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Chapter 6

Contents

CHAPTER VI

Operation of the Dental Service- General Considerations

DENTAL STANDARDS FOR MILITARY SERVICE

In time of peace the Army tends to establish physical standards for military service which cannot be maintained in time of emergency. This policy is not inconsistent since it ensures that time and money will not be wasted in training poor physical specimens, but when these rigid standards are carried over into a general mobilization difficulties may result.

The dental standards for full military duty which were in effect at the end of the First World War were not significantly altered prior to World War II. The early Mobilization Regulations (MR 1-9, dated 31 August 1940) which established the physical criteria to be used by Selective Service in time of emergency, prescribed dental requirements which were substantially the same as those published in AR 40-105 for the Regular Army in time of peace. Section VII of these regulations reads as follows:

DENTAL REQUIREMENTS

31. Classes 1-A and 1-B.-a. Class 1-A. (1) Normal teeth and gums.

(2) A minimum of 3 serviceable natural masticating teeth above and three below opposing and three serviceable natural incisors above and three below opposing. (Therefore the minimum requirements consist of a total of 6 mastleating teeth and 6 incisor teeth.) All of these teeth must be so opposed as to serve the purpose of incision and mastication.

(3) Definitions.

    (a) The term "masticating teeth" includes molar and bicuspid teeth and the term "incisors" includes incisor and cuspid teeth.

    (b) A natural tooth which is carious (one with a cavity), which can be restored by filling, is to be considered a serviceable natural tooth.

    (c) Teeth which have been restored by crowns or dummies attached to bridge-work, if well placed will he considered as serviceable natural teeth when the history and appearance of these teeth are such as to clearly warrant such assumption.

b. Class 1-B. Insufficient teeth to qualify for class I-A, if corrected by suitable dentures.

32. Class 4.-a. Irremediable disease of the gums of such severity as to interfere seriously with useful vocation in civil life.

b. Serious disease of the jaw which is not easily remediable and which is likely to incapacitate the registrant for satisfactory performance of general or limited military service.

c. Extensive focal infection with multiple periapical abscess, the correction of which would require protracted hospitalization and incapacity.

d. Extensive irremediable caries.

 


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(Note: Class I-A was acceptable for full military duty, class I-B was eligible only for limited duty, and class IV was rejected for any military service. No registrants found acceptable for limited service were called for military service prior to July 1942.)1

These regulations did not specify whether or not teeth replaced on removable bridges would be counted as serviceable natural teeth, and this point was not made clear until March 1941, when Selective Service Medical Circular No. 2 provided that either fixed or removable bridges were acceptable if supported at least in part by the remaining teeth.2

When the preceding regulation was published the United States was still more than a year from actual participation in the war. The partial mobilization then in progress was for training purposes only, and fairly strict physical standards were necessary to avoid waste of effort in the instruction of men who might later prove unfit for military service. However, the Dental Division did not expect the criteria of the prewar MR 1-9 to apply in case, of actual conflict, for as early as May 1941 Brig. Gen. Leigh C. Fairbank, Director of the Dental Division, stated:

    It is estimated that a large percentage of men, inducted into the Army in the operation of a compulsory draft law, would require extensive dental replacements. The men of military age today will certainly show the [effects of] lack of dental care during the depression years. This condition must not be permitted to constitute a disqualifying factor.... However great our desire to maintain high dental standards for military service, we must realize that the safety of our nation depends on trained manpower. If the situation at present indicates a lowered state of dental health among those of military age, we must provide the means for adequate dental service to correct the dental health of drafted men. The entire plan for dental service in time of mobilization has been revised to meet the conditions which we are certain will exist in every Army camp.3

The number of men actually disqualified for dental reasons under MR 1-9 far exceeded all expectations. About 8.8 percent of the registrants examined during the period from November 1940 through September 1941 could not qualify for general service. About one-third of these disqualified registrants were classified as IV-F, namely, as totally unfit for military service, and the remainder as I-B, fit for limited service only.4 Since no registrants with limited service qualification were called for, military service during this period, the 8.8 percent was the actual disqualification rate for dental reasons. In addition to those registrants who were disqualified for strictly dental conditions (8.8 percent), about 0.4 percent of the examined registrants were rejected by the local boards for serious pathology of the mouth or gums, and while

    1Teeth, mouth, and gum defects of men physically examined through the Selective Service System, 1940-1944, 28 Dec 45, p. 11. Natl Hq, Selective Service System.
    2Medical Circular No. 2, Dental, 28 Mar 41. Natl Hq, Selective Service System.
    3Fairbank, L. C. : Prosthetic dental service for the Army in peace and war. J. Am. Dent. A, 28: 798-802, May 1941.
    4Causes of rejections and incidence of defects, Medical Statistics Bulletin No. 2, 1 Aug 43, pp. 6 and 9. Natl Hq, Selective Service System.

 


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the proportion disqualified by the induction stations for such pathology is not known it is apparent that about 1 of each 11 registrants examined was disqualified at that time for military service because of dental or oral diseases. These disqualification rates refer to rejections where the dental defects were the principal disqualifying cause. It should be noted, however, that in establishing the disqualification rates, only one disqualifying reason was given as the cause of rejection. Obviously, whenever there was more than one disqualifying defect, an order of precedence was followed in determining the principal disqualifying cause. In this respect, dental defects had a low priority. Therefore, if it were assumed that the frequency of disqualifying dental defects was the same among the registrants who were disqualified for reasons other than dental, it seems that about 1 out of 8 examined registrants would have failed to meet the early dental standards for general service.

During 1940 and 1941, when 89 percent of all dental rejections were made by local boards, dental and oral disqualifications by these boards were based on the following specific conditions:5

Defects of the teeth:

 

Percentage of all dental rejections

 

Total

White

Negro

Missing teeth, replaced by dentures

23.1

23.8

6.3

Missing teeth, no dentures

64.0

63.6

73.6

Excessive caries

10.0

9.7

16.1

Other defects of the teeth

2.9

2.9

4.0

Defects of the mouth and gums:

 

Percentage of all oral rejections

 

Total

White

Negro

Periodontoclasia

71.7

71.4

73.8

Gingivitis

5.1

4.7

8.2

Congenital defects, lips and palate

8.6

9.6

1.6

Other defects of the mouth and gums

14.6

14.3

16.4

For a year and a half after the early MR 1-9 (1 August 1940) was published, changes in dental standards were relatively unimportant. In October 1940 the War Department directed that the provisions of MR 1-9 which had previously applied only to inductees would thereafter also constitute the physical standard for voluntary enlistment in the Regular Army and the National Guard.6 In March 1941 both Selective Service and the Office of The Surgeon General published circulars of interpretation directing that (1) the specified minimum number of teeth were required to be in occlusion only during movements of the mandible, as long as there was no impingement on soft tissues while the jaw was at rest, (2) missing teeth replaced by either a fixed or removable bridge could be counted as serviceable teeth if at least part of the stress of mastication was carried by the remaining natural teeth, (3) teeth with pyorrhea

    5See footnote 1, p. 200.
    6WD Cir 110, 4 Oct 40.

 


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pockets would be considered unserviceable if the pockets involved the bifurcation of multirooted teeth or the apical third of single-rooted teeth, and (4) teeth with caries involving the pulp would be considered unserviceable.7 8 In May 1941 dental requirements for officers of the Medical Department Reserve and the Chaplains' Reserve were relaxed to authorize commissioning of men with less than the minimum 12 teeth if the missing teeth were replaced by full or partial dentures.9

After Pearl Harbor it was apparent that the manpower needed to fight a global war could be obtained only if dental standards for induction were drastically relaxed. The War Department and Selective Service therefore directed, in February 1942, that pending revision of MR 1-9 the following Would be acceptable for general military service: 10 11

    Registrants who lack the required number of teeth as set forth in paragraph 31a, Mobilization Regulations 1-9, 31 August 1940, when, in the opinion of the examining physician, they are well nourished, of good musculature, are free of gross dental infections, and have sufficient teeth (natural or artificial) to subsist on the Army ration.

This modification, interpreted literally, temporarily authorized the induction of edentulous individuals provided they had procured the necessary dental replacements. The revised MR 1-912 which was published 15 March 1942 provided for acceptance for general military duty:

    Individuals who are well nourished, of good musculature, are free from gross dental infections, and have the following minimum requirements:

    1. In the upper jaw-Edentulous, if corrected or correctable by a full denture.

    2. In the lower jaw-A minimum of a sufficient number of natural teeth in proper position and condition to stabilize or support a partial denture which can be removed and replaced by the individual and which is retained by means of clasps, with or without rests, to stabilize or support the denture.

Malocclusion was a cause for rejection only when it interfered. with the individual's health or resulted in damage to the soft tissues. Registrants with less than the required number of natural teeth were to be placed in Class I-B, for limited military Service, if the condition was correctable by the construction of dentures. In April 194213 these revised standards were made applicable to graduates of officer candidate schools and, after October 1942,14 applied to Reserve and National Guard officers.

    7See footnote 2, p. 200.
    8SG Ltr 26, 28 Mar 41.
    9SG Ltr 39, 5 May 41.
    10Memo, Dir, Selective Service System, for all State Directors, No. I-372, 13 Feb 42, sub: Revised physical standards. Natl Hq, Selective Service System.
    11WD Cir 43, 12 Feb 42.
    12MR 1-9, 15 Mar 42.
    13WD Cir 126, 28 Apr 42.
    14AR 40-105, 14 Oct 42.

 


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In a further revision of MR 1-9 in October 1942, dental requirements for induction were practically eliminated.15 Thereafter the prospective inductee needed only "at least an edentulous upper jaw and/or an edentulous lower jaw, corrected or correctable by a full denture or dentures." No dental conditions were thereafter to warrant classification for limited service, and the only disqualifying dental defects were "diseases of the jaws and associated structures which are irremediable or not easily remedied, or which are likely to incapacitate the individual for the satisfactory performance of military duty" or "extensive loss of oral tissue in an amount that would prevent replacement of missing teeth by a satisfactory denture." The effects of the relaxed dental standards soon became evident. The available statistics for 1942 (beginning with April) indicate that the disqualification rate for dental reason during that year was around 1 percent. It decreased from 2.9 percent in April 1942 to about 0.1 percent in December 1942.16 In 1953, the, disqualification rate for dental defects fluctuated around 0.1 percent, and it remained practically at that level for the remainder of World War II.17 Selective Service Headquarters estimated that out of 4,828,000 registrants aged 18-37 who were still classified as IV-F on 1 August 1945, 36,000 registrants were so classified because of dental defects. An additional 12,500 registrants were disqualified by mouth and gum defects. In other words, according to this estimate defects of the teeth accounted for 0.7 percent of the IV-F category, and mouth and gum defects accounted for another 0.3 percent, together amounting to 1.0 percent of the entire IV-F class. These data refer to the entire period since the enactment of the 1940 Selective Service Act.18

At the end of hostilities higher dental standards were still maintained for commission in the Regular Army, for divers, for cadets, and for airborne duty; other components, including flying personnel, were subject only to the relaxed provisions of MR 1-9.

Selective Service Regulations of World War II did not at first provide for dentists to serve on induction boards, but the mounting importance of dental defects as a cause for rejection, plus the fact that many men accepted by the local boards were subsequently disqualified at induction stations, led to the decision in March 1941 to include dentists in the local and advisory boards when ever feasible.19 By 7 December 1941, 8,040 dentists had been officially appointed to this voluntary duty20 and a Selective Service memorandum of 1 August 1941 noted that dentists were then available on all local boards.21 After Febru-

    15MR 1-9, 15 Oct 42.
    16Unpublished data from the Medical Statistics Division, SGO.
    17Induction Data, Results of Examination of Selectees at Induction Station, during 1943, Army Service Forces, Office of The Surgeon General, Medical Statistics Division.
    18Medical Statistics Bulletin No. 4, Natl Hq, Selective Service System, Table 4.
    19Selective Service Regulations, vol. I, sec V, amendment 12 to par 134. In Selective Service Regulations, 23 Sep 40 to 1 Feb 42. Washington, Government Printing Office, 1944.
    20Camalier, C. W.: Preparedness and war activities of the American Dental Association. J. Am. Dent. A. 33: 84, 1 Jan 46.
    21Memo, Dir, Selective Service System, for all State Directors, 1 Aug 41, sub: Dental examination. Natl Hq, Selective Service System.

 


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ary 1942 local boards limited their dental examinations to a gross screening for obviously disqualifying pathology.22 The more detailed examination necessary to chart all defects and finally determine eligibility for military service was thereafter carried out at Army induction stations.23

MISSION AND CAPABILITIES OF THE DENTAL SERVICE

At the start of World War II, available information on the dental condition of young adults of military age was at best fragmentary and often contradictory. Though studies on the dental needs of the civilian population had been conducted by various agencies,24 25 26 27 28 these had been restricted to small segments of the population which were not representative because of age, economic status, or geographical distribution. No governmental or private agency had attempted the nationwide examination of hundreds of thousands of persons from all income, age, and racial groups, both urban and rural, which alone could have given a complete picture of the dental needs of the American public. However, the one conclusion accepted by all researchers was that the dental attention received by the average citizen during the preceding decade had been anything but adequate. The reasons for this inadequacy were not primarily the concern of the Armed Forces, but since the dental care of the average inductee had not been sufficient to prevent the steady accumulation of serious, preventable dental defects, this accumulation materially complicated the problems of the Army Dental Service during the emergency. Thus in formulating a policy for the dental care of military personnel, the Dental Service had a choice of one of three principal alternatives.

First, it might have continued to furnish only such treatment as the average inductee had received in civilian life. Sporadic attention of this type, limited very often to the relief of intolerable conditions, was being provided the American public with a ratio of only 1 dentist for each 1,850 persons, including infants and the aged.29 The Dental Corps could have supplied such symptomatic treatment without serious difficulty.

    22See footnote 10, p. 202.
    23Though induction stations operated under Army supervision they were often staffed with contract civilian medical and dental personnel.
    24Beck, D. F. : Costs of dental care for adults under specific clinical conditions. Under the auspices of the Socio-economics Committee of the American College of Dentists. Lancaster, Lancaster Press Inc., 1943.
    25Walls, R. M.; Lewis, S. R., and Dollar, M. L.: A study of the dental needs of adults in the United States. Chicago, American Dental Association, Economics Committee, 1941.
    26Collins, S. D. : Frequency of dental service among 9,000 families, based on nationwide periodic canvasses, 1928-31. Pub. Health Rep. 54: 629, Apr 1939.
    27Dollar, M. L: Dental needs and the cost of dental care in the United States. Ill. Dent. J. 14: 185-199, May 1945.
    28Klein, H., and Palmer, C. E.: The dental problem of elementary school children. Milbank Mem. Fund Quart. 16: 281, Jul 1938.
    29O'Rourke, J. T.: An analysis of the personnel resources of the dental profession. J. Am. Dent. A. 30: 1002, 1 Jul 45.

 


205

Unfortunately, such a low standard of dental health was not acceptable for military personnel. The civilian whose health was being undermined by oral sepsis might conceivably follow his normal sedentary pursuits without noticeable inconvenience, but in the Army. he had to function at top efficiency under the most adverse conditions, and disease which would reduce his physical endurance or cause him to be lost to his unit at a critical time, had to be eliminated. Moreover, the soldier had to be able to masticate any rough food which might be available in the field. Disregarding all humanitarian con-siderations, the Army could expect the most effective service from inductees only if their oral health was maintained at a much higher level than was common in civilian life.

As a second alternative, the Dental Service might have provided only such regular annual care as was essential to prevent further deterioration of the soldier's dental health, ignoring old defects except when treatment became urgently necessary for the relief of pain. It had been estimated, on the basis of the ADA study of 1940, that 267,000 dentists, or a ratio of 1 dentist for each 493 persons, would be able to furnish such attention for the civilian population.30 This figure was of course not directly applicable to the military population, but it is certain that all regular maintenance care could have been provided Army personnel with the authorized ratio of 1 officer for each 500 men. However, this policy was undesirable because the average inductee as he was received in the Armed Forces was dentally unfit for military service even if the development of new defects could be checked. In addition, it was open to all the objections discussed in the preceding paragraph.

The remaining alternative was for the Dental Service to undertake the complete dental rehabilitation of every inductee, providing not only annual maintenance care, but correcting as far as possible the old defects which had resulted from earlier neglect. In view of the demand for top physical condition in military personnel this was the only objective which could be accepted, but based on fundamental considerations of available dental personnel and supply, it was necessarily a long-term project, not to he achieved in a few months, or even in a year.

The first goal of the Army Dental Service was to correct conditions which might cause a man to become a dental casualty, adversely affect his health, or result in further serious damage to dental structures. The precedence for this care was determined by the following dental classification:31

Classification

Treatment required

Class I

Extractions, other treatment urgently needed for the relief of pain or the maintenance of health.

Class I-D

Replacement of missing teeth for the necessary restoration of function.

    30See footnote 27, p. 204.
    31AR 40-510, 31 Jul 42.

 


206

Classification

Treatment required

Class II

Fillings or other routine, preventive care.

Class III

Replacement of missing teeth not urgently required for the restoration of function. Care for chronic conditions.

Class IV

No treatment required.

Though this classification gave some indication of the amount of treatment needed, the information was qualitative rather than quantitative; a man in Class II might have one carious tooth, or a dozen. Nor did it indicate all the types of work required; a single individual might have defects coming under three or more groupings, but only the most urgent classification was reported. Furthermore, different camps reported widely varying dental classification, indicating a lack of uniformity in application of the specified criteria.

Sample surveys of men arriving at three large replacement training centers at different periods from 1942 through 1915 show that they fell into approximately the following categories. These figures are given in round numbers because the available statistics do not justify more detailed conclusions:32

Class I

15 percent

Class I-D

5 percent

Class II

40 percent

Class III and IV (combined)

40 percent

It must be noted, however, that a large proportion of the men in Class I eventually required prosthetic replacements; similarly the men in Classes I and I-D often required routine fillings as well.

Treatment was normally rendered while the soldier was in training, and, in any event had to be completed before his departure for an active theater.33 After urgent work was taken care of the next objective was to provide men destined for a combat area as much routine treatment as possible. By the latter part of 1943 one major theater was able to report that 85 percent of new replacements were in Class IV, requiring no dental attention.34

The final goal of the Dental Service was to provide all essential treatment for every soldier, no matter where located. The extent to which this objective was attained is difficult to determine. It is known that the number of men needing the most urgent types of treatment, including the construction of dentures, was reduced from 20 percent on entry into the service to 3 percent at time of discharge; the number requiring routine care was correspondingly reduced from 40 percent to 14 percent.35 These figures fail completely to reveal the actual improvement in dental health, however, since the man who

    32Calculations based on unpublished data in the files of the Dental Division, SGO, covering the initial classifications of 25,000 men examined at Ft. Sill, Oka., in 1944 and 1945; 5,884 men examined at Ft. Meade, Md., in Jan. 1945; and 5,000 men examined at Camp Robinson, Ark., in 1942. Obviously a high proportion of these men came from the states in which the incidence of caries was low.
    33Preparation for overseas movement, 1 Aug 43. HD: 370.5-1.
    34History of the Dental Corps in the Southwest Pacific Area, World War II. HD: 314.7 (Southwest Pacific).
    35See footnote 32, above. The dental classification of separatees was calculated on data covering 12,000 men discharged at Ft. Dix, N. J., in 1946.

 


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entered the Army with 10 carious teeth and left it with 1 small cavity detected at the time of examination for discharge, would still be recorded is "needing routine treatment," and statistically no change in his dental condition would be noted. It is probable that many of the dischargees listed as still needing dental care fell in this category, but pending a study of individual induction and separation records, it is possible to say only that the average soldier returned to civilian life in much better condition than when he left it.

PERSONS AUTHORIZED TO RECEIVE DENTAL CARE

Military Personnel

During World War II dental treatment was authorized on an equal basis and without cost for all Army personnel on active duty without respect to rank or component.36 At least once a year, and usually more often, members of each organization were examined in a "dental survey" and placed in the appropriate category as listed on pages 205-206. First priority was given to emergency conditions; other personnel, beginning with those in Class 1, were treated in accordance with their classification established on the survey. Retired personnel were authorized dental care when facilities were available, but total requirements for this group were so small that they were a negligible factor in planning the Dental Service.

Civilian Dependents

Prior to the war, dependents of military personnel were authorized dental treatment in Army clinics. Most of this treatment was maintenance care for persons receiving fairly regular attention, but it accounted for about 25 percent of all work completed by the Dental Corps.37 To have continued this type of treatment for the dependents of the millions of men being taken into the Armed Forces for the emergency would have required a minimum of 5,000 additional dentists, with equipment and housing, at a time when both manpower and supplies were critically short. The Dental Division therefore recommended that treatment for Army dependents be limited to the care of emergencies, and then only when such care would not interfere with the treatment of military personnel.38

However, enforcement of the limitations on dental care for dependents sometimes led to considerable embarrassment for dental officers. The Dental Division had recommended that only "emergency care for the actual relief of pain" be authorized, and the application of even this provision would probably have required the exercise of a great deal of tact. But through

    36For a detailed list of persons entitled to dental treatment see AR 40-505, 1 Sep 42.
    37Summary of dental attendance (Dental Corps, U. S. Army, 1939). Dental Bulletin, supp. to Army Medical Bulletin 11 : 128, Jul 1940.
    38Memo, Brig Gen Leigh C. Fairbank for Exec Off, SGO, 8 Oct 40. SG: 337-1.

 


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error or intent the published directive merely provided for "emergency treatment," leaving a loophole for strong and continuous pressure for all kinds of care.39 A wife who lost a bridge-facing on the day before a dinner party had no trouble in convincing herself that hers was an emergency situation, and patients demanded, and sometimes received, permanent fillings, denture repairs, and even the replacement of missing teeth. Some contended that dental care was authorized by Army regulations and that it could not be denied by an emergency directive, but the Legal Division of the SGO decided that medical attention for dependents was "a, matter of discretion and not a matter of right."40

Even with the above defect rigid application of the directive would have eliminated almost all dental. work for dependents since it also prohibited such care when it would interfere with the treatment of military personnel, and very rarely could it honestly be said that any work for dependents would not be at the expense of the troops. But the dental surgeon who tried to refuse civilian dental care on this basis sometimes found that he did not have the support of either the surgeon or the commanding officer. He could legally enforce the restriction, but such action frequently had to be taken on his own responsibility and against the fairly clear wishes of the superiors who made out his efficiency reports, assigned his duties, and approved or disapproved recommendations for promotion. This situation was understandable since officers outside the Dental Service seldom understood the time-consuming nature of dental work. Few realized that the request to "just take a look at this tooth" usually meant at least a half-hour lost from a busy day. Only the dentist knew that in spite of his best efforts some of his men would leave for combat areas with uncorrected dental defects, and that every minute devoted to nonmilitary personnel was taken from a soldier. But the knowledge that he was in the right was very little consolation to a dental officer who had to enforce a regulation which was unpopular with his immediate superiors.

In spite of these deficiencies, the directive against wartime treatment of dependents accomplished its primary purpose fairly well. Only 1.4 percent of all care rendered during 1942-1945, inclusive, went to nonmilitary personnel, and much of that to civilian employees overseas.41 Its principal defect was ambiguity; a flat prohibition against any care for dependents was enforceable, but a compromise, attempt to provide only a little treatment was not. The very fact that only 2 or 3 percent of dependents received any

    39Ltr. TAG to CGs all CAs and Depts and COs of Exempted Stas, 14 Jan 41, sub: Dental service during the national emergency. AG : 703.1.
    40Memo, Lt E. R. Taylor, Legal Div, SGO, for Col McDowell, 25 Jan 45, sub: Dental attendance for dependents of military personnel.. SG: 703.
    41Data on the treatment of civilians assembled by author from data in the files of the Dental Division, SGO.

 


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dental care at all is in itself evidence that dental surgeons could not provide even the minimal authorized treatment on an equitable basis. The dentist was forced to select a very few patients from the hundreds needing attention, and under such circumstances charges of favoritism were inevitable. Dependents of overseas personnel who had no one to support their requests for assistance, and dependents of men in the lower grades, who could least afford to pay for civilian dental care, generally fared worst of all. The few dependents who received the scanty treatment authorized were seldom satisfied, while the majority who did not, felt that they had been arbitrarily denied a valuable privilege because they lacked influence or because the dentist was lazy. Wives of Army personnel published lurid accounts of the "run-around" they had experienced, describing graphically how they had waited all day for consultation, only to be told to come back the following day. The net result of this attempt to do just a little work for dependents was inadequate treatment for a very few, and widespread ill will for the Medical Department and the Dental Corps. It appears that a complete suspension of treatment for dependents during the emergency would have been fairest to all concerned and would have created less, bad feeling than the temporizing policy actually in effect. The Navy has successfully enforced such a policy for many years, in peace as well as in war.42

Civilian Employees and Associated Personnel

Dental care for civilian employees of the War Department in the continental United States was limited to emergency treatment for the relief of pain until definitive care could be provided by a civilian dentist.43 Overseas, however, where satisfactory dental attention could not be obtained from nonmilitary agencies, the Army had to assume responsibility for the dental care of its civilian specialists. Under these conditions, civilian employees were authorized the same treatment as soldiers, without cost.44 Red Cross personnel in the United States, where civilian facilities were available, were authorized dental care only when hospitalized and when such dental treatment was an essential part of therapy.45 In no case was replacement of

    42Statements concerning defects in the policy regarding dental treatment for dependents are very hard to document. Those who received no treatment had no legal basis for complaint, and those who received more than emergency care did not court publicity, for obvious reasons. The author gained personal knowledge of this problem while serving as dental surgeon of two large ZI posts. Most of the facts stated were also common knowledge among dental officers.
    43Policy in respect to dental treatment for civilian employees in the ZI was published by 1st ind, SG on Ltr, CG, 9th SvC, to SG, 5 Mar 43. Both the original letter and indorsement have been lost, but the latter is quoted verbatim in History of the Army Denal Corps, 1941-43, Professional Sec, p. 42. HD: 314.7-2 (Dental).
    44Ltr, SecWar to SG, 14 Sep 42, sub : Medical attention for civilians on foreign military missions. SG: 703.1.
    451st ind, TAG, 3 Oct 42, on Ltr, TAG from CO, Sta Hosp, Ft. Lewis, Wash. 21 Sep 42, sub: Dental treatment for Red Cross personnel. SG: 703.1 (Ft. Lewis) N.

 


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missing teeth permitted. Overseas, Red Cross personnel were entitled to all types of dental care without cost.46

AUTHORIZED DENTAL TREATMENT

Extent of Authorized Treatment

In deciding what care should be provided military personnel, the Dental Division had to compromise between what was theoretically desirable and what was possible with the maximum resources available. Such operations as the replacement of single missing teeth with fixed bridgework, the treatment of pulpless teeth, the restoration of anteriors with porcelain jacket crowns, and the construction of full-cast, precision-attachment partial dentures could of course be defended as good dentistry, but the expenditure of time on such procedures could not be justified while other soldiers suffered from oral sepsis or were threatened with the loss of additional teeth from rapidly progressing caries. It was therefore necessary to limit the care provided by following the principle of "the greatest good for the greatest number," with primary attention to those conditions which affected the health of the individual or which would result in permanent damage if neglected.

In 1940 the United States was not involved in actual hostilities, and it was expected that inductees would return to civilian life after one year of training. Also, these inductees were required to meet minimum standards of dental health before they were called to active duty. The Dental Division therefore felt that it was both unnecessary and unwise to attempt, in a, short time, the complete dental rehabilitation of every individual entering the service in a temporary status. In October 1940 the attitude of the Director of the Dental Division was expressed as follows:47

    Under no circumstances is it believed desirable to set up a policy requiring that every man drafted into the Army receive complete dental attention to place him in class IV.... It is believed that it is only right that we should adopt a policy that any Reserve Officer or draftee or National Guard personnel in the Army for a period of one year's training is not to receive dental service replacing teeth lost prior to his entrance into the military service, except in the case of dental pathology involving other teeth or oral tissue where the replacement is necessary to maintain health. In other words, a man who has been able to carry on his business or hold a job in civilian life with

    46Authority for the outpatient dental care of Red Cross personnel overseas has proved impossible to document. Such treatment was obviously essential and to the personal knowledge of the author who served in two theaters, it was rendered without question, but flies of The Adjutant General or The Surgeon General fail to reveal any clear-cut reference to the subject. In a telephone interview of 21 August 47, Miss Jeanette Ross of the Insular and Foreign Hospital Service, National Headquarters, Red Cross, stated that it was her understanding that Red Cross employees were authorized hospitalization under AR 40-590, that 40-505 approved medical attention for anyone hospitalized under 40-590, and that AR 40-510 in turn provided for dental attendance for anyone hospitalized under AR 40-505. If strictly interpreted, however, even this complicated series of regulations does not specifically authorize outpatient dental care for Red Cross personnel overseas. It appears that this was a situation where no formal objection was ever raised or a specific directive published.
    47See footnote 38, p. 207.

 


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    his mouth in a neglected state cannot and should not anticipate that a complete and perfect dental service will be given him in the Army, placing his mouth in perfect condition when he would not have gone to the expense to secure such service had he remained in civilian life.

On the basis of this opinion, The Surgeon General recommended to The Adjutant General that dental attendance for temporary personnel be limited to the treatment of emergency conditions, the filling of cavities with routine materials, and the replacement of teeth lost in the performance of duty or as a necessary part of treatment.48 The Adjutant General disapproved this recommendation, however, because it was against War Department policy to distinguish in any way between temporary and permanent personnel.49 The Surgeon General then agreed to make the proposed restrictions applicable to all Army personnel50 and the following policy was published by the Office of The Adjutant General (AGO) on 14 January 1941:51

    a. Dental attendance for all military personnel will be confined to the treatment of emergency cases, infectious conditions, and the restoration of carious teeth with amalgam, silicate, or cement fillings, except as provided in b below.

    b. Replacement of missing teeth will not be made, except when teeth were damaged or lost in the performance of duty, while engaged in athletic games, or as a necessary part of treatment. Such replacements will be the standard type of partial or full dentures provided for Army personnel.

    c. Dental attendance for dependents will be limited to emergency treatment. Such treatment will interfere in no instance with the routine dental treatment of military personnel.

With the lowering of dental standards in February 1942, large numbers of men entered the service whose teeth did not meet minimum requirements for health, and it became necessary to remove some of the restrictions against the construction of dentures. On 8 April 1942 the Director of the Dental Division recommended that subparagraph (b) of the aforementioned letter be amended to read as follows:52

    Replacement of missing teeth for military personnel will be made when in the opinion of the dental surgeon it is necessary from a health or functional standpoint; that is, insufficient natural or artificial teeth to satisfactorily masticate the Army ration. Such replacements will be the standard type of full or partial dentures provided in the Army, except that anterior teeth lost in line of duty may be replaced by fixed bridgework when in the opinion of the dental surgeon it is advisable. This type of replacement is to be kept at a minimum consistent with the best interests of the Government and the individual.

This change was published verbatim in an AGO letter of 25 April 1942.53

    48Ltr, Exec Off, SGO, to TAG, 30 Nov 40, sub: Dental service during the national emergency. SG: 703.1.
    491st ind, 26 Dec 40, TAG on ltr cited in footnote 48, p. 211.
    502d ind, 3 Jan 41, SG on ltr cited in footnote 48, p. 211.
    51See footnote 39, p. 208.
    52Memo, Brig Gen R. H. Mills for Gen McAfee, 8 Apr 42. SG:703.-1
    53Ltr, TAG to CGs all CAs and Depts, COs of Exempted Stas, 25 Apr 42, sub: Dental service during and for six months after the war. AG: 703.1.

 


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Limitations on the construction of fixed bridges were still further liberalized by a War Department directive of March 1945 providing that "A fixed bridge may be inserted in the anterior segment, in limited cases, as a morale or functional factor in those instances where extraction has caused a disfiguring space."54 Under the terms of War Department policy every soldier was authorized all the care necessary to preserve dental health, though the single missing tooth of one patient would not be replaced as long as other men had insufficient teeth for proper mastication, nor would an inlay be supplied at an expenditure of time that might better be used to save several teeth with standard amalgam fillings.

Quality of Treatment Rendered

Though expensive and time-consuming operations were not authorized when simpler procedures would be effective, the Dental Division consistently demanded that treatment rendered in Army dental clinics be of the highest quality. This policy was partly altruistic in that it was felt that the soldier was entitled to care at least as good as he would receive in civilian life; it was partly selfish because it was believed that work of high quality would prove most economical of both time and money. The attitude of the Dental Division was expressed in the Army Medical Bulletin as follows:55

    There is no substitute for quality in the service rendered the soldier by the Army Dental Corps. The Dental Division has on many occasions emphasized that, above all, quality and not quantity is the real objective of the dental service in every hospital, camp or post. There are times and situations which demand an extended effort on the part of the dental officer to complete a certain assignment, but regardless of the circumstances, the dental service cannot afford to be jeopardized by permitting inferior work to leave the dental clinic.

Only standard, high-grade materials were furnished dental clinics, and gold was available when the more common items were not satisfactory. Dentures were normally made of acrylic resin, with gold bars and clasps when required. No charge was made for special materials or treatment, and the practice of having military personnel pay civilian laboratory costs, except in extreme emergency, was specifically prohibited.56 Surgical procedures were carried out by qualified personnel with due attention to asepsis, and the incidence of infections following oral surgery was very small.57 Officers with special qualifications were also designated as prosthodontists in all the larger installations. Teeth which could be saved in a healthy condition were not extracted, and the

    54TB Med 148, Mar 1945.
    55Dental service-accepted procedures no experimentation. Bulletin of the U. S. Army Medical Department 82: 20, Nov 1944 (cited hereafter as Army Medical Bulletin).
    56Ltr, SG to CGs, SvCs, 26 Nov 42, sub: Prosthetic dental appliances. SG: 703.1.
    57Control of dental infections.Army Medical Bulletin 69: 33, Oct 1943.

 


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number of teeth replaced during the war exceeded the number lost.58 Liberal use of protective bases under deep fillings was encouraged, but very little root canal treatment was attempted, both because of the time required and because of the risk that a later acute infection might incapacitate the soldier when he could not get dental care. Only a limited amount of porcelain work was done, though anterior jacket crowns were routinely provided after the acrylic resins became available.

With the exception of hygienists and x-ray technicians, only officers of the Dental Corps were permitted to work on patients at the chair. Army regulations provided that in the absence of a dental officer, medical officers might render dental care "to the extent that their training and skill justify," but such treatment was very rarely given.59 It was specifically directed that "except as otherwise prescribed...the selection of professional procedures to be followed in each case, including the use of special dental materials, will be left to the judgement of the dental officer concerned."60

It was especially directed that the soldier would not be used as a guinea pig for testing untried procedures.61

Of the 15,000 dentists on duty there were inevitably a few who failed to attain expected standards. There were also a few who mistakenly tried to set records for quantities of work completed, without due regard for quality. As these situations came, to the attention of higher authority, men of the first type were placed under responsible supervision or relieved from duty; those of the second were informed that high production, without quality, was not the route to advancement in the Dental Corps.

But while the quality of Army dentistry was generally satisfactory, the amount supplied during the first part of the war was the subject of some critical comment. Due to supply difficulties, and to the enormous accumulation of untreated defects in the civilian population, the Dental Service had to defer a considerable amount of elective treatment during the period of rapid mobilization, before dental facilities reached peak strength. The Director of the Dental Division admitted that:62

    The Army Dental Corps has accepted the most momentous job in the history of dentistry, since one man in every four, when inducted, is in a dental state which requires emergency treatment.... Time is the biggest handicap since men must be ready and trained in a few months. Then, about three out of every four boys had little dental attention prior to entrance into the service, and about one-half rarely went to

    58Exact figures on the number of teeth replaced are not available, but if the reasonable assumption is made that an average of 8 teeth were replaced by each partial denture, a total of 18,000,000 teeth were supplied soldiers from Jan 1942 through Aug 1945. In the same period 15,000,000 teeth were extracted.
    59See footnote 31, p. 205.
    60Ibid.
    61Accepted dental therapeutics and procedures.Army Medical Bulletin 69: 14, Oct 1943.
    621st Ind, SG, 10 Oct 43, on Ltr, Mrs. Walter R. Agard to Gen George C. Marshall, 29 Sep 43. SG: 703.1.

 


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    the dentist.... It is humanly impossible to complete all of the dental work for all of the inductees.

This statement should not be interpreted to mean that the dental health of military personnel suffered because of their induction into the Army. It merely confirms the knowledge acquired during the World War II period that, in the event of any future mobilization, the Dental Service should not promise the complete dental rehabilitation of every soldier until it has adequate information on the dental needs of inductees, and on the factors which may affect its own ability to mobilize a large number of dentists in a limited time. The Dental Corps was also accused of being more interested in extracting than saving teeth. This impression was probably gained during mobilization when the first objective was to make men fit for military duties, necessitating the extraction of large numbers of septic or nonrestorable teeth. As any dentist or physician knows, the worst dental infections, chronic in nature, are often painless, and it is easy to understand how soldiers might assume that symptomless teeth had needlessly been extracted. One criticism which came to the attention of The Surgeon General was answered as follows:63

    It is the opinion of this office that Dr.... has not been correctly informed as to the constructive dentistry now being accomplished by the Dental Corps.... A ratio of approximately 27 permanent fillings to every tooth extracted was established during the month (May 1942). The dental reports for the armed forces for the month of May show that conservative constructive dentistry is carried out in every Army dental clinic. Since the lowering of dental requirements for inductees has been in effect, an enormous amount of work has devolved upon the Dental Corps, and many of the men now being inducted into the military establishment present oral conditions which require extensive treatment, and the extraction of many badly broken down teeth.

Qualified civilian dental consultants reported that in general the treatment rendered in the Army met the accepted standards of the American dental profession. The editor of the Journal of the American Dental Association stated in April 1944 that:64

    ...a beneficial result from the preventive and corrective dental program now in operation in the Army and Navy will be that an enormous number of men heretofore dentally deficient will be rehabilitated for military service and a large percentage of them will return from war in improved physical condition as a result of improvement in dental health.

The attitude of enlisted men toward the dental service was not as favorable as the quality of the treatment rendered seemed to justify. In October 1942, 5,538 enlisted men in the AGF and AAF answered questions concerning the medical and dental service as follows:65

    63Ltr, SG to Hon. Clyde L. Herring, 20 Jul 42. SG: 703.-1.
    64Is the Dental Corps meeting its obligations to the Armed Forces? J. Am. Dent. A. 31 : 537-540, Apr 1944.
    65Attitude of enlisted men toward medical, dental, and hospital services, among white enlisted men forming a cross section of Ground Forces and Air Forces, 2 Nov 42. Research Div, Office of Armed Forces Information and Education.

 


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Question: "Do you think good medical (dental) care is provided by the Army?"

 

Yes Percent

No Percent

Can't decide percent

No reply percent

Medical

80

5

14

1

Dental

68

9

19

4

Question: "Do you think Army dentists try as hard as civilian dentists to keep from hurting their patients?"

 

Yes Percent

No Percent

Can't decide percent

No reply percent

 

44

27

24

5

Question: "Do Army dentists prefer to pull teeth rather than fill them?"

 

Yes Percent

No Percent

Can't decide percent

No reply percent

 

22

45

31

2

Later surveys in England and Alaska showed an even smaller percentage completely satisfied with the dental service, though in all of these studies except the one listed previously the dental service was preferred over the medical service.66 67 Some of this dissatisfaction was based on general discontent and the normal tendency of the soldier to "gripe." Much of it was based on hearsay rather than personal experience for the percentage who thought that the dental service was good was much higher among men who had actually been patients. Nevertheless, too many enlisted patients had grave doubts concerning the Army dentist's use of the forceps and his humanitarian qualities. More detailed analysis of specific complaints showed that most men felt the end results of treatment were excellent, but they apparently believed that the military practitioner lacked a personal interest in his patient, that he tended to be rough, and that it was sometimes hard to get desired care.

The enlisted patient, lacking the professional knowledge on which to base an informed evaluation of his dental treatment, attached an understandable importance to details which the dental officer considered unimportant. The dentist tended to regard the patient as "another Class II" to be rehabilitated as rapidly as possible, with a minimum of nonessential conversation or explanation; the patient, on the other hand, felt that the situation called for a more sympathetic attitude. There is every evidence that conscientious, careful treatment was the rule in Army dental installations, but it also seems certain that the patient was not made to realize this clearly. Since the soldier's whole attitude toward the Army may be colored by his opinion of the medical care

    66European Survey No. 17, Dec 1943, of a cross section of men in lettered infantry companies in a division in training in England. Research Div, Office of Armed Forces Information and Education.
    67Report No. 12, Morale Serviecs Division, Research Unit, Headquarters, Alaskan Department, Aug 1944. Research Div, Office of Armed Forces Information and Education.

 


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he receives, it seems that this factor should be given attention in the event of a future mobilization.

THE PROSTHETIC SERVICE IN WORLD WAR II

Period Prior to World War II

Prior to the First World War, military personnel were expected to have sufficient teeth for mastication when they entered the service. If replacements later became necessary they had to be obtained by the individual. Regulations published in 1916 authorized restorations at Government expense. This, however, applied only to those individuals whose teeth had been lost by traumatic injury in line of duty. Prior approval of a department surgeon or of The Surgeon General was required in each instance and materials had to be obtained by special request to a medical supply depot.68

With the entry of the United States into the First World War, however, large numbers of men in poor dental condition were drafted into the Army and more adequate provision had to be made for the construction of prosthetic appliances. After May 191769 complete laboratory equipment was issued to the larger installations. In October 1917 The Surgeon General authorized dental officers in base hospitals, general hospitals, and certain larger camps, to repair bridges or dentures for men originally accepted with these appliances and to construct new restorations for soldiers for whom such work was considered essential by a regimental surgeon or dental surgeon. In March 1918 this regulation was further liberalized to permit the replacement, in time of war only, of any teeth essential to mastication. In time of peace, restoration was still to be restricted to teeth lost by traumatic injury in line of duty. After March 1919 teeth lost otherwise than by traumatic injury in line of duty could also be replaced by the Army but no gold or other precious metals could be expended on these appliances.70 In October 1920 it was pro-vided that gold could be used for:71

Replacements for teeth lost by traumatic injury in line of duty, in peace or war. Partial dentures requiring gold clasps for their retention. Repair of crowns or bridges which were originally necessary to establish eligibility of an enlisted man for entry into the service. Routine inlays, crowns, or bridges for officers and nurses and for enlisted men with at least 5 years service. Finally, in 1925, the use of any prosthetic material was authorized for any person entitled to receive dental care at Government expense, including the dependents of military personnel.72

    68Manual for the Medical Department. Washington, Government Printing Office, 1916, p. 261.
    69The Medical Department of the United States Army in the World War. Washington, Government Printing Office, 1928, vol III, p. 611 (cited hereafter as The Medical Department ... in the World War).
    70SG Ltr 126, 6 Mar 19.
    71SG Ltr 129, 27 Oct 20.
    72SG Ltr 9, 6 Feb 25.

 


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Prior to 1927, prosthetic appliances for soldiers were generally completed by small laboratories in the individual station dental clinics. In these a single assistant often worked on cases under construction whenever he could be spared from other duties. The dental officer commonly had to exercise close supervision over all procedures even if he was not required to do the work personally. Very little organization was possible and technicians were expected to perform all operations, yet men sufficiently skilled to pour up impressions, set teeth, fabricate gold skeletons, and polish the completed dentures were seldom attracted by the wages offered in the Army. As a result, dental officers wasted much time and effort in work which the civilian dentist routinely delegated to trained auxiliary personnel.

In 1927 central dental laboratories (CDL) were established at the Army Medical Center, Walter Reed General Hospital; Letterman General Hospital; and the Station Hospital, Fort Sam Houston.73 During calendar year 1933 another was installed at Corozal in the Panama Canal Zone, but the laboratory at Fort Sam Houston was closed for lack of personnel while the one at Letterman General Hospital produced only 38 cases.74 At the end of fiscal year 1935 only the Army Medical Center CDL remained in effective operation.75 At the same time, however, it was announced that a plan for expanding central dental laboratory facilities was under consideration. By the end of fiscal year 1937 the CDL at Fort Sam Houston was again functioning and another had been established at Fort Clayton in the Panama Canal Zone. On 16 March 1938 The Surgeon General announced a general plan for initiating central dental laboratory service on a large scale76 and a War Department circular of 16 September 1938 stated further that CDL's would be established in Washington, D. C.; Atlanta, Ga.; St. Louis, Mo.; San Antonio, Tex.; and San Francisco, Calif.77 By January 1939 all the new CDL's were in operation except the one at St. Louis, completion of which was delayed until July.78 79 Two subcentral laboratories were also established at Beaumont General Hospital in El Paso, Tex., and at Fitzsimons General Hospital in Denver, Colo.80

All the CDL's except the one in Washington functioned under the control of the respective corps area commanders, but personnel were assigned by The Surgeon General and it was specifically provided that technicians would not

    73Annual Report of The Surgeon General, U. S. Army, 1927. Washington, Government Printing Office, 1927, p. 241 (cited hereafter as Annual Report . . . Surgeon General).
    74Annual Report . . . Surgeon General, 1934. Washington, Government Printing Office, 1934, p. 163.
    75Annual Report . . . Surgeon General, 1935. Washington, Government Printing Office, 1935, p. 156.
    76SG Ltr 9, 16 Mar 38.
    77WD Cir 53, 16 Sep 38.
    78Central dental laboratories. The Dental Bulletin, supp. to The Army Medical Bulletin 10: 30, Jan 1939.
    79Ibid.
    80Annual Report . . . Surgeon General, 1939. Washington, Government Printing Office, 1939, p. 200.

 


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be used for other duties except in case of urgent emergency. The standard allotment of personnel was set at 2 officers, 1 staff sergeant, 1 sergeant, 2 privates first class, and 2 privates. Extra men and higher ratings were authorized for the CDL at the Army Medical Center, where vitallium cases were constructed.81

By the beginning of World War II a central dental laboratory system had thus become well established.

Policies Concerning the Provision of Prosthetic Treatment, World War II

Another major problem which confronted the Dental Service in World War II was the determination of the extent to which it should attempt to provide prosthetic appliances for inductees. Previously this question had been left to the judgment of individual officers, but with the enormous increase in requirements incident to mobilization a more definite policy was necessary. The first directive on this subject was issued by the AGO in January 1941. At that time inductees were expected to be in the Army for only one year, and they were required to meet at least minimum dental standards at the time they entered training. The Dental Division, SGO, felt that it was neither feasible nor necessary to undertake the complete rehabilitation, of almost a million men a year when it was expected that most of them would revert to civilian status almost as soon as treatment could be completed. Therefore, the amount of prosthetic treatment to be rendered was limited by the order of 14 January 1941 (see page 211, subparagraph b).

By April 1942 the situation had changed radically. The United States was in the war, inductees were in the Army for the "duration," and dental standards for induction had been lowered to admit men who would require extensive replacements before they could perform their military duties. To meet these new conditions a more liberal dental care policy was established by AGO directive of 25 April 1942 (see page 211) and a subsequent War Department directive of March 1945 (see page 212).82 83

For all practical purposes, the interpretation of these directives was again left to the individual dentist. An attempt was generally made to apply the peacetime standard for enlistment which provided that a man with less than 3 posterior teeth above and below in occlusion, and 3 anteriors above and below in occlusion, was not fitted for service. However, one meeting these minimum requirements might actually be a dental cripple. Also the decision in any doubtful case might depend to a considerable degree upon intangible personal factors. One man would wear a denture, which was necessary only to preserve the health of the remaining teeth; another would not. One would feel the need of a replacement when only a few teeth were missing; another would wear an

    81SG Ltr 1, 2 Jan 40.
    82See footnote 53, p. 211.
    83See footnote 54, p. 212.

 


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appliance only after all his posterior teeth and most of his anteriors had been lost. An SGO circular letter of 22 June 1943 attempted to clarify the situation, but after calling attention to certain fundamental considerations it left the principal responsibility just where it had been before, on the individual dental officer.84 No rigid formula was found to be universally applicable in World War II and it is doubtful if any fixed standard could ever prove entirely satisfactory.

In view of the difficulty in determining which cases should receive dental replacements it is not surprising that military personnel were sometimes furnished dentures which subsequently rested in a barracks bag or footlocker. One separation center reported that about I percent of the men discharged after less than 6 months' service were classified "I-D" (needing prosthetic appliances) but were found, on investigation, to have been provided replacements which they were not wearing. Of the men discharged after more than 6 months' service approximately 41/2 percent neglected to, wear the dentures which had been supplied them.85 If we accept the estimate that 10 percent of all military personnel had been provided with dentures, the findings of this separation center indicate that some 40 percent of those for whom appliances had been constructed did not wear them. This figure is admittedly based on a small sample and must be considered highly tenuous; the actual proportion may have been much smaller. But is cannot be said that the dentures which were not worn were "unnecessary" since in most cases their use would have prevented further damage to mouths already partly crippled.

Experience has shown, however, that the policy of relative liberality in authorizing dental replacements, applied reasonably, was in the best interest of all concerned even though some men undoubtedly failed to wear the dentures provided them. The great benefit to the large number who did, justified the extra effort involved. Further, the knowledge that teeth lost would subsequently be replaced, instilled in the soldier a greater confidence in the efforts of the Dental Service.

Requirements for Prosthetic Service
as Revealed by Wartime Experience

During the period of hostilities (1942-1945 inclusive) 109 dentures, 32 denture repairs, and 8 bridges were completed each year for each 1,000 men. This average rate was far from constant, however, and actual yearly output from 1938 through 1945 varied as follows:86 87 88

    84SG Ltr 114, 22 Jun 43.
    85Information on 7,469 men separated at an unspecified separation center from Nov 1944 through 16 Mar 45. Given to Lt Col John C. Brauer by Maj Gen Robert H. Mills, 27 Mar 45. SG: 703.
    86Figures from 1938-40 taken from annual reports of The Surgeon General for those years.
    87Data for 1941-43 taken from: A history of The Army Dental Corps, 1941-1943, Professional Service Section. HD: 314.7-2 (Dental).
    88Figures for 1944-45 calculated by author from data in the files of the Dental Division, SGO.

 


220

Prosthetic Operations per 1,000 Men Per Year

Year

Dentures

Dentures repaired

Bridges

1938

36.6

12.1

7.2

1939

41.9

13.8

6.7

1940

26.1

9.1

4.8

1941

14.1

5.1

2.2

1942

45.4

12.6

3.6

1943

125.0

23.8

5.8

1944

129.6

40.0

11.3

1945

96.1

40.0

13.1

The cited figures cannot be interpreted to mean that the need for prosthetic appliances was low in 1940-1941, and 1942, and high in 1943, 1944, and 1945. The small output of 1941-1942 represented inadequate capacity, which in turn was due mainly to lack of equipment, and trained technicians. With the start of mobilization in 1940 the laboratories were unable to increase their facilities to keep pace with the increase in the strength of the Army, and production did not again reach even the per capita rates of 1938-1939 until 1942. In this same period very few bridges were constructed since only the more urgent cases could be handled and the proportion of full dentures to partial dentures was much higher than in the later years of the war.

Improvements in the supply and personnel situation in 1943 made it possible for the prosthetic service, to meet current needs and also to start reduction of the accumulated backlog of prosthetic treatment, so that the per capita output of dental appliances reached a figure many times that of the prewar average. At the same time, the number of bridges constructed increased rapidly and the proportion of partial dentures to full dentures approximately doubled, showing that less urgent cases were receiving attention. By 1945, the backlog of treatment accumulated earlier in the war had been substantially depleted and the demand for new dentures began to fall off. Requirements for denture repairs remained high, however, due to the large number of appliances in use, and the high proportion of bridges constructed showed that more optional treatment was being provided as the need for urgent replacements diminished. Unfortunately, pending a detailed study of individual medical records there is no way to break down the preceding figures into requirements for initial rehabilitation and requirements for annual maintenance care.

During the war about 2,566,000 dentures were constructed for military personnel.89 Since 38 percent of all patients received 2 appliances, about 1,860,000 patients were given dentures. If there had been no replacement of broken, lost, or unsatisfactory prostheses, this would have meant that 19 percent of all soldiers wore artificial replacements. The Dental Division ac-

    89Information compiled by author from monthly reports of dental service on file in the Dental Division, SGO.

 


221

tually estimated that 15 percent of all military personnel wore prosthetic devices90 but since loss and breakage were inevitably high under wartime conditions, it seems probable that the proportion of men wearing dentures AW, at any one time was somewhat less than that estimated. If 50 percent of all dentures were replaced during the war, the proportion of soldiers wearing these would have been closer to 10 percent, a figure which corresponds more closely with the few available reports from tactical units.

Of the appliances constructed for one group of 107,542 patients in 1943, 17.0 percent were full uppers, 7.4 percent full lowers, 37.5 percent partial uppers, and 38.1 percent partial lowers.91 Thirty-eight percent of all patients required more than one appliance. These figures were, accumulated early in the war, however, and the later trend was toward fewer full dentures and more partial dentures. During 1942, the proportion of partial dentures to full dentures was 2.1,92 later a more liberal attitude was adopted and in January 1944, 4.4 partial dentures were being supplied for each full denture.93 The average ratio over the 4 years 1942-1945 was 3.5 partial replacements for each full denture.94

The evidence of World War II experience was clear on one point: During a mobilization the need for prosthetic service may be expected to increase out of all proportion to the increase in the strength of the Army. From the end of 1940 to the end of 1943 the strength of the Army increased by about 1,105 percent;95 during the same period the number of prosthetic cases completed per month increased nearly 5,600 percent, or 5.1 times the increase in the strength of the Army. The number of dentures supplied each 1,000 men in 1944 was 3.5 times the number supplied in 1938.96 Though some increase had been expected because of lowered dental standards, it certainly was not foreseen that a thousand inductees would require approximately four times as many prosthetic appliances as an equal number of men in the peacetime establishment.

Professional Standards of the Prosthetic Service

Certain "luxury" types of denture service, such as full-cast gold appliances, cast-base full dentures, and those involving the use of special attachments were obviously out of place in the wartime prosthetic service. However, every effort was made to provide soldiers with replacements which met the standards of ethical civilian practice. Materials employed were of the highest quality and included all of the commonly accepted types. The usual partial denture was constructed on an acrylic resin base, with assembled gold clasps and a gold

    90Final Rpt for ASF, Logistics in World. War II. HD:319.1-2 (Dental).
    91See footnote 87, p. 219.
    92Army reveals data on denture construction. J. Am. Dent. A. 15 Aug 45, p. 1080.
    93Ibid.
    94Calculation by author from monthly reports in the files of the Dental Division, SGO.
    95Strength of the Army, 1 Mar 46.
    96Calculation by author from monthly reports in the files of the Dental Division, SGO.

 


222

lingual bar. Cast gold and vitallium dentures were available when no other materials would be satisfactory, though their use was kept to a minimum. Little ceramic work was done in Army laboratories but acrylic resin was used in the construction of crowns and bridges when indicated. Whenever possible, specially skilled dentists were put in charge of the prosthetic service, and laboratories operated under the close supervision of full-time dental officers. Each model sent to a laboratory was surveyed and the necessary replacement designed by a dentist before being turned over to a technician.

No attempt was made to prescribe any uniform technique for taking impressions or constructing dentures. So long as acceptable standards were maintained each dental officer was free to use the methods with which he was familiar. However, inferior models and registrations were sometimes received in the laboratories, and certain generally recognized requirements were therefore established by directives published in July 1943 and March 1945.97 98 These did not state how results were to be attained, but did prescribe certain essential objectives (e. g. all full denture impressions to be muscle-trimmed, relations to be taken with well-fitted bite rims, etc.).

Prosthetic consultants reported that in general the dentures constructed by the Army met all requirements for health, comfort, function, and appearance. In isolated instances, however, the overwhelming demand for prosthetic service and the need for completing cases in a limited period resulted in the adoption of methods which left much to be desired. Such practices as the use of acrylic resin in place of gold lingual bars, the use of one-armed clasps, and soldering clasps on the same model which was later to be used for vulcanization were rare, but sufficiently frequent to warrant some criticism.99 Dentures were occasionally inserted before the ridges had become reasonably stabilized after extractions, though the dental surgeon usually had no choice but to supply a replacement to a soldier who would soon leave for an active theater, even when he was certain that the appliance would have a short useful life.100 Since these difficulties were due in large part to such f actors as inadequate dental care for the civilian population and inability to obtain equipment during the early part of the war, it is surprising that they were not more common. On the other hand, the fact that they existed, even temporarily, emphasized the importance of planning for an extensive prosthetic service from the start of any future mobilization.

From 1 January 1942 until the end of August 1945, the prosthetic service completed the following operations for military personnel:101

    97SG Ltr 128,17 Jul 43.
    98See footnote 54, p. 212.
    99Personal knowledge of the author who was successively the dental surgeon of a replacement training center, an overseas theater, and a large permanent post in the ZI.
    100Memo, Col Rex McK. McDowell for Exec Off, SGO, 18 Jan 44. SG: 703-1.
    101Information assembled by the author from monthly reports in the files of the Dental Division, SGO.

 


223

Dentures

2,566,000

Denture repairs

743,000

Bridges

206,500

About 800,000 of the above operations were carried out overseas. An additional 10,300 full dentures, 35,500 partial dentures, and 16,600 denture repairs, were completed for prisoners and nonmilitary personnel.

REFUSAL OF DENTAL TREATMENT

No soldier could refuse dental treatment if failure to correct the dental defect could normally be expected to interfere with the efficient performance of his military duties. A War Department General Order of 31 January 1942 provided that:102

    In time of war if a person in the military service refuses to submit to dental or surgical operations or dental, surgical or medical diagnostic procedures or dental or medical treatment, such person will be examined by a board of three medical officers convened by a corps area or department commander or a commander of a base or general hospital, or a commanding officer of any post, camp, or station where there are four or more officers of the Medical Department on duty. If, in the opinion of the board, the operation or diagnostic procedure or medical or dental treatment advised is necessary to enable such person to perform properly his military duties and will normally have such effect, and he persists in his refusal after being notified of the findings of the board, he may be tried by court martial.

In practice, it was seldom necessary to apply the provisions of this order, but it recognized that a soldier had no right to maintain a condition which might damage his health or make him unavailable in some future emergency.

"QUOTA" DENTISTRY

A persistent problem of the Dental Service, during the first part of the war was the tendency of dental surgeons to prescribe daily quotas of operations to be performed by their subordinates. The plans proposed ranged from a simple requirement that each dental officer complete from 10 to 30 fillings a day, to ingenious schemes under which the dentist received "points" of credit for each different operation, with a minimum total established for the day's work. The Pressure on the dental clinics, especially in the camps which were preparing men for duty overseas, was so formidable that it is not surprising that heads of clinics sometimes fell back on desperate measures to speed treatment. The Dental Division did not minimize the need for maximum output of all clinics, but the defects of any quota system were so serious that all such plans were disapproved individually and in principle. Among these defects the following were most important:

    102WD GO 8, 31 Jan 42.

 


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1. The dentist who produced superior work was made to appear inferior to the careless operator.

2. Dentists varied greatly in the speed with which they normally operated. If a moderate quota was set the fast operator might reduce his output, feeling that he was expected to accomplish no more than the prescribed average. The slow operator could increase his speed only at the expense of quality.

3. When too high quotas were established the conscientious dental officer, who required no spur, became discouraged and apathetic. The lazy operator could easily take refuge in such practices as falsifying records, selecting only the smallest cavities for attention, polishing old fillings to make them appear new, and generally doing slipshod work.

The Dental Division wanted to handle the question of quota dentistry with as little publicity as possible and no specific prohibition against it was ever published, but repeated statements of policy in respect to "quality versus quantity" could have left no doubt of its official position. The War Service Committee of the American Dental Association reported in November 1944 that:103

    It was called to the attention of the committee that, in some Army (and Navy) installations, certain dental officers were required to perform services under a "speed-up" system. These complaints were presented to officials of the armed services in Washington, who stated that they would be thoroughly investigated and, if such practices did exist, they would be discontinued. The officials further stated that this was not the policy of the Corps, which was to encourage quality and not quantity dentistry, and that they would cooperate in every way possible.

The Dental Division went further to condemn even the appearance of quota-setting by registering its disapproval of such schemes as that established by the Control Division, Seventh Service Command, under which the "efficiency" of various hospitals was reported, even though no minimum output was prescribed. This Service Command had determined that a dentist should see 1.58 patients an hour. Using this figure as a norm, it rated the relative production of the various hospitals on the basis of the number of patients actually seen. The response of the Dental Division to this plan was clear and to the point. In a memorandum to the Control Division, SGO, on 12 March 1945, it stated that:104

    The principal criterion used in making such an analysis is sittings. A sitting is recorded for every visit to the dental clinic, and with a large turn-over of patients in a hospital it is possible to show a large number of examinations recorded as sittings. Likewise, a post-operative treatment is recorded as a sitting, and an inefficient oral surgeon might have ten (10) post-operative treatments (sittings) when a very competent surgeon could accomplish the same with one POT (sitting). Furthermore, an inefficient dental officer or one who wants to see the total number of sittings high can insert one small filling per appointment (15-20 minutes), when the more efficient operator, who is vitally interested in the patient and the service, would place several fillings which would require an hour or more. Then too, the operator who places a

    103Report of the War Service Committee. J. Am. Dent. A. 15 Nov 44, p. 1551.
    104Memo, Maj Gen Robert H. Mills for Control Div, SGO, 12 Mar 45, sub: Efficiency of work measurement reports of dental service, general hospitals. SG 703.-1.

 


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    superior filling, produces a superior denture, or who is more considerate of his patient in oral surgery, will require more time with resultant less fillings than the careless, fast, inconsiderate operator.

    A method which attempts to evaluate the efficiency of a dental service on sittings is decidedly unfair and impractical. Such a method places a premium on poor work, injudicious consideration of the patient and the service, and will terminate in an inferior quality of dental service. This method, or any method where mathematical figures are employed, leads to false impressions, and the true values cannot be analyzed. Anyone can pile up an impressive figure in sittings, but it is an inaccurate, incomplete, and dangerous criterion to use in determining the efficiency of work measurement. . . .

    The Army Dental Corps has been stigmatized wrongly and criticized editorially as being interested only in, and sponsoring, quantity. This office has continually empha- sized quality with a full measure of service and duty hours, but never quantity at the expense of quality. Efficiency reports such as those instituted by the Seventh Service Command . . . can only lead to an inferior service and an inadequate evaluation of the dental service.

    Recommend that suitable steps be taken to eliminate such unwarranted ratings which deal with mathematical evaluation of the dental service.

Whenever the quota system was reported in operation at any installation, the Dental Division took prompt and vigorous action, usually in the form of a personal letter from the Director, so that the practice was gradually and quietly, but effectively, eliminated.105

DENTAL REHABILITATION OF SELECTIVE SERVICE
REGISTRANTS BEFORE INDUCTION

World War I

In the First World War, the Preparedness League of American Dentists, operating under the auspices of the National Dental Association, proposed a plan for completing as much dental work as possible for draftees before they were called for active, duty. Members of the League pledged themselves to assist in the program on a voluntary basis, without cost to the Government or to the individual, and The Surgeon General and The Provost Marshal General authorized the local boards to refer registrants needing care to the cooperating dentists. By 30 June 1918, 375,000 operations had been carried out by league members106 and a total of nearly 1,000,000 operations were performed by 1,700 civilian dentists during the entire war.107

World War II

During World War II no plan similar to that of the Preparedness League of American Dentists was attempted. In the first place, the Army Dental Corps

    105Statement of Maj Gen Robert H. Mills (Ret) to author, 8 Sep 47.
    106Annual Report . . . Surgeon General, 1918. Washington, Government Printing Office, 1918, p. 413.
    107The Medical Department . . . in the World War. Washington, Government Printing Office, 1923, vol I, p. 193.

 


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was much better prepared to assume the burden in 1941. Also, it seems to have been the general opinion of all concerned that the dental rehabilitation of military personnel was a responsibility of the entire nation and was too big a problem to be delegated to any limited group. From the start of the war, however, the American Dental Association offered to cooperate in any matter affecting the dental health of inductees.

In February 1941 Selective Service announced that a Dental Advisory Committee of prominent members of the, profession had been appointed "to guide us in all matters pertaining to dentistry."108 With the assistance of this Committee a tentative plan for the "prehabilitation" of registrants was proposed in July 1941.109 Initially this plan was very limited in scope, and was designed to accomplish little more than to acquaint dentists with the, requirements for military service and encourage them to give special attention to the care of men of military age. Responsibility for obtaining and paying for dental treatment remained with the Selective Service registrant.

On 2 July 1941 a more elaborate program was proposed by the Commission on Physical Rehabilitation, a subcommittee of the Health and Medical Com mittee of the Federal Security Agency. The principal provisions of this plan were as follows:110

1. Congress to appropriate sufficient funds to defray the cost of treatment for men not able or willing to obtain care at their own expense.

2. State and local rehabilitation committees to be formed under the joint auspices of the Federal Security Agency and the Selective Service System. These committees would administer the program in their areas, determine how payment for treatment would be made, and designate the facilities which would render dental care. Private dentists, semipublic clinics or hospitals, or any combination of dental facilities might be utilized.

3. Local Selective Service boards to indicate on examination records whether or not disqualifying defects found were correctable, the registrant to be directed to his own dentist or to a designated agency for treatment. The board would also set a time-limit within which treatment would have to be completed.

The Commission on Physical Rehabilitation recognized that:

Only a small percentage of the population can afford to pay or will be willing to pay for corrective measures which may make them available for military or industrial service, but which do not as yet interfere with their present civilian occupations... Because of widespread shifting of population during and after the National Emergency, the responsibility is national as well as local. In order to meet the situation realistically it is recommended that Congress enact legislation to defray the cost... Without federal legislation of this nature, it can be predicted that little progress in voluntary rehabilitation is to be expected.

    108Rowntree, L. G. : Dentistry and Selective Service. J. Am. Dent. A. 28: 636-638, Apr 1941.
    109Plan for the prehabilitation of registrants. J. Am. Dent. A. 28: 1161, Jul 1941.
    110Report of the Commission on Physical Rehabilitation. J. Am. Dent. A. 28: 1362-1364, Aug 1941.

 


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The Commission stated that:

    ... the alternative to such a program is lower physical standards of eligibility for selective service and compulsory physical rehabilitation after induction into the Army. Action is required along the lines of one or the other of these alternatives, for the present standards of physical eligibility have reduced the nation's reservoir of eligible registrants to a number far lower than had been expected.

In August 1941 the President of the American Dental Association urged consideration of the problem of dental rehabilitation in the following discussion: 111

    It is well-known, of course, that many registrants under the, Selective Service and Training Act of 1940 have been rejected for active military service because of dental defects. The large number of such rejections has been a matter of grave concern to officials of the American Dental Association as well as to our military authorities. A good deal of study has been devoted to the development of a practicable plan through which the correction of dental defects, either before or after the registrant has been examined by his local draft board, can be promoted.

    The problem of rehabilitation, in its initial stage, proposed certain questions of a jurisdictional nature in addition to many others. Was a program of rehabilitation to be set up by the Selective Service System or was such a program to be developed by the American Dental Association in consultation with the proper governmental agencies? What types of dental care would be made available under such a program?

    By whom and under what conditions was dental care to be provided for a deficient registrant? Was the financial burden of such a rehabilitation program to be borne by the dentist, the registrant himself, the government or the organized profession?

The President of the American Dental Association went on to state that the National Health Program Committee of that organization had been directed to cooperate with the governmental agencies and that the American Dental Association had officially offered its services to the Coordinator of Health, Welfare, and Related Activities in the National Defense Program, to The Surgeon General of the United States Public Health Service, and to the Director of the Selective Service System.

On 3 August 1941 the President of the American Dental Association called a joint meeting of the board of trustees and members of the committees on Dental Preparedness, Legislation, and the National Health Program. After an all-day session this group made the following recommendations:112

1. It was believed that dental rehabilitation would be most effectively accomplished by inducting deficient registrants into the Armed Forces under lowered physical standards, necessary treatment to be rendered subsequent to induction by dental officers of the respective services.

2. If a "prehabilitation" program was considered necessary by Selective Service, consideration should be given to a plan Similar to that proposed by the Commission on Physical Rehabilitation. If the latter program were

    111Robinson, W. H. : President's Page. J. Am. Dent. A. 28: 1332-1333, Aug 1941.
    112Program for rehabilitation of registrants rejected for dental defects under the Selective Service Act. J. Am. Dent. A. 28: 1518-1519, Sep 1941.

 


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adopted, however, it was recommended that the state rehabilitation committees contemplated in the proposed plan should be headed by the ranking dental officer in the state government as executive officer and that they should include representatives of the appropriate state agencies, the organized dental profession, and such other groups and agencies as were deemed necessary. The American Dental Association also recommended that the majority of the mem-bers of these committees should be dentists nominated by the organized dental profession. Local committees would be organized along similar lines under the jurisdiction of the state committees. Standards of fees, methods of payment, and the designation of the agencies to render treatment would be largely the responsibility of the local committees.

On 9 October 1941, the President told a conference of the Secretary of War, the Chief of Staff , and Selective, Service officials, that he desired action to effect the rehabilitation of an estimated 100,000 men with correctable dental defects out of a total of 188,000 rejected.113 The following day the, President announced a, program to "salvage" 200,000 men out of 1,000,000 rejected for all causes. He stated that treatment would be made available by the registrant's own dentist or physician, with the cost borne by the Government through funds made available to Selective Service.114 The President also stated that it was believed that care could be provided by local medical personnel at less cost than by the Armed Forces.

In February 1942 the Selective Service System inaugurated a test rehabili-tation program in the states of Maryland and Virginia. From February to September about 300 men received medical care, but reports from the pilot test headquarters did not distinguish between medical and dental cases, so the number of inductees who had dental defects corrected is not known.115 Average time required for dental cases was 38.5 days.116 Reports on the cost are conflicting; one official placed the average expense at $54.19,117 another at $78.00.118

The reasons why this test Was considered a failure are not clear, but as early as June 1942 General Lewis B. Hershey, Director of the, Selective Service System, told the annual meeting of the American Medical Association that "results of the pilot test did not justify the current adoption of a rehabilitation program on a nation-wide basis. . . ."119 In July 1944 a representative of Selective Service told a Senate Subcommittee on Wartime Health and Education that:

    It appears that dental rehabilitation by the armed forces during the basic training period of personnel offered a more logical method than the slower method contemplated

    113Wells, C. R.: Role of dentistry in the war effort. J. Am. Dent. A. 29: 835-841, May 1942.
    114Plans for rehabilitation of rejected draftees. J. Am. Dent. A. 28: 1884-1885, Nov 1941.
    115Ltr, Brig Gen Carlton S. Dargusch to Brig Gen Thomas L. Smith, 5 Dec 46. SG: 702.
    116Hearings before a subcommittee of the Committee on Education and Labor, United States Senate, Seventy-eighth Congress. Washington, Government Printing Office, 1944, pt. 5.
    117Ibid.
    118See footnote 115, above.
    119Ibid.

 


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    in the offices of civilian dentists, particularly since the ranks of civilian dentists were becoming rapidly depleted due to the demand for thousands of dentists by the Armed Forces and the lowering of dental standards made more men available for military service without prior dental rehabilitation.120

The Senate Subcommittee itself found that:

    Early in the war, test rehabilitation programs were undertaken by the Selective Service System, but yielded meager results and were abandoned. In sharp contrast to the results of the Selective Service efforts are those of the Army rehabilitation program. Here remarkable success has been achieved. Approximately one and one-half million men with major defects have been inducted and rendered fit for duty, including 1,000,000 men with major dental defects.121

It has been hinted, but not specifically stated, that the civilian prehabilitation program was unsatisfactory because:

1. Selective Service was too deeply involved in other matters to be able to devote the time and effort necessary.122

2. The time required for treatment in busy civilian offices Was too long.123

3. Civilian dentists were already working at top capacity and could not accept new patients without neglecting essential civilian need.124

In any event, it seems clear that if the Armed Form take approximately one-third of the dentists in the country, the remaining dentists will be too busy to assume responsibility for preinduction care of Selective Service registrants.

The poor results attained in the Selective Service test program discouraged further efforts to promote large-scale dental rehabilitation by civilian agencies. The American Dental Association, which had from the first favored rehabilitation by the Army, continued to sponsor a "Victory" program to encourage high school students to maintain dental health on a voluntary basis, but the care of inductees became the sole responsibility of the Armed Forces.

DENTAL CRITERIA FOR OVERSEAS SERVICE

The Dental Service of World War II was organized to provide approximately twice as many dental officers per capita in the United States as were allotted to overseas theaters. This ratio was justified by the obvious fact that it would be more satisfactory to carry on dental rehabilitation during training rather than after the soldier had assumed his military duties in the field. The basic authorization of 1 dentist for each 1,200 men in tactical units was expected to provide only routine maintenance care of troops who were in good dental condition when received into the organization. Un-

    120See footnote 116, p. 228.
    121Report of Senate Committee on Wartime Health and Education. J. Am. Dent. A. 32: 270-284, 1 Mar 45.
    122See footnote 116, p. 228.
    123See footnote 116, p. 228.
    124Ibid.

 


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fortunately, shortages of personnel, equipment, and lack of a definite dental standard for foreign service led to the shipment overseas during 1942 and 1943 of large numbers of men with serious dental defects. The reports of almost all theaters during this period note that their dental facilities were unable to cope with the unexpected demand. The Southwest Pacific Area, for instance, found that up to 80 percent of the men arriving in Australia early in the war needed some form of dental treatment.125 The Director of Training, ASF, stated as late as May 1943 that men were still leaving replacement training centers and replacement depots for subsequent shipment overseas prior to the completion of apparently necessary dental work."126

On 20 June 1942 the War Department directed that all enlisted men designated for combat units overseas must meet physical standards prescribed in MR 1-9, though limited service categories could be sent to overseas hospitals and other Zone of lnterior-type installations.127 However, this publication was rescinded in November of the same year.128 In October of 1942 it was provided that nonprogressive dental defects would not bar shipment of officers overseas, implying, though not stating specifically, that other serious dental defects would prevent transfer to a foreign theater.129 Neither of these directives was sufficiently explicit in respect to dental deficiencies.

On 26 March 1943 War Department Circular No. 85 provided that "all replacements so ordered [overseas] will be mentally and physically qualified for service in an overseas combat theater"; limited service categories were not to be shipped outside the continental United States.130 A subsequent War Department circular stated that officers were still arriving for overseas shipment with Class I dental conditions and that the provisions of the previous circular were not being complied with, so it would appear that Circular No. 85 was intended to prevent shipment of Class I dental cases overseas. Its very general terms were not always so interpreted, however, and about a month after it was published the Commanding General, AGF, notified the Assistant Chief of Staff G-1 that great difficulty was being experienced because of differences of opinion as to what constituted "dental fitness." He recommended that "definite standards of dental requirements relative to overseas eligibility be established."131 This recommendation was forwarded to The Surgeon General for comment, and on advice of the Dental Division, The Surgeon General suggested that:

    125See footnote 34, p. 206.
    126Memo, Brig Gen Walter L. Weible for Brig Gen Robert H. Mills, 13 May 43. SG : 703.
    127WD Cir 198, 20 Jun 42.
    128WD Cir 363, 4 Nov 42.
    129WD Cir 349, 19 Oct 42.
    130WD Cir 85, 26 Mar 43.
    131Memo, Maj Theodore R. Pitts, Asst Ground Adj Gen, AGF, for ACofs, G-1, 24 Apr 43, sub: Eligibility of enlisted men as overseas replacements. SG: 702.-1.

 


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... the following should be accomplished for military personnel prior to departure for staging areas and ports of embarkation for service overseas: "Dental correction of all Class I cases to include those with 'insufficient teeth to masticate the Army ration' as outlined in Change 1, dated September 10, 1942, of AR 40-510 and so far as practical correction of Class II cases."132

On 13 May 1943 the Director of Military Personnel, ASF, recommended to the Assistant Chief of Staff G-1 that approximately the same provisions be published as a change to War Department Circular No. 85.133 This request was disapproved on technical grounds as it was desired to keep War Department Circular No. 85 couched in general terms, with specific requirements on any individual point to be published separately.134 Definite requirements for dental health of personnel ordered overseas were finally established in "Preparations for Overseas Movement," in August 1943, as follows:135

    All necessary dental treatment, from a health and functional standpoint, will be provided troops prior to their departure from home station. The following policy will govern dental qualifications for overseas service: dental correction of all Class I cases as outlined in AR 40-510, including Change 1 and, as far as practicable, correction of Class II cases.

The same provisions were essentially repeated in War Department Circular No. 189, published 21 August 1943.136 These directives remained in effect during the remainder of the war, though a slight modification was made in June 1945 when the suspicion that some men were intentionally destroying their dental appliances to delay shipment caused the War Department to direct that soldiers requiring dentures were not to be withheld from shipments if they had been able to perform their military duties previously and if their history indicated that replacement was not absolutely essential.137

It will be noted that the published standard did not make, mandatory the completion of all dental treatment. In fact, the Director of the Dental Division stated in September 1943 that it was physically impossible to complete all work prior to shipment.138 Routine care of nonemergeney conditions was to be rendered whenever possible, but a man was not to be kept from shipment overseas for such treatment.

The order directing that essential dental care would be rendered before departure for a combat area was aimed more directly at commanding officers than at dentists. Prior to its publication, unit commanders had been extremely reluctant to release men from training schedules for dental appointments; now

    1321st ind, SG, 5 May 43, on memo cited in footnote 131.
    133Memo, Brig Gen Russel B. Reynolds, Dir, Mil Pers Div, SOS, for ACofS, G-1, 13 May 43, sub: Eligibility of enlisted men as overseas replacements. SG: 702.-1.
    134Memo, R. W. Berry, Exec Off, ACofS, G-1, for TAG, 17 May 43, sub: Eligibility of enlisted men for overseas service. SG: 702-1.
    135See footnote 33, p. 206.
    136WD Cir 189, 21 Aug 43.
    137WD Cir 196, 30 Jun 45.
    138Memo, Maj Gen Robert H. Mills for Brig Gen W. L. Weible, 8 Sep 43. [D]

 


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they knew that they would lose the men anyway if the latter did not meet required standards when the unit went overseas, and they vigorously supported the dental surgeon's efforts to provide urgent treatment.

As a result of improvements in dental facilities, and the establishment of definite standards for foreign service, men received as replacements overseas after 1943 were in much better dental condition than those who preceded them. The change was so marked, in fact, that the Southwest Pacific Area, which had claimed that 80 percent of new troops needed dental care, now reported that 85 percent were in Class IV on arrival.139 In general the shipment of men in poor dental condition ceased to be a serious problem in the latter part of 1943.

USE OF CIVILIAN DENTISTS

The amount of dental care rendered military personnel by civilian dentists during World War II was not important in spite of the fact that such attend-ance had been authorized, in an emergency, for many years. In October 1925, AR 40-510 provided that when no dental officer was available, emergency civilian dental treatment could be obtained by military personnel on a duty status at Government expense and without prior authority. Routine dental care could be provided with the prior authorization of The Surgeon General.140 Military personnel on duty overseas without troops could procure civilian dental attendance without prior authority, subject to later approval by The Surgeon General. In July 1942, it was further authorized that personnel on leave or furlough could procure emergency dental care at Government expense.141

The cited regulations were not interpreted to authorize civilian dental treatment as a routine procedure when Army facilities were inadequate due to shortages of equipment or personnel, though such an interpretation was possible and it was actually the basis for the use of civilian dental laboratories on a large scale at one stage of the war.

EXCESSIVE LOSS OR DESTRUCTION OF DENTURES

The careless loss or intentional destruction of dentures was an annoying problem throughout the war. Varying circumstances led to this waste of effort and materials. In many cases dentures were lost through simple failure to observe normal precautions in caring for a fragile and expensive appliance. The soldier who daily saw millions of dollars worth of property destroyed was not likely to be impressed with his responsibility for such a small item as a denture. In time of stress the denture often went into a hip pocket, where it suffered irreparable damage when its owner rode in a truck or hit a fox-

    139See footnote 34, p. 206.
    140AR 40-510, 10 Oct 25.
    141See footnote 31, p. 205.

 


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hole. Some were lost because soldiers neglected to remove them when they became nauseated on a sea-crossing. Also, since the appliance cost the soldier nothing, he was likely to be very impatient of defects. It was reported that in some cases men discarded dentures if a single tooth was broken because they knew that a new one would be forthcoming without delay.142 It has also been stated that partial dentures containing gold were occasionally sold in France, where they brought a good price.143

Even more serious in its effect on morale was the intentional destruction of dental appliances to avoid dangerous duty or to delay departure for an overseas theater. The Commanding General of the Army Ground Forces stated in April 1943:

    Although it is not possible to obtain positive evidence in any considerable number of cases, this headquarters has observed indications that individual enlisted men in proper dental condition upon departure from Replacement Training Centers have destroyed their dental fittings and rendered themselves unsuitable for overseas shipment, with a view to shirking hazardous duty.144

The North African theater reported in January 1944:

    It is impossible to say that men break or lose their dentures intentionally, but the incidence of this type of accident is so high that the suspicion seems warranted.145

The Seventh Army, in the Mediterranean area, noted that:

Accurate figures were not available as to the deliberate loss or breakage of dentures in order to be evacuated from combat, but it was believed that the rate was highest just before and during amphibious operations.146

One step recommended to give dental surgeons information on past prosthetic treatment was to record dental appliances in individual service records.147 The Dental Division did not concur in this plan since it was believed that even with a clear record that a denture had existed, it would be impossible to prove intent in case of loss or destruction.148 The further course of this recommendation is not certain, but a War Department directive of 1 August 1943 provided that dentures would be listed in the service records of enlisted men going overseas.149 In October 1943 it was further provided that prosthetic appliances of officers be listed in the Immunization Register.150 In January 1945 the War

    142The fact that soldiers discarded dentures on slight provocation was reported by the 5th Auxiliary Surgical Group in Europe. This report was seen by the author in 1946 but it was subsequently lost or misplaced. The situation noted has since been confirmed, however, in conversations between the author and numerous senior dental surgeons.
    143Information from Maj Gen Thomas L. Smith who was dental surgeon in Europe during the war.
    144See footnote 142, above.
    145Essential Technical Medical Data Report, Headquarters, North African Theater, 27 Jan 1944. HD: 350.05.
    146Seventh Army Section, supp. to the Dental History, MTO. HD: 314.7-2.
    147Ltr, Dental Surg, Sta Hosp, Ft. McDowell, Calif, to TAG, 19 Mar 43, sub: Entry in service record. SG: 703.
    1481st ind, Col McDowell, 14 Apr 43, on footnote 147.
    149See footnote 33, p. 206.
    150Preparation for overseas movement, 1 Oct 43.

 


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Department finally directed that a record of all prosthetic appliances be entered in the individual's Immunization Register.151

Late in 1943 the question of charging military personnel for dental appliances lost through carelessness or intent was brought up by the Army Ground Forces Replacement Depot No. 1, at Fort George G. Meade, Md. This station reported that men who had been given replacements were arriving without them and stated its intention to enter a statement of charges in such cases.152 At about the same time the Army Service Forces Replacement Depot at Camp Reynolds, Pa., reported that in a recent shipment to that station 18 men were found not to meet dental requirements for overseas duty. Investigation showed that 9 of these men had been supplied dentures within the past 3 months. One had been given his replacement only a few days before. None had any reasonable excuse for the shortage. This station therefore recommended that dentures be entered on the individual soldier's record of personal equipment and that a charge be made in case of negligent loss.153 On the basis of these recommendations the Commanding General, Army Ground Forces, asked The Adjutant General for an opinion as to the legality of making a charge for dentures and spectacles lost through carelessness. Noting that "There have been cases where it is apparent that enlisted men have willfully destroyed or wrongfully disposed of dentures and spectacles in order to forestall their shipment overseas" and that "such acts are highly prejudicial to good order and military discipline" AGF recommended that "in the event that soldiers cannot be penalized under present regulations for loss or destruction of the subject items . . . regulations be changed so that punitive action may be sustained, at least to the extent of requiring enlisted men to pay for such losses."154 The Adjutant General referred the matter to The Surgeon General for comment and the latter stated that in the opinion of his Legal Division dentures and spectacles became the personal property of the soldier and that there was no basis for a charge even if the man deliberately destroyed the appliances. He stated further that his Office would be opposed to establishing property accountability for dentures since it was believed that the procedures involved would be too cumbersome to justify the effort. The Surgeon General recommended, as an alternative, that court martial action be taken to punish offenders.155 The Adjutant General concurred in the recommendations of The Surgeon General and notified the Commanding General, AGF, that men could not be charged for destroyed dental appliances.156 In March 1944 a Bulletin

    151WD Cir 32, 27 Jan 45.
    152Ltr, CG, AGF Replacement Depot No 1, Ft. George G. Meade, Md, to CG, AGF, 5 Nov 43, sub: Replacement of dentures and spectacles. SG: 413.75-2 (Ft. George G. Meade).
    153Ltr, Hq, ASF Replacement Depot, Camp Reynolds, Pa, to TAG, 12 Nov 43, sub: Issue of dentures and corrective appliances to replacements. SG: 220.31-1 (Camp Reynolds).
    154lst Ind. CG, AGF, 2 Dec 43, on ltr cited in footnote 152, above.
    155Ltr, Chief, Oprs Br, SGO, to Enlisted Br, AGO, 15 Jan 44, sub: Replacement of dentures and spectacles. SG: 413.75-2 (Ft. George G. Meade).
    1562d ind, TAG, 22 Feb 44, on ltr cited in footnote 152, above.

 


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of The Judge Advocate General's Office confirmed the opinion of the Legal Division, SGO, that military personnel could not be charged for dental appliances under existing regulations.157

As a result of the above opinions no further attempt was made to penalize soldiers for the loss or destruction of dental appliances. It was true that a man could be tried for such action, but the burden of proof was on the prosecution and the very nature of the offense was such that no matter how strong the presumptive evidence it was practically impossible to prove intent to the degree required for conviction before a court martial.

The chief of the Operations Service, SGO, suggested in 1944 that port medical officers should hold as few men as possible for the replacement of dentures;158 and a War Department circular of June 1945 provided that Class I dental patients who needed only replacement of missing teeth would not be held back when they had previously performed their military duties satisfactorily and if their history indicated that restoration was not necessary.159 In May 1944 it was directed that all dentures would carry the names and serial numbers of their owners, partly to assist in the return of lost appliances and partly to aid in identification of the patient in case of accident.160 All of these measures did not greatly deter the few men who were inclined to use any means to avoid shipment overseas, or any other dangerous assignment, from "losing" or destroying their dentures.

It would appear that a practical solution to this problem would be to enter dental appliances on the list of articles for which the soldier is responsible, to be paid for if lost through negligence. Under such circumstances, a commanding officer could collect the cost of a denture through a simple administrative action. No charge would have to be made if negligence were not involved, but the soldier would have the same responsibility for a dental appliance as for any other valuable piece of equipment issued for his use.161

ROLE OF THE DENTAL SERVICE IN THE DEVELOPMENT
OF THE ACRYLIC RESIN ARTIFICIAL EYE

In the latter part of 1943 the Army was faced with a critical shortage of satisfactory artificial eyes. Replacements were needed for the casualties which were arriving from the battle zones and physical requirements had been lowered to permit the induction of men with only one eye. At the same time, the normal supply of glass eyes from Europe had been cut off. Ordinary glass eyes had many disadvantages for military use. They were extremely fragile and even

    157Bulletin of the Judge Advocate General of the Army, 1944-45. Washington, Government Printing Office, 1944, vol. 3-4, p. 126.
    158See footnote 155, p. 234.
    159See footnote 137, p. 231.
    160TB Med 44, May 1944.
    161Brig Gen Thomas L. Smith, Chief of the Dental Consultants Division, in 1947, in a statement to the author said that he favored some system for property accountability for dental appliances.

 


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small factors like sudden changes in temperature might result in breakage; they became etched in the fluids of the socket so that they required frequent replacement; custom-fitted eyes for difficult conditions required as much as 2 months for construction and some men lost up to 8 months' duty in a single year while getting successive eye replacements; stocks of as many as a hundred thousand eyes were required for the proper fitting of only a thousand patients.162 As a result of this situation which was almost as serious for the civilian population as for the military, several agencies undertook investigations to develop an artificial eye which would readily be available and which would be superior to the glass eye in common use.

A clear synthetic resin (methyl methacrylate) had been in use for some years for the construction of artificial dentures. It was strong, well tolerated by human tissues, and easy to form into irregular shapes. It is not surprising, therefore, that the idea of using this material for ocular prostheses suggested itself to several persons at approximately the same time.163 As early as 1941 the pink acrylic resin used in denture work was made up into temporary eyes to maintain socket form until a permanent appliance could be placed.164

Captain Stanley F. Erpf, DC, on duty with the 30th General Hospital in England, was probably the first Army officer to produce a satisfactory acrylic eye; Captain Erpf 's own statement of his work is as follows:165

May 1943 to December 1943. Initial research begun. Forty prostheses constructed for patients of the 30th General Hospital. December 1943. Research report and training manual written and submitted to the Office of the Chief Surgeon, ETOUSA. January 1944 to May 1944. Training program conducted at the 30th General Hospital for 40 U.S. Army and 10 British Army dental officers.
June 1944. Training center at 30th General Hospital terminated and Capt. Erpf en route to the United States to aid in setting up center at Valley Forge General Hospital in the United States.
July 1944 to December 1944. Research and training program conducted at Valley Forge General Hospital in collaboration with Major Victor Dietz and Major Milton Wirtz, who had also been working independently on development of the acrylic prosthesis.

At approximately the same time that Captain Erpf was doing his work in England, Major Victor H. Dietz and Major Milton S. Wirtz were experiment-ing along similar lines at Thomas M. England General Hospital, Atlantic City, N.J., and at Camp Crowder, Mo.166 It appears that these two officers of the Dental Corps produced acrylic eyes for patients somewhat later than Captain

    162Randolph, M. E. : History of the artificial eye program (glass and plastic), 2 Jan 46. HD: 314.7-2.
    163At least three Army Dental Corps officers and an unknown number of Naval officers and civilian investigators apparently worked independently along similar lines.
    164Holmes, A. G. : Use of acrylic resins in the construction of temporary artificial eyes. Dental Bulletin, supp. to Army Medical Bulletin 12: 265-266, Oct 1941.
    165Personal letter from Dr. Stanley F. Erpf to the author, 9 Oct 46. HD: 422.2.
    166Erpf, S. F., et al.: Prosthesis of the eye in acrylic resin. Army Medical Bulletin 4: 76-86, Jul 1945.

 


237

Erpf, but determination of this point must await decision by the United States Patent Office. In any event, each worked on his own initiative and each was awarded the Legion of Merit for his contribution. In July 1944 both officers joined Captain Erpf in developing a standard technique.

The acrylic eye proved so superior in every respect that it was eventually adopted as the exclusive type of replacement by the Army. In October 1944 it was announced that 12 Eye Centers would accept patients for acrylic eyes, though glass eyes were still furnished on request.167 By August 1945, 29 general hospitals and 1 regional hospital were rendering this service.168 The exact number of acrylic eyes constructed is not known, though 7,500 appliances had been made in the United States alone by October 1945.169 170 Captain Erpf estimated that about 10,000 eyes were made in the first 18 months of the program.171 The Army technique was adopted by the Veterans Administration when it took over responsibility for the continued care of former soldiers. The part played by dental officers in developing and staffing the artificial eye program reflected great credit on the Dental Corps and the Medical Department.172

ROLE OF THE DENTAL SERVICE IN THE DEVELOPMENT
OF THE ACRYLIC HEARING-AID ADAPTER

For a decade or more before the war it had been known that the efficiency of hearing-aids depended to an important extent on the accuracy with which the receiver was adapted to the external auditory canal. An ear mold custom-fitted to the individual case eliminated outside noise, prevented "feedback" to the receiver, and channeled sound waves directly to the tympanum without loss of intensity. At the start of the war, ear molds were being constructed by civilian laboratories from individual impressions of the canal, but this system was not altogether satisfactory for the following reasons:173

1. Patients had to be held in the hospital while time was lost in mailing work to commercial laboratories.

2. Impressions were subject to distortion or breakage in the mail.

3. Commercial laboratories could not take chances on their ear molds impinging on the tympanum so they habitually shortened the mold to a degree which sometimes resulted in loss of efficiency.

    167WD Cir 398, 11 Oct 44.
    168SG News Notes 26, 15 Aug 45.
    169Erpf, S. F., et al.: Plastic-artificial-eye-program, U. S. Army. Am. J. Ophth. 29: 984-992, Aug 1946.
    170The Army technique was adopted by the Veterans Administration when it took over responsibility for the continued care of former soldiers. SG News Notes, 15 Jan 47. HD: 000.71.
    171See footnote 165, p. 236.
    172The subject of the chronological development of the acrylic eye is not considered in detail in this discussion because it is believed that only the U.S. Patent Office can evaluate claims of the military and civilian personnel involved.
    173McCracken, G. A. : Construction of ear molds for hearing-aid appliances. HD: 314.7-2.

 


238

Late in 1943 the Chief of the Aural Rehabilitation Service and Col. Gerald A. McCracken, Chief of the Dental Service at Deshon General Hospital, Butler, Pa., consulted on the possibility of constructing ear molds in a. laboratory established in the hospital itself. The project appeared practical and it was presented to the Dental Division and The Surgeon General for approval. The Surgeon General not only concurred in the plan but also directed that laboratories be established at Borden General, Hospital (Chickasha, Okla.) and Hoff General Hospital (Santa Barbara, Calif.).174 The laboratories were supervised and operated by dental personnel because of their experience in taking impressions and handling plastics. Improvements were made in the techniques commonly used by the commercial laboratories and the work produced was eminently satisfactory. While it is not yet known how many ear molds were fabricated, it was reported that Deshon General Hospital alone employed 6 technicians on 2 shifts to turn out from 250 to 350 cases a month while the plan was at peak operation.175

ROLE OF THE DENTAL SERVICE IN THE FABRICATION
OF TANTALUM PLATES FOR THE REPAIR, OF SKULL DEFECTS

Tantalum plates for the repair of skull defects were first used in the Army in September 1942. They were found to be strong and well-tolerated, but the fabrication of a plate with irregular outline and contour offered considerable difficulty. Lt. Col. Arthur J. Hemberger, of the Dental Service at Walter Reed General Hospital, suggested that dental procedures might be applicable to the problem and thereafter dental officers were given the responsibility for taking impressions of cases before operation and forming appliances which could he adapted with a minimum of alteration at the time of repair. Impressions were first made of the area involved. A model was then poured and built up to the desired contour. From this model dies were formed which were used to mold the sheet of tantalum under high pressure. The plate was then trimmed to the desired outline on the model and was ready for insertion after cleaning and sterilization.

This technique was described to Army neurosurgeons at the annual meeting at Walter Reed General Hospital in 1943. Motion pictures of the process were distributed throughout the Army and Navy and the method was reported in the Journal of Neurosurgery in 1945.176 177

    174Ibid.
    175Ibid.
    176Hemberger, A. J. : The fabrication of tantalum plates for the repair of skull defects. HD 314.7-2.
    177Hemberger, A. J. ; Whitcomb, B. B. ; and Woodhall, B.: The technique of tantalum plating of skull defects. J. Neurosurg. 2: 21-25, Jan 1945.

 


239

INCIDENCE OF THE PRINCIPAL DENTAL DISEASES AND
THE AMOUNT OF TREATMENT RENDERED

Tables 4 through 6 show the incidence of some of the more important dental diseases during the period 1 January 1942 through 31 August 1945. Tables 7 through 14 show the more significant treatments rendered in the same period. (In some instances, reports on the incidence of dental diseases, and the amount of treatment rendered, contained no breakdown for military and "other" personnel; however, the number of "others" treated was generally so small that the rates for military personnel were not greatly affected.) The incidence of five important dental diagnoses are shown graphically in Charts 2 through 6. Considerable confusion has existed in the dental profession concerning the diagnosis of Vincent's infection. It is probable that the rates reported for this disease were excessive and included many cases which should properly have been listed as "gingivitis." The statistics shown for Vincent's stomatitis are probably no more nor less accurate than those which would have been obtained from a similar group of civilian dentists.

CHART 2. INCIDENCE* OF CELLULITIS OF DENTAL ORIGIN IN THE UNITED STATES ARMY, 1938-1945.

*Includes new cases, readmissions, and both in- and out-patients.

Source: Bar graphs (1938-40), prepared from statistical data obtained from Annual Reports of The Surgeon General, U. S. Army, 1938-41. Washington, Government Printing Office, 1938-41. Other graphic presentation, including bar graph for 1941, prepared by the author from reports received in the Dental Division, SGO.

 


240

CHART 3. INCIDENCE* OF FRACTURED MANDIBLES IN THE UNITED STATES ARMY, 1938-1945.

*Includes new cases, readmissions, and both in- and out-patients.

Source: Bar graphs (1938-40), prepared from statistical data obtained from Annual Reports of The Surgeon General, U. S. Army, 1938-41. Washington, Government Printing Office, 1938-41. Other graphic presentation, including bar graph for 1941, prepared by the author from reports received in the Dental Division, SGO.

 


241

CHART 4. INCIDENCE* OF FRACTURED MAXILLAE IN THE UNITED STATES ARMY, 1938-1945.

*Includes new cases, readmissions, and both in- and out-patients.

Source : Bar graphs (1938-40), prepared from statistical data obtained from Annual Reports of The Surgeon General, U. S. Army, 1938-41. Washington, Government Printing Office, 1938-41. Other graphic presentation, including bar graph for 1941, prepared by the author from reports received in the Dental Division, SGO.

 


242

CHART 5. INCIDENCE* OF OSTEOMYELITIS OF ORAL STRUCTURES IN THE UNITED STATES ARMY, 1938-1945.

*Includes new cases, readmissions, and both in- and out-patients.

Source: Bar graphs (1938-40), prepared from statistical data obtained from Annual Reports of The Surgeon General, U. S. Army, 1938-41. Washington, Government Printing Office, 1938-41. Other graphic presentation, Including bar graph for 1941, prepared by the author from reports received in the Dental Division, SGO.

 


243

CHART 6. INCIDENCE* OF VINCENT'S STOMATITIS IN THE UNITED STATES ARMY, 1938-1945.

*Includes new cases, readmissions, and both in- and out-patients.

Source : Bar graphs (1938-40), prepared from statistical data obtained from Annual Reports of The Surgeon General, U. S. Army, 1938-41. Washington, Government Printing Office, 1938-41. Other graphic presentation, including bar graph for 1941, prepared by the author from reports received in the Dental Division, SGO.

 


244

TABLE 4. INCIDENCE1 OF CELLULITIS OF DENTAL ORIGIN, UNITED STATES ARMY, AND
OTHER PERSONNEL,1 JANUARY 1942-31 AUGUST 1945

Area

Army2

Others3

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

441,320

1.7

43,643

United States

426,080

1.9

41,865

Overseas

415,240

1.6

41,778

1942

Total

7,416

2.1

147

United States

6,949

2.5

147

Overseas

467

0.7

---------

1943

Total

413,647

2.0

(4)

United States

410,595

2.1

(4)

Overseas

43,052

1.8

(4)

1944

Total

12,561

1.6

1,236

United States

6,061

1.5

866

Overseas

6,500

1.6

370

19455

Total

7,696

1.4

2,260

United States

2,475

1.2

852

Overseas

5,221

1.4

1,408

    1Includes new cases, readmissions, and both inpatients and outpatients.
    2Except where otherwise indicated, consists of Army personnel and a negligible number of Navy and Allied military personnel.
    3Consists of dependents, civilian employees, prisoners of war, and all other personnel not part of the Allied Armed Forces.
    4During 1943, data for "Other" personnel were not reported separately from "Army" personnel. The statistics shown for "Army" for this year include therefore, data for both "Army" and "Other" personnel.
    5Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


245

TABLE 5. INCIDENCE1 OF VINCENT'S STOMATITIS, UNITED STATES ARMY, AND OTHER
PERSONNEL, 1 JANUARY 1942-31 AUGUST 1945

Area

Army2

Others3

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

4958,940

40

418,203

United States

4657,482

47

46,993

Overseas

4301,458

31

411,210

1942

Total

102,133

30

957

United States

96,519

35

957

Overseas

5,614

9

---------

1943

Total

4277,174

40

(4)

United States

4228,932

45

(4)

Overseas

448,242

28

(4)

1944

Total

327,116

41

3,106

United States

215,183

54

1,813

Overseas

111,933

28

1,293

19455

Total

252,517

46

14,140

United States

116,848

59

4,223

Overseas

135,669

39

9,917

    1Includes new cases, readmissions, and both inpatients and outpatients.
    2Except where otherwise indicated, consists of Army personnel and a negligible number of Navy and Allied military personnel.
    3Consists of dependents, civilian employees, prisoners of war, and all other personnel not part of the Allied Armed Forces.
    4During 1943, data for "Other" personnel were not reported separately from "Army" personnel. The statistics shown for "Army" for this year include therefore, data for both "Army" and "Other" personnel.
    5Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


246

TABLE 6. INCIDENCE1 OF OSTEOMYELITIS OF ORAL STRUCTURES, UNITED STATES ARMY, AND OTHER PERSONNEL, 1 JANUARY 1942-31 AUGUST 1945

Area

Army2

Others3

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

42,136

0.08

4213

United States

41,372

0.09

4121

Overseas

4764

0.08

492

1942

Total

507

0.15

19

United States

458

0.17

19

Overseas

49

0.08

---------

1943

Total

4500

0.07

(4)

United States

4376

0.07

(4)

Overseas

4124

0.08

(4)

1944

Total

689

0.08

113

United States

344

0.08

83

Overseas

345

0.09

30

19455

Total

440

0.08

81

United States

194

0.10

19

Overseas

246

0.07

62

    1Includes new cases, readmissions, and both inpatients and outpatients.
    2Except where otherwise indicated, consists of Army personnel and a negligible number of Navy and Allied military personnel.
    3Consists of dependents, civilian employees, prisoners of war, and all other personnel not part of the Allied Armed Forces.
    4During 1943, data for "Other" personnel were not reported separately from "Army" personnel. The statistics shown for "Army" for this year include therefore, data for both "Army" and "Other" personnel.
    5Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


247

TABLE 7. PERMANENT FILLINGS PLACED BY THE UNITED STATES ARMY DENTAL SERVICE,
1 JANUARY 1942-31 AUGUST 1945

Area

Army1

Others2

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

68,092,479

2,880

1,454,081

United States

55,393,744

4,000

1,266,310

Overseas

12,698,735

1,290

187,771

1942

Total

7,768,357

2,300

91,851

United States

7,122,475

2,580

68,808

Overseas

645,882

1,030

23,043

1943

Total

23,643,902

3,420

176,962

United States

20,898,379

4,060

149,352

Overseas

2,745,523

1,560

27,610

1944

Total

24,426,685

3,080

594,258

United States

19,306,933

4,860

540,333

Overseas

5,119,752

1,290

53,925

19453

Total

12,253,535

2,250

591,010

United States

8,065,957

4,050

507,817

Overseas

4,187,578

1,210

83,193

    1Except where otherwise indicated, consists of Army personnel and a negligible number of Navy and Allied military personnel.
    2Consists of dependents, civilian employees, prisoners of war, and all other personnel not part of the Allied Armed Forces. The great increase in treatment after 1943 largely represents care given prisoners of war.
    3Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


248

TABLE 8. EXTRACTIONS PERFORMED BY THE UNITED STATES ARMY DENTAL SERVICE,
1 JANUARY 1942-31 AUGUST 1945

Area

Army1

Others2

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

15,189,936

643

1,041,328

United States

12,627,293

912

705,900

Overseas

2,562,643

262

335,428

1942

Total

3,246,910

960

53,940

United States

3,030,146

1,099

40,945

Overseas

216,764

347

12,995

1943

Total

6,007,658

870

164,005

United States

5,316,079

1,032

118,612

Overseas

691,579

393

45,393

1944

Total

3,842,788

484

395,105

United States

2,919,953

735

282,813

Overseas

922,835

233

112,292

19453

Total

2,092,580

384

428,278

United States

1,361,115

684

263,530

Overseas

731,465

212

164,748

    1Except where otherwise indicated, consists of Army personnel and a negligible number of Navy and Allied military personnel.
    2Consists of dependents, civilian employees, prisoners of war, and all other personnel not part of the Allied Armed Forces.
    3Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


249

TABLE 9. FULL DENTURES CONSTRUCTED BY THE UNITED STATES ARMY DENTAL SERVICE,
1 JANUARY 1942-31 AUGUST 1945

Area

Army1

Prisoners of War

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

568,669

24

10,359

United States

467,108

34

9,103

Overseas

101,561

10

1,256

1942

Total

41,208

12

-----

United States

39,530

14

-----

Overseas

1,678

3

-----

1943

Total

214,368

31

-----

United States

196,708

38

-----

Overseas

17,660

10

-----

1944

Total

208,263

26

3,023

United States

159,594

40

2,939

Overseas

48,669

12

84

19452

Total

104,830

19

7,336

United States

71,276

36

6,164

Overseas

33,554

10

1,172

    1In addition to Army personnel, consists of dependents, civilian employees, and a negligible number of Navy and Allied military personnel.
    2Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


250

TABLE 10. PARTIAL DENTURES CONSTRUCTED BY THE UNITED STATES ARMY DENTAL SERVICE,
1 JANUARY 1942-31 AUGUST 1945

Area

Army1

Others2

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

1,997,162

85

35,522

United States

1,636,757

118

25,247

Overseas

360,405

36

10,275

1942

Total

115,648

34

1,860

United States

108,072

39

1,691

Overseas

7,576

12

169

1943

Total

638,435

92

1,598

United States

588,951

114

1,137

Overseas

49,484

28

461

1944

Total

819,921

103

18,226

United States

669,750

169

9,985

Overseas

150,171

38

8,241

19453

Total

423,158

78

13,838

United States

269,984

136

12,434

Overseas

153,174

44

1,404

    1Except where otherwise indicated, consists of Army personnel and a negligible number of Navy and Allied military personnel.
    2Consists of dependents, civilian employees, prisoners of war, and all other personnel not part of the Allied Armed Forces.
    3Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


251

TABLE 11. DENTURES REPAIRED BY THE UNITED STATES ARMY DENTAL SERVICE,
1 JANUARY 1942-31 AUGUST 1945

Area

Army1

Others2

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

743,261

31

16,596

United States

464,699

34

10,841

Overseas

278,562

28

5,755

1942

Total

39,507

12

1,020

United States

35,858

13

874

Overseas

3,649

6

146

1943

Total

160,978

23

1,495

United States

125,972

24

750

Overseas

35,006

20

745

1944

Total

316,711

40

4,787

United States

200,058

50

3,255

Overseas

116,653

29

1,532

19453

Total

226,065

41

9,294

United States

102,811

52

5,962

Overseas

123,254

36

3,332

    1Except where otherwise indicated, consists of Army personnel and a negligible number of Navy and Allied military personnel.
    2Consists of dependents, civilian employees, prisoners of war, and all other personnel not part of the Allied Armed Forces.
    3Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


252

TABLE 12. FIXED BRIDGES CONSTRUCTED BY THE UNITED STATES ARMY DENTAL SERVICE,
1 JANUARY 1942-31 AUGUST 1945

Area

Army1

Others2

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

206,484

8.7

1,584

United States

169,980

12.3

1,178

Overseas

36,504

3.7

406

1942

Total

11,110

3.3

175

United States

10,038

3.6

148

Overseas

1,072

1.7

27

1943

Total

39,235

5.7

192

United States

34,549

6.7

139

Overseas

4,686

2.7

53

1944

Total

89,488

11.3

600

United States

74,057

18.7

426

Overseas

15,431

3.9

174

19453

Total

66,651

12.2

617

United States

51,336

25.8

465

Overseas

15,315

4.4

152

    1Except where otherwise indicated, consists of Army personnel and a negligible number of Navy and Allied military personnel.
    2Consists of dependents, civilian employees, prisoners of war, and all other personnel not part of the Allied Armed Forces.
    3Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


253

TABLE 13. TEETH REPLACED BY THE UNITED STATES ARMY DENTAL SERVICE,
1 JANUARY 1942-31 AUGUST 1945
(Based on an estimated 8 teeth replaced per partial denture)

Area

Army1

Prisoners of War

Teeth replaced for Army personnel and others2 per 100 extractions

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

18,306,800

775

309,305

115

United States

15,060,978

1,086

284,195

115

Overseas

3,245,822

332

25,110

113

1942

Total

980,769

290

-----

30

United States

931,293

338

-----

30

Overseas

49,476

79

-----

22

1943

Total

6,466,248

936

-----

105

United States

5,953,376

1,156

-----

110

Overseas

512,872

292

-----

70

1944

Total

7,067,700

891

103,697

169

United States

5,721,652

1,441

101,847

182

Overseas

1,346,048

339

1,850

130

19453

Total

3,792,083

696

205,608

159

United States

2,454,657

1,232

182,348

162

Overseas

1,337,426

387

23,260

152

    1In addition to Army personnel, consists of dependents, civilian employees, and a negligible number of Navy and Allied military personnel.
    2"Others" include prisoners of war, in addition to those listed in footnore 1.
    3Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


254

TABLE 14. DENTAL PROPHYLAXES PERFORMED BY THE UNITED STATES ARMY DENTAL SERVICE
1 JANUARY 1942-31 AUGUST 1945

Area

Army1

Others2

Number

Number per 1,000 mean strength per year

Number

1942-45

Total

8,187,932

346

271,347

United States

5,999,091

433

229,653

Overseas

2,188,841

224

41,694

1942

Total

978,769

290

19,089

United States

880,458

319

14,050

Overseas

98,311

157

5,039

1943

Total

2,301,367

333

31,123

United States

1,865,542

362

24,356

Overseas

435,825

248

6,767

1944

Total

2,995,851

377

88,824

United States

2,109,597

531

77,876

Overseas

886,254

223

10,948

19453

Total

1,911,945

351

132,311

United States

1,143,494

574

113,371

Overseas

768,451

222

18,940

    1Except where otherwise indicated, consists of Army personnel and a negligible number of Navy and Allied military personnel.
    2Consists of dependents, civilian employees, prisoners of war, and all other personnel not part of the Allied Armed Forces.
    3Data are for 1 January-31 August only.

    Source: Compiled by the author from reports received in the Dental Division, SGO.

 


255

DISCHARGES FOR DENTAL DEFECTS

Discharges for physical disability due to dental defects were negligible during the war. Of 956,232 enlisted men separated from the Army for disability from January 1942 through December 1945, only 312 were separated due to pathology of the teeth.178 This figure, however, does not, cover other possible losses due to dental or oral defects since oral structures may have been involved for some of the men reported as separated for other diseases or traumatic injuries.

CASH VALUE OF TREATMENT RENDERED BY DENTAL OFFICERS

Table 15 gives the average number of five of the more important operations completed per dental officer per year in the continental United States, overseas, and in the Army as a whole, for the period 1 January 1942 through 31 August 1945. Under Veterans Administration fee-schedules published in May 1946 the average yearly work of each dentist, for these five items only, would be valued at over $16,000 a year. The value of the other miscellaneous care given cannot be determined with accuracy, but since it constituted numerically more than half of all treatments rendered, an estimate of $4,000 a year would seem conservative, bringing the gross value of the dental officer's yearly work to about $20,000.

    178Separations from the Army for Physical and Mental Reasons, Health of the Army, Vol 1, No. 2, Aug 1946, pp. 20-23.

 


256

TABLE 15. AVERAGE NUMBER OF FIVE PRINCIPAL OPERATIONS COMPLETED PER DENTAL
OFFICER PER YEAR, 1 JANUARY 1942-31 AUGUST 1945

Operation

19421

1943

1944

19452

Total3

Permanent fillings:

Total Army

1,307

1,950

1,678

1,315

1,630

United States

-----

2,058

1,944

1,630

1,898

Overseas

-----

1,392

1,099

948

1,067

Extractions:

Total Army

549

505

284

258

340

United States

-----

531

314

309

391

Overseas

-----

370

220

199

232

Dentures:

Total Army

26

70

70

56

65

United States

-----

77

83

68

77

Overseas

-----

34

44

42

42

Dentures repaired:

Total Army

7

13

22

24

20

United States

-----

12

20

21

17

Overseas

-----

18

25

28

26

Fixed bridges:

Total Army

2

3

6

7

6

United States

-----

3

7

10

7

Overseas

-----

2

3

3

3

    1Accurate statistics are not available on the number of dental officers overseas and in the continental United States.
    2Average based on figures for the period 1January-31 August 1945.
    3Averaged based on figures for the period 1 January 1943-31 August 1945.

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