Virginia . 
1 
4126 
In considerable parts of the country, especially in the 
South, only one dentist to over 4,000 people is not infre- 
quent. 
The proportion in the city is generally larger than in 
the country. Thus Chicago has about one dentist to 
every 1,200 persons; New York about the same propor- 
tion; Boston, with a population of only 750,000 or a little 
more than a fourth that of Chicago, has nearly 2,000 
dentists against Chicago's 2,500, but the dentists in 
Boston largely serve the metropolitan area with a popula- 
tion of about 1,500,000, so the ratio of dentists to popula- 
tion in greater Boston may be stated as approximately 
one to 800. 
Dentistry has become specialized. There are a certain 
number of dentists who confine their work mainly or DENTAL FACILITIES 
19 
wholly to extractions; others who do little or nothing but 
orthodontia. Thus there are some 375 dentists in the 
country now practicing orthodontia. These and other 
specialists are chiefly found in the larger cities. 
B. Dental Quacks. The dental "parlor" is found in 
many small industrial communities as well as in large 
cities. No general study so far as known has been made 
of the dental quack. They correspond to the medical 
institute, to which considerable attention has been given 
in recent years by the medical profession and by public 
health interests, in the endeavor to limit or suppress a 
serious evil. 
The dental "parlor" generally advertises the more 
profitable forms of work, such as false teeth, crown and 
bridge work. The letter of the law may be observed by 
having only licensed dentists in attendance, but over the 
quality of work there is no control. The spirit is wholly 
commercial. Reputable dentists tell of cases coming to 
them whose teeth have been improperly treated in the 
dental "parlor." Careless cleaning of a cavity before 
filling, for instance, means continued decay and later a 
larger filling to be put in and paid for, or a still more 
serious and expensive procedure. Undoubtedly dental 
"parlors" do an enormous amount of evil to the health 
and to the pocketbook of thousands of adults of limited 
means. With the existing shortage of dental service and 
the ignorance of the lay public as to dental standards, it is 
difficult to see how to control this evil, except by offering 
adequate public facilities in competition with them. 
The existence of dental "parlors" has little bearing 
upon dental work for children, since preventive work is 
not profitable enough to make it worth while for the 
advertising dentist to give it his attention, but the 20 
COMMUNITY DENTAL SERVICE 
knowledge that dental quacks are active should increase 
the desire of every public spirited person to see more 
adequate dental facilities of high grade provided for the 
adult population as well as for children. 
C. Dental Hygienists. Legislation providing for li- 
censing of dental hygienists has been passed in twelve 
states,-Alabama, Colorado, Connecticut, Iowa, Maine, 
Massachusetts, Michigan, Minnesota, New Hampshire, 
New York, Oklahoma, and Tennessee. The first law of 
the kind was the New York law in 1916. Massachusetts 
and Iowa followed in 1917. Legislation for this purpose 
is now being sought in other states, notably Illinois, 
California, Pennsylvania. 
The applicant for license must be a woman, in eight 
states, while in four sex is not specified in the law. 
The required age for the practicing dental hygienist 
is twenty years or over in all states, except Iowa, Maine 
and Oklahoma, where it is eighteen. A training course 
in oral hygiene, at an acceptable school, is required in all 
states; but in Massachusetts, Minnesota and New 
Hampshire a trained nurse with three months clinical 
work in a school for dental hygienists may also be 
accepted, and in Maine six months training with a 
dentist is accepted. New Hampshire, Minnesota and 
Iowa made provision for licensing women who had had 
one, three and five years respectively of practical experi- 
ence in dental hygiene under the direction of a licensed 
dentist, if they passed the state examination within one 
year after the passage of the law. 
The general educational requirement varies from one 
or two years of high school to a full high school course 
(required in Michigan and Minnesota); while in Massa- 
chusetts and Oklahoma no educational requirement is DENTAL FACILITIES 
21 
specified. The length of the training course is required to 
be one academic year, except in Minnesota, where it must 
be a two-year course. 
The requirements are highest in Minnesota, being a 
brief school course followed by two years of special train- 
ing. 
The required examination is given in all states by the 
board of dental examiners, and the nature of it is left to 
their judgment, except in Connecticut, where the examina- 
tion is to consist of (1) a practical test on a patient of 
cleaning and instruction, (2) an oral inquiry by .the 
examiner, and (3) a written examination in anatomy, 
physiology, dental histology, bacteriology and steriliza- 
tion, dental caries, malocclusion, and oral prophylaxis. 
The registration fee ranges from $5 to $25. Five 
states,-Alabama, Maine, Massachusetts, Michigan, 
Minnesota, provide for yearly registration, with a fee 
of $0.50 or $1.00; and Massachusetts requires re-registra- 
tion on change of place of employment. 
The dental hygienist is permitted only to remove 
deposits and stains from the exposed surfaces of the 
teeth (and in a few instances, beneath the free margin of 
the gum). She may be employed in most states in public 
institutions, in schools, and in offices of licensed dentists; 
but New Hampshire permits her to work only in schools 
and institutions, and Oklahoma and Tennessee only in 
dentists' offices. 
In all states the work must be done under direction of a 
licensed dentist. In most of the laws, provision is made 
for revoking the license of either dentist or dental hygienist 
who violate the conditions of the act. 
In most states any recognized dental infirmary may 
establish a training school for dental hygienists. In some 22 
COMMUNITY DENTAL SERVICE 
states the law makes no specifications regarding training- 
courses. In Michigan the dental examining board is 
given power to determine what constitutes an acceptable 
course. 
Three training schools for dental hygienists have so far 
been established,-at the Forsyth Dental Infirmary, 
Boston, 1916; at the Rochester Dental Dispensary, 
Rochester, 1916; and at Columbia University, New York, 
1916. In Bridgeport, Connecticut, a training course was 
given under the auspices of the Board of Health, in 1913, 
for the special purpose of fitting a staff of dental hygienists 
to work in the city's public schools. Training courses for 
dental hygienists are under consideration at North- 
western University, Chicago; University of Michigan, 
University of Minnesota, University of Pennsylvania, 
University of California, and Colorado University. The 
admission requirements at Columbia are eighteen years 
of age and four years of high school or its equivalent; at 
Rochester Dispensary, twenty years of age and one year 
of high school; at Forsyth Infirmary, nineteen years of 
age and four years of high school or its equivalent. 
The length of the course at the Forsyth Infirmary is 
twelve months, at the Rochester Dispensary and at 
Columbia University it is about eight months. In all 
three schools the time is divided about equally between 
theoretical instruction and practical work. The courses 
of study are similar in all schools, including anatomy, 
physiology, chemistry, bacteriology and sterilization, 
dental histology and pathology, oral prophylaxis, dietetics 
and nutrition. 
The dental hygienist has two functions of equal im- 
portance, (1) the giving of prophylactic treatments, and 
(2) the teaching of oral hygiene. The educational part of DENTAL FACILITIES 
23 
her work involves personal instruction to the children 
when she gives them treatments, and instruction to 
groups through talks and toothbrush drills.* She should 
not be confused with the dental nurse; for she has not 
received training in the care of the sick. On the other 
hand the dental nurse who assists the dentist in clinical 
and surgical work is not ordinarily trained to give prophy- 
lactic treatment or oral hygiene instruction. Occasionally 
a dental nurse is trained under the direction of a dentist 
to perform the functions of a dental hygienist. 
The total number of graduates from all existing schools 
is about 470 (Forsyth, 99; Rochester, 159; Columbia, 
200; Bridgeport, 13). The total number of students in 
this year's classes is 136. 
There is considerable apprehension that the dental 
hygienists will be absorbed as quickly as they are grad- 
uated into the offices of private dentists, as the majority 
have been so far. By employing a dental hygienist on 
salary, a dentist adds to his capacity for work; and the 
question is under discussion whether he is justified in 
receiving fees for work done by an assistant. The argu- 
ment is that the hygienist does her work better than the 
dentist himself would do it, that she is not merely assisting 
him but is contributing professional service to the treat- 
ment of the patient. 
It may be mentioned that in England it is proposed to 
have dental " dressers." At the Chesterfield School Dental 
Clinic in London, they extract teeth, do dressings with 
silver nitrate, and do fillings. The British Dental Associa- 
tion in 1917 recommended the training of nurses for dental 
examinations including the making of mouth charts. 
*For certain limitations to be exercised in this connection, see 
page 103. 24 
COMMUNITY DENTAL SERVICE 
Thus in England as well as in this country, the necessity 
for providing assistants to the dentists has been recog- 
nized, and a practical movement is under way. 
D. Dental Schools. Prior to the establishment of the 
first dental school, in 1840, dental training could be 
obtained only in the office of a preceptor, and for many 
years thereafter, until all sections of the country were 
fairly well provided with schools, this method of studying 
dentistry existed. The United States Census Bureau's 
published statistics show that in 1902 there were 26,142 
practicing dentists in the country, and of that number, 
only 16,831 were graduates of dental schools. Eventually, 
however, all the states adopted dental laws, requiring a 
college education to practice dentistry, and state boards 
of dental examiners were appointed in all states to pass 
upon the qualifications of graduates who applied for 
licensure.* 
The dental course has been continually lengthened and 
strengthened. Lecture courses of four or five months 
have disappeared and a four year course with a con- 
stantly rising entrance standard is now general. The 
Dental Educational Council of America, organized in 
1909, has had great influence in advancing dental stand- 
ards. Doctor Friesell says, "The gradual development 
and enlargement of the dental curriculum, always more 
closely approaching that of medicine in many subjects; 
the advancement of the entrance requirements, and the 
general supervision of dental education by the profession 
as represented in the Dental Educational Council, will 
eventually bring dental education to a point at which 
the foundation training will be practically the same as 
that of medicine." 
* Quoted from Friesell, op. cit. DENTAL FACILITIES 
25 
The increase in the number of graduates of dental 
schools is shown by the following figures: 
Year 1860 266 graduates 
" 1890 943 " 
" 1900 2,029 " 
" 1907 1,754 
" 1919 3,597 
Enrollment for the academic year 1920 at the 46 dental 
schools was 9,302, the schools varying in size from one of 
13 to one of 540 students. 
Quoting again from Doctor Friesell, "In view of the 
astonishing increase in the demand for dentists that has 
arisen during recent years, the existing dental schools will 
be taxed far beyond their normal capacity to meet such 
demand, and established universities in logical centers 
should recognize the necessity for providing adequate 
dental education for the communities they now serve in 
other fields of education. 
"An increase in the number and available capacity of 
dental schools of good standing is of the most fundamental 
importance in the improvement of dental facilities for the 
people of the United States, and a most worthy subject 
for assistance by public authorities or private individuals." 
A dental school maintains a dental infirmary for the 
practice work of its students. Ordinarily all kinds of 
dental work are done. In many schools orthodontia is 
done only for a few demonstration cases, enough to teach 
the principles of this specialty, but not to fit a student to 
practice it. 
Preparation for orthodontia is coming to be regarded 
as a post-graduate course. There is no satisfactory course 
at the present time to prepare a dentist to practice ortho- 
dontia. Some post-graduate courses are offered, and some 
dental colleges give this training to their students. 26 
COMMUNITY DENTAL SERVICE 
A number of dental colleges send their students to work 
in other clinics. Tufts Dental School has developed this 
practice to an unusual extent. Squads of six students are 
sent to the Boston Dispensary and the Roxbury Dis- 
pensary for periods of one or two weeks; and a clinic of 
ten chairs has been established at the School for the 
Feeble-minded, operated by an instructor and students. 
The instructor is a member of the school faculty in each 
instance. 
E. Dental Clinics of Various Types. Dental clinics 
have been developed in four relations: 
1. In connection with dental colleges 
2. In connection with hospitals and dispensaries 
3. In connection with industrial or commercial 
establishments 
4. As public health clinics: 
a. Public school 
b. Independent local clinics 
c. Dental institutions founded as part of a com- 
munity dental program 
These four types must be discussed separately, as a 
basis of understanding the facilities surveyed in various 
cities and the elements of a community dental program. 
1. The dental infirmary (of the dental college) has had 
a limited range of community service. The demands of 
dental practice have largely been for curative work, and 
the service of the dental infirmary connected with the 
dental college had been primarily to give the student 
opportunities for practice in various forms of curative 
work, chiefly in adults. 
A certain proportion of dental colleges and the dental 
infirmaries attached to them have been commercial in 
nature, and still others, while not commercial, have made DENTAL FACILITIES 
27 
themselves self-supporting or more than self-supporting, 
by charging fees. Charging fees is by no means an 
indictment of a dental infirmary, as there are many 
reasons why fees should be charged, and there are good 
reasons for having such institutions wholly or largely 
self-supporting. The point is that in the past the kind 
of work that has been regarded of value in teaching dental 
students has not been to any large extent work with 
children nor preventive dentistry of any kind. Those 
responsible for shaping the policy and for the manage- 
ment of a dental infirmary connected with a dental school 
must necessarily endeavor to furnish the dental student 
with that kind of practical experience which will equip 
him technically to be a successful practitioner of den- 
tistry. To make the equipment and staff of a dental 
infirmary and the time of the dental student serve the 
community demands is only legitimate from the stand- 
point of the dental school in so far as community demands 
are consistent with the immediate educational demands. 
Only as the character of dental practice itself changes 
and it is generally recognized as worth while for the 
student to have a larger proportion of work in preventive 
dentistry and a larger proportion of work with children, 
can the dental infirmary connected with the dental college 
play an important part in a community dental program. 
Considerable steps in this direction have been taken by 
a certain number of leading dental colleges of this coun- 
try, and the advancement of dental education is pro- 
ceding in this direction. Yet it is essential to bear in 
mind that the clinics which the dental school needs can- 
not be made the primary basis of the community dental 
program. The community interests and the dental 
educational interests are not identical; they are not 28 
COMMUNITY DENTAL SERVICE 
fundamentally in conflict yet they pull in somewhat 
different directions. Affiliation between dental education 
and the community dental program is essential, as will 
be brought out later, but not identification either of 
practical facilities or of control. 
2. Dental Service in Hospitals and Dispensaries. The 
growing recognition of the connection between dentistry 
and medicine has been manifested in many ways, among 
them the increase in dental service in general hospitals 
and dispensaries. Dental work or dental diagnosis in the 
general hospital was practically unknown a few years ago. 
Inquiries were sent during the course of this survey to 
282 general hospitals, including almost all those in the 
United States of 100 beds or over. 144 replies, or 51 per 
cent, were received, a rather high average of replies to 
questionnaires of this sort. 
The following questions were asked: 
1. Do you have a dental service in connection with your hos- 
pital? 
2. If so, is this a dental service with rank as a hospital depart- 
ment and ward beds assigned, or is it merely diagnostic in 
character? 
3. Is there also a dental clinic in your out-patient depart- 
ment, in which treatments are given, and if so, what is the size 
and scope of such clinic? 
4. Do you feel the need of a dental service, either therapeutic 
or diagnostic, in your hospital or your out-patient department, 
if you have not already developed it, and what policy do you 
think a hospital should pursue in this matter? 
Eighty-nine of the 144 replies reported dental services 
in the hospital; in four more a dental service was in the 
process of establishment; in twelve more it was being 
planned, and in two more it was hoped for. Thus dental 
service was either definitely established or well under way DENTAL FACILITIES 
29 
in more than one-third of the 282 larger general hospitals 
of the United States. 
In 46 of these hospitals, dental service is recognized as 
of departmental rank, with assigned beds in some in- 
stances and in others with use of beds as needed. In 32 
of the 89, dental service is not recognized as a department, 
but is organized for purposes of consultation and diagno- 
sis. In eleven of the 89 hospitals, dental work includes 
offering dental treatment to patients but is not recognized 
as a general department of the hospital. 
Of the 89 hospitals with dental service, 41 maintained 
dental work for their ward patients, but had no general 
dental clinic. Seventeen of the 89 hospitals had no dis- 
pensary clinics of any kind, but of the remaining 72 which 
had some out-patient department, 48 had a dental clinic 
as part thereof. 
Most of these clinics were for dental treatment as well 
as for diagnosis, only five being limited to diagnosis only. 
The great pressure for dental service is illustrated by 
the fact that a large number of these hospitals have found 
it necessary to limit their dental clinic for the use of 
patients referred from other parts of the hospital or 
dispensary. Examples will appear on pages 45 and 60. 
From the answers to the general questions of our 
inquiry, it may be said that all the leading hospitals, as 
reported by their superintendents, recognized the desir- 
ability of dental service. The only question that existed 
was as to the details of its organization and the extent to 
which dental work should be carried out, owing to the 
expense and to the risk that the hospital or dispensary 
would be swamped if a dental clinic were opened up for 
general community purposes. 
On the basis of this survey and of studies of dental work 30 
COMMUNITY DENTAL SERVICE 
in various hospitals made in connection with other sur- 
veys, certain points or principles might well be set down 
as contributary toward the community dental program 
formulated in the final section of this report. These are 
stated in appendix B. 
3. Industrial plants, coming to a realization of the 
importance of sound teeth to health and efficiency, have 
in many instances installed a dental clinic. Some 72 
plants in the United States are known to have taken this 
step. Sometimes the expense is borne entirely by the 
firm, and sometimes the employees pay for the cost of 
materials. Some firms offer only emergency treatment, 
and send the employee to private dentists for further 
care; others require the employee to have his teeth put 
in order and offer him the service of the clinic. The firms 
that have installed dental service are invariably enthu- 
siastic about its benefits both to the health and to the self- 
respect of the employees. 
The industrial dental clinic obviously fits in to the 
scheme for community dental service by assisting in 
providing service for adults. The extent to which industry 
may wisely proceed in the direction of prophylactic or 
reparative dental facilities is somewhat an open question. 
It is not wise for industry to go so far as to take from the 
community its due burden of providing the necessary 
facilities which might be used for adults as well as for 
children, or to make business men feel that because they 
are giving moral and financial support to dental clinics 
in their own establishments, they need not cooperate in 
the support of community dental services. At the present 
time there is little danger that the development of indus- 
trial dental clinics will interfere with the development of 
community dental service. There is need for both. DENTAL FACILITIES 
31 
4. Public Health Dental Clinics. The dental clinic 
established primarily for the purpose of meeting com- 
munity dental needs is a very recent development. It is 
important to recognize that these public health dental 
clinics are not merely those which have been established 
in public schools or in special dental institutions par- 
ticularly for preventive work but largely for children, for 
the public interest has lead to the establishment of many 
dental clinics in general dispensaries and under inde- 
pendent auspices, mentioned later. The public health 
movement has taken hold of the dental clinic because of 
recognition that adequate dental care for the community 
cannot be furnished as an adjunct to private dental 
practice, and is in large measure a public project and 
must be handled by public and semi-public agencies. 
Aside from such community dental service as rendered 
by many dental clinics which are parts of general dis- 
pensaries (e.g. clinics described on pages 44, 45, 60 in 
Boston and New York) the chief groups of public health 
clinics are as follows: 
(a) In schools 
(b) Under independent local auspices 
(c) Large institutions especially established for the 
sake of the community dental program 
Clinics in the Schools, (a) School clinics have been 
tried in the United States on various plans, most fre- 
quently in the school, but sometimes in a building adja- 
cent thereto. The plan is usually to set up a dental chair 
in some unoccupied space, which may be an unused room, 
a corner of the hall, or the principal's office, and to employ 
a dentist to operate three or six hours a day, with a nurse 
to assist him in preparing the instruments and looking 
after the children. Sometimes another chair is set up and 32 
COMMUNITY DENTAL SERVICE 
a dental hygienist is employed to clean and polish the 
teeth. 
Another plan, followed in Rochester and Bridgeport, 
is to have portable dental chairs set up in the schools for 
the hygienists' work of prophylactic cleaning, while the 
dental work is done at a control institution. 
School Clinics in England. The question of school 
dental clinics was discussed in England as early as 1885, 
at a meeting of the British Dental Association. In 1890 
the first school clinic was established in Cambridge. Eight 
years later there were a number of school clinics of the 
poor-law schools of Great Britain, and the School Dentists 
Society was organized. It is significant that it is now about 
to amalgamate with the School Medical Officers Associa- 
tion. The Education Act of 1907 made medical inspection 
compulsory and empowered the local education authori- 
ties to provide medical treatment. From the start, dental 
treatment was assumed to be included, and was specially 
reported upon every year in the annual report of the 
Chief Medical Officer. Inspection stimulated the develop- 
ment of dental clinics. 
The British Royal Commission on Dentistry in its 
report,* 1919, says, "The advantage of children coming 
under dental supervision before school age has been 
forced on the attention of school medical officers and 
dental officers by the extent of decay which has been 
found to exist at the first medical inspection of children 
after entering school." The report recommends that 
measures for dental care among children of this age be 
energetically pressed. 
England has recently developed school dental clinics 
under the local education authorities. In 1919 there were 
* Great Britain, Royal Commission on Dentistry, op. cit. DENTAL FACILITIES 
33 
306 school clinics, with 239 dentists. Forty-nine of these 
dentists were on full time. Arrangements for treatment 
organized by local education authorities include not only 
school clinics, but traveling ''dental caravans" and small 
centers visited by a "peripatetic" school dentist, and also 
various forms of contract practice in which private 
dentists are used. The school dental clinics are arranged 
to include a play room and waiting room, an operating 
room, and a rinsing room. 
The Education Board requires that the dental work in 
the schools be co-ordinated with the medical work, and 
be under the administrative supervision of the school 
medical officer. In London in 1918-1919 there were 
reported to be 44 centers serving 90,000 school children, 
and several centers were also used for expectant and 
nursing mothers. 
It is interesting to note that while the work is free in 
most districts of England, in some places fees are charged, 
3d to 2s 6d, and in some places fees are assessed upon the 
parents after reports on their ability to pay. 
The first school dental clinic in Germany was opened in 
1902 in Strasbourg. Ten years earlier the town had made 
an appropriation for dental inspection. The most ad- 
vanced public measures for dental care of school children 
are in New Zealand, where a national bureau of mouth 
hygiene has been established to care for the teeth of all 
school children at the expense of the government. 
Independent Local Clinics, (b) A number of social 
settlements and social organizations, feeling acutely the 
need of their clients for dental service, particularly adults, 
have established small clinics in neighborhood houses or 
health centers, paying the cost of a dental chair and 
equipment, and the salary of a dentist, and giving the 34 
COMMUNITY DENTAL SERVICE 
service to the people of the neighborhood either free or at 
a small cost. 
As will be seen in the surveys of Boston, New York, and 
elsewhere, there are a growing number of such clinics, 
doing, however, because of their small size and limited 
means an inconsiderable amount of work in comparison 
with the need. 
Community Dental Institutions, (c) The two examples 
of the large institutions which have been founded as the 
center of a community dental program are the Forsyth 
Dental Infirmary in Boston, and the Rochester Dental 
Dispensary, which will be studied in detail later. CHAPTER III 
Dental Facilities and Dental Practice 
The different dental needs of adults and children have 
very different relations to the private practice of dentistry. 
The dentist has been supported in the past almost entirely 
by corrective work, fillings, extractions, crown and bridge 
work, provision of false teeth, etc. The older conception 
of dentistry as mostly mouth mechanics and the relief of 
pain is still dominant among most practitioners. Pre- 
ventive work has been non-remunerative, and even now, 
with the increased interest in preventive dentistry, pre- 
ventive work does not pay in comparison with curative. 
Private Practice Based on Curative Work. The time 
element is of very great practical importance to the den- 
tist. The physician may spend an hour with a patient, or 
five minutes, and render adequate and valuable service 
either way, depending on the nature of the medical need. 
Dental work, however, either curative or preventive, in- 
volves always a mechanical element which takes a con- 
siderable and fairly definite time for each type of work, 
and the work cannot be hurried without the quality 
deteriorating. The dentist must therefore count his time 
carefully and charge for it. With the general shortage of 
dentists and the rapidly growing demand for dental 
service, almost all dentists have had all the work they 
could physically perform. The financial incentive has 
been entirely towards the encouragement of reparative 
rather than preventive work. 
35 36 
COMMUNITY DENTAL SERVICE 
The expense of dental equipment has been increasing. 
A better type of equipment than formerly is expected in a 
dental office by the patients, and much more is demanded 
of the dentist by the advance of dental science, and of 
the practical arts of dentistry. The use of the X-ray alone 
has added a very large item of expense to dental work, 
although it has of course greatly increased its efficiency. 
One has only to see a modern well-equipped dental office 
and to contrast it with what was regarded as a satisfactory 
dental office twenty or even ten years ago to appreciate 
what great technical improvements have been made, also 
how much these have increased the expense which the den- 
tist needs to incur before he has a really satisfactory outfit. 
As a consequence of these conditions, preventive work 
in dentistry and in general the movement toward the 
development of a community dental program has not 
grown up to any extent as a part or adjunct of private 
dental practice, but has had to proceed along inde- 
pendent lines. It is indeed true that many public spirited 
dentists have led the movement, often at much personal 
sacrifice, and the public and community owe a debt of 
gratitude to these men. Yet in the main, preventive 
dentistry and the program for adequate community 
facilities have had to develop organized facilities. This 
is a fundamental point in planning a dental program for 
any community. It is impractical to expect that any 
large part of the preventive work needed can be done by 
dentists in private practice or in private offices. It is 
necessary to develop organized facilities under control of 
public or semi-public bodies. 
The plant and expensive equipment with which the 
dentist is to work must be provided by this public or 
semi-public body. The dentist's service in general must DENTAL FACILITIES AND DENTAL PRACTICE 
37 
be paid for. Preventive dentistry in particular will only 
be carried on if it is thus recognized and if it is paid for 
out of funds of which only a part, usually only a small 
part will come from those who benefit from the service. 
Payment of Dentists. In clinics doing medical work, 
it will be recalled that the physicians have as a rule given 
their services without financial compensation and the 
question is sometimes asked why the dentists have not 
done the same thing. There is no one reason for this 
difference. It may fairly be said that the work which the 
physician does in the clinic generally gives him some re- 
turn in medical experience, and in the best organized 
clinics, a very substantial return. He has an opportunity 
to study many cases of disease, in numbers larger than he 
would ordinarily see in private practice within the same 
period, and thus to improve his technical ability. The 
work in dental clinics, on the other hand, is largely 
mechanical in nature, and is chiefly confined to kinds of 
work with which even the young student has been made 
familiar. After a comparatively short experience in the 
clinic, he will learn little more from what he does there. 
The demand foi' dental service in the private office and 
the importance of the time element in dentistry make 
the financial sacrifice of giving time to a clinic more real 
and more obvious than to most physicians. For these and 
probably for other reasons, dental service in clinics has, 
as a rule, had to be paid for, even at moderate rates. This 
is a reasonable and proper policy and efficient service can- 
not otherwise be expected in any adequate amount. 
To Summarize 
1. Adequate dental facilities for a community cannot 
be built up on the basis of private dental practice. 38 
COMMUNITY DENTAL SERVICE 
2. Preventive dentistry in particular cannot be de- 
veloped as part of private practice. 
3. Facilities for dental work supported by public or 
semi-public bodies must be depended on to provide dental 
facilities for a considerable part of the adult population 
and to furnish almost all the preventive facilities needed 
for the children. CHAPTER IV 
Dental Resources in Relation to Dental 
Needs 
The dental service required in proportion to population 
is fairly easy to estimate in relation to children, and also 
may be computed at least as to minimum requirements in 
respect to adults. 
Putting the matter for the moment on the basis of work 
done let us assume that a dentist works six hours a day 
for three hundred days a year. It has been estimated on 
the basis of many examinations that adults average five 
tooth cavities each. Allowing half an hour for each tooth, 
a dentist would care for seven hundred and twenty pa- 
tients in a year. In the British Army and also in the 
Regular Army of the United States, one dental officer is 
estimated to be required for one thousand men. It may 
be roughly estimated that one dentist could give treat- 
ment to one thousand adults a year, not including pre- 
ventive work. 
Supply of Dentists Inadequate. It will be recalled that 
the number of dentists in the United States is one for 
every twenty-four hundred people, and that only in a 
few large cities of the country is the total proportion as 
low as one per thousand. In most communities the ratio 
is higher than one to twenty-five hundred. It is obviously 
impossible for the present number of dentists to give a 
thorough program of care for adults whose teeth have 
been neglected throughout childhood. Given the present 
39 40 
COMMUNITY DENTAL SERVICE 
condition of the teeth of the population of the United 
States as revealed by school examinations for children and 
by draft and industrial examinations among adults, it is 
obvious that at least two and a half times as many den- 
tists as are now in the country would be necessary to give 
a complete service. 
This fact has fundamental bearing upon community 
dental programs. It means that a community dental 
program must concentrate upon a comparatively few 
points of greatest significance; that the work done outside 
this selected area cannot be intensive or complete. Prac- 
tically this means that for the sake of the children of the 
present day and of the adults and children of the next 
generation, the primary aim in a community dental 
program must be the children, and particularly the young 
children of today. The organized dental facilities for 
adults must limit their work to such kinds of service as will 
do the most good, recognizing that at the maximum, only 
a small fraction of the total dental needs for adults can be 
met. 
The problem of dental service for children, therefore, 
is one of determining the best policy and of endeavoring 
then to secure the funds necessary to carry this policy 
out for all children. The problem for adults is that of 
determining the principles on which selection should be 
made among the various needs, so that the facilities 
available shall be used in the best way. 
Financial Aspects-A. Adults. A very low estimate of 
the salary for a well-trained young dentist is $40 a week, 
or about $2000 a year. For every 100,000 of the adult 
population, 100 dentists would be required at a total 
salary of $200,000. One hundred chairs would be needed 
for this work (or if the chairs could be used also for three RESOURCES IN RELATION TO NEEDS 
41 
hours in the evening, 66 chairs would be sufficient), cost- 
ing at the rate of <$250 or $300 each (for a portable chair 
and equipment), between $25,000 and $30,000 (or if used 
in the evening $16,500 to $19,800). Materials and sup- 
plies cost about one-fourth of the amount of salaries,* 
about $50,000. This would amount to a total cost for 
service of $250,000 or $2.50 per person, exclusive of build- 
ing and overhead expenses. No allowance is here made 
for crown and bridge and plate work, or artificial teeth. 
There is no satisfactory information available as to the 
proportion of adults who are able to pay for complete 
dental service. A large proportion of adults now do pay 
for the relief of pain and other reparative treatment, for 
false teeth and for crown and bridge work. To put a 
mouth that has been neglected for years into good condi- 
tion is as a rule an expensive process, requiring an outlay 
which a good proportion of the population cannot meet 
at the rates charged by dentists who give adequate ser- 
vice. The work needed by adults would of course be 
greatly diminished if proper care had been taken of the 
teeth from childhood. The financial as well as the techni- 
cal solution of the adult problem ultimately lies here. 
The experience of a number of dental infirmaries shows 
that a dental clinic for adults can be made self-supporting. 
But if any considerable amount of work were to be done 
for the very poor, there would be .a deficit, if overhead as 
well as immediate running expenses had to be covered. 
Financial Aspects-B. Children. Estimates of the 
number of children a dentist can care for vary from 
50 a month (Kent) to 100 a month (Cross). Another 
* Figures of Middlesex County (Mass.) Farm Bureau Dental 
Clinic. The Commonhealth, Mouth Hygiene Number, Vol. 7, No. 5. 
September-October, 1920, p. 343. 42 
COMMUNITY DENTAL SERVICE 
estimate allows 1,500 children a year for a dentist with the 
assistance of a dental hygienist. The younger the children 
the less work generally has to be done per child and the 
more children can be cared for by a given staff. Further- 
more, if the children of older years have been given con- 
tinuous dental attention the amount of work to be done 
per child is diminished and a given staff can care for a 
much larger number. 
For the cleaning of teeth, if done by dental hygienists, 
one hygienist to every 2,000 school children (giving two 
treatments a year) seems to be an estimate that strikes 
an average amongst divergent opinions. The average 
time allowed for a cleaning varies from 15 minutes 
(Burkhart), twenty-five minutes (Cross), and thirty-five 
minutes (Black), to one hour (Hughes and Millberry). 
The usual salary of a dental hygienist is from $1,200 to 
$1,500 a year; so that the salaries of 50 hygienists required 
for 100,000 children would amount to $60,000 to $75,000. 
Supervisory salaries would bring it closer to the latter 
figure. 
The number of dentists required for 100,000 children 
will vary with the conditions above mentioned, but will 
be somewhere between one dentist for every 1,000 to 2,000 
children. 
Adequate provision for 100,000 school children would 
therefore call for an expenditure of approximately $325,000 * 
for salaries and materials and $37,500 for dental chairs. 
Some dentists would have one hygienist for every 
dentist, others one for two dentists, while others believe 
it is more economical to have two hygienists for three 
dentists. 
*$200,000 for dentists, $75,000 for hygienists, $50,000 for mate- 
rials. RESOURCES IN RELATION TO NEEDS 
43 
At the Middlesex Co. (Mass.) Farm Bureau Dental 
Clinic* the cost of service per child is $7 allowing 3/^ hours 
for each child at $2 an hour. Their plan is to employ two 
dentists and one hygienist who can care for 100 children 
a month, 60 to 80 per cent of whom have never been to a 
dentist. These 100 children average 750 fillings, 100 
extractions, 94 cleanings, 15 canal fillings, 200 silver 
nitrate treatments, totalling 1,200 operations. A year 
later one hour is sufficient for each child previously treated. 
This is a higher average of operations than is usually 
estimated. At the Forsyth Infirmary in 1919 the average 
number of operations in the dental clinic, extracting clinic, 
and oral hygiene department was about nine. The 
Middlesex clinic runs for about 90 hours a week and costs 
$180 ($120 for salaries, and $30 for supplies and laundry, 
and $30 for overhead and depreciation). The school 
clinics of New York City cost $23,800 the first year and 
cared for 7,300 children at a cost of $3.25 per child. The 
original cost of equipment is about 10 per cent of the cost 
of maintaining the service, so that in New York about $3 
would be the average cost of dental service per child.t 
It is believed that about 50 per cent of school children 
require free dental service. In some communities (notably 
Rochester and Bridgeport) the prophylactic cleaning is 
given to every school child free, while parents who can 
afford to pay for dental work are referred to private 
dentists. 
* Commonhealth, Mouth Hygiene Number, op. cit. 
t It will be observed that these per capita costs are higher than 
those given in Rochester or Bridgeport (pages 77 and 84). The 
reason is partly the smaller scale of the work, and the further fact 
that when only a small proportion of children can be given dental 
care, those selected for the clinic are those who have more than 
average dental needs, and who therefore require more time per case. 44 
COMMUNITY DENTAL SERVICE 
Orthodontia for children with crooked teeth must be 
done by dentists trained in this specialty; therefore the 
cost must be computed separately. The average time 
required for each child is said to be 30 hours a year, over a 
period of two or three years (Waugh). One dentist then 
could care for 60 children in two or three years. The 
salary of the orthodontist is the same as that of other 
dentists, about $2,000 a year. The materials required 
for orthodontia are expensive, running from $12 to $100 
per case. At the Harvard Dental School $12 is the average 
cost. At the Rochester Dispensary the average cost per 
operation in the orthodontia department is $1.15. Thirty 
hours a year indicates 40 to 60 operations, making the cost 
per child for the year $46 to $69. The shortage of trained 
orthodontists, brought out elsewhere in this report will 
at the high cost of the work, present insuperable obstacles 
to enlarging this branch of service in proportion to the 
need. 
The cost of dental work, so far as salaries are con- 
cerned, will be substantially diminished in those com- 
munities where dental students are available, since these 
will give their services free. It must be remembered, 
however, that the number of dental students in the junior 
and senior years is at the present time less than 2,000, 
and that these are located chiefly in a few large cities. 
Even in Chicago the number of dental students in the two 
later years amounts to only about 374, and while it is of 
great importance to link up their services with any com- 
munity dental program, the total amount of work which 
students can do in proportion to the total needs is too 
small to be the major reliance for the community as a 
whole. 
Summary of Resources in Relation to Needs. The RESOURCES IN RELATION TO NEEDS 
45 
relation between dental resources and dental needs may 
be summarized as follows: 
1. The number of dentists is everywhere far below the num- 
ber needed. 
2. The number of dental students is too small to be a large 
factor in the country-wide situation, although they are an 
important element in developing certain institutions in the 
relatively few communities which possess dental schools. 
3. A large increase in the number of dental hygienists is an 
urgent need. 
4. A complete dental program for adults is not practical, 
both because of its expense and because of lack of sufficient 
dental personnel. 
5. A complete dental program for children is necessary, and is 
practicable if the work is definitely planned to concentrate on 
the points of greatest importance and upon the younger years, 
with a follow-up system. 
6. This policy, if adopted, should ultimately reduce the adult 
dental problem to proportions manageable for the existing dental 
personnel, and within the financial means of patients and of 
the community. 
7. A dental program for all children within selected age groups 
and within selected types of work should be determined and 
sought. (Page 99.) 
8. A dental program for adults should be rigidly limited to 
certain types of service. (Page 100.) 
9. The service to children must be developed upon a public 
semi-public basis, since private dental practice cannot be 
depended upon to deal with this to any considerable degree. 
10. Public or semi-public dental clinics must also be largely 
depended on to deal with the adult dental problem, but these 
clinics for adults can and should be largely self-supporting. CHAPTER V 
Dental Service in Various Cities 
Boston. Boston has about 2,000 dentists for a popula- 
tion of approximately 750,000, in the politically defined 
city but as above mentioned, these dentists serve in con- 
siderable measure greater Boston, with about double the 
population. Taking into account additional dentists in 
the outlying regions, it is probable that there is one dentist 
for every 600 population, a very high ratio. 
A law permitting the employment of dental hygienists 
under direction of registered dentists was passed in 
Massachusetts in 1915. Examination by the Board of 
Dental Examiners is required, and the applicant must be 
a person of good moral character, twenty years old or 
over, who is a graduate of a training school offering a 
course of not less than one academic year or a graduate 
nurse with three months clinical training in a school for 
dental hygienists. 
There are a number of dental hygienists in the city, 
graduates of the school established by the Forsyth Dental 
Infirmary, in 1916, and of the Bridgeport course. The 
majority are employed by private dentists. 
In 1920 the Forsyth-Tufts Training School for Dental 
Hygienists had 99 graduates, of whom 23 were in public 
service, two in industrial clinics, 61 with private dentists, 
and the remaining thirteen not employed. 
This course is conducted in affiliation with Tufts Dental 
School. It covers twelve months and fits the pupil to teach 
46 DENTAL SERVICE IN VARIOUS CITIES 
47 
oral hygiene, to do prophylactic cleaning of the teeth, 
and to assist in dental surgical operations. The require- 
ments for admission are good character, age not under 
nineteen years, and four years of high school or its equiva- 
lent. 
Boston is noteworthy for the variety of its dental 
facilities, the chief of which is the Forsyth Dental Infir- 
mary. There are in addition the following dental clinics: 
Harvard Dental School Infirmary . . 120 chairs 
Tufts Dental School 100 " 
Roxbury Dispensary 6 " 
Boston Dispensary 5 " 
Maverick Dispensary 3 " 
Lincoln House Dispensary .... 1 " 
Massachusetts General Hospital ... 3 " 
Hyde Park Health Center .... 1 " 
239 chairs 
The chair hours of service a week in these clinics total 
7,601. In addition, the Massachusetts Homeopathic 
Hospital, Carney Hospital and the Children's Hospital 
maintain small dental clinics for their own cases. The 
Massachusetts General Hospital clinic is also limited to 
the patients of its out-patient department. In the Homeo- 
pathic Hospital, a beginning has been made in having 
dental hygienists from the Forsyth School clean the teeth 
of ward patients. 
Certain points of interest may be noted. The clinics 
such as the Boston Dispensary, the Maverick Dispensary, 
and the Roxbury Dispensary of the Salvation Army are in 
large measure devoted to community dental service. At 
the Boston Dispensary clinic, for instance, about half the 
30 patients treated during the day are children brought 
by the school nurses. An evening clinic is also open, 
primarily for adults, which charges fees that for the year 48 
COMMUNITY DENTAL SERVICE 
1920 enabled it almost to meet expenses. At the Maverick 
Dispensary the work is also confined almost entirely to 
children, largely brought by school nurses of the district. 
At the Roxbury Dispensary 75 per cent are children and 
half the clinic time is reserved exclusively for school 
children brought by school nurses. The District Nursing 
Association of Boston, in connection with its Health 
Center in the Hyde Park district, conducted for a year 
an experiment along the lines of the Bridgeport dental 
plan to be described hereafter. This included two dental 
hygienists in the neighboring public schools, and a dentist 
in the clinic at the Health Center. It was hoped that the 
School Committee of Boston would continue this experi- 
ment, but it did not do so. The clinic, however, has been 
continued by the Association. The Lincoln House Settle- 
ment has maintained its dental clinic primarily for com- 
munity purposes, and again' its patients are three-fourths 
children. 
Need for dental work has been fully recognized in Bos- 
ton, and great pressure has been felt by all the clinics as 
well as by the two dental school infirmaries. The hospital 
clinics at the Massachusetts General Hospital, Homeo- 
pathic Hospital, Children's Hospital and Carney Hospital 
have as above mentioned, all found it necessary, as stated 
above, to limit their work to patients already cared for 
by the hospital for other reasons. For fillings, for instance, 
the Massachusetts General refers patients to the dental 
school. Out of nearly 28,000 new patients cared for in 
the Massachusetts General Hospital out-patient depart- 
ment in 1918, the dental clinic cared for only 308 new 
patients, or a little more than one per cent. These were 
referred cases, selected for special reasons. The Children's 
Hospital dental program is more extensive, and aims to DENTAL SERVICE IN VARIOUS CITIES 
49 
cover a large proportion of the patients, the plan being to 
give every child a thorough dental examination before 
discharge. Cooperation has been arranged by the Chil- 
dren's Hospital with the Harvard Dental School for 
orthodontic work. 
It is apparent that these hospital and dispensary dental 
clinics in Boston show a considerable measure of com- 
munity interest, and that efforts have been made to 
develop community relations through cooperation as well 
as by accepting patients who most need the service, and 
whose care is particularly desired by related community 
agencies. The two dental schools have been placed under 
great pressure, and have been unable to meet the demands. 
There are no school dental clinics in Boston. Examina- 
tions of the teeth are made by the school physicians and as 
many children requiring dental treatment as can be 
accommodated are taken by the school nurses to the 
various clinics of the city. The majority are received by 
the Forsyth Dental Infirmary, which this year has limited 
it s admissions during the school year to Boston school 
children of the first three grades. All the other clinics 
reserve special hours for groups of school children. 
The superintendent of schools says that the appropria- 
tion ($150,000 to $200,000 yearly) for health work in the 
schools is specifically for inspection and not for treatment, 
and Boston is not yet ready to endorse medical treatment 
by schools. The medical inspection department is con- 
trolled by the School Committee, and is not connected 
with the Department of Health. 
In 1920, 105,193 children were examined by school 
physicians, who reported 45,567 with defective teeth. 
There were 42,700 reported to the school nurses for treat- 
ment. There were 15,806 treated by private dentists, 50 
COMMUNITY DENTAL SERVICE 
and 16,178 at dental clinics. The nurses escorted to clinics 
10,923 for the first time and 20,923 for revisits. 
In 1920, the physicians reported 14,015 cases of hyper- 
trophied tonsils. The nurses reported 2,363 operations 
upon tonsils, and 2,259 upon adenoids. 
A few lectures on dental hygiene are given in the schools, 
15 in 1919 and "several" in 1920. Toothbrushes and 
tooth powder are sold at cost by the school nurses. The 
school nurses aim to visit each class once a month for a 
toothbrush drill, and are instructed to inspect the teeth 
of all children in all grades once a month. The Forsyth 
Dental Infirmary awards certificates to class rooms in 
which the entire class has had all necessary dental work 
done. 
There have been no reports as yet made regarding the 
effect of dental treatment upon school attendance and 
upon the diminution of contagious diseases, but it is 
stated that a survey is soon to be made of certain schools 
in Boston and that statistics will then be kept currently. 
It is to be noted that there is no inspection by dentists 
of school children's teeth in Boston, the examinations be- 
ing made by the school physicians. It is somewhat char- 
acteristic of New England tradition that the public 
schools of the city of Boston have depended upon private 
funds for the dental treatment of school children. 
The Forsyth Infirmary. Since 1915 Boston school 
children have had the advantages of the Forsyth Dental 
Infirmary, which may now be described. The Infirmary 
is an independent endowed institution located about two 
miles from the business center of the city, on a fine site 
near the Fenway. The building is of white marble, con- 
structed as a memorial. The present value of the invest- 
ment, including building and equipment, is stated by DENTAL SERVICE IN VARIOUS CITIES 
51 
Dr. Harold De Witt Cross, the superintendent, to be 
approximately $800,000. It was founded by John H. 
and Thomas F. Forsyth in 1910, and was opened in 1915. 
A Board of Trustees is the governing authority, five of 
whom are business men, four dentists, and two physicians. 
It is quite near the Tufts Medical and Dental Schools and 
a little over half a mile from Harvard Medical and Dental 
Schools. There is no organized relationship with the 
public schools nor with any community agency. The 
trustees include certain persons who are officially inter- 
ested in the Harvard Medical and Dental Schools and 
others similarly interested in Tufts, but the relationship 
is not of an official character in either case. It receives 
children under sixteen for all forms of dentistry (except 
prosthetic work, for which patients are referred to the 
dental colleges). Tonsil and adenoid operations are per- 
formed when required in dental cases. The Institution 
also conducts research, public education through lectures, 
instruction for graduate dentists, a School of Orthodontia, 
and a Training School for Dental Hygienists. 
There are two wards with ten beds each. A charge of 
$1 a night is made but free cases are accepted, and the 
average amount collected is 25 to 30 cents. Last year 770 
tonsil and adenoid operations were done and 35 surgical 
cases were treated. At the second visit every child is 
given a nose and throat examination; 5,407 examinations 
were made in 1920. 
There are 65 chairs, but only eighteen dentists are on 
the regular staff at the present time. About twenty chairs 
are used by student dental hygienists for cleaning. The 
clinic is in operation seven hours a day, with a half day on 
Saturday. Children of any age up to sixteen years from 
the neighborhood of Boston were at first received, but 52 
COMMUNITY DENTAL SERVICE 
this year admissions have been limited to school children 
of Boston from the first three grades. The aim is to get 
children as young as possible, and the average age of 
patients has been reduced to seven years. Children are 
kept thirty-five minutes, in the chair and average three 
visits a year. 
Only children from families where the per capita income 
is $6 or less are received. The statement of the school 
nurse is accepted, subject to scrutiny by the registrar. 
Five cents a visit is the only charge and a few free cases 
are received. School nurses from all parts of the city have 
regular assignments for one or two sessions a week. 
Emergency cases of suffering are received for one treat- 
ment and put upon the waiting list to be seen on Satur- 
days, when the school nurses do not have appointments, 
and during the summer months. By summer, in addition 
to several hundred who have received one emergency 
treatment, there are usually 1,200 on the waiting list. 
The total number of cases treated-in 1920 was 22,652, 
of which 13,687 were new cases; 8,965 were returned cases; 
and 8,801 were emergency cases. The daily average of 
dental patients was 169. The total visits were 45,686. The 
number of prophylactic treatments given by student 
dental hygienists was 30,945. 
Every child before receiving treatment is sent to the 
Oral Hygiene Department for a talk by a student hygien- 
ist on oral and personal hygiene. The child then receives 
a prophylactic treatment from a student. 
The educational work of the Infirmary includes the 
utilization of students from the dental colleges, and also 
the Training School for Dental Hygienists, which was 
conducted for three years by the Infirmary alone, and in 
1919 became affiliated with Tufts Dental School. Ninety- DENTAL SERVICE IN VARIOUS CITIES 
53 
nine students have been graduated, and there are 42 in 
this year's class. The course covers a period of twelve 
months. The time is apportioned as follows: 
Lectures and Quizzes 260 hours 
Laboratory 200 " 
Prophylactic Clinic 880 " 
Special Clinics 268 " 
Registration and Oral Hygiene . . . 250 " 
The School of Orthodontia is a post-graduate course 
conducted since 1919 in cooperation with the Harvard 
Dental School. It has the use of a clinic with three chairs. 
In 1920, there were two students; 35 cases were under 
treatment and received 1,103 treatments. This year there 
are three students. 
A nutrition clinic was started about a year ago for 25 
selected operative cases, with a dentist for follow-up. 
This method has been begun lately with the younger 
children. A medical staff has been built up, including 
pediatricians, a neurologist, an orthopedist, and others. 
It will be noted that the Forsyth Infirmary is not integ- 
rally associated with a medical school or a general hos- 
pital. It has proceeded to develop the medical relation- 
ships of dentistry along independent lines. 
The staff consists of a Supervisor on full-time, paid 
$2,500, with an Assistant Supervisor on half-time, paid 
$1,500, and eighteen operators on full-time at a salary 
of $1,000 a year and with the privileges of whatever 
instruction the institution offers and of training in pre- 
ventive dentistry for children. Some service is received 
from visiting dentists, but this has not been found 
dependable. 
The gross expense of the Forsyth Dental Infirmary in 
1920 was $90,000. Omitting research, the total expense 
of the dental work was $80,343, of which departmental 54 
COMMUNITY DENTAL SERVICE 
expenses were given as $39,051, and overhead as $41,292. 
If the entire 65 chairs were in actual use, the departmental 
expense would of course be larger, and the overhead 
slightly higher. It is estimated that if the 65 chairs were 
all in use, the total dental expenses would be about $115,- 
000 or an average cost of about $1,800 per year per chair. 
As a matter of fact, with post-war difficulties and other 
conditions causing only 18 chairs to be in operation, the 
average cost per chair for the year 1920, on this basis, 
was $4,463. These figures ($1,800 and $4,463) do not 
include expenses for research, tonsil and adenoid work, 
or orthodontia, but do include expenses for the dental 
service proper,-prophylaxis, fillings, etc., extractions, and 
X-ray. 
In 1920 there were 45,686 visits made to the Infirmary 
for dental purposes (excluding extractions, X-ray, ortho- 
dontia, oral surgery, etc.). Including the appropriate 
charge for overhead, the estimated cost per visit was 
$1.55. Excluding the overhead, and considering the 
expenses of the dental department only, without extrac- 
tions, research, orthodontia and tonsil and adenoid work, 
the cost per visit was seventy-seven cents. 
It will be observed that thege unit costs are on the basis 
of a comparatively small amount of dental visits made to 
the Infirmary, which ran only to about one-third of its 
capacity as a dental clinic in 1920. A total of 150,000 
visits, if all the dental units were in operation, would be 
approximately its full capacity. If this full capacity had 
been utilized, the cost of dental visits alone, including 
overhead, would have been $115,000, or an average cost 
of seventy-six cents per visit, and without overhead, an 
average cost of fifty-six cents per visit. 
The effect of the comparatively small number of dental DENTAL SERVICE IN VARIOUS CITIES 
55 
chairs in use in the Forsyth Infirmary upon increasing the 
unit cost is obvious. While the war undoubtedly increased 
the difficulty of securing dental operators and increased 
the expenses, the shortage of staff existed before the war. 
The Forsyth Infirmary has never been operated to its 
capacity. Considering the great demand for additional 
dental service, it is unfortunate that for Jack of main- 
tenance funds or for other reasons this valuable plant and 
equipment has never been able to operate to more than a 
fraction of its capacity. No financial statements have 
been published by the Infirmary. Probably the salaries 
paid the assistant dentists have been too low to secure 
a sufficient number of men, considering the general 
shortage of dentists, and the opportunities open in 
private practice or other salaried positions. 
In the above cost estimates, no consideration has been 
given to the investment in plant and equipment. It is 
estimated that the present value of this is $800,000 so 
that an interest charge of five per cent on this invest- 
ment would be $40,000 per year. About three-fourths of 
the total expense of the Infirmary is for the dental depart- 
ment. Thus the dental service represents an investment 
which would carry an interest charge, at five per cent, of 
$30,000 a year, and which amounts to about $10,000 per 
chair, if the total capacity were employed, or over $30,000 
per chair in use in 1920. 
It may be urged that a monumental building, inviting 
literary description and attracting visitors from all over 
the country, possessed a certain distinctive value during 
the pioneer years of the dental hygiene movement. The 
establishment of the Forsyth Infirmary, in fact, proved 
to be an important stimulus towards the movement which 
of recent years has spread so rapidly throughout the 56 
COMMUNITY DENTAL SERVICE 
country for the education of the public in the need of 
adequate care of the teeth of children. While the establish- 
ment of a monumental structure without sufficient funds 
for annual maintenance should set no precedent for other 
communities, the Forsyth Infirmary is justly entitled to 
the credit which it has received from the general public 
and from the dental profession as a pioneer in its field. 
Since it represents the largest benefaction thus far made 
to general dentistry, it must also be considered a shining- 
example of the recognition by benevolent laymen of the 
value of dental service as an asset for the public good. 
The Boston System as a Whole. The relationships 
between the different agencies giving dental service in 
Boston may now be considered as a whole. The out- 
standing element is the Forsyth Dental Infirmary, 
centralizing the prophylactic, reparative, operative, and 
other dental work for the children of the city. The results 
achieved must be considered in relation to (1) the effi- 
ciency of the service rendered; (2) to the number of 
children and (under another category) the adults cared 
for in proportion to those who need care; and (3) finally 
the expense of the system in relation to results. 
From the standpoint of technical efficiency, the work 
of the Forsyth Dental Infirmary and of other dental 
clinics in Boston appears in general to be of high grade. 
It is interesting that despite a large variety of comment 
unfavorably directed towards certain elements of the 
Boston system, which will be mentioned later, there has 
been practically no criticism of the treatment of patients 
in the clinics themselves. 
So far as ability to cope with the bulk of the dental 
problem is concerned, it is obvious from figures already 
given that the Forsyth Dental Infirmary is now running DENTAL SERVICE IN VARIOUS CITIES 
57 
to only a small proportion of capacity and has found it 
necessary to limit its work 'to a small part of the school 
children of younger years. If a limit must be applied, the 
limitation to early years in school is a desirable policy. 
The system, however, of centralizing the work for the 
school children at a single institution for a city of three- 
fourths of a million persons has evidently broken down. 
Even if the Forsyth Dental Infirmary were run to its 
capacity in the dental department, three times the amount 
of work now done would be much less than the prophy- 
lactic and reparative work demanded by the children in 
the public and parochial schools. 
Transportation is one of the most difficult problems in 
the Boston situation. Dental prophylaxis for children 
requires that each child should come to the dentist twice 
a year as a routine, and sometimes more frequently. All 
children need this treatment, and only a very few receive 
routine prophylactic care through private dentists, so 
this demand may be regarded as applying to almost one 
hundred per cent of the child population. In Boston this 
would mean more than 200,000 children between the ages 
of two and fifteen, or over 100,000 children attending the 
public and parochial schools. The children of school age 
alone would need 200,000 prophylactic visits a year, 
whereas the capacity of the Forsyth Infirmary is only 
150,000, and the visits last year in the dental department 
were only 45,000 (this number including visits for more 
than prophylaxis). 
At present the time of the school nurses in Boston 
must be spent in escorting children to the Forsyth Infir- 
mary from all parts of the city. For instance, a school nurse 
in Jamaica Plain, an outlying section of the city, has a 
district with a school population of about 18,000. She 58 
COMMUNITY DENTAL SERVICE 
devotes one day a week to escorting children to the dental 
clinic. She does not attempt to take children from the 
kindergarten or from the first grade, because it is too hard 
to take such young children on the cars. 
A dentist writing in 1918 in "Oral Hygiene,"* estimated 
that transportation to the Forsyth Infirmary cost $250 
a year for each school nurse, or about $8,000 for all the 
school nurses of Boston; and $5,000 a year for the carfares 
paid for the children by their parents; that the time 
children lost from school, figured at the cost per year for 
the education of a child, mounted to about $4,500 a 
year; and that the time lost to the city for the school 
nurses, on the basis of spending a day a week escorting 
pupils to the clinic was about $6,000 a year. Without 
taking these figures too seriously, it is obvious that there 
is a very large waste of time and money, risk of exposure 
of children to infection in traveling, and that moreover, 
a very expensive central plant is used for prophylactic 
work which requires comparatively simple technical 
equipment. 
It has already been brought out that the reaction of the 
community to this situation has been in part to fill up 
local clinics, of which Boston has rather an unusual num- 
ber in comparison with other cities, with school children 
who should theoretically be treated at the Forsyth. Even 
if the Forsyth Dental Infirmary had been able to overcome 
the financial or other difficulties which have stood in the 
way of utilizing the plant to capacity, it is not believed 
that the Boston system could show adequate results in 
terms of number of children cared for and relative expense 
per child. The testimony gathered from persons connected 
* Keyes, Frederick A., M.D. Mouth Hygiene in the Public 
Schools. Oral Hygiene, March, 1918. DENTAL SERVICE IN VARIOUS CITIES 
59 
with school children is to the effect that taking Forsyth 
and other clinics together, not more than half of the dental 
work needed for children is done, and this is regarded as an 
outside estimate. If dental clinics were more accessible 
to the schools, the dental work for school children would 
undoubtedly be greatly increased. Of approximately 
100,000 children examined in one year, over 42,000 were 
reported to the school nurses for dental care, of whom 
about 16,000 were treated by private dentists and 16,000 
were taken to dental clinics. 
The Forsyth Infirmary and the two dental school clinics 
are in the same neighborhood, two miles from the business 
center of the city. Children coming from all sections of the 
city, except the one district lying beyond the location of 
these institutions, must make one or two changes of cars. 
The Finance Committee in a recent report* comments 
on the danger to health and the liability of accident in 
street car travel for young children and recommends an 
additional appropriation for the School Committee to 
provide transportation facilities. The school nurses cheer- 
fully accept the conveying of groups of children twice a 
week and are eager to do so, because they feel strongly the 
benefits of dental care to the children. But they feel that 
it is a great strain on them. They are reluctant to take the 
younger children because it is so difficult to protect them 
from danger of accident or from getting lost; although it 
is now the aim of the clinics to get the children as soon as 
they enter school or earlier (at the age of two) if possible. 
The testimony of social workers and public health 
nurses is that dental facilities are inadequate. The need 
* Report of Finance Commission on Petition of School Committee 
to Increase its Appropriation Power $1.05 per $1,000-City Record. 
Vol. 12, No. 50, Dec. 11, 1920. 60 
COMMUNITY DENTAL SERVICE 
is felt more acutely for adults, for whom the problem of 
securing dental care is considered nearly hopeless. The 
nurses of the District Nursing Association of Boston say 
that to get dental care for their patients is their greatest 
problem, particularly acute in relation to pregnant 
women. The Baby Hygiene Association finds it imposs- 
ible to give thorough attention to care of the teeth. The 
remoteness of the existing clinics from certain thickly 
populated districts is an almost unsurmountable obstacle 
in the case of many adults and of younger children. 
Some consideration has been given in Boston to a 
motor bus service for children. The Guild of St. Appolonie 
has provided an auto bus for the children of the parochial 
schools, with a matron, which has been estimated to cost 
something like $2,000 a year to maintain. The establish- 
ment of a motor bus system to transport children in gen- 
eral to the Forsyth Infirmary has been considered but 
no action has yet been taken. Even if this were estab- 
lished, it is clear that the Forsyth Infirmary, when run to 
its maximum capacity, could not do nearly all the work 
for Boston's children, and that additional clinics are 
necessary if a one hundred per cent job is to be done, or 
else the endeavor to centralize the prophylactic work 
should be abandoned in favor of something like the 
Rochester or the Bridgeport plan. 
Cleveland. Cleveland has a population of 796,000, 
slightly more than that of Boston, but Cleveland with its 
immediate suburbs has a population of not much over a 
million, whereas greater Boston, as already mentioned, 
has about one million and a half. There are 550 dentists 
in Cleveland, or one to each 1,400 persons, approximately. 
A law permitting dental hygienists to practice in institu- 
tions under supervision of a licensed dentist is now being DENTAL SERVICE IN VARIOUS CITIES 
61 
sought. The contrast between Cleveland and Boston with 
respect to the ratio of dentists to population and as to the 
presence of dental hygienists is emphasized by a brief 
review of the limited facilities of Cleveland. 
Two hospitals, The City Hospital and Mount Sinai, 
maintain each a dental chair, and Lakeside Hospital and 
St. Luke's are each about to establish a dental department. 
The Board of Education maintains six school clinics, 
consisting each of a dentist with an assistant operating 
five days a week for three hours, during forty weeks of the 
year. Children are referred by the school medical in- 
spectors and nurses. In 1919, the number of children 
treated was 4,421. 
The Cleveland Mouth Hygiene Association conducts 
dental dispensaries in three of the health centers of the 
Division of Health. A dentist and an assistant operate in 
each for fifty weeks a year, five days a week, for three 
hours. The cost of these clinics is met from the Com- 
munity Fund as a part of the Welfare Federation's budget. 
Western Reserve University Dental School operates a 
clinic for all kinds of dental work. The charges are similar 
to those of private dentists practicing among working-class 
people; and they more than support the clinic. The school 
in its bulletin reports for the year 1918-1919 a total of 
42,000 operations. In 1920 the enrollment was 161 students. 
The Cleveland Hospital and Health Survey in its 
reports published in the autumn of 1920 calculated that 
the provision of dental service then in existence in the city 
amounted to a total of ten dental chairs, running a total of 
156 hours a week.* It will be recalled that the Boston 
figures totalled 7,601. The three clinics run by the Mouth 
* Cleveland Hospital and Health Survey. Part 8, Education and 
Practice in Medicine, Dentistry, Pharmacy, pp. 683-690. 62 
COMMUNITY DENTAL SERVICE 
Hygiene Association of Cleveland provide all the organized 
dental service available for 130,000 parochial school 
children, whereas it is estimated that eleven clinics operat- 
ing eleven half-days a week are needed for these children 
alone. The public school children are even less well pro- 
vided for. The dental care for persons of small means is 
limited to extractions and relief from acute conditions and 
is obviously most insufficient, even in this respect. The 
Hospital and Health Survey recommended a dental 
department in each hospital, and a dental clinic in each 
dispensary connected with a hospital, as well as in each of 
the eight health centers maintained by the Department 
of Health, instead of in only three as at present. The 
Survey also recommended that some of the dental clinics 
be pay clinics, charging fees covering the cost, as a pro- 
vision for persons of moderate means. 
It will be seen that in Cleveland the movement for 
dental hygiene and organized dental service in general has 
reached only a slight development. The very limited 
range of community service of the dental school infirmary 
is worthy of note. No relationship has been established 
between the dental school and other community resources 
for dental or medical care. 
New York. The Boroughs of Manhattan and the Bronx 
have a population of approximately 3,080,000, and con- 
tain about 2,600 dentists, or one for every 1,200 persons. 
In 1916, New York passed a law for licensing dental 
hygienists to practice in public institutions, schools, and 
offices of private dentists. Columbia University offers a 
nine months training course for dental hygienists, open to 
women 18 years or over, who have had four years of high 
school, or its equivalent. There are 26 students in the 
present class and 200 graduates. DENTAL SERVICE IN VARIOUS CITIES 
63 
A Directory of Dental Clinic and Dispensary Service 
was compiled in January, 1921, by the Health Service 
Department of the New York County Chapter of the Red 
Cross. There are 22 hospitals and dispensaries in New 
York that afford some form of dental out-patient service. 
In several places the work is limited to extraction, in 
several more to extractions and surgery. About one-third 
of these clinics are in operation one to three half days a 
week; 13 are open daily. The service in some dispensaries 
is confined to patients referred from other departments. 
The hospital conditions can be illustrated by two among 
a number of examples. Bellevue and Allied Hospitals, 
maintained by the municipality, have a dental interne in 
each hospital whose primary duties are to examine and 
treat all children admitted to the hospital, and to relieve 
acute conditions in adults. They also treat children from 
the out-patient department. An extension of the service 
is desired by the authorities. 
In the Presbyterian Hospital all ward patients have 
prophylactic treatment by a dental hygienist and an 
X-ray of the teeth. They are later given dental treatment 
in the dispensary, if they require it. A few patients are 
treated in the wards. Patients are not admitted directly 
to the dental service, but dental conditions are treated if 
they are complications of other troubles. 
Other hospitals might be mentioned, such as Mount 
Sinai, which maintain a dental department, but limit their 
work to hospital patients and ambulatory cases referred 
for special reasons from medical departments of the same 
institution. 
Three dental schools exist in Manhattan and the Bronx; 
Columbia University School of Dentistry, with 113 
students in 1919-1920; The College of Dental and Oral 64 
COMAIUNITY DENTAL SERVICE 
Surgery, with 511 students; and the New York College of 
Dentistry, with 573 students; a total of 1,207 in the three 
schools. 
Manhattan and the Bronx contain fourteen privately 
supported dental clinics, maintained by social settlements, 
churches, the Red Cross, the Children's Aid Society, and 
other welfare organizations. A number of industrial 
concerns in New York have dental dispensaries for their 
employees, including large department stores, such as 
Bloomingdale's, Lord and Taylor, R. H. Macy and Com- 
pany, James McCreery and Company, and John Wana- 
maker. The New York Telephone Company and the 
Metropolitan Life Insurance Company are two notable 
examples of industrial dental service, while at the In- 
dustrial Health Center of the International Ladies Gar- 
ment Workers' Union a well equipped dental clinic is 
maintained. 
The clinic of the Metropolitan Life Insurance Company 
is finely equipped and under competent direction. The 
work is entirely for adults and this should be borne 
in mind in comparing expenses with other clinics. The 
cost per case for prophylactic work alone was $3.03 for 
5,233 different employees. The cost per chair hour was 
$2.35 for the prophylactic work alone. Most of the work 
in this clinic is prophylactic, but some emergency dentistry 
and some X-ray work is done. The cost per employee per 
annum for all branches of service was $4.39 on the basis 
of the 6,191 employees to whom service was given. Of this 
cost per employee, the cost of prophylaxis alone was $4.15. 
This clinic was equipped in the year 1915, the cost of 
equipment being stated to be about $1,000 per chair. 
The figure of $3.03 cost per case may be cautiously com- 
pared with the cost of prophylaxis shown in the carefully DENTAL SERVICE IN VARIOUS CITIES 
65 
worked out cost accounting of the University of California 
College of Dentistry. Their cost figures came to 47 cents 
for each prophylactic operation (cleaning of teeth). The 
difference is due to the fact that the work in the dental 
infirmary is done by students, so that there is no salary 
charge. At the Metropolitan Life Insurance Company 
Clinic, salaries constitute about four-fifths of the expense 
of the prophylactic work. Furthermore, "the case" in 
the Metropolitan statistics is not the same unit as the 
"operation" in the California figure. No definite con- 
clusion can be drawn from this comparison, but it is made 
to point out the very large element of salary charge in 
prophylactic work, and the great saving that can be made 
by utilizing students so far as possible. 
There are three school clinics in Manhattan and the 
Bronx which have been maintained by the Department of 
Health since January 1, 1913. There are in addition four 
school clinics in the Borough of Brooklyn and one in the 
Borough of Queens. Six are located in school houses, and 
two in buildings in the vicinity of schools. One dentist, 
with the assistance of a nurse, operates in each clinic for 
three and a half hours a day, six days a week. In Public 
School number 21, the services of a dental hygienist are 
provided by the Association for Improving the Condition 
of the Poor. The method of work is wholly prophylactic. 
Entering children are referred to the clinic for examination, 
the slight repair work necessary, and instruction in mouth 
hygiene. They are then required to report in six months.* 
*The following figures give some idea of the amount of work done 
in the eight school clinics: 
New Cases 
1917 
. . 8,069 
1918 
7,116 
1919 
6,689 
Cases brought forward . . 
. . 3,675 
3,698 
4,313 
Visits 
. . 21,503 
18,306 
16,942 
Discharged cases .... 
. . 6,220 
6,206 
5,358 66 
COMMUNITY DENTAL SERVICE 
These services are obviously inadequate for New York. 
The eight school clinics of the Board of Health complete 
about 6,000 cases a year, among the 900,000 school children 
of the city. The aim is to extend it as soon as it is possible 
to obtain a sufficient appropriation to cover at least the 
children of kindergarten and the first two grades. Examin- 
ation of the teeth is part of the medical inspection in the 
schools. Attempts are made to instruct the children in 
oral hygiene through talks and toothbrush drills, but the 
staff of school nurses is wholly insufficient for carrying 
out this plan. 
The school nurses take children, as far as they are able, 
for dental treatment to the various dispensaries of the city. 
Only a small part of the required dental work in the schools 
is being done. There is need for care of the teeth of 
children who, when they apply for employment certificates, 
cannot pass the physical examination on account of dental 
disease. Some of these cases are taken at the school clinics 
on certain days. 
Owing to the small number of clinics and the limited 
working force under the supervision of the Bureau of Child 
Hygiene, at the present time, the Bureau welcomes the co- 
operation of all citizens and agencies who are sufficiently 
interested in the care of school children to provide funds, 
not only for the equipment and maintenance of dental 
clinics, but also for providing the necessary number of 
dentists, nurses, and dental hygienists. 
An appropriation for increasing the number of school 
dental clinics was included in the budget of the De- 
partment of Health for 1921, but was not approved 
by the Board of Estimate because of the extreme pres- 
sure for economy at the time the budget came up for 
action. DENTAL SERVICE IN VARIOUS CITIES 
67 
The Association for Improving the Condition of the 
Poor is now conducting a very interesting demonstration 
of thorough dental care for children of the kindergarden 
and the first five years of school. Its experiment was begun 
in January, 1920 with a five-year program. The district 
selected for the work has a population of 40,000, about 
10,000 children of whom 6,000 are under the sixth grade. 
In this district are schools numbers 21 and 106, and a 
parochial school. There is a Children's Aid Society in- 
dustrial school of 1,200, which has a dental clinic attended 
occasionally by a dentist for the worst cases. The Associa- 
tion employs a supervising dentist on part-time (salary 
$150 a month) a full-time dentist ($200 a month), and 
two dentists on half-time ($100 to $150 a month). They 
have three portable chairs which they use in School 106 
and in the parochial school. In School 21 there is a dental 
clinic of the Board of Health. In each school the Associa- 
tion has put a dental hygienist. The three hygienists are 
paid at the rate of $100-$150 a month, two are on full 
time and one on half time. Fifteen students from the 
Columbia School of Oral Hygiene work in the Community 
House for ten weeks, three hours a day, caring for children 
from the schools sent by classes in charge of a teacher. 
They take 40 children a morning. The graduate hygienists 
take 160 to 175 children a month. 
In the month of December, 1920, the amount of work 
done by the dentists (with one chair in use 6 hours a day, 
and two chairs 3 hours a day, and at irregular hours for 
extractions), was as follows: 
Total cases 490 
Fillings 615 
Extractions 84 
Treatments 78 
Cleaning 483 68 
COMMUNITY DENTAL1 SERVICE 
This demonstration is not yet advanced far enough to 
show results, but the plan itself is noteworthy. It in- 
cludes a well devised co-operative scheme related (1) to 
the school system (2) to an educational organization for 
training dental hygienists and dental students, and finally 
(3) to a definite population unit in a specified district. In 
other words, the plan is not merely to render service to a 
certain number of children, but to enable the dental 
results achieved to be measured in terms of total need for 
this particular group of child population. 
The community house which is the center of this ex- 
periment has come into such relation to its neighborhood 
as to bring out dental needs for adults, and it is stated that 
a dental clinic for adults, probably of a self-supporting- 
nature, is contemplated. 
The value of such a thought-out demonstration is 
obvious. The amount of money invested in such a piece of 
work ought to yield much larger ultimate returns than if 
expended without such a plan. To demonstrate what 
would be required to do thorough dental work for 
children in a specified area may have great influence in 
leading the metropolis to finance a more adequate dental 
program. 
Although the dental facilities of Manhattan and the 
Bronx seem so numerous, it is obvious they are totally 
inadequate for a population of 3,000,000 people. To 
secure dental care for adults is reported by the social 
agencies of the city to be an almost hopeless undertaking. 
The visiting nurses of the Henry Street Settlement find 
that it is almost impossible to secure dental attention for 
adults of limited means; all existing clinics are always 
filled to capacity. With regard to the children, the visiting 
nurses from all districts of the city feel that more dental DENTAL SERVICE IN VARIOUS CITIES 
69 
work is one of the most crying needs. Effort is made to 
meet a small part of the need by one expedient or another. 
In one district, for instance, two local dentists have been 
asked by the nurses to volunteer their services for the 
children, and they are taking ten children per week. At 
one of the health centers associated with this nursing 
service, the nurses and dietitians, although they needed 
assistance badly for their clerical work, wished instead to 
have the funds go to establish a dental clinic. 
The testimony of the United Hebrew Charities furnishes 
a similar illustration: They have just had one of their 
nurses prepare a report on the dental facilities of her 
neighborhood house, which are very inadequate. This 
nurse succeeds in getting dental treatment for about nine 
persons in a month, whereas there are about 80 persons a 
month needing it in her district. Some dental care is 
required in almost every case of sickness. They make no 
systematic attempt to take care of the teeth of adults, as 
it is impossible to get treatment. The organization 
maintains a dental clinic; they provide equipment, and 
the patients pay three dollars an hour for the dentist's 
services. 
The facilities in New York are furthermore not organ- 
ized according to any general plan. The Health Depart- 
ment realizes that its eight school clinics only scratch the 
surface. Except for the carefully considered dental demon- 
stration of the Association for Improving the Condition of 
the Poor, relations between the different medical, dental, 
education, and community agencies which should co- 
operate in a dental program are not worked out in New 
York to any degree worthy of mention. 
Various Other Cities. An inquiry was made by letter to 
the Boards of Health and School Departments of the 46 70 
COMMUNITY DENTAL SERVICE 
cities mentioned in the foot-note.* These include all the 
larger cities in the United States and a few smaller ones. 
Forty-three of the 46 cities replied. Thirty of the 43 cities 
had dental clinics for school children. These are conducted 
under the auspices of the school department in 18 cities, 
and under the health department in twelve cities. All 
but nine of these had one or more clinics operated in school 
buildings. Dental hygienists are operating in the schools 
of five cities, namely, Bridgeport, Hartford, Waterbury, 
Rochester and New York. The number of school clinics 
varies within wide limits. Thus there are eight cities 
having one dental clinic for school children. 
Three cities, St. Paul, Syracuse and Toledo have two 
clinics for school children; six cities have three each, 
Indianapolis, Springfield, Minneapolis, Cincinnati, Phil- 
adelphia, Milwaukee; two cities have four each, Baltimore 
and Washington; two cities have six each, Oakland and 
Jersey City; New York has eight and Pittsburgh has 
eleven school clinics. Chicago has six dentists operating 
in twelve schools; Bridgeport has three dentists, and 
Hartford four, for school dental work. Atlanta has several 
*Ala., Birmingham 
Cal., Los Angeles 
Oakland 
San Francisco 
Conn., Bridgeport 
Hartford 
Waterbury 
Colo., Denver 
D. C., Washington 
Ga., Atlanta 
111., Chicago 
Ind., Indianapolis 
Ky., Louisville 
La., New Orleans 
Md., Baltimore 
Mass., Boston 
Springfield 
Worcester 
Mich., Detroit 
Flint 
Minn., Minneapolis 
St. Paul 
Mo., Kansas City 
St. Louis 
Nebr., Omaha 
N. J., Jersey City 
Newark 
N. Y., Buffalo 
Albany ' 
New York 
Rochester 
Syracuse 
Ohio, Akron 
Cincinnati 
Cleveland 
Columbus 
Day ton 
Toledo 
Ore., Portland 
Pa., Erie 
Philadelphia 
Pittsburgh 
R. I., Providence 
Va., Richmond 
Wash., Seattle 
Wis., Milwaukee DENTAL SERVICE IN VARIOUS CITIES 
71 
school clinics, and Kansas City is beginning to establish 
them. Detroit has sixteen clinics in schools and elsewhere, 
conducted by the Health Department. In Providence the 
Health Department furnishes dental inspection for school 
children and privately conducted clinics are used for 
treatment. 
Philadelphia has three school dental clinics conducted 
by the Board of Public Education. Two dentists are in 
constant attendance and children of the surrounding 
schools are brought by the school nurses to these centers. 
Children are also taken to seven other dental dispensaries 
in the city by the school nurses. The Department of 
Public Health maintains ten branch dental dispensaries 
at various points in the city, employing nineteen assistant 
dentists and a chief. All services are free. The scope of 
the service includes prophylactic treatments, filling and 
extracting. In 1920, 9,646 patients were cared for and 
75,343 operations performed. 
In Albany the Board of Education has maintained a free 
dental dispensary for school children for seven years. One 
dentist is engaged for three half days a week during the 
school year and takes about 300 cases a year. The 
children received are certified by a school nurse for free 
treatment. About 4,000 children in the schools are in need 
of free treatment. 
Omaha has a dental dispensary under the Board of 
Education, with one dentist on full time and one dental 
assistant, to care for needy children under sixteen. Cases 
are investigated and referred by the school nurses. The 
dispensary is open all the year and cares for between four 
and five thousand children. 
St. Paul has a dental clinic for school children in the city 
physician's office and also two school clinics, one permanent 72 
COMMUNITY DENTAL SERVICE 
and one itinerant, both primarily for teaching dental 
hygiene with repair work as a secondary matter. The plan 
of the itinerant clinic is to stay in a building one month 
for prophylactic and educational work. 
Minneapolis has the school dental clinics supported by 
the Board of Education under the directorship of the 
Commissioner of Health. The dentists work four hours a 
day for six days and are assisted by dental hygienists or 
nurses. Children are received who cannot pay for private 
dentists. A little orthodontia is done. A dentist is detailed 
when necessary for relief work in the special schools for 
the crippled, the blind and the retarded children. 
In Washington the dental work of the schools is under 
the supervision of the Health Department. Four dental 
inspectors are employed. In 1920 they examined 14,314 
children, finding 90 per cent with carious teeth and an 
average of 3.5 carious teeth per child. Four school dental 
clinics are conducted with eight operators on half time 
and four dental hygienists on full time. In 1920, 3,339 
pupils (5.88 per cent of the pupils in the graded schools) 
were given treatment. The dental work is free to all pupils 
and each clinic has now a waiting list of about 1,000 pupils. 
The actual cost is estimated to be about one-third of the 
average cost of dental work elsewhere. 
The City of Flint, Michigan, began dental work among 
school children three years ago with one dentist, under the 
auspices of the Health Department. The population of 
the city is 91,599 and the school population is about 16,000. 
The Health Department now employs five full time 
dentists. The work is administered from a central clinic in 
the Health Department, where there are also free medical 
clinics for school children not able to obtain private 
treatment. Other dental clinics are held in the schools or DENTAL SERVICE IN VARIOUS CITIES 
73 
nearby. The dental work is free to children most in need 
of treatment. 4,000 children a year can be cared for. 
Examination by a dentist of all children in the elementary 
schools is made once a year. Treatment is given first to 
children of the lower grades, and the aim is to extend it as 
far as possible to all the grammar grades. The Health 
Officer believes that the dental work has had a large 
influence upon the health of the children. What has been 
accomplished by this comparatively small city indicates 
how much can be done with strong local leadership which 
secures community backing for an adequate dental 
program. It will also be observed that Flint has a central 
clinic where dentistry has been associated with medicine, 
with other dental clinics held in schools or in association 
with them. 
Detroit. The city of Detroit has a community plan for 
dental work, based thus far almost exclusively upon the 
school clinic. Detroit's population is about 990,000, and 
there are about 450 dentists, or one to 1,800 persons. The 
Health Department of Detroit maintains 16 clinics, nearly 
all of which are in school buildings. Three are located in 
hospitals. Part of the expense of maintenance of the 
hospital clinics is borne by the city and in at least one case 
the expense of installation was met also. In the central 
office of the Department of Health is a clinic with four 
chairs. This old office building was not constructed for 
clinic purposes, but the dental equipment is satisfactory. 
A few orthodontia cases are taken. The bulk of the work 
is prophylactic and reparative work for children. Some 
work for adults, is done in the central clinic but for 
emergency cases only. 
The University of Michigan at Ann Arbor, forty miles 
from Detroit, plans a two year course for dental hygienists. 74 
COMMUNITY DENTAL SERVICE 
The first year includes the usual courses. The second year 
the student may undertake work which is expected to be 
for pay in a dental clinic or other Department of Health 
institution. The diploma will not be awarded until the 
end of the third year. The aim will be to keep students 
in institutional work rather than to let them go into pri- 
vate offices. 
The school children of Detroit are inspected annually by 
both physicians and dentists. Dr. Henry F. Vaughan, 
Health Officer, states that 80 per cent of the children of 
both public and parochial schools are now examined an- 
nually. There are 55 medical inspectors on part-time, and 
55 school nurses; but after July first they expect to have 45 
additional school nurses. At present they are unable to 
cover all schools, but after July first they will be able to do 
so. The co-operation of the parochial schools is excellent. 
Last year repair work was done for about 16,000 school 
children, and prophylactic work for about 12,000; but 
the number who receive prophylactic treatment is increas- 
ing rapidly, as more and more emphasis is annually laid 
upon this. Educational talks are also given in the schools. 
The policy is to stress prophylactic work for the younger 
children. Owing to the lack of hygienists, it has been 
impossible to do nearly as much of this work as is desired. 
The appropriation for dental service by the Health 
Department was $25,000 for the year 1921, which can be 
expended at the discretion of the Health Officer. Four 
full-time dentists are employed, paid at the rate of $6 to 
$10 a day, and ten or twelve are employed on part-time. 
There are three dental hygienists devoting themselves to 
prophylactic work, and one who is doing some educational 
and dental work in the schools. There is a supervising 
dentist on part-time, at a salary of $1,800. Once a month DENTAL SERVICE IN VARIOUS CITIES 
75 
this supervisor holds a special clinic for his dental staff, 
and he visits the clinics while they are in operation. There 
is, however, no really adequate supervision of the field 
work. The records are on cards, and there is some mention 
of what was done for each case, but there are no mouth 
charts. 
From the figures given it is obvious that the amount of 
work done for the children of Detroit meets only a small 
fraction of the need. The lack of a general well-equipped 
central dental institution deprives the supervising and 
operating staff of a source of coordination and a center of 
professional stimulation. 
Bridgeport. Bridgeport, Connecticut, illustrates a city 
of small size, compared with Chicago, in which dental work 
has remarkably advanced, largely due as in Flint to the 
local leadership of one man. Dr. Alfred C. Fones, one of 
the leading dentists of the country, has made Bridgeport 
widely known for its development of dental prophylaxis 
for children. 
The population of the city is about 148,000. The number 
of dentists in the city is about 100, or one to each 1,400 of 
the population. There are 26 dental hygienists working 
in the schools. Connecticut has as yet no school for 
dental hygienists. In 1913-1914 a training course was 
given in Bridgeport under the auspices of the Department 
of Health to prepare a number of hygienists for work about 
to be undertaken in the schools. 
The Bridgeport Hospital has had a dental service for 
about twelve years. Until three years ago this consisted 
in caring for emergencies-acute and chronic infections 
and surgical cases. It has now been developed to the extent 
of dental examination of all patients in the wards, and 
treatment when required, as part of the routine care of the 76 
COMMUNITY DENTAL SERVICE 
patient. There is no dental out-patient clinic, the clinic 
conducted by the city being relied upon. 
The Department of Health has maintained dental work 
for school children since 1914. Dental prophylaxis is 
carried on in 41 schools (parochial and public), with a 
population of 21,000 children. Three dentists and twenty- 
six dental hygienists are employed. The work of the 
dental hygienists includes prophylactic treatment, clean- 
ing and polishing the teeth, toothbrush drills and class- 
room talks, stereopticon lectures to older children, and 
educational work among parents. The work of the 
dentists is confined to filling the first permanent molars for 
children in the first and second grades and extracting 
abscessed teeth for children of all grades. 
In the year 1919-1920, 28,012 prophylactic treatments 
were given by the hygienists to 20,918 children; 889 
children had teeth filled with a total of 2,443 molars filled; 
and 5,991 teeth were extracted. 
The aim is to give two prophylactic treatments a year 
to children of the first and second grades. All children 
receive this treatment regardless of the parents' financial 
status, and are all eligible for the services of the dentists 
in filling first permanent molars and extracting abscessed 
teeth. 
During the summer vacation, dental clinics are opened 
in various schools where children from the higher grades, 
including the high school, may receive a prophylactic 
treatment and instruction in dental hygiene. Nearly 3,000 
children received treatment last summer. 
A dental clinic in the Welfare Building is conducted by 
the Department of Health. It has four dental chairs with 
.three dentists in attendance seven hours a day for five and 
a half days a week. A large majority of the patients are DENTAL SERVICE IN VARIOUS CITIES 
77 
children. In 1920 there were 1,038 new patients and 5,552 
treatments. The cost of maintenance was $6,268.82 for 
the year ending April 1, 1920, and the amount paid by 
patients was $1,399.60. Only persons from families with a 
per capita income of not over $7 a week are admitted. 
It is well to know that in the Bridgeport clinic, a 
municipal undertaking, ten cents is charged for admission, 
and fees for services as follows: 
Examination $0.10 
Cleaning 0.25 to $1.00 
Filling 0.25 to 1.00 
Extracting 0.25 to 0.35 
Treating 0.25 
The Forsyth clinic charges five cents for admission, and 
the same fee is asked at the Rochester Dental Dispensary. 
It should be observed that in Bridgeport, practically the 
entire child population in public and parochial schools 
received prophylactic treatment last year, with an average 
of one and a half treatments per child. Moreover, tooth, 
brush drills and class room talks were given in 1920 to 
22,587 children, which again is practically equivalent to 
the whole school population. 
The cost of the work was $45,913 for what was done in 
the school, parochial and public, and $6,268.82 for the 
dental clinic in the Public Welfare Building, a total of 
$52,181.82. Part of the work of the welfare clinic is for 
adults, the proportion of which could not be ascertained. 
Estimating roughly that the share of the expenses of the 
clinic chargeable to children's work was $4,000, we would 
have a total cost for the children's service of about 
$50,000, for a school population of $22,000, or about 
$2.27 per child per year. This is a lower figure than has 
been observed elsewhere, but as can be seen, no extensive 
reparative work for children is included. 78 
COMMUNITY DENTAL SERVICE 
Doctor Fones had laid great emphasis upon prophylaxis 
and upon instruction of children and their parents in the 
care of the mouth and in diet. He believes that "from 
seventy per cent to eighty per cent of dental caries can 
be eliminated through the public school system by the 
incorporation in the school curriculum of a definite health 
program, making hygiene one of the requisites for pro- 
motion. This would insure the cooperation and interest of 
the child, teacher, and parent." * 
Substantial results are reported in the reduction of 
absences from school, as one of the probable results of the 
dental hygiene program. A reduction of the percentage of 
retarded pupils, in the incidence of contagious disease, and 
a reduction in the number of cavities found in the perma- 
nent teeth of children in the fifth grade are felt to be due to 
the intensive prophylactic campaign which Bridgeport 
has conducted since the organization of the dental system 
in 1915. 
The report of the Division of Dental Hygiene for the 
year ending in 1920, of which Doctor Fones is Director, 
may be quoted in part: 
"Previous to September, 1919, the school work was handled 
entirely by a traveling corps of hygienists with portable equip- 
ments. The corps remained in a school until the work was 
completed and then moved to the next school, returning at a 
later period. The interest in mouth hygiene in the intervals 
between the visits of the hygienists depended in a great measure 
upon the influence of teachers. 
"In September, 1919, we placed a resident hygienist in cer- 
tain schools and a comparison of the records with those of the 
traveling corps indicates that this procedure would be ideal if 
sufficient hygienists could be secured. We intend this year to 
* Quoted from Annual Report of the Division of Dental Hygiene, 
Department of Health, Bridgeport, Conn., 1920. DENTAL SERVICE IN VARIOUS CITIES 
79 
locate as many resident hygienists as can be spared from the 
traveling corps. A few of the many advantages of this plan are 
as follows: A reduction of the number of children with whom she 
comes in contact and works for, enables her to remember the 
mouths of individual children and to give special help in cases 
which need it. Her constant presence in the schools is a daily 
reminder of clean mouths and sound teeth to all the pupils and 
teachers in her school. She is able to carry through lively com- 
petition between rooms for the reward of clean teeth banners, 
honor rolls, etc. Her undivided interest in the children of one 
school brings her in touch with the parents, who are frequent 
visitors at her clinic. 
"It is apparent that the improvement in any school depends 
materially upon cooperation of principals and teachers with the 
hygienists and our records will show how heartily this help has 
been given. The personal attitude of the teacher means so much 
to the child, and it is invariably true that the best records come 
from the room of the teacher who has an appreciation of mouth 
hygiene." 
One danger in this program is the over-development of 
the work of the dental hygienist. The school dental 
program is part of the general health program for children, 
and what the school nurses and other medical and health 
workers need to do for these children should be considered 
as well as what the dental hygienist may do. 
It may be noted that organized dental service for 
adults in Bridgeport is only slightly developed. 
Rochester. Rochester, New York, has the most com- 
prehensive plan for dental work for children in this 
country. The city had a population of 295,750 in the cen- 
sus of 1920, with 45,000 children in the public and parochial 
schools. 
The center of its dental system is the Rochester Dental 
Dispensary, an institution founded by Mr. George 
Eastman, and governed by a board of directors. The 80 
COMMUNITY DENTAL SERVICE 
expense of the building and equipment is said to have been 
approximately $450,000. An endowment of $750,000 was 
also provided by Mr. Eastman, and has since been in- 
creased to $1,800,000. Mr. Eastman made it a condition 
of his initial foundation that twelve leading business men 
of Rochester should become members of the board of 
directors, and should each contribute $1,000 a year for five 
years; and that the city should appropriate $20,000 
annually for a similar period to pay for prophylactic work 
for children in the schools, and in institutions such as 
orphan asylums. The Dispensary is in no way under con- 
trol of the city government, but is entirely in the hands of 
its board of directors. 
The location of the building is not far from the business 
center of the city, and is convenient to car lines. The 
building is attractive but not of the monumental character 
of the Forsyth Dental Infirmary. There are 37 chairs 
in all, 28 in the dental departments, 2 for extractions, and 
2 for orthodontia. There is space, however, for adding 31 
additional chairs. The surgical department has 18 beds for 
oral surgery and tonsil and adenoid operations. 
The Dispensary is in operation all day. Children up to 
sixteen years are accepted. There are 23 dental operators 
on the staff, and a supervisory staff. 
At present there is no research department, such as is 
maintained at the Forsyth Dental Infirmary. The 
foundation of the medical and dental school of the Univer- 
sity of Rochester, now assured through contributions of 
the General Education Board and of Mr. Eastman, will 
establish a great medical and dental center with which 
the Dental Dispensary will be affiliated, and which will 
provide relationships with medical education, with re- 
search, and with a general hospital and dispensary, upon DENTAL SERVICE IN VARIOUS CITIES 
81 
the importance of which so much stress has been laid in 
this report. 
A five cent admission fee is charged but is not always 
collected; only those children are admitted whose family 
income is as follows: not more than 
$20 a week for 2 in the family 
$27 " " " 3 " " " 
$32 " " " 4 " " " 
$ 7 a person a week for 5 or more in the family. 
The statements of school nurses regarding income are 
accepted. In other cases, the applicant's statements are 
checked up by letters of inquiry sent to employers. 
The statistics of work done in the Rochester Dental 
Dispensary are given in its Annual Reports, together with 
the receipts and disbursements. Among the significant 
figures are the number of visits to the Dispensary, which 
was in 1919, 48,813 and 46,911 in 1920. The decrease is 
attributed to enlargement of the tonsil and adenoid clinic 
during the summer of 1920, when many children received 
surgical operations who would otherwise have been dental 
patients. The number of treatments however, is larger 
by 4,000 in 1920 than in 1919. The number of extractions 
is also larger. The prophylactic treatments in the schools 
were 66,953 in 1919 and 63,528 in 1920. 
The cost per visit during the year 1920 was $1.42. The 
cost of the dental department, making an allowance for 
overhead, was about $1,500 per chair. The figures may be 
compared with the Forsyth Infirmary, although caution 
must be exercised in drawing deductions from such compar- 
isons. It will be remembered that prophylactic cleanings 
are done at the Forsyth, but not to any large extent at the 
Rochester Dispensary. This would tend to increase rather 
than to decrease the unit cost in the Rochester institution. 82 
COMMUNITY DENTAL SERVICE 
In the orthodontia department 150 cases were under 
treatment in 1920, involving 4,155 treatments. Seven 
chairs are used for orthodontia. The work is under the 
direction of an experienced supervisor. It is hoped soon to 
double the number of cases carried. 
The Rochester Dental Dispensary is closely linked with 
the community. Rochester has no school dental clinics for 
reparative dentistry. The plan is that reparative work of 
all kinds for children whose parents cannot afford a private 
dentist shall be done at the Rochester Dental Dispensary, 
the children being taken there by school nurses; but that 
all prophylactic cleaning shall be done in the schools 
themselves by dental hygienists working under supervision 
of dentists of the Dental Dispensary staff. 
Squads are arranged as follows: two of 8 or 9 members 
each, who are graduate hygienists, with a supervising 
dentist for each squad; four squads of 12 or 15 members 
who are student hygienists, each having also a supervising 
dentist. All schools and orphan asylums are visited twice 
a year. Twenty-five to 30 children a day are treated by 
each hygienist. The average cost per cleaning is 40 cents. 
The present staff of dental hygienists is not sufficient to 
give prophylactic treatments twice a year to all the 
children. In 1920, the number of treatments in the schools, 
was 63,528, about 70 per cent of the whole number 
required for 47,000 children. The chief obstacle in carry- 
ing out the plan completely is the lack of a sufficient num- 
ber of school nurses to see that children needing dental 
work are taken to the Dispensary, and to persuade parents 
to take their children to private dentists. 
The Dispensary maintains a school for dental hygienists 
which graduated its first class of 38 members in 1917. The 
present class includes 58 students. There have been 159 DENTAL SERVICE IN VARIOUS CITIES 
83 
graduates. The course covers one academic year, one 
year of high-school being required for admission. It is 
these students who go to the schools as members of the 
squads just referred to, as part of their training. 
Aside from the Rochester Dispensary there are a few 
other dental facilities in Rochester. The Homeopathic 
Hospital has one' dental chair for its patients, and a 
dentist takes four or five adult patients a morning for 
extractions. The Hahnemann Hospital has a dental 
department with a visiting nember of the staff and dental 
service for patients who require it. The Rochester General 
Hospital has a dental clinic in its dispensary two evenings 
a week, which also does prophylactic and emergency work 
for child patients in the wards. An average of 20 patients 
a month are treated. The dispensary of the Social Settle- 
ment on Baden Street has one dental chair for adults only, 
with two dentists on half-time. This clinic has been in 
operation about a year. An evening clinic is held one day 
a week, an evening being substituted for one afternoon. 
In 1919-1920 there were 673 visits. Charges are for 
materials only-50 cents is paid for an appointment and 
deducted from the cost of the materials. 
It will be seen that the clinic facilities for adults are 
extremely limited, being hardly more than a one-chair 
clinic in the Social Settlement and a little service for adults 
in some of the hospital clinics. 
The Rochester Dental Dispensary, however, plans to 
open a dental clinic for adults, so soon as a sufficient 
number of internes can be obtained. It has definitely an- 
nounced this intention in its report, and included the 
necessary items in its budget for 1921. 
Persons connected with the charitable, welfare, and 
educational agencies of Rochester express only apprecia- 84 
COMMUNITY DENTAL SERVICE 
tion and satisfaction with the service for children given by 
the Dental Dispensary. The distance from some sections 
of the city is a difficulty in the minds of some, the escorting 
of children being regarded as a strain upon the school 
nurses. However the transportation problem is limited to 
the children needing reparative work, who constitute, it 
must be remembered, only a certain' proportion of the 
total number of children, and as appeared in the preceding 
figures, the prophylactic service reaches practically the 
whole child population in the schools. 
The plan combines the advantages of the Bridgeport 
system, which also reaches the whole school population for 
prophylactic purposes, with the benefits of a well equipped 
centralized clinic doing reparative work, orthodontia, and 
surgery and supervising the field work in prophylaxis. A 
very marked contrast is apparent in the testimony re- 
ceived from agencies in Boston and that obtained from 
similar sources in Rochester. There is some feeling among 
responsible heads of educational and health organizations 
in Rochester that branch clinics for dental treatment in 
the schools would be desirable, as a supplement to the 
central dispensary, in some distant sections of the city. 
It -will be noted that the total cost of the central Dis- 
pensary plus the prophylaxis in the schools was $115,000 in 
1920, for a child population of approximately 47,000. 
About $24,000 of this amount, however, was for surgical 
work, nearly all on tonsils and adenoids. Deducting this, 
there remains a cost of $92,000 or slightly less than $2 per 
child, for a fairly complete program of service to a school 
population about one-ninth the size of Chicago. When 
dental student service is available after the opening of the 
new medical and dental school, this cost can be sub- 
stantially reduced and the work enlarged. DENTAL SERVICE IN VARIOUS CITIES 
85 
The centralized supervision of the dental work in the 
schools brought about through affiliation with the Roches- 
ter Dental Dispensary is one of the distinctive features of 
the Rochester plan, which it is felt must exert a strong- 
influence in maintaining a high quality in the prophylactic 
service. A system of school clinics without an affiliated 
central institution, such as in Detroit, suffers severely in 
contrast. 
Chicago. The city of Chicago, with a population of over 
2,700,000, has about 2,500 dentists, one for every 1,200 
persons. A law to permit dental hygienists to be licensed 
to practice in schools and public institutions is now urged. 
Provision for hygienists to practice in the offices of private 
dentists has been omitted in framing this law, in order to 
conserve the available supply of dental hygienists for 
public health work. 
A number of hospitals have a consulting dental surgeon 
on their staff for consultation and operation. Several 
hospitals are planning a complete dental service with both 
diagnostic and therapeutic functions. The dental clinic of 
the Michael Reese Dispensary is the only example at 
present of a dental clinic for general service associated with 
a hospital. 
The Board of Health maintains dental service in several 
dispensaries of the Municipal Tuberculosis Sanitarium, 
treating their tuberculosis patients, although a few 
children who are not patients are received for emergency 
dental treatment. In the stockyards district, the United 
Charities installed a dental clinic in a neighborhood center 
because the need there for dental work was so pressing. 
The dentist's salary is now paid by the Board of Health. 
School dental clinics were started in 1910 by private 
subscription, and with volunteer dental service. In 1914, 86 
COMMUNITY DENTAL SERVICE 
the Board of Health took them under control, and support- 
ed six clinics, while eight more were supported by Mr. 
Julius Rosenwald. This private support was withdrawn in 
1921, and at present the Board of Health maintains six 
dentists, who operate in twelve schools, each being a center 
for a district. There is no systematic dental inspection of 
the children, although their teeth are examined as part of 
the inspection by the school physicians. The school nurses 
are expected to inquire into the ability of parents to pay 
for private dental care, and to see that children receive 
treatment in a clinic if necessary. The clinics of the dental 
colleges are also used. At the Illinois University Dental 
Infirmary a third of the children received are brought by 
school nurses, and about one-fourth of all patients are 
children. There are not enough school nurses to attend to 
getting the dental work done for the children, even if there 
were dental facilities available; but the existing facilities 
do not begin to meet the need. There is always a long 
waiting list in every clinic, and patients must be turned 
away. The six school dentists cannot care for more than 
6,000 children a year, or not over one per cent of the 
children of Chicago. 
Attempts at instruction in oral hygiene are made in the 
schools, through lectures, literature, and toothbrush drills, 
but there is no thorough or systematic plan. 
The neglected condition of the school children's teeth 
is conspicuous in the Bureau of Compulsory Education. 
When children apply for work certificates, they are re- 
quired to have medical attention for physical defects be- 
fore the certificate is granted allowing them to go to work. 
But because it is impossible for most of the children to get 
the necessary dental work done with the few dental 
facilities that exist, the Bureau cannot require the cor- DENTAL SERVICE IN VARIOUS CITIES . 
87 
rection of dental defects. Upon change of job, when the 
child has presumably earned enough to pay a private 
dentist, the certificate is withheld in cases of serious condi- 
tion until arrangements for treatment have been made. 
Last year 693 children were held up for dental defects 
representing only the very serious troubles. 
There are three dental college clinics,--at Northwestern 
University, Illinois University, and the Chicago College of 
Dental Surgery, a privately owned school. Altogether 
they care for between 15,000 and 20,000 patients a year. 
Last year Northwestern received over 9,000 patients and 
turned away 6,000. Patients from all sections of the city 
go to all three of these clinics without regard to conveni- 
ence of location. 
The number of students at these three dental colleges 
for the year 1919-1920 was as follows: 
Northwestern University Dental School . . . 447 
Illinois University Dental School 194 
Chicago College of Dental Surgery . . . .416 
Total . ' 1,057 
The feeling among public health workers with regard 
to the existing dental facilities of Chicago is that they are 
almost zero in relation to the need. The Visiting Nurse 
Association regards its dental work as a farce. In ex- 
treme cases of suffering, money is supplied for private 
dentistry. The director does not stimulate interest in 
dental care among the nurses because of the hopelessness 
of getting treatment. The urgency of the need for dental 
clinics for adults is felt especially in cases of young preg- 
nant women. The Children's Aid Society finds it im- 
possible to give its children proper dental care, and is now 
engaged in studying the problem. The Infant Welfare 
Society desires dental examinations and treatments for all 88 
COMMUNITY DENTAL SERVICE 
the children in its care, but cannot get the facilities. The 
United Charities do not pretend to give attention to the 
dental needs of their clients because of the impossibility of 
getting treatment. Only the most serious emergency cases 
get attention. It is a struggle to get even these cared for. 
In one district they were forced to organize volunteer 
service among local dentists. In another district, as above 
mentioned, they established a clinic, afterwards supported 
by the Board of Health. 
It is evident that in Chicago the dental facilities now 
provided are far less than in many smaller cities; and in 
proportion to population the deficiencies are still more 
obvious. 
The hospitals in Chicago are less advanced in their pro- 
vision for dental facilities for their bed patients and for 
their out-patient departments than in New York. In 
comparison with Manhattan and the Bronx, the popula- 
tion of which is nearly the same as that of Chicago, few 
local clinics established by hospitals or under independent 
auspices. The three dental colleges of Chicago do a large 
amount of work, but nothing in comparison with the need, 
and of course only a very small fraction of their work is 
preventive. 
Thus far there has been no definite plan for demonstrat- 
ing dental needs by an intensive carefully worked-out 
experiment, such as that of the Association for the Im- 
provement of the Conditions of the Poor in New York. It 
is difficult to believe that the general public of Chicago has 
yet been awakened to the need for dental care for children 
and to the utter inadequacy of the present facilities both 
for children and adults. CHAPTER VI 
Tonsil and Adenoid Work 
Tonsil and adenoid work has been mentioned a number 
of times, particularly in connection with the dental 
facilities in various cities. The Forsyth Dental Infirmary 
and the Rochester Dental Dispensary have both organized 
departments for this service. 
The close relation of adenoid growths and diseased ton- 
sils to mouth development and to dental conditions is 
significant and well recognized, but it is no more significant 
and no better recognized than the relation of the tonsil 
and adenoid to medical problems such as cardiac disease 
and to the general development of children. The opera- 
tion for the removal of diseased tonsils and adenoids was 
given a great impetus by the spread of medical school 
inspection throughout the country. The general and 
special hospitals which have provided facilities for this 
work have consequently been asked to assume a burden 
which in most communities they have not been able to 
bear. It is highly important not to regard tonsil and 
adenoid work as predominantly connected with the dental 
program. It is connected therewith, but its fundamental 
connection is with the broader program of child health. 
From the standpoint of demand for tonsil and adenoid 
work, some curious contrasts have appeared in the course 
of this study. In Chicago, where dental facilities are so 
limited and the testimony of health, social, and charitable 
agencies was so strong with regard to this deficiency, very 
89 90 
COMMUNITY DENTAL SERVICE 
little feeling of need for enlarged facilities for tonsil and 
adenoid work were expressed. No doubt a portion of the 
explanation for this lies in the fact that the need has not 
yet been adequately revealed through the development of 
dental and medical examinations. As a contrast may be 
mentioned the Borough of Manhattan, with dental 
facilities only slightly better than Chicago in proportion to 
population, where there is an active and acute demand for 
more facilities for tonsil and adenoid operations. 
The demand for tonsil and adenoid operations, arising 
from medical inspection in the schools and from the 
specialists in throat work, has been reinforced by the 
pediatricians, as the latter have studied out the effect of 
diseased tonsils in producing systemic diseases or in- 
fections leading to symptoms in heart, joints, or elsewhere 
in the body. The dentists also have emphasized the con- 
nection of the tonsil and the adenoid with the general 
health of the child, as well as with dental conditions them- 
selves. The demand for tonsil and adenoid operations 
has thus come from general as well as from special sources, 
and has brought pressure from many angles upon opera- 
tive facilities of hospitals. 
The tonsil operation is now taken much more seriously 
than formerly, as a surgical procedure. Only a few years 
ago it was common to remove tonsils in the out-patient 
clinic, and to send children home again within a short time 
after the operation, even when performed under general 
anesthesia. The experience in New York City is suggestive 
in this connection. As a result of the inadequate perform- 
ance of many tonsil operations in dispensaries, and the 
difficulties and dangers attendant upon the return of 
patients to their homes shortly after the operation, the 
matter was taken up by the Public Health Committee of TONSIL AND ADENOID WORK 
91 
the New York Academy of Medicine, the Associated Out- 
Patient Clinics, and the State Charities' Aid Association in 
1913. The report of these bodies warned against per- 
formance of the tonsil operation without bed facilities. 
In April of the same year, the Section on Laryngology 
and Rhinology of the New York Academy of Medicine 
took a census of opinion among its members (the leading 
specialists in these branches in New York) and found that 
the large majority were of the belief that a tonsillectomy 
required bed care. 
The Public Health Committee of the Academy, of 
Medicine recommended in a public report the following: 
"That all adenoid and tonsil operations on children should 
be done under general anesthesia. 
"That hospitals which undertake these operations should 
keep the patients for a certain length of time after the operation. 
"That school physicians and nurses should exercise more care 
in seeing that only proper cases for operation be referred to 
hospitals, and that the children carry out the instruction given." 
These recommendations and pressure from other bodies 
have produced a very marked effect in New York in im- 
proving condition under which tonsillectomies are per- 
formed, and elsewhere in the country it is now generally 
recognized that at least over-night bed care is necessary 
in connection with this operation. 
Considerable light has been shed on the problem of 
facilities for tonsil and adenoid work by a recent report of 
the Public Health Committee of the New York Academy 
of Medicine, just published in the "Medical Record" of 
May 14, 1921. In substance it is found that the results 
of the general examinations made in the schools of New 
York City by medical inspectors of the Department of 
Health show that between 10 per cent and 19 per cent of 92 
COAIMUNITY DENTAL SERVICE 
the children examined have tonsil and adenoid defects, 
the large majority of which require surgical operation. 
These statistics are based on the children examined during 
the last ten years, ranging in number from 230,000 to 
308,000 per year. About one-fourth of the school popula- 
tion is covered each year. 
A recent canvass made by the Babies' Welfare Federa- 
tion brings out the extent to which operative facilities are 
available in the New York hospitals. The total number of 
operations performed in 1920 is reported as approximately 
47,000. This figure is greater by several thousand than the 
number of children suffering from enlarged tonsils and 
adenoids, as discovered in the annual school inspection. 
There are, of course, the pre-school children to be con- 
sidered also. "On the basis of the 1920 census figures, 
there arc 455,000 children from two to six years of age, of 
whom at least 15 per cent have tonsil and adenoid defects. 
If only one-fourth of the pre-school age cases should apply 
for treatment, the annual demand from this source would 
amount to over 15,000. In that event, the annual demand 
for surgical facilities of the type under consideration would 
be in excess of the available supply. If systematic follow- 
up effort, similar to that of the Health Department 
nurses, could be instituted, in connection with the pre- 
school age children, and if one-fourth of both the school 
and the pre-school age children needing treatment should 
apply, the annual demand for the first few years would be 
for 55,000 operations. Gradually as the pre-school age 
children who have had nose and throat defects attended 
to, enter school, fewer defects of that kind would be found 
on examination, and the demand eventually would resolve 
itself to the needs of the annual increment of child popula- 
tion. For the time being, however, and for a number of TONSIL AND ADENOID WORK 
93 
years to come, the annual demand will remain about the 
n * 
same. 
It will be observed that in New York City the child 
population of the school and pre-school ages is about one 
and a half million, and that probably 15 per cent of these 
are believed to need tonsil and adenoid operations, or 
225,000. The present facilities in New York City in the 
hospitals are apparently nearly equal to the effective 
demand, considering that out of the whole number of 
children needing the operation, only a certain proportion 
of the parents will apply for or consent to it. 
The problem of the tonsil and adenoid work in New York 
is therefore the three-fold problem of (a) "catching up" 
with the cases not thus far operated on, (b), stimulating 
more parents whose children need the operation to apply 
for it or give their consent to it, and (c), organizing in the 
best way the facilities now available. 
There are certain hospitals in New York at the present 
time which find their facilities for tonsil and adenoid work 
greatly overtaxed, and make appointments a long time in 
advance. This is an unfortunate procedure, as the pro- 
portion of appointments not kept always increases greatly 
when there is a period of a month or more between the 
time the arrangement is made and the date appointed for 
the operation. 
The following summary of the conclusions of the New 
York study will be suggestive in this respect: 
"1. The present annual demand for tonsil and adenoid 
operations can be estimated as over 55,000. The existing 
facilities when fully utilized can probably be made sufficient to 
meet this demand, but the number of operations performed in 
1920 was 9,000 below the estimated demand. 
* From "The Tonsil and Adenoid Situation in New York City," a 
report by the Public Health Committee of the New York Academy 
of Medicine. Medical Record, May 14, 1921. 94 
COMMUNITY DENTAL SERVICE 
"2. There is need for a regulatory system to secure a more 
uniform distribution of patients among the hospitals, and to 
reduce the excessively long waiting lists in some hospitals. 
"3. The standards of operative procedure, as well as the care 
of children before and after a tonsillectomy, differ considerably 
in the several hospitals. There is a need of stimulating the 
institutions to an appreciation of the importance of a thorough 
physical examination of the patients before operation, as well 
as for more effective methods of instruction as to care to be 
taken after the patients leave the hospital. 
"4. A longer period of pre- and post-operative care would 
reduce the number of cases which can be accommodated in 
hospitals, and an extension of facilities in certain directions or 
during certain periods of the year might, therefore, be required."* 
In connection with the last point, a new hospital 
especially for tonsil work, with facilities for ten ward 
patients daily, has recently been established in New York, 
and some other additional beds of similar nature are con- 
templated. The suggestion is made that during the 
summer, when general hospital work is usually light, the 
number of beds for tonsil cases in certain hospitals be con- 
siderably increased, in order to help 11 catch up." The 
establishment of any large number of permanent beds for 
tonsil and adenoid work in New York is not recommended 
by the Public Health Committee. The problem is one of 
temporary increase and better organization of facilities, 
and better distribution of cases. 
It is important to observe that this great amount of 
tonsil work in New York, amounting to 47,000 operations, 
or three per cent of the entire school and pre-school popu- 
lation, has been done in general or special hospitals scat- 
tered over the city, and not in connection with a special 
dental institution or a special dental program. 
*From "The Tonsil and Adenoid Situation in New York City," 
a report by the Public Health Committee of the New York Academy 
of Medicine. Medical Record. May 14, 1921. TONSIL AND ADENOID WORK 
95 
In Boston, only a relatively small number of tonsil and 
adenoid operations appear to have been performed 
unnually in recent years. The total number of tonsil 
operations reported by the school authorities as performed 
during 1920 was 2,363. Of these, 770 were done at -the 
Forsyth Infirmary. If 20 per cent of school children need 
the operation, the figure 2,363 is only about one-tenth of 
the number who need it in Boston. It is probable that the 
figure as reported is lower than the actual number of 
operations, but the true total is certainly far less than the 
total needed. There has been thus far no movement, 
initiated from dental or other sources, to arouse the com- 
munity in this matter. 
Another phase of the tonsil and adenoid problem and 
another method of dealing with it is illustrated by 
Rochester. Last summer (1920) the Rochester Dental 
Dispensary conducted an intensive tonsil and adenoid 
clinic during which 14,070 children were operated on during 
a period of seven weeks. The publicity given this clinic 
caused a large number of cases to apply for the operation 
who could not be received at that time. This with other 
considerations led the City Health Department to make 
a survey of the schools with a view to determining the 
total need for tonsil and adenoid work among the school 
children of Rochester.* 
*It may be of technical interest to note that in this examination 
of children, the Rochester Department of Health classified them in 
five grades: 
0. Tonsils and adenoids already out 
1. Operation not needed 
2. Moderate or probable need of operation, best to wait 
3. Urgent need for operation 
4. Need for operation very urgent 
Classes 3 and 4 are those which are recommended for operation in 
the clinic, and which are mentioned as needing operation in the 
statistics cited in this report. A special report was issued by the 
Rochester Dental Dispensary descrbiing the summer tonsil clinic. 96 
COMMUNITY DENTAL SERVICE 
In three schools selected because the attendance was 
made up of children from varied social classes, the percent- 
ages of classes 3 and 4 together, as defined in the footnote 
on this page, were 44.9 per cent, 45.7 per cent, and 
3.54 per cent respectively. If was found that in one of 
these schools, chiefly attended by children of well-to-do 
families, more than 41 per cent of the children had 
previously had tonsil and adenoid operations, and but 3.54 
per cent, needed it. In another school in a poor neighbor- 
hood, only 13 per cent of the children had had the opera- 
tion, and 44.9 per cent of them needed it. In a school 
made up of mixed classes, the percentage of children who 
had previously had the operation was midway, 34.3 per 
cent, and those needing it, 45.7 per cent. 
Applying these percentages to the school population of 
Rochester, it was estimated that 27,000 children of 16 
years or under needed the tonsil and adenoid operation. It 
is worth noting that the school inspections in Rochester 
led to recommending for tonsil or adenoid operation, over 
twice the percentage of school children who have usually 
been thus recommended in New York City. It is impossi- 
ble to say to what extent this divergence is due, (1) to a 
real difference in the condition of the children in the two 
cities, or (2) to different medical standards, or (3) to 
psychological factors. The New York figures are closer to 
those usually reported elsewhere. 
The number of children believed to need tonsillectomy 
was evidently far beyond the capacity of the few hospitals 
of Rochester, including the beds in the Rochester Dental 
Dispensary. The importance of "catching up" was 
forcibly brought out by this survey, and a clinic was 
therefore organized under the auspices of a committee of 
the four chief hospitals, supported financially by the TONSIL AND ADENOID WORK 
97 
Community Chest of Rochester, for doing tonsil opera- 
tions on a large scale for a temporary period. In the Con- 
vention Hall, which was loaned by the city, a temporary 
hospital was organized by this committee. The capacity 
was nearly 100 operations a day. It was estimated that 
about one-third of the 29,000 children needing the opera- 
tion were of families whose parents could afford to pay for 
it at the usual private rates, and that the remaining two- 
thirds needed to have it done at the clinic free or for a 
nominal charge. The temporary clinic in the Convention 
Hall was supplemented by increased operative work in the 
hospitals. Altogether 100 to 120 operations were done a 
day for a considerable period, from January to April, 1921. 
The final results are not yet ready for publication at the 
time of preparation of this report, but it is reported that 
9,900 operations in all have been performed. After a 
summer recess, the hospitals of the city will assume a per- 
manent program for tonsil and adenoid operations for 
school children and also for children of the pre-school age. 
Certain evident dangers are apparent in this public and 
dramatic method of dealing with a surgical procedure of 
this kind. Undue fear of the operation among the lay 
public or on the other hand an hysterial demand for it 
must both be avoided. This particular clinic in Rochester 
seems to have been carefully conceived and excellently 
worked out, with intelligent cooperation on the part of 
newspapers and other sources of public information, so as 
to create the right understanding on the part of the 
public and avoid these perils. Focusing general interest 
upon the tonsil and adenoid problem, through this cam- 
paign, has undoubtedly assisted materially in gaining the 
consent of parents to have their children undergo the 
operation when recommended by medical authority. To 98 
COMMUNITY DENTAL SERVICE 
overcome parents' objections is under ordinary conditions 
a real and difficult problem in many cases. 
In a larger community, however, it would be much less 
easy to concentrate the necessary degree of public atten- 
tion upon a specialized campaign of this type, and to carry 
through the extensive organization necessary in a city five 
or ten times the size of Rochester. Considerations of this 
sort apparently led the Public Health Committee of the 
New York Academy of Medicine, after consideration of 
the Rochester experiment, to decide not to recommend an 
attempt of the kind in New York City. This judgment is 
believed wise, and it is believed the same judgment would 
apply to a city the size of Chicago. 
Nevertheless, "catching up" is extremely important, 
and to do this, the hospitals must be stimulated, and where 
facilities are as limited as they are at present in Chicago for 
tonsil and adenoid operations, the development of special 
facilities, possibly of a temporary nature, might be advis- 
able. The importance of this can be illustrated by the 
estimates made in Rochester that after they had once 
"caught up," the "annual crop" of children to be cared 
for would be somewhere between 3,000 and 6,000, or only 
between 10 and 20 per cent of the number of operations 
which were believed to be needed in Rochester in the early 
months of 1921. 
These points are taken up later in the recommendations 
relating to Chicago. CHAPTER VII 
Principles of a Community Dental Program 
It is now desirable to summarize in general terms the 
conclusions which have been drawn from this study. 
Specific application to Chicago can then be made. 
A. Dental Policy. 
1. Dental care is essential to the maintenance of health 
and working efficiency. 
2. The dental needs of any community taken as a whole 
are far beyond the reach of present and prospective 
facilities, both as to plant and to equipment, and as to 
dental personnel in either private or clinic practice. 
3. Preventive dentistry is the only measure which offers 
hope for the future. 
4. The primary application of preventive dentistry 
must be to children. 
5. The test of any plan for children must be not only 
the number reached and the character of the results 
achieved for them, but the proportion reached in com- 
parison with the total child population. The aim must be 
parallel to that of school education, which is to reach 
one hundred per cent of the children. 
6. If selection has to be made because of limited 
facilities, with regard to work to be done, it is important 
that children of the younger years be reached. 
7. If selection must be made in relation to kinds of 
service, general prophylaxis and hygienic instruction 
should come first. The hygienic instruction should include 
99 100 
COMMUNITY DENTAL SERVICE 
both mouth hygiene and general hygiene. Curative work 
comes second. 
8. Orthodontic service, because of its relatively great 
expense and the very limited dental personnel available 
for this difficult and highly specialized work, cannot be 
regarded as feasible for all the children who need it in any 
community. In any large community, however, or in any 
large dental institution, orthodontic work should be de- 
veloped so far as possible as a service to children, and as a 
field for the education of dentists and technicians in this 
important specialty. 
9. A dental program for children is part of the general 
child health program. It should never be forgotten that 
the medical center of the child health program is not the 
dentist but the pediatrician. 
10. Tonsil and adenoid work should be viewed in the 
same light, not as an adjunct of a dental program, but as 
part of the general child health program, which is associat- 
ed in many ways with dental care. 
11. In regard to adults, a one hundred per cent pro- 
gram is impossible. 
12. As principles of selection in determining what 
facilities should be offered to adults, the following may be 
mentioned: 
(a) Dental service for relief of pain. 
(b) Dental service to persons who are under medical care and 
whose dental conditions are inseparably associated with their 
general medical problems. 
(c) Dental service required in the education of dental students 
and dental hygienists. 
(d) Reparative dentistry of a palliative nature. 
(e) Dental prophylaxis including cleaning and instruction. 
Dental prophylaxis, however, should always accompany work 
under (b). PRINCIPLES OF DENTAL PROGRAM 
101 
13. As to the relation between the dental program and 
private dental practice, preventive dentistry cannot be 
expected to develop as an adjunct of private practice ex- 
cept for that small proportion of. the population who have 
ample means. Preventive dentistry must be dealt with 
by public and semi-public facilities, in dental institutions 
or in local or school clinics. 
14. Similarly, curative dental work for both adults and 
children cannot be handled by private practitioners for a 
large part of the population, who must be provided for by 
public or semi-public clinics. 
15. Dental service in clinics should be salaried. 
16. There is no reasonable ground for opposition on the 
part of private dental practitioners to the development of 
a preventive or reparative dental program, on a public or 
semi-public basis, since there is more work to be done than 
present and prospective dentists can possibly undertake. 
17. Preventive and curative dentistry in dental in- 
stitutions and in local clinics should be assisted by the 
present movements for closer affiliation of dentistry with 
medicine; for greater attention to preventive dentistry in 
training the dental student; and for the training of various 
technical assistants to the dentist. 
18. The following financial policies are reasonable in the 
maintenance of organized dental service: 
(a) Prophylactic work for children should be free and open to 
all children of school and pre-school ages on the same terms as is 
public education. 
(b) With respect to the cost of this service, it should be borne 
in mind that the estimated cost of tooth cleaning and of instruc- 
tion in mouth hygiene to children on a large scale is less than 
five per cent of the usual per capita cost of school education, 
and is a measure which will make more efficient the other ninety- 
five per cent expended. 102 
COMMUNITY DENTAL SERVICE 
(c) For dental care other than prophylaxis, a charge should 
be made in the clinic, including an admission fee and in addition 
charges for materials used for fillings, anesthesia, and other 
purposes; these fees being remitted when necessary. 
(d) For adults, clinics should charge fees covering the cost of 
the service, but these should be remitted to persons seriously 
in need of the service and unable to pay for it. 
(e) For children it is often essential to establish fees lower 
than the cost rates in order that the service may be sought by 
many of those who need it. 
B. Relations to Education and Research. 
19. Research into the conditions and causes of dental 
decay and into the methods of its prevention is of funda- 
mental importance. The entire program of dentistry may 
be radically changed by future discoveries of specific 
causes of dental decay and agents of infection. Definite 
provision for research is supremely important in any pro- 
gram for a community large enough to support a dental 
institution of the first rank associated with medical and 
dental education. 
20. In any community which has dental schools, the 
organized dental facilities in clinics and institutions should 
be affiliated with dental education. Every dental school 
must have its own or a closely affiliated clinic or infirmary 
for teaching students, and in addition, use should be 
made by students of dental facilities established primarily 
for community service, both for children and for adults. 
More attention to dental work for children is recognized 
by leading dentists as part of future dental education. 
21. The teaching of dental hygienists should be an 
integral part of a community dental program in any com- 
munity of size. The function of the dental hygienist will 
require study and possibly re-definition as time goes on, 
particularly with regard to the part to be played by the PRINCIPLES OF DENTAL PROGRAM 
103 
hygienist, on the one hand, in technical assistance to the 
dentist in cleaning teeth, and on the other hand, as an 
instructor in mouth hygiene. It is desirable that the 
development of dental hygienists shall not interfere with 
the instructive functions of the school nurse. The school 
system cannot be expected to support a double set of 
health educators. Instruction in hygiene for school 
children must not be dealt with by a series of specialized 
instructors. 
The education of all nurses and other public health 
workers should include more dental subject matter. 
22. Dental service is needed by the general hospital as 
follows: 
(a) For diagnostic purposes, in connection with medicine and 
many of its specialties. 
(b) Routine dental examinations for all hospital patients are 
desirable. 
(c) Dental care for patients whose medical conditions require 
it should be furnished or arranged for by every hospital. 
(d) Development of dental therapeutic service beyond this 
point is a question to be decided by a hospital with regard to its 
means and the other dental facilities available in the com- 
munity. 
23. Dental service is a desirable part of every general 
dispensary, as follows: 
(a) As a diagnostic service. 
(b) As a therapeutic service for patients whose medical con- 
ditions require it, either furnished in the dispensary or arranged 
for elsewhere. 
(c) Development of a general dental clinic should be carried 
out by every dispensary so .far as its space and resources will 
permit. For children, the service should be work that supple- 
ments other facilities in the schools or in special dental institu- 
tions; for adults, the service should be along the lines outlined 
in No. 12. 104 
COMMUNITY DENTAL SERVICE 
(d) Clinics for adults should be made self-supporting so far 
as possible, and at least some should be held after the usual 
working hours. 
C. Organization. 
24. In a large city, a dental institution affiliated with 
dental and medical education and with a general hospital 
should be the center of the system. 
25. The central institution should be the scientific and 
supervisory center of both prophylactic and curative 
dental service for the community, but the work actually 
done within its walls should be primarily for curative 
dentistry, dental research, and dental education. 
26. Prophylactic and educational work for children 
should be decentralized, and should be done through local 
agencies, primarily the school system. 
27. The prophylactic dental work in the schools should 
be under centralized professional supervision, the staff of 
the central institution (directly or through its branches) 
being the responsible supervisory body. 
27-a. The benefits of localization of the prophylactic 
work for children should be both financial and educational. 
(a) A substantial saving in cost of plant and .equipment would 
be achieved by doing the cleaning of teeth in the schools where 
the building overhead is already carried, and where equipment, 
being solely for children's prophylaxis, can be of simple and 
relatively inexpensive character. 
(b) A large saving in transportation expense, in incidental 
inconveniences, in danger to children, and in loss of time by 
escorts is achieved through decentralizing the prophylactic 
work, which should reach one-hundred per cent of the school 
population. 
(c) Intimate local connection between the prophylactic work 
and the school system increases for children and parents alike 
the educational weight of the dental program; and links it more PRINCIPLES OF DENTAL PROGRAM 
105 
closely with the general child health progress than is possible 
in any other way. 
28. It is undesirable to centralize the curative work for 
the children in a community of over 250,000 population 
(unless a small congested area); but instead the central 
institution should be supplemented by branches, or by 
affiliated clinics attached to school's or hospitals. 
29. The administration of the central institution and of 
its branches should be under an independent board. 
Affiliations with dental, medical, educational, public 
health, and hospital work, and with the city school system, 
may be in part achieved through appropriate members 
upon the board, but the board should be primarily a body 
interested in a community dental program, and not in 
special aspects thereof or in special institutions or agencies. 
30. If branches are under the management of in- 
dependent institutions (as for instance dental clinics in the 
out-patient departments of hospitals) there should be a 
formally understood working affiliation between the cen- 
tral institution and each branch, if the latter are to serve 
effectively as part of the community program. 
31. The expenses of a community dental program are 
at the present time fairly to be divided between the com- 
munity (city government) and private individuals such as 
the board of trustees of the dental institution and its 
financial supporters. The first charge upon the municipal 
interests is dental prophylaxis for children and given the 
right start, a steady increase in public readiness to assume 
financial obligations for the support of curative work for 
children and also certain services for adults should follow. 
32. Financial economy and a gain in efficiency would 
result through the centralization of some phases of the 
dental educational program in a national organization. 106 
COMMUNITY DENTAL SERVICE 
This is particularly true of the preparation of literature, 
exhibits, and other informational and publicity material. 
A large number of local organizations are now spending 
much time and effort on such work. Much less than the 
amount of money that these local organizations are to- 
gether spending would, if concentrated through one 
national center, enable a more expert publicity staff under 
the highest grade of professional guidance to produce 
better material, which would be accessible at minimum 
expense to an indefinite number of local agencies. CHAPTER VIII 
Recommendations for Chicago 
It is well to summarize the dental needs of Chicago as a 
whole, and then to suggest the best procedure, since the 
entire program cannot be realized at once. 
It is believed that dental service in Chicago should be 
developed under the following system: 
(1) A central institution, of approximately 60 chairs. 
(2) Four branches, approximately 30 chairs each. 
(3) School clinics (for curative work), located in outlying 
districts and supplementing the branches. 
(4) Dental prophylaxis and instruction in oral hygiene for all 
school children, to be done in the schools, according to the 
Rochester plan, by traveling squads of hygienists under cen- 
tralized dental supervision. 
(5) The central institution to be under an independent 
board, but affiliated with medical and dental education and with 
a general hospital. 
(6) Dental research to be an integral part of the program, and 
provided for in the facilities of the central institution. 
It will be seen that this general scheme follows in the 
main the Rochester plan of decentralizing the prophylactic 
work. Chicago is far too large to make it possible for any 
single dental institution of whatever size To fill the place 
for the community as a whole that the Rochester Dental 
Dispensary does in that much smaller community. Con- 
sequently four branches are recommended. It is not be- 
lieved, however, that in a city which is so populous as 
Chicago and which covers so large an area, a central 
institution with four branches would be adequate for all 
107 108 
COMMUNITY DENTAL SERVICE 
districts, and it is therefore recommended that curative 
clinics be located in certain school buildings, or possibly in 
some instances in other buildings, such as dispensaries 
adjacent to one or more schools. It is believed that 
locating such clinics in school buildings or in juxtaposition 
to them would be less expensive and better for the educa- 
tion of the community than an additional number of 
branches established as special dental institutions. 
The characteristic development throughout the country 
in dental service is through school clinics, and while it is 
not believed that school clinics without a central institu- 
tion are desirable in a community of large size, close con- 
nection between the dental system and the schools in 
curative as well as preventive work is strongly recom- 
mended. 
It will be useful to sketch out certain details regarding 
this proposed plan. As regards the central institution, it is 
recommended that it should be affiliated with the dental 
school of the Northwestern University, and located if 
possible in immediate proximity to the new site of this 
institution, upon which a general hospital will also be 
located. The institution should provide facilities sufficient 
for all forms of dental work for children and adults, except 
such laboratory and clinical dental facilities for adults as 
may already be provided for adequately in the infirmary 
of the dental college itself. 
A surgical department (with provision for oral surgery 
and for tonsil and adenoid work) should be included, unless 
it is possible to arrange that in the adjoining hospital 
adequate facilities of this sort shall be provided, with a 
working understanding between the hospital and the 
dental institution. 
The affiliation of the dental institution should be such as RECOMMENDATIONS FOR CHICAGO 
109 
well secure the advantage of the medical staff of the ad- 
joining hospital as consultants in relation to the dental 
service, and in return diagnostic and therapeutic dental 
services should be offered patients referred from the 
hospital and its staff. 
It is strongly urged that a dental research laboratory be 
included in the institution, with adequate provision for the 
support of a research staff. 
The training of dental hygienists as well as of dentists 
should be a function of this institution, in affiliation with 
the dental school. 
It may be noted that the new location of the North- 
western University Dental School is not central for 
Chicago. It is, however, accessible to transportation lines. 
Affiliation with and proximity to an important medical 
and dental school is essential, and the only other practical 
choice is the new medical and dental school of the Univer- 
sity of Illinois, which has the disadvantage of being an 
institution under state management, whose primary re- 
sponsibilities are not to Chicago. It does not seem an 
appropriate center for an institution whose fundamental 
aim is a community dental program for the city. 
The material and building should follow the com- 
paratively simple plan of the Rochester Dental Dispensary 
rather than the monumental type represented by the 
Forsyth Infirmary. 
The branch institutions need not include facilities for 
research or for orthodontia and surgery, nor dental 
laboratories. 
It will be observed that the proposed plan would not 
displace any of the existing school clinics, although it 
might cause the relocation of some of them in districts 
which the central institution or the branches could not 110 
COMMUNITY DENTAL SERVICE 
so readily serve for curative work because of location. The 
school clinics would do only the simpler forms of reparative 
work, referring difficult cases either to the branches or to 
the central institutions; just as the branches in their turn 
would refer all orthodontia and surgery to the central 
institution. 
The dental facilities of the central institution, so far as 
children are concerned, should be utilized after the general 
plan of the Rochester Dental Dispensary, in confining 
work definitely to children sent from the schools or from 
agencies dealing with the child of pre-school age. The area 
from which such children are accepted should be limited to 
definite boundaries, except that cases referred by dentists 
or medical agencies of a nature which would require the 
advantages only provided in this large central institution 
should be received there from any part of the city. The 
number of such cases, however, would from their nature 
be very limited. 
The training of dental hygienists as well as dental 
students should be conducted in the central institution and 
in the branches, in affiliation with the dental school. The 
prophylactic work in the schools should be done according 
to the Rochester plan of sending dental hygienists, partly 
students and partly graduates, to the schools in squads, 
each with a supervising dentist responsible to the central 
institution staff. In Bridgeport, it will be recalled, a 
resident hygienist has been put in certain schools, and it is 
suggested that this scheme might be adopted as a supple- 
ment to the Rochester plan, particularly at some of the 
outlying schools, in which school clinics were located. 
The facilities of the central institution and its branches 
should be opened to adults, and the clinics for adults 
should be made, so far as possible, self-supporting. There RECOMMENDATIONS FOR CHICAGO 
111 
should be a scale of fees, which when paid in full, would 
cover the cost, and which might be remitted in whole or 
in part to those who could pay only a little or who could 
pay nothing. It is advised that for children a fee of ten 
cents per visit be charged at the central institution and its 
branches, with remission of fee in individual cases recom- 
mended by suitable charaitable or educational agencies, or 
at the discretion of the authorities of the institution. 
It is urged that encouragement be given to the hospitals 
of the city to establish dental service or to develop it if 
already established, both for bed patients and for out- 
patients. It would be well to assist in the demonstration 
of the advantages of this by financial aid if necessary to 
selected hospitals to install adequate dental equipment 
and provide interne and visiting service to carry on an 
out-patient clinic of the type previously described. 
Regarding tonsil and adenoid work, it is believed de- 
sirable not to establish large permanent facilities in special 
institutions for this service, but rather to encourage the 
general and special hospitals of the city to develop this 
branch of work in order to "catch up" with the existing 
needs of children for this operation. Of still more im- 
portance is a demonstration which will attract public 
attention to this need. 
It is therefore proposed that the tonsil and adenoid 
clinic now in process of development in connection with 
the Michael Reese Hospital in the neighborhood of the 
Michael Reese Dispensary be definitely developed as a 
demonstration clinic serving the children of a defined area, 
by arrangement with neighboring public schools and with 
the Michael Reese Dispensary. This would require no 
change in the present plans for the plant of this clinic, 
but would render it essential that some one be placed in 112 
COMMUNITY DENTAL SERVICE 
supervision of the scheme who would be able to develop 
these community relationships, and to provide sufficient 
assistance to this person to enable the methods and results 
of the work, month by month and year by year, during the 
first two years, to be carefully studied out and presented. 
It is believed that this clinic would be rendered of much 
larger value to Chicago if the comparatively small ad- 
ditional outlay herein recommended is undertaken, in 
order to provide supervision and direction by someone 
who is especially interested in the area to be covered and 
who is familiar with community work. 
It will be apparent from the previous discussion of units 
of dental service that if the prophylactic work were done 
in the schools, the facilities of the central institution would 
provide curative work for approximately 75,000 children a 
year. It is believed that besides the dental schools of 
Chicago, there are needed about 400 dental chairs for the 
children of the city, assuming the prophylactic work for 
children to be done in the schools. A complete program 
would include 60 chairs in the central institution, 120 
chairs in four branches (taken together), some 60 chairs to 
be provided in dispensary clinics, chiefly those associated 
with hospitals,* and the remaining 160 chairs in the school 
clinics. 
Since the heavy initial and maintenance expense of a 
complete program will prevent its establishment as a 
whole at one time, it is desirable to indicate the procedure 
that would best lead up to its ultimate establishment. It is 
recommended that in the beginning at least the following 
program be set under way:- 
* These clinic chairs would only be used partly for children, and 
60 chairs or more would simply be the equivalent of this amount of 
service for children distributed through a larger number of out- 
patient clinic chairs. RECOMMENDATIONS FOR CHICAGO 
113 
(a) A central institution 
(b) One branch 
(c) Arrangements with dental clinics in schools for suitable 
relationship to the central institution and to the branch, so that 
in at least a certain part of the city the school clinic element as 
well as the institutional element will be represented. 
(d) Provision of prophylactic work for all the schools in a 
certain area, which should be either the area most accessible to 
the central institution or the area most accessible to the branch, 
or both such areas. 
The 90 chairs in the central institution and one branch 
might be expected to serve 120,000 children, assuming the 
prophylaxis is done in the schools. This would be approx- 
imately one-fifth of the children of Chicago of the school 
and pre-school age. It would be a good policy to limit the 
curative work to children of the first four years in school, 
except for emergency dental service to older children, and 
to take in addition all pre-school children who could be 
brought through any agency. This would enable a some- 
what larger area to be covered by the initial installation, 
without, however, covering so wide an area as to make 
the transportation difficulty a very serious one. 
The proposed branch should be so located with refer- 
ence to school clinics that an area would be created in 
which (1) the prophylactic work in the schools, and (2) the 
curative work in certain school clinics, the branch, and the 
central institution could function altogether as a complete 
demonstration, serving in an adequate way a substantial 
fraction of the children of Chicago. It is believed that not 
only would these children be greatly benefited, but that a 
convincing demonstration could be made which would 
lead to the expansion of the system by private benefaction 
and by increased municipal support. 
As to expense, the central institution and its equipment 114 
COMMUNITY DENTAL SERVICE 
would probably cost $700,000, and the branch probably 
not more than $300,000, excluding the land cost in both 
cases. Proximity to the dental school and hospital would 
probably enable certain economies to be made in the 
central institution, by securing certain diagnostic and 
surgical facilities through affiliation rather than by 
separate provision. 
The maintenance cost can best be estimated on the basis 
of the Rochester figures. For prophylaxis in the schools, 
the cost there is. 40 cents per treatment, which would be 80 
cents per child, with two treatments annually; the super- 
vision being maintained centrally and a share of the work 
being done by student hygienists. For 120,000 children 
this would be $96,000 a year. The city should bear a share 
of this from the first, and ultimately all of it. 
The central institution, on the basis of the Rochester 
and other figures, would cost, excluding research and tonsil 
and adenoid work, $1,750 per chair, or approximately 
$105,000 a year, and the branch approximately $55,000 a 
year. Clinics for adults, if maintained, as they should be, 
in the central institution and its branches, should not add 
to the net annual expense, since their overhead expenses 
would be already covered. 
It is important to bear in mind that the cost of the 
central institution might be considerably reduced by the 
use of dental students. 
If tonsil and adenoid work cannot be arranged for in the 
hospital near the central institution,'20 beds ought to be 
provided (a few of which would be used for oral surgery). 
The maintenance of these beds to capacity would cost 
about $25,000 per year. 
All of these costs are gross figures. It may be estimated 
that half the cost of tonsil and adenoid operations, if RECOMMENDATIONS FOR CHICAGO 
115 
carried on in the central institution, would be repaid by 
patients; and that at 10 cents a visit, with special fees for 
materials and other work, probably 20 per cent of the 
dental work for children would be paid for. The net an- 
nual maintenance, therefore, of the central institution and 
one branch, excluding the tonsil and adenoid work, would 
thus be $130,000, -much less if a considerable amount of 
dental student service were available. The tonsil and 
adenoid work would add $12,500. To this should be added 
$3,500 for completing the Michael Reese experiment as 
above suggested. At least $15,000 per year should be made 
available for research, either by endowment or by pledges 
secured for a period of not less than five years. 
In summary form: 
Estimated annual cost of proposed service 
Central institution . . $105,000 
Branch 55,000 
$160,000 * 
Less 20 per cent repaid nnn 
by children . . . 
Net cost .... $128,000 
Net cost, tonsil and ade- 
noidwork. .... 16,000 
Research ..... 15,000 
Total $159,000 
The cost of the curative clinics in the schools should be 
borne by the city, as at present. At least half of the ex- 
pense of the prophylactic work in the schools should be 
borne by the city from the first. A total of about $200,000 
* In Bridgeport, the expenses of the prophylactic and the curative 
work in the schools cannot be separated. Their total (including also 
the children's work in the central clinic) amounts to about $2.27 per 
child. The gross cost for 120,000 children in Chicago as herein 
calculated amounts to $2.15 per child, excluding tonsil and adenoid 
service and research, but it is assumed that some student hygienist 
service would be secured. 116 
COMMUNITY DENTAL SERVICE 
a year from private sources should maintain this program, 
and if dental students can be extensively used, this cost 
can be substantially reduced. 
The Rochester Dental Dispensary has been endowed 
with $1,800,000. Its original cost was less than $500,000. 
A building expenditure of $1,000,000 and an endowment of 
$4,000,000 would be sufficient to provide Chicago with a 
central institution of a permanent nature, and a branch 
through which, given the necessary school affiliations, 
there could be demonstrated a complete plan for serving 
the entire population of the city, and which private and 
public interests would undoubtedly come to support. 
This survey has brought out the wide contrasts between 
different cities in this country in their dental facilities, and 
has made clear that Chicago is far behind a number of 
other communities. It would be difficult to over-emphasize 
the importance and urgency of Chicago's need, or the 
influence of an adequate dental program in increasing the 
value of school education, improving the training of 
physicians, dentists, and assistants, and increasing the 
efficiency and promoting the.health of the people of the 
whole city. APPENDICES 
APPENDIX A 
Bibliography 
A list follows of a few articles and reports which have 
been of especial service in this Survey. Much more exten- 
sive bibliographies, ranging however, into other fields are: 
Annoted Bibliography of Medical Inspection and Health 
Supervision of School Children in the United States for Years 
1909-1912. U. S. Bureau of Education, Bulletin 16, 1913. 
Index to the Periodical Dental Literature in the English 
Language, 1911-1915. Arthur D. Black. Dental Index Bureau, 
1921. 
Mention should also be made of the annual reports of 
the Rochester Dental Dispensary, the Forsyth Dental 
Infirmary, and of Health or School Departments in various 
cities. 
Annual Report, 1917, Chief Medical Officer, Board of Education, 
England. London, 1918. 
Annual Report, Division of Dental Hygiene, Department of 
Health, Bridgeport, Connecticut. 1920. 
Children's Teeth, A Community Responsibility. Taliaferro 
Clark. U. S. Public Health Reports, November 19, 1920. 
Commonhealth, The. Mouth Hygiene Number. Massachusetts 
Department of Public Health Bulletin. September-October, 
1920. 
Dental Division of the Metropolitan Life Insurance Company. 
Thaddeus P. Hyatt. Modern Medicine, Vol. 2, pp. 237-40. 
March, 1920. 
Dental Hygiene: Public Dental Clinics in California and Their 
Purpose. Guy S. Milberry. California State Board of Health, 
Special Bulletin No. 21, 1917. 
117 118 
COMMUNITY DENTAL SERVICE 
Dental Lessons of the War. Dental Cosmos, Vol. 41, 1919. 
pp. 414-418. 
Dental Service for the Other Eighty Percent. Guy S. Milberry. 
Journal of the National Dental Association, Vol. 7, No. 7. 
July, 1920. 
Dental Work Done in the Hyde Park Schools by the Instructive 
District Nursing Association. Educational Standards, Vol. 6, 
No. 1. September, 1918. 
Dentistry and Public Health, with an Account of the Flint 
Dental Clinic. William R. Davis. Journal of the National 
Dental Association, Vol. 7, No. 2, November, 1920. 
Dentistry and Health Conservation. Harvey J. Burkhart. 
Modern Medicine, Vol. 1, No. 1, May, 1919. 
Education and Practice in Medicine, Dentistry, and Pharmacy. 
Cleveland Hospital and Health Survey, Part VIII. 1920, pp. 
683-690. 
Fate of the First Molar. Harry B. Butler. U. S. Public Health 
Reports, March 4, 1921. 
Institutional Dentistry-Methods, Results. Frederick A. Keyes. 
Boston Medical and Surgical Journal, July 25, 1912. 
Mare Island Dental Facilities. J. L. Brown. Dental Cosmos, 
Vol. 41, 1919. pp. 510-512. 
Mouth Hygiene-A Course of Instruction for Dental Hygienists. 
Alfred C. Fones. Lea & Febiger, New York. 1918. 
Mouth Hygiene in the Public Schools. Frederick A. Keyes. 
Oral Hygiene, March, 1918. 
Oral Hygiene and Public Dental Service in the Philippine 
Islands. Louis Ottefy. Transactions of 6th International 
Dental Congress, 1914. 
Progress in Dental Education. H. E. Friesell. Journal of 
American Medical Association, November 6, 1920. Vol. 75, 
No. 19. pp. 1247-1248. 
Report of Finance Commission on Petition of School Committee 
to Increase its Appropriation Power $1.05 per $1,000. City 
Record, New York. Vol. 12, No. 50. December 11, 1920. 
Report of Five Years of Mouth Hygiene in the Public Schools of 
Bridgeport, Connecticut. Alfred C. Fones. 1918. 
Report of Committee to Investigate the Practice of Dentistry. 
1919. Great Britain Royal Commission on Dentistry. Dental 
Cosmos, Vol. 61, 1919. pp. 525-605. APPENDIX B 
119 
Report of Scientific Experiments Conducted in the Cleveland 
Public Schools for the Purpose of Ascertaining the Value of 
Healthy Conditions of the Mouth. E. G. Ebersole. National 
Mouth Hygiene Association, April, 1912. 
Standards of Child Welfare. Health of Children and Mothers. 
Dental Clinics. Lewis Terman. Children's Bureau, U. S. 
Department of Labor, pp. 234-237. 
Time, the Place, and the Work, The. D. M. Gallie. Dental 
Review, June 1911. 
Tonsil-Adenoid Clinic of the Rochester Dental Dispensary, The. 
1920. 
Tonsil and Adenoid Situation in New York City. Public Health 
Committee of New York Academy of Medicine. Medical 
Record, May 14, 1921;' 
Transactions International Dental Congress, London. August, 
1914. Section IX, Oral Hygiene, Public Instruction, and 
Public Dental Services. 
Value, Scope, and Expense of Routine Dental Treatment in 
Hospitals. Thomas B. Hartzel. Modern Hospital, Vol. 7, 
November, 1916. pp. 442-444. 
APPENDIX B 
Dental Clinics in Hospitals and Dispensaries 
(1) Dental service is an essential part of the work of a general 
hospital, as an element in complete diagnosis, and as a treatment 
need of many patients. 
(2) A dentist competent as a dental diagnostician should be 
recognized with adequate rank on the staff of the hospital, and 
should be given the necessary facilities, such as access to the 
X-ray and to beds when necessary. 
(3) The primary responsibility of the hospital in dental care is 
the dental diagnosis of patients whose mouth conditions are 
involved as a factor in the disease for which the hospital accepted 
these cases, and for whom dental treatment is necessary in order 
that the hospital's medical or surgical work shall attain satis- 
factory results. In other words, a hospital cannot carry out 
adequate diagnosis and treatment without undertaking dental 
diagnosis, and in some instances dental treatment also. 120 
COMMUNITY DENTAL SERVICE 
(4) A routine dental examination of hospital cases should be 
included as part of the physical examination. 
(5) Hospitals maintaining out-patient departments should 
include a dental clinic for treatment purposes as part of this 
out-patient department, unless by some definite affiliation with 
another accessible dental clinic, the necessary dental care of its 
patients can be assured. 
(6) The service of a dental clinic as part of the hospital out- 
patient department must ordinarily be limited in order to avoid 
over-crowding. Patients should be accepted for treatment in 
the following order: 
a. Patients already received by the hospital or dispensary, 
whose mouth conditions are involved in a general medical or sur- 
gical condition which the hospital or dispensary has diagnosed, and 
for which it has assumed responsibility for treatment. 
To give dental care to these patients, or to arrange for their 
care by definite reference and follow-up to some other institution 
is a responsibility which every hospital ought to meet. 
b. Patients referred to the dental clinic from other medical 
or community agencies (such as a doctor or the visiting nursing 
organization) with the indication that the dental conditions are 
involved in the general condition of the patient. 
c. Relief of pain and; other emergency dental work for patients 
not otherwise connected with the hospital, but accepted merely as 
emergency cases. 
d. Other patients accepted up to whatever number may be 
consistent with the facilities. So far as possible, this restriction 
should be on a district basis. 
(7) Dental organization in the Hospital. 
a. The dentist recognized as head of the dental service of the 
hospital should be in charge of the organization of its dental work, 
including the out-patient clinic. 
b. Assistant dentists are desirable as visiting members of the 
staff of the dental clinic. 
c. A dental interne is desirable, as a member of the staff of 
the hospital. His work cannot be confined primarily to assisting 
in the therapeutic work of the out-patient department, but he 
should be given opportunity to work in the diagnostic service 
with the chief of the hospital department, in order that his year 
of internship shall be a year of advanced dental education in both 
curative and diagnostic work. The supply of dental internes is 
inadequate, but the trend of dental education will stimulate young APPENDIX B 
121 
graduates to a hospital year, and the increasing demand for dental 
service in hospitals may be expected to increase also the facilities 
which hospitals will offer. 
d. The dental hygienist is a desirable member of the staff of the 
dental clinic, and as an agent for cleaning the teeth of bed patients 
in the hospital. 
e. Salaries for visiting dentists are generally necessary. 
f. The dental clinic should charge fees covering cost of treat- 
ment, remitted, however, if the patients are unable to pay. PRINTED BY R. R. DONNELLEY 
AND SONS COMPANY, AT THE 
LAKESIDE PRESS, CHICAGO, ILL.