AMEDD Corps History > U.S. Army Dental Corps > United States Army Dental Service in World War II
DENTAL STANDARDS FOR MILITARY SERVICE
In time of peace the Army tends to establish physical standards formilitary service which cannot be maintained in time of emergency. Thispolicy is not inconsistent since it ensures that time and money will notbe wasted in training poor physical specimens, but when these rigid standardsare carried over into a general mobilization difficulties may result.
The dental standards for full military duty which were in effect atthe end of the First World War were not significantly altered prior toWorld War II. The early Mobilization Regulations (MR 1-9, dated 31 August1940) which established the physical criteria to be used by Selective Servicein time of emergency, prescribed dental requirements which were substantiallythe same as those published in AR 40-105 for the Regular Army in time ofpeace. Section VII of these regulations reads as follows:
DENTAL REQUIREMENTS
31. Classes 1-A and 1-B.-a. Class 1-A. (1) Normal teethand gums.
(2) A minimum of 3 serviceable natural masticating teeth above and threebelow opposing and three serviceable natural incisors above and three belowopposing. (Therefore the minimum requirements consist of a total of 6 mastleatingteeth and 6 incisor teeth.) All of these teeth must be so opposed as toserve the purpose of incision and mastication.
(3) Definitions.
(a) The term "masticating teeth" includes molar andbicuspid teeth and the term "incisors" includes incisor and cuspidteeth.
(b) A natural tooth which is carious (one with a cavity), whichcan be restored by filling, is to be considered a serviceable natural tooth.
(c) Teeth which have been restored by crowns or dummies attachedto bridge-work, if well placed will he considered as serviceable naturalteeth when the history and appearance of these teeth are such as to clearlywarrant such assumption.
b. Class 1-B. Insufficient teeth to qualify for class I-A, ifcorrected by suitable dentures.
32. Class 4.-a. Irremediable disease of the gums of suchseverity as to interfere seriously with useful vocation in civil life.
b. Serious disease of the jaw which is not easily remediableand which is likely to incapacitate the registrant for satisfactory performanceof 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 rejectedfor any military service. No registrants found acceptable for limitedservice were called for military service prior to July 1942.)1
These regulations did not specify whether or not teeth replaced on removablebridges would be counted as serviceable natural teeth, and this point wasnot made clear until March 1941, when Selective Service Medical CircularNo. 2 provided that either fixed or removable bridges were acceptable ifsupported at least in part by the remaining teeth.2
When the preceding regulation was published the United States was stillmore than a year from actual participation in the war. The partial mobilizationthen in progress was for training purposes only, and fairly strict physicalstandards were necessary to avoid waste of effort in the instruction ofmen who might later prove unfit for military service. However, the DentalDivision 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, inductedinto the Army in the operation of a compulsory draft law, would requireextensive dental replacements. The men of military age today will certainlyshow 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 militaryservice, we must realize that the safety of our nation depends on trainedmanpower. If the situation at present indicates a lowered state of dentalhealth among those of military age, we must provide the means for adequatedental service to correct the dental health of drafted men. The entireplan for dental service in time of mobilization has been revised to meetthe conditions which we are certain will exist in every Army camp.3
The number of men actually disqualified for dental reasons under MR1-9 far exceeded all expectations. About 8.8 percent of the registrantsexamined during the period from November 1940 through September 1941 couldnot qualify for general service. About one-third of these disqualifiedregistrants were classified as IV-F, namely, as totally unfit for militaryservice, and the remainder as I-B, fit for limited service only.4Since no registrants with limited service qualification were called for,military service during this period, the 8.8 percent was the actual disqualificationrate for dental reasons. In addition to those registrants who were disqualifiedfor strictly dental conditions (8.8 percent), about 0.4 percent of theexamined registrants were rejected by the local boards for serious pathologyof the mouth or gums, and while
1Teeth, mouth, and gum defects of men physicallyexamined 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, SelectiveService System.
3Fairbank, L. C. : Prosthetic dental service for the Army inpeace and war. J. Am. Dent. A, 28: 798-802, May 1941.
4Causes of rejections and incidence of defects, Medical StatisticsBulletin 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 pathologyis not known it is apparent that about 1 of each 11 registrants examinedwas disqualified at that time for military service because of dental ororal diseases. These disqualification rates refer to rejections where thedental defects were the principal disqualifying cause. It should be noted,however, that in establishing the disqualification rates, only one disqualifyingreason was given as the cause of rejection. Obviously, whenever there wasmore than one disqualifying defect, an order of precedence was followedin determining the principal disqualifying cause. In this respect, dentaldefects had a low priority. Therefore, if it were assumed that the frequencyof disqualifying dental defects was the same among the registrants whowere disqualified for reasons other than dental, it seems that about 1out of 8 examined registrants would have failed to meet the early dentalstandards for general service.
During 1940 and 1941, when 89 percent of all dental rejections weremade by local boards, dental and oral disqualifications by these boardswere 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 1940the War Department directed that the provisions of MR 1-9 which had previouslyapplied only to inductees would thereafter also constitute the physicalstandard for voluntary enlistment in the Regular Army and the NationalGuard.6 In March 1941 both Selective Service and the Officeof The Surgeon General published circulars of interpretation directingthat (1) the specified minimum number of teeth were required to be in occlusiononly during movements of the mandible, as long as there was no impingementon soft tissues while the jaw was at rest, (2) missing teeth replaced byeither a fixed or removable bridge could be counted as serviceable teethif at least part of the stress of mastication was carried by the remainingnatural 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 thebifurcation of multirooted teeth or the apical third of single-rooted teeth,and (4) teeth with caries involving the pulp would be considered unserviceable.78 In May 1941 dental requirements for officers of the MedicalDepartment Reserve and the Chaplains' Reserve were relaxed to authorizecommissioning of men with less than the minimum 12 teeth if the missingteeth were replaced by full or partial dentures.9
After Pearl Harbor it was apparent that the manpower needed to fighta global war could be obtained only if dental standards for induction weredrastically relaxed. The War Department and Selective Service thereforedirected, in February 1942, that pending revision of MR 1-9 the followingWould be acceptable for general military service: 10 11
Registrants who lack the required number of teeth as setforth in paragraph 31a, Mobilization Regulations 1-9, 31 August1940, when, in the opinion of the examining physician, they are well nourished,of good musculature, are free of gross dental infections, and have sufficientteeth (natural or artificial) to subsist on the Army ration.
This modification, interpreted literally, temporarily authorized theinduction of edentulous individuals provided they had procured the necessarydental replacements. The revised MR 1-912 which was published15 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 correctableby a full denture.
2. In the lower jaw-A minimum of a sufficient number ofnatural teeth in proper position and condition to stabilize or supporta partial denture which can be removed and replaced by the individual andwhich is retained by means of clasps, with or without rests, to stabilizeor support the denture.
Malocclusion was a cause for rejection only when it interfered. withthe individual's health or resulted in damage to the soft tissues. Registrantswith less than the required number of natural teeth were to be placed inClass I-B, for limited military Service, if the condition was correctableby the construction of dentures. In April 194213 these revisedstandards were made applicable to graduates of officer candidate schoolsand, after October 1942,14 applied to Reserve and National Guardofficers.
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, SelectiveService 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 requirementsfor induction were practically eliminated.15 Thereafter theprospective inductee needed only "at least an edentulous upper jawand/or an edentulous lower jaw, corrected or correctable by a full dentureor dentures." No dental conditions were thereafter to warrant classificationfor limited service, and the only disqualifying dental defects were "diseasesof the jaws and associated structures which are irremediable or not easilyremedied, or which are likely to incapacitate the individual for the satisfactoryperformance of military duty" or "extensive loss of oral tissuein an amount that would prevent replacement of missing teeth by a satisfactorydenture." The effects of the relaxed dental standards soon becameevident. The available statistics for 1942 (beginning with April) indicatethat the disqualification rate for dental reason during that year was around1 percent. It decreased from 2.9 percent in April 1942 to about 0.1 percentin December 1942.16 In 1953, the, disqualification rate fordental defects fluctuated around 0.1 percent, and it remained practicallyat that level for the remainder of World War II.17 SelectiveService Headquarters estimated that out of 4,828,000 registrants aged 18-37who were still classified as IV-F on 1 August 1945, 36,000 registrantswere so classified because of dental defects. An additional 12,500 registrantswere disqualified by mouth and gum defects. In other words, according tothis estimate defects of the teeth accounted for 0.7 percent of the IV-Fcategory, and mouth and gum defects accounted for another 0.3 percent,together amounting to 1.0 percent of the entire IV-F class. These datarefer to the entire period since the enactment of the 1940 Selective ServiceAct.18
At the end of hostilities higher dental standards were still maintainedfor commission in the Regular Army, for divers, for cadets, and for airborneduty; other components, including flying personnel, were subject only tothe relaxed provisions of MR 1-9.
Selective Service Regulations of World War II did not at first providefor dentists to serve on induction boards, but the mounting importanceof dental defects as a cause for rejection, plus the fact that many menaccepted by the local boards were subsequently disqualified at inductionstations, led to the decision in March 1941 to include dentists in thelocal and advisory boards when ever feasible.19 By 7 December1941, 8,040 dentists had been officially appointed to this voluntary duty20and a Selective Service memorandum of 1 August 1941 noted that dentistswere 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 InductionStation, during 1943, Army Service Forces, Office of The Surgeon General,Medical Statistics Division.
18Medical Statistics Bulletin No. 4, Natl Hq, Selective ServiceSystem, Table 4.
19Selective Service Regulations, vol. I, sec V, amendment 12to par 134. In Selective Service Regulations, 23 Sep 40 to 1 Feb42. Washington, Government Printing Office, 1944.
20Camalier, C. W.: Preparedness and war activities of the AmericanDental 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 screeningfor obviously disqualifying pathology.22 The more detailed examinationnecessary to chart all defects and finally determine eligibility for militaryservice 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 conditionof young adults of military age was at best fragmentary and often contradictory.Though studies on the dental needs of the civilian population had beenconducted by various agencies,24 25 26 27 28 these had beenrestricted to small segments of the population which were not representativebecause of age, economic status, or geographical distribution. No governmentalor private agency had attempted the nationwide examination of hundredsof thousands of persons from all income, age, and racial groups, both urbanand rural, which alone could have given a complete picture of the dentalneeds of the American public. However, the one conclusion accepted by allresearchers was that the dental attention received by the average citizenduring the preceding decade had been anything but adequate. The reasonsfor this inadequacy were not primarily the concern of the Armed Forces,but since the dental care of the average inductee had not been sufficientto prevent the steady accumulation of serious, preventable dental defects,this accumulation materially complicated the problems of the Army DentalService during the emergency. Thus in formulating a policy for the dentalcare of military personnel, the Dental Service had a choice of one of threeprincipal alternatives.
First, it might have continued to furnish only such treatment as theaverage inductee had received in civilian life. Sporadic attention of thistype, limited very often to the relief of intolerable conditions, was beingprovided the American public with a ratio of only 1 dentist for each 1,850persons, including infants and the aged.29 The Dental Corpscould have supplied such symptomatic treatment without serious difficulty.
22See footnote 10, p. 202.
23Though induction stations operated under Army supervisionthey were often staffed with contract civilian medical and dental personnel.
24Beck, D. F. : Costs of dental care for adults under specificclinical conditions. Under the auspices of the Socio-economics Committeeof the American College of Dentists. Lancaster, Lancaster Press Inc., 1943.
25Walls, R. M.; Lewis, S. R., and Dollar, M. L.: A study ofthe dental needs of adults in the United States. Chicago, American DentalAssociation, 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 inthe United States. Ill. Dent. J. 14: 185-199, May 1945.
28Klein, H., and Palmer, C. E.: The dental problem of elementaryschool children. Milbank Mem. Fund Quart. 16: 281, Jul 1938.
29O'Rourke, J. T.: An analysis of the personnel resources ofthe dental profession. J. Am. Dent. A. 30: 1002, 1 Jul 45.
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Unfortunately, such a low standard of dental health was not acceptablefor military personnel. The civilian whose health was being underminedby oral sepsis might conceivably follow his normal sedentary pursuits withoutnoticeable inconvenience, but in the Army. he had to function at top efficiencyunder the most adverse conditions, and disease which would reduce his physicalendurance or cause him to be lost to his unit at a critical time, had tobe eliminated. Moreover, the soldier had to be able to masticate any roughfood which might be available in the field. Disregarding all humanitariancon-siderations, the Army could expect the most effective service frominductees only if their oral health was maintained at a much higher levelthan was common in civilian life.
As a second alternative, the Dental Service might have provided onlysuch regular annual care as was essential to prevent further deteriorationof the soldier's dental health, ignoring old defects except when treatmentbecame 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 ratioof 1 dentist for each 493 persons, would be able to furnish such attentionfor the civilian population.30 This figure was of course notdirectly applicable to the military population, but it is certain thatall regular maintenance care could have been provided Army personnel withthe authorized ratio of 1 officer for each 500 men. However, this policywas undesirable because the average inductee as he was received in theArmed Forces was dentally unfit for military service even if the developmentof new defects could be checked. In addition, it was open to all the objectionsdiscussed in the preceding paragraph.
The remaining alternative was for the Dental Service to undertake thecomplete dental rehabilitation of every inductee, providing not only annualmaintenance care, but correcting as far as possible the old defects whichhad resulted from earlier neglect. In view of the demand for top physicalcondition in military personnel this was the only objective which couldbe accepted, but based on fundamental considerations of available dentalpersonnel and supply, it was necessarily a long-term project, not to heachieved in a few months, or even in a year.
The first goal of the Army Dental Service was to correct conditionswhich might cause a man to become a dental casualty, adversely affect hishealth, or result in further serious damage to dental structures. The precedencefor 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.
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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 treatmentneeded, the information was qualitative rather than quantitative; a manin Class II might have one carious tooth, or a dozen. Nor did it indicateall the types of work required; a single individual might have defectscoming under three or more groupings, but only the most urgent classificationwas reported. Furthermore, different camps reported widely varying dentalclassification, indicating a lack of uniformity in application of the specifiedcriteria.
Sample surveys of men arriving at three large replacement training centersat different periods from 1942 through 1915 show that they fell into approximatelythe following categories. These figures are given in round numbers becausethe 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 ClassI eventually required prosthetic replacements; similarly the men in ClassesI 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.33After urgent work was taken care of the next objective was to provide mendestined for a combat area as much routine treatment as possible. By thelatter part of 1943 one major theater was able to report that 85 percentof new replacements were in Class IV, requiring no dental attention.34
The final goal of the Dental Service was to provide all essential treatmentfor every soldier, no matter where located. The extent to which this objectivewas attained is difficult to determine. It is known that the number ofmen needing the most urgent types of treatment, including the constructionof dentures, was reduced from 20 percent on entry into the service to 3percent at time of discharge; the number requiring routine care was correspondinglyreduced from 40 percent to 14 percent.35 These figures failcompletely to reveal the actual improvement in dental health, however,since the man who
32Calculations based on unpublished data inthe files of the Dental Division, SGO, covering the initial classificationsof 25,000 men examined at Ft. Sill, Oka., in 1944 and 1945; 5,884 men examinedat 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 statesin 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 separateeswas 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 cavitydetected at the time of examination for discharge, would still be recordedis "needing routine treatment," and statistically no change inhis dental condition would be noted. It is probable that many of the dischargeeslisted as still needing dental care fell in this category, but pendinga study of individual induction and separation records, it is possibleto say only that the average soldier returned to civilian life in muchbetter 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 basisand without cost for all Army personnel on active duty without respectto rank or component.36 At least once a year, and usually moreoften, members of each organization were examined in a "dental survey"and placed in the appropriate category as listed on pages 205-206. Firstpriority was given to emergency conditions; other personnel, beginningwith those in Class 1, were treated in accordance with their classificationestablished on the survey. Retired personnel were authorized dental carewhen facilities were available, but total requirements for this group wereso small that they were a negligible factor in planning the Dental Service.
Civilian Dependents
Prior to the war, dependents of military personnel were authorized dentaltreatment in Army clinics. Most of this treatment was maintenance carefor persons receiving fairly regular attention, but it accounted for about25 percent of all work completed by the Dental Corps.37 To havecontinued this type of treatment for the dependents of the millions ofmen being taken into the Armed Forces for the emergency would have requireda minimum of 5,000 additional dentists, with equipment and housing, ata time when both manpower and supplies were critically short. The DentalDivision therefore recommended that treatment for Army dependents be limitedto the care of emergencies, and then only when such care would not interferewith the treatment of military personnel.38
However, enforcement of the limitations on dental care for dependentssometimes led to considerable embarrassment for dental officers. The DentalDivision had recommended that only "emergency care for the actualrelief of pain" be authorized, and the application of even thisprovision would probably have required the exercise of a great deal oftact. But through
36For a detailed list of persons entitled todental 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 Oct40. SG: 337-1.
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error or intent the published directive merely provided for "emergencytreatment," leaving a loophole for strong and continuous pressurefor all kinds of care.39 A wife who lost a bridge-facing onthe day before a dinner party had no trouble in convincing herself thathers was an emergency situation, and patients demanded, and sometimes received,permanent fillings, denture repairs, and even the replacement of missingteeth. Some contended that dental care was authorized by Army regulationsand that it could not be denied by an emergency directive, but the LegalDivision 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 wouldhave eliminated almost all dental. work for dependents since it also prohibitedsuch care when it would interfere with the treatment of military personnel,and very rarely could it honestly be said that any work for dependentswould not be at the expense of the troops. But the dental surgeon who triedto refuse civilian dental care on this basis sometimes found that he didnot have the support of either the surgeon or the commanding officer. Hecould legally enforce the restriction, but such action frequently had tobe taken on his own responsibility and against the fairly clear wishesof the superiors who made out his efficiency reports, assigned his duties,and approved or disapproved recommendations for promotion. This situationwas understandable since officers outside the Dental Service seldom understoodthe time-consuming nature of dental work. Few realized that the requestto "just take a look at this tooth" usually meant at least ahalf-hour lost from a busy day. Only the dentist knew that in spite ofhis best efforts some of his men would leave for combat areas with uncorrecteddental defects, and that every minute devoted to nonmilitary personnelwas taken from a soldier. But the knowledge that he was in the right wasvery little consolation to a dental officer who had to enforce a regulationwhich was unpopular with his immediate superiors.
In spite of these deficiencies, the directive against wartime treatmentof dependents accomplished its primary purpose fairly well. Only 1.4 percentof all care rendered during 1942-1945, inclusive, went to nonmilitary personnel,and much of that to civilian employees overseas.41 Its principaldefect was ambiguity; a flat prohibition against any care for dependentswas enforceable, but a compromise, attempt to provide only a little treatmentwas not. The very fact that only 2 or 3 percent of dependents receivedany
39Ltr. TAG to CGs all CAs and Depts and COsof 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, 25Jan 45, sub: Dental attendance for dependents of military personnel.. SG:703.
41Data on the treatment of civilians assembled by author fromdata in the files of the Dental Division, SGO.
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dental care at all is in itself evidence that dental surgeons couldnot provide even the minimal authorized treatment on an equitable basis.The dentist was forced to select a very few patients from the hundredsneeding attention, and under such circumstances charges of favoritism wereinevitable. Dependents of overseas personnel who had no one to supporttheir requests for assistance, and dependents of men in the lower grades,who could least afford to pay for civilian dental care, generally faredworst of all. The few dependents who received the scanty treatment authorizedwere seldom satisfied, while the majority who did not, felt that they hadbeen arbitrarily denied a valuable privilege because they lacked influenceor because the dentist was lazy. Wives of Army personnel published luridaccounts of the "run-around" they had experienced, describinggraphically how they had waited all day for consultation, only to be toldto come back the following day. The net result of this attempt to do justa little work for dependents was inadequate treatment for a very few, andwidespread ill will for the Medical Department and the Dental Corps. Itappears that a complete suspension of treatment for dependents during theemergency would have been fairest to all concerned and would have createdless, bad feeling than the temporizing policy actually in effect. The Navyhas successfully enforced such a policy for many years, in peace as wellas in war.42
Civilian Employees and Associated Personnel
Dental care for civilian employees of the War Department in the continentalUnited States was limited to emergency treatment for the relief of painuntil definitive care could be provided by a civilian dentist.43Overseas, however, where satisfactory dental attention could not be obtainedfrom nonmilitary agencies, the Army had to assume responsibility for thedental care of its civilian specialists. Under these conditions, civilianemployees were authorized the same treatment as soldiers, without cost.44Red Cross personnel in the United States, where civilian facilitieswere available, were authorized dental care only when hospitalized andwhen such dental treatment was an essential part of therapy.45In no case was replacement of
42Statements concerning defects in the policyregarding dental treatment for dependents are very hard to document. Thosewho received no treatment had no legal basis for complaint, and those whoreceived more than emergency care did not court publicity, for obviousreasons. The author gained personal knowledge of this problem while servingas dental surgeon of two large ZI posts. Most of the facts stated werealso common knowledge among dental officers.
43Policy in respect to dental treatment for civilian employeesin the ZI was published by 1st ind, SG on Ltr, CG, 9th SvC, to SG, 5 Mar43. Both the original letter and indorsement have been lost, but the latteris 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 forcivilians 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 entitledto 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 DentalDivision had to compromise between what was theoretically desirable andwhat was possible with the maximum resources available. Such operationsas the replacement of single missing teeth with fixed bridgework, the treatmentof pulpless teeth, the restoration of anteriors with porcelain jacket crowns,and the construction of full-cast, precision-attachment partial denturescould of course be defended as good dentistry, but the expenditure of timeon such procedures could not be justified while other soldiers sufferedfrom oral sepsis or were threatened with the loss of additional teeth fromrapidly progressing caries. It was therefore necessary to limit the careprovided by following the principle of "the greatest good for thegreatest number," with primary attention to those conditions whichaffected the health of the individual or which would result in permanentdamage if neglected.
In 1940 the United States was not involved in actual hostilities, andit was expected that inductees would return to civilian life after oneyear of training. Also, these inductees were required to meet minimum standardsof dental health before they were called to active duty. The Dental Divisiontherefore felt that it was both unnecessary and unwise to attempt, in a,short time, the complete dental rehabilitation of every individual enteringthe service in a temporary status. In October 1940 the attitude of theDirector of the Dental Division was expressed as follows:47
Under no circumstances is it believed desirable to setup a policy requiring that every man drafted into the Army receive completedental attention to place him in class IV.... It is believed that it isonly right that we should adopt a policy that any Reserve Officer or drafteeor National Guard personnel in the Army for a period of one year's trainingis not to receive dental service replacing teeth lost prior to his entranceinto the military service, except in the case of dental pathology involvingother teeth or oral tissue where the replacement is necessary to maintainhealth. In other words, a man who has been able to carry on his businessor hold a job in civilian life with
46Authority for the outpatient dental careof Red Cross personnel overseas has proved impossible to document. Suchtreatment was obviously essential and to the personal knowledge of theauthor who served in two theaters, it was rendered without question, butflies of The Adjutant General or The Surgeon General fail to reveal anyclear-cut reference to the subject. In a telephone interview of 21 August47, Miss Jeanette Ross of the Insular and Foreign Hospital Service, NationalHeadquarters, Red Cross, stated that it was her understanding that RedCross employees were authorized hospitalization under AR 40-590, that 40-505approved medical attention for anyone hospitalized under 40-590, and thatAR 40-510 in turn provided for dental attendance for anyone hospitalizedunder AR 40-505. If strictly interpreted, however, even this complicatedseries of regulations does not specifically authorize outpatient dentalcare for Red Cross personnel overseas. It appears that this was a situationwhere 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 anticipatethat 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 theexpense to secure such service had he remained in civilian life.
On the basis of this opinion, The Surgeon General recommended to TheAdjutant General that dental attendance for temporary personnel be limitedto the treatment of emergency conditions, the filling of cavities withroutine materials, and the replacement of teeth lost in the performanceof duty or as a necessary part of treatment.48 The AdjutantGeneral disapproved this recommendation, however, because it was againstWar Department policy to distinguish in any way between temporary and permanentpersonnel.49 The Surgeon General then agreed to make the proposedrestrictions applicable to all Army personnel50 and the followingpolicy was published by the Office of The Adjutant General (AGO) on 14January 1941:51
a. Dental attendance for all military personnelwill be confined to the treatment of emergency cases, infectious conditions,and the restoration of carious teeth with amalgam, silicate, or cementfillings, 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, whileengaged in athletic games, or as a necessary part of treatment. Such replacementswill be the standard type of partial or full dentures provided for Armypersonnel.
c. Dental attendance for dependents will be limitedto emergency treatment. Such treatment will interfere in no instance withthe routine dental treatment of military personnel.
With the lowering of dental standards in February 1942, large numbersof men entered the service whose teeth did not meet minimum requirementsfor health, and it became necessary to remove some of the restrictionsagainst the construction of dentures. On 8 April 1942 the Director of theDental Division recommended that subparagraph (b) of the aforementionedletter be amended to read as follows:52
Replacement of missing teeth for military personnel willbe made when in the opinion of the dental surgeon it is necessary froma health or functional standpoint; that is, insufficient natural or artificialteeth to satisfactorily masticate the Army ration. Such replacements willbe 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 fixedbridgework when in the opinion of the dental surgeon it is advisable. Thistype of replacement is to be kept at a minimum consistent with the bestinterests 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, 25Apr 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 furtherliberalized by a War Department directive of March 1945 providing that"A fixed bridge may be inserted in the anterior segment, in limitedcases, as a morale or functional factor in those instances where extractionhas caused a disfiguring space."54 Under the terms of WarDepartment policy every soldier was authorized all the care necessary topreserve dental health, though the single missing tooth of one patientwould not be replaced as long as other men had insufficient teeth for propermastication, nor would an inlay be supplied at an expenditure of time thatmight better be used to save several teeth with standard amalgam fillings.
Quality of Treatment Rendered
Though expensive and time-consuming operations were not authorized whensimpler procedures would be effective, the Dental Division consistentlydemanded that treatment rendered in Army dental clinics be of the highestquality. This policy was partly altruistic in that it was felt that thesoldier was entitled to care at least as good as he would receive in civilianlife; it was partly selfish because it was believed that work of high qualitywould prove most economical of both time and money. The attitude of theDental Division was expressed in the Army Medical Bulletin as follows:55
There is no substitute for quality in the service renderedthe soldier by the Army Dental Corps. The Dental Division has on many occasionsemphasized that, above all, quality and not quantity is the real objectiveof the dental service in every hospital, camp or post. There are timesand situations which demand an extended effort on the part of the dentalofficer to complete a certain assignment, but regardless of the circumstances,the dental service cannot afford to be jeopardized by permitting inferiorwork to leave the dental clinic.
Only standard, high-grade materials were furnished dental clinics, andgold was available when the more common items were not satisfactory. Dentureswere normally made of acrylic resin, with gold bars and clasps when required.No charge was made for special materials or treatment, and the practiceof having military personnel pay civilian laboratory costs, except in extremeemergency, was specifically prohibited.56 Surgical procedureswere carried out by qualified personnel with due attention to asepsis,and the incidence of infections following oral surgery was very small.57Officers with special qualifications were also designated as prosthodontistsin all the larger installations. Teeth which could be saved in a healthycondition were not extracted, and the
54TB Med 148, Mar 1945.
55Dental service-accepted procedures no experimentation. Bulletinof the U. S. Army Medical Department 82: 20, Nov 1944 (cited hereafteras 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.58Liberal use of protective bases under deep fillings was encouraged,but very little root canal treatment was attempted, both because of thetime required and because of the risk that a later acute infection mightincapacitate the soldier when he could not get dental care. Only a limitedamount of porcelain work was done, though anterior jacket crowns were routinelyprovided after the acrylic resins became available.
With the exception of hygienists and x-ray technicians, only officersof the Dental Corps were permitted to work on patients at the chair. Armyregulations provided that in the absence of a dental officer, medical officersmight render dental care "to the extent that their training and skilljustify," but such treatment was very rarely given.59 Itwas specifically directed that "except as otherwise prescribed...theselection of professional procedures to be followed in each case, includingthe use of special dental materials, will be left to the judgement of thedental officer concerned."60
It was especially directed that the soldier would not be used as a guineapig for testing untried procedures.61
Of the 15,000 dentists on duty there were inevitably a few who failedto attain expected standards. There were also a few who mistakenly triedto set records for quantities of work completed, without due regard forquality. As these situations came, to the attention of higher authority,men of the first type were placed under responsible supervision or relievedfrom duty; those of the second were informed that high production, withoutquality, 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 ofsome critical comment. Due to supply difficulties, and to the enormousaccumulation of untreated defects in the civilian population, the DentalService had to defer a considerable amount of elective treatment duringthe period of rapid mobilization, before dental facilities reached peakstrength. The Director of the Dental Division admitted that:62
The Army Dental Corps has accepted the most momentousjob in the history of dentistry, since one man in every four, when inducted,is in a dental state which requires emergency treatment.... Time is thebiggest 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 toentrance into the service, and about one-half rarely went to
58Exact figures on the number of teeth replacedare not available, but if the reasonable assumption is made that an averageof 8 teeth were replaced by each partial denture, a total of 18,000,000teeth were supplied soldiers from Jan 1942 through Aug 1945. In the sameperiod 15,000,000 teeth were extracted.
59See footnote 31, p. 205.
60Ibid.
61Accepted dental therapeutics and procedures.Army Medical Bulletin69: 14, Oct 1943.
621st Ind, SG, 10 Oct 43, on Ltr, Mrs. Walter R. Agard to GenGeorge C. Marshall, 29 Sep 43. SG: 703.1.
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the dentist.... It is humanly impossible to complete allof the dental work for all of the inductees.
This statement should not be interpreted to mean that the dental healthof military personnel suffered because of their induction into the Army.It merely confirms the knowledge acquired during the World War II periodthat, in the event of any future mobilization, the Dental Service shouldnot promise the complete dental rehabilitation of every soldier until ithas adequate information on the dental needs of inductees, and on the factorswhich may affect its own ability to mobilize a large number of dentistsin a limited time. The Dental Corps was also accused of being more interestedin extracting than saving teeth. This impression was probably gained duringmobilization when the first objective was to make men fit for militaryduties, necessitating the extraction of large numbers of septic or nonrestorableteeth. As any dentist or physician knows, the worst dental infections,chronic in nature, are often painless, and it is easy to understand howsoldiers might assume that symptomless teeth had needlessly been extracted.One criticism which came to the attention of The Surgeon General was answeredas follows:63
It is the opinion of this office that Dr.... has not beencorrectly informed as to the constructive dentistry now being accomplishedby the Dental Corps.... A ratio of approximately 27 permanent fillingsto every tooth extracted was established during the month (May 1942). Thedental reports for the armed forces for the month of May show that conservativeconstructive dentistry is carried out in every Army dental clinic. Sincethe lowering of dental requirements for inductees has been in effect, anenormous amount of work has devolved upon the Dental Corps, and many ofthe men now being inducted into the military establishment present oralconditions which require extensive treatment, and the extraction of manybadly broken down teeth.
Qualified civilian dental consultants reported that in general the treatmentrendered in the Army met the accepted standards of the American dentalprofession. The editor of the Journal of the American Dental Associationstated in April 1944 that:64
...a beneficial result from the preventive and correctivedental program now in operation in the Army and Navy will be that an enormousnumber of men heretofore dentally deficient will be rehabilitated for militaryservice and a large percentage of them will return from war in improvedphysical condition as a result of improvement in dental health.
The attitude of enlisted men toward the dental service was not as favorableas the quality of the treatment rendered seemed to justify. In October1942, 5,538 enlisted men in the AGF and AAF answered questions concerningthe medical and dental service as follows:65
63Ltr, SG to Hon. Clyde L. Herring, 20 Jul42. 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 hospitalservices, among white enlisted men forming a cross section of Ground Forcesand Air Forces, 2 Nov 42. Research Div, Office of Armed Forces Informationand Education.
215
Question: "Do you think good medical (dental) care is providedby 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 dentiststo 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 fillthem?"
| 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 percentagecompletely satisfied with the dental service, though in all of these studiesexcept the one listed previously the dental service was preferred overthe medical service.66 67 Some of this dissatisfaction was basedon general discontent and the normal tendency of the soldier to "gripe."Much of it was based on hearsay rather than personal experience for thepercentage who thought that the dental service was good was much higheramong men who had actually been patients. Nevertheless, too many enlistedpatients had grave doubts concerning the Army dentist's use of the forcepsand his humanitarian qualities. More detailed analysis of specific complaintsshowed that most men felt the end results of treatment were excellent,but they apparently believed that the military practitioner lacked a personalinterest in his patient, that he tended to be rough, and that it was sometimeshard to get desired care.
The enlisted patient, lacking the professional knowledge on which tobase an informed evaluation of his dental treatment, attached an understandableimportance 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 nonessentialconversation or explanation; the patient, on the other hand, felt thatthe situation called for a more sympathetic attitude. There is every evidencethat conscientious, careful treatment was the rule in Army dental installations,but it also seems certain that the patient was not made to realize thisclearly. Since the soldier's whole attitude toward the Army may be coloredby his opinion of the medical care
66European Survey No. 17, Dec 1943, of a crosssection of men in lettered infantry companies in a division in trainingin 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 Informationand Education.
216
he receives, it seems that this factor should be given attention inthe 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 havesufficient teeth for mastication when they entered the service. If replacementslater became necessary they had to be obtained by the individual. Regulationspublished in 1916 authorized restorations at Government expense. This,however, applied only to those individuals whose teeth had been lost bytraumatic injury in line of duty. Prior approval of a department surgeonor of The Surgeon General was required in each instance and materials hadto 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 Armyand more adequate provision had to be made for the construction of prostheticappliances. After May 191769 complete laboratory equipment wasissued to the larger installations. In October 1917 The Surgeon Generalauthorized dental officers in base hospitals, general hospitals, and certainlarger camps, to repair bridges or dentures for men originally acceptedwith these appliances and to construct new restorations for soldiers forwhom such work was considered essential by a regimental surgeon or dentalsurgeon. In March 1918 this regulation was further liberalized to permitthe replacement, in time of war only, of any teeth essential to mastication.In time of peace, restoration was still to be restricted to teeth lostby traumatic injury in line of duty. After March 1919 teeth lost otherwisethan by traumatic injury in line of duty could also be replaced by theArmy but no gold or other precious metals could be expended on these appliances.70In October 1920 it was pro-vided that gold could be used for:71
Replacements for teeth lost by traumatic injury in line of duty, inpeace or war. Partial dentures requiring gold clasps for their retention.Repair of crowns or bridges which were originally necessary to establisheligibility of an enlisted man for entry into the service. Routine inlays,crowns, or bridges for officers and nurses and for enlisted men with atleast 5 years service. Finally, in 1925, the use of any prosthetic materialwas authorized for any person entitled to receive dental care at Governmentexpense, 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 WorldWar. Washington, Government Printing Office, 1928, vol III, p. 611 (citedhereafter 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.
217
Prior to 1927, prosthetic appliances for soldiers were generally completedby small laboratories in the individual station dental clinics. In thesea single assistant often worked on cases under construction whenever hecould be spared from other duties. The dental officer commonly had to exerciseclose supervision over all procedures even if he was not required to dothe work personally. Very little organization was possible and technicianswere expected to perform all operations, yet men sufficiently skilled topour up impressions, set teeth, fabricate gold skeletons, and polish thecompleted dentures were seldom attracted by the wages offered in the Army.As a result, dental officers wasted much time and effort in work whichthe civilian dentist routinely delegated to trained auxiliary personnel.
In 1927 central dental laboratories (CDL) were established at the ArmyMedical Center, Walter Reed General Hospital; Letterman General Hospital;and the Station Hospital, Fort Sam Houston.73 During calendaryear 1933 another was installed at Corozal in the Panama Canal Zone, butthe laboratory at Fort Sam Houston was closed for lack of personnel whilethe one at Letterman General Hospital produced only 38 cases.74At the end of fiscal year 1935 only the Army Medical Center CDL remainedin effective operation.75 At the same time, however, it wasannounced that a plan for expanding central dental laboratory facilitieswas under consideration. By the end of fiscal year 1937 the CDL at FortSam Houston was again functioning and another had been established at FortClayton in the Panama Canal Zone. On 16 March 1938 The Surgeon Generalannounced a general plan for initiating central dental laboratory serviceon a large scale76 and a War Department circular of 16 September1938 stated further that CDL's would be established in Washington, D. C.;Atlanta, Ga.; St. Louis, Mo.; San Antonio, Tex.; and San Francisco, Calif.77By 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 Twosubcentral laboratories were also established at Beaumont General Hospitalin El Paso, Tex., and at Fitzsimons General Hospital in Denver, Colo.80
All the CDL's except the one in Washington functioned under the controlof the respective corps area commanders, but personnel were assigned byThe Surgeon General and it was specifically provided that technicians wouldnot
73Annual Report of The Surgeon General, U.S. Army, 1927. Washington, Government Printing Office, 1927, p. 241 (citedhereafter as Annual Report . . . Surgeon General).
74Annual Report . . . Surgeon General, 1934. Washington, GovernmentPrinting Office, 1934, p. 163.
75Annual Report . . . Surgeon General, 1935. Washington, GovernmentPrinting Office, 1935, p. 156.
76SG Ltr 9, 16 Mar 38.
77WD Cir 53, 16 Sep 38.
78Central dental laboratories. The Dental Bulletin, supp. toThe Army Medical Bulletin 10: 30, Jan 1939.
79Ibid.
80Annual Report . . . Surgeon General, 1939. Washington, GovernmentPrinting Office, 1939, p. 200.
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be used for other duties except in case of urgent emergency. The standardallotment of personnel was set at 2 officers, 1 staff sergeant, 1 sergeant,2 privates first class, and 2 privates. Extra men and higher ratings wereauthorized for the CDL at the Army Medical Center, where vitallium caseswere constructed.81
By the beginning of World War II a central dental laboratory systemhad thus become well established.
Policies Concerning the Provision of Prosthetic Treatment, WorldWar II
Another major problem which confronted the Dental Service in World WarII was the determination of the extent to which it should attempt to provideprosthetic appliances for inductees. Previously this question had beenleft to the judgment of individual officers, but with the enormous increasein 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 thetime they entered training. The Dental Division, SGO, felt that it wasneither feasible nor necessary to undertake the complete rehabilitation,of almost a million men a year when it was expected that most of them wouldrevert to civilian status almost as soon as treatment could be completed.Therefore, the amount of prosthetic treatment to be rendered was limitedby the order of 14 January 1941 (see page 211, subparagraph b).
By April 1942 the situation had changed radically. The United Stateswas in the war, inductees were in the Army for the "duration,"and dental standards for induction had been lowered to admit men who wouldrequire extensive replacements before they could perform their militaryduties. To meet these new conditions a more liberal dental care policywas established by AGO directive of 25 April 1942 (see page 211) and asubsequent War Department directive of March 1945 (see page 212).8283
For all practical purposes, the interpretation of these directives wasagain left to the individual dentist. An attempt was generally made toapply the peacetime standard for enlistment which provided that a man withless than 3 posterior teeth above and below in occlusion, and 3 anteriorsabove and below in occlusion, was not fitted for service. However, onemeeting these minimum requirements might actually be a dental cripple.Also the decision in any doubtful case might depend to a considerable degreeupon intangible personal factors. One man would wear a denture, which wasnecessary only to preserve the health of the remaining teeth; another wouldnot. One would feel the need of a replacement when only a few teeth weremissing; another would wear an
81SG Ltr 1, 2 Jan 40.
82See footnote 53, p. 211.
83See footnote 54, p. 212.
219
appliance only after all his posterior teeth and most of his anteriorshad been lost. An SGO circular letter of 22 June 1943 attempted to clarifythe situation, but after calling attention to certain fundamental considerationsit left the principal responsibility just where it had been before, onthe individual dental officer.84 No rigid formula was foundto be universally applicable in World War II and it is doubtful if anyfixed standard could ever prove entirely satisfactory.
In view of the difficulty in determining which cases should receivedental replacements it is not surprising that military personnel were sometimesfurnished dentures which subsequently rested in a barracks bag or footlocker.One separation center reported that about I percent of the men dischargedafter less than 6 months' service were classified "I-D" (needingprosthetic appliances) but were found, on investigation, to have been providedreplacements which they were not wearing. Of the men discharged after morethan 6 months' service approximately 41/2 percent neglected to, wear thedentures which had been supplied them.85 If we accept the estimatethat 10 percent of all military personnel had been provided with dentures,the findings of this separation center indicate that some 40 percent ofthose for whom appliances had been constructed did not wear them. Thisfigure is admittedly based on a small sample and must be considered highlytenuous; the actual proportion may have been much smaller. But is cannotbe said that the dentures which were not worn were "unnecessary"since in most cases their use would have prevented further damage to mouthsalready partly crippled.
Experience has shown, however, that the policy of relative liberalityin authorizing dental replacements, applied reasonably, was in the bestinterest of all concerned even though some men undoubtedly failed to wearthe dentures provided them. The great benefit to the large number who did,justified the extra effort involved. Further, the knowledge that teethlost would subsequently be replaced, instilled in the soldier a greaterconfidence 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 foreach 1,000 men. This average rate was far from constant, however, and actualyearly 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 separationcenter from Nov 1944 through 16 Mar 45. Given to Lt Col John C. Brauerby Maj Gen Robert H. Mills, 27 Mar 45. SG: 703.
86Figures from 1938-40 taken from annual reports of The SurgeonGeneral for those years.
87Data for 1941-43 taken from: A history of The Army DentalCorps, 1941-1943, Professional Service Section. HD: 314.7-2 (Dental).
88Figures for 1944-45 calculated by author from data in thefiles 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 prostheticappliances was low in 1940-1941, and 1942, and high in 1943, 1944, and1945. The small output of 1941-1942 represented inadequate capacity, whichin turn was due mainly to lack of equipment, and trained technicians. Withthe start of mobilization in 1940 the laboratories were unable to increasetheir facilities to keep pace with the increase in the strength of theArmy, and production did not again reach even the per capita rates of 1938-1939until 1942. In this same period very few bridges were constructed sinceonly the more urgent cases could be handled and the proportion of fulldentures to partial dentures was much higher than in the later years ofthe war.
Improvements in the supply and personnel situation in 1943 made it possiblefor the prosthetic service, to meet current needs and also to start reductionof the accumulated backlog of prosthetic treatment, so that the per capitaoutput of dental appliances reached a figure many times that of the prewaraverage. At the same time, the number of bridges constructed increasedrapidly and the proportion of partial dentures to full dentures approximatelydoubled, showing that less urgent cases were receiving attention. By 1945,the backlog of treatment accumulated earlier in the war had been substantiallydepleted and the demand for new dentures began to fall off. Requirementsfor denture repairs remained high, however, due to the large number ofappliances in use, and the high proportion of bridges constructed showedthat more optional treatment was being provided as the need for urgentreplacements diminished. Unfortunately, pending a detailed study of individualmedical records there is no way to break down the preceding figures intorequirements for initial rehabilitation and requirements for annual maintenancecare.
During the war about 2,566,000 dentures were constructed for militarypersonnel.89 Since 38 percent of all patients received 2 appliances,about 1,860,000 patients were given dentures. If there had been no replacementof broken, lost, or unsatisfactory prostheses, this would have meant that19 percent of all soldiers wore artificial replacements. The Dental Divisionac-
89Information compiled by author from monthlyreports of dental service on file in the Dental Division, SGO.
221
tually estimated that 15 percent of all military personnel wore prostheticdevices90 but since loss and breakage were inevitably high underwartime conditions, it seems probable that the proportion of men wearingdentures AW, at any one time was somewhat less than that estimated. If50 percent of all dentures were replaced during the war, the proportionof soldiers wearing these would have been closer to 10 percent, a figurewhich corresponds more closely with the few available reports from tacticalunits.
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 partialuppers, and 38.1 percent partial lowers.91 Thirty-eight percentof all patients required more than one appliance. These figures were, accumulatedearly in the war, however, and the later trend was toward fewer full denturesand more partial dentures. During 1942, the proportion of partial denturesto full dentures was 2.1,92 later a more liberal attitude wasadopted and in January 1944, 4.4 partial dentures were being supplied foreach full denture.93 The average ratio over the 4 years 1942-1945was 3.5 partial replacements for each full denture.94
The evidence of World War II experience was clear on one point: Duringa mobilization the need for prosthetic service may be expected to increaseout of all proportion to the increase in the strength of the Army. Fromthe end of 1940 to the end of 1943 the strength of the Army increased byabout 1,105 percent;95 during the same period the number ofprosthetic cases completed per month increased nearly 5,600 percent, or5.1 times the increase in the strength of the Army. The number of denturessupplied each 1,000 men in 1944 was 3.5 times the number supplied in 1938.96Though some increase had been expected because of lowered dental standards,it certainly was not foreseen that a thousand inductees would require approximatelyfour times as many prosthetic appliances as an equal number of men in thepeacetime establishment.
Professional Standards of the Prosthetic Service
Certain "luxury" types of denture service, such as full-castgold appliances, cast-base full dentures, and those involving the use ofspecial attachments were obviously out of place in the wartime prostheticservice. However, every effort was made to provide soldiers with replacementswhich met the standards of ethical civilian practice. Materials employedwere of the highest quality and included all of the commonly accepted types.The usual partial denture was constructed on an acrylic resin base, withassembled gold clasps and a gold
90Final Rpt for ASF, Logistics in World. WarII. 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 ofthe Dental Division, SGO.
95Strength of the Army, 1 Mar 46.
96Calculation by author from monthly reports in the files ofthe Dental Division, SGO.
222
lingual bar. Cast gold and vitallium dentures were available when noother materials would be satisfactory, though their use was kept to a minimum.Little ceramic work was done in Army laboratories but acrylic resin wasused in the construction of crowns and bridges when indicated. Wheneverpossible, specially skilled dentists were put in charge of the prostheticservice, and laboratories operated under the close supervision of full-timedental officers. Each model sent to a laboratory was surveyed and the necessaryreplacement designed by a dentist before being turned over to a technician.
No attempt was made to prescribe any uniform technique for taking impressionsor constructing dentures. So long as acceptable standards were maintainedeach dental officer was free to use the methods with which he was familiar.However, inferior models and registrations were sometimes received in thelaboratories, and certain generally recognized requirements were thereforeestablished by directives published in July 1943 and March 1945.9798 These did not state how results were to be attained, butdid prescribe certain essential objectives (e. g. all full denture impressionsto be muscle-trimmed, relations to be taken with well-fitted bite rims,etc.).
Prosthetic consultants reported that in general the dentures constructedby the Army met all requirements for health, comfort, function, and appearance.In isolated instances, however, the overwhelming demand for prostheticservice and the need for completing cases in a limited period resultedin the adoption of methods which left much to be desired. Such practicesas the use of acrylic resin in place of gold lingual bars, the use of one-armedclasps, and soldering clasps on the same model which was later to be usedfor vulcanization were rare, but sufficiently frequent to warrant somecriticism.99 Dentures were occasionally inserted before theridges had become reasonably stabilized after extractions, though the dentalsurgeon usually had no choice but to supply a replacement to a soldierwho would soon leave for an active theater, even when he was certain thatthe appliance would have a short useful life.100 Since thesedifficulties were due in large part to such f actors as inadequate dentalcare for the civilian population and inability to obtain equipment duringthe 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, emphasizedthe importance of planning for an extensive prosthetic service from thestart of any future mobilization.
From 1 January 1942 until the end of August 1945, the prosthetic servicecompleted 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 thedental surgeon of a replacement training center, an overseas theater, anda 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 reportsin 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. Anadditional 10,300 full dentures, 35,500 partial dentures, and 16,600 denturerepairs, were completed for prisoners and nonmilitary personnel.
REFUSAL OF DENTAL TREATMENT
No soldier could refuse dental treatment if failure to correct the dentaldefect could normally be expected to interfere with the efficient performanceof his military duties. A War Department General Order of 31 January 1942provided that:102
In time of war if a person in the military service refusesto submit to dental or surgical operations or dental, surgical or medicaldiagnostic procedures or dental or medical treatment, such person willbe examined by a board of three medical officers convened by a corps areaor department commander or a commander of a base or general hospital, ora commanding officer of any post, camp, or station where there are fouror more officers of the Medical Department on duty. If, in the opinionof the board, the operation or diagnostic procedure or medical or dentaltreatment advised is necessary to enable such person to perform properlyhis military duties and will normally have such effect, and he persistsin his refusal after being notified of the findings of the board, he maybe tried by court martial.
In practice, it was seldom necessary to apply the provisions of thisorder, but it recognized that a soldier had no right to maintain a conditionwhich 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 ofthe war was the tendency of dental surgeons to prescribe daily quotas ofoperations to be performed by their subordinates. The plans proposed rangedfrom a simple requirement that each dental officer complete from 10 to30 fillings a day, to ingenious schemes under which the dentist received"points" of credit for each different operation, with a minimumtotal established for the day's work. The Pressure on the dental clinics,especially in the camps which were preparing men for duty overseas, wasso formidable that it is not surprising that heads of clinics sometimesfell back on desperate measures to speed treatment. The Dental Divisiondid not minimize the need for maximum output of all clinics, but the defectsof any quota system were so serious that all such plans were disapprovedindividually and in principle. Among these defects the following were mostimportant:
102WD GO 8, 31 Jan 42.
224
1. The dentist who produced superior work was made to appear inferiorto 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 prescribedaverage. The slow operator could increase his speed only at the expenseof quality.
3. When too high quotas were established the conscientious dental officer,who required no spur, became discouraged and apathetic. The lazy operatorcould easily take refuge in such practices as falsifying records, selectingonly the smallest cavities for attention, polishing old fillings to makethem appear new, and generally doing slipshod work.
The Dental Division wanted to handle the question of quota dentistrywith as little publicity as possible and no specific prohibition againstit was ever published, but repeated statements of policy in respect to"quality versus quantity" could have left no doubt of its officialposition. The War Service Committee of the American Dental Associationreported 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 requiredto perform services under a "speed-up" system. These complaintswere presented to officials of the armed services in Washington, who statedthat they would be thoroughly investigated and, if such practices did exist,they would be discontinued. The officials further stated that this wasnot the policy of the Corps, which was to encourage quality and not quantitydentistry, and that they would cooperate in every way possible.
The Dental Division went further to condemn even the appearance of quota-settingby registering its disapproval of such schemes as that established by theControl 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 patientsan hour. Using this figure as a norm, it rated the relative productionof the various hospitals on the basis of the number of patients actuallyseen. The response of the Dental Division to this plan was clear and tothe 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 analysisis 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 toshow a large number of examinations recorded as sittings. Likewise, a post-operativetreatment is recorded as a sitting, and an inefficient oral surgeon mighthave ten (10) post-operative treatments (sittings) when a very competentsurgeon could accomplish the same with one POT (sitting). Furthermore,an inefficient dental officer or one who wants to see the total numberof sittings high can insert one small filling per appointment (15-20 minutes),when the more efficient operator, who is vitally interested in the patientand the service, would place several fillings which would require an houror 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 Mar45, sub: Efficiency of work measurement reports of dental service, generalhospitals. SG 703.-1.
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superior filling, produces a superior denture, or whois more considerate of his patient in oral surgery, will require more timewith resultant less fillings than the careless, fast, inconsiderate operator.
A method which attempts to evaluate the efficiency ofa dental service on sittings is decidedly unfair and impractical. Sucha method places a premium on poor work, injudicious consideration of thepatient and the service, and will terminate in an inferior quality of dentalservice. This method, or any method where mathematical figures are employed,leads to false impressions, and the true values cannot be analyzed. Anyonecan pile up an impressive figure in sittings, but it is an inaccurate,incomplete, and dangerous criterion to use in determining the efficiencyof work measurement. . . .
The Army Dental Corps has been stigmatized wrongly andcriticized editorially as being interested only in, and sponsoring, quantity.This office has continually empha- sized quality with a full measure ofservice and duty hours, but never quantity at the expense of quality. Efficiencyreports such as those instituted by the Seventh Service Command . . . canonly lead to an inferior service and an inadequate evaluation of the dentalservice.
Recommend that suitable steps be taken to eliminate suchunwarranted ratings which deal with mathematical evaluation of the dentalservice.
Whenever the quota system was reported in operation at any installation,the Dental Division took prompt and vigorous action, usually in the formof a personal letter from the Director, so that the practice was graduallyand 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, proposeda plan for completing as much dental work as possible for draftees beforethey were called for active, duty. Members of the League pledged themselvesto assist in the program on a voluntary basis, without cost to the Governmentor to the individual, and The Surgeon General and The Provost Marshal Generalauthorized the local boards to refer registrants needing care to the cooperatingdentists. By 30 June 1918, 375,000 operations had been carried out by leaguemembers106 and a total of nearly 1,000,000 operations were performedby 1,700 civilian dentists during the entire war.107
World War II
During World War II no plan similar to that of the Preparedness Leagueof American Dentists was attempted. In the first place, the Army DentalCorps
105Statement of Maj Gen Robert H. Mills (Ret)to author, 8 Sep 47.
106Annual Report . . . Surgeon General, 1918. Washington, GovernmentPrinting Office, 1918, p. 413.
107The Medical Department . . . in the World War. Washington,Government Printing Office, 1923, vol I, p. 193.
226
was much better prepared to assume the burden in 1941. Also, it seemsto have been the general opinion of all concerned that the dental rehabilitationof military personnel was a responsibility of the entire nation and wastoo big a problem to be delegated to any limited group. From the startof the war, however, the American Dental Association offered to cooperatein any matter affecting the dental health of inductees.
In February 1941 Selective Service announced that a Dental AdvisoryCommittee of prominent members of the, profession had been appointed "toguide us in all matters pertaining to dentistry."108 Withthe assistance of this Committee a tentative plan for the "prehabilitation"of registrants was proposed in July 1941.109 Initially thisplan was very limited in scope, and was designed to accomplish little morethan to acquaint dentists with the, requirements for military service andencourage them to give special attention to the care of men of militaryage. Responsibility for obtaining and paying for dental treatment remainedwith the Selective Service registrant.
On 2 July 1941 a more elaborate program was proposed by the Commissionon Physical Rehabilitation, a subcommittee of the Health and Medical Committee of the Federal Security Agency. The principal provisions of thisplan were as follows:110
1. Congress to appropriate sufficient funds to defray the cost of treatmentfor men not able or willing to obtain care at their own expense.
2. State and local rehabilitation committees to be formed under thejoint auspices of the Federal Security Agency and the Selective ServiceSystem. These committees would administer the program in their areas, determinehow payment for treatment would be made, and designate the facilities whichwould 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 recordswhether or not disqualifying defects found were correctable, the registrantto 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 haveto be completed.
The Commission on Physical Rehabilitation recognized that:
Only a small percentage of the population can afford to pay or willbe willing to pay for corrective measures which may make them availablefor military or industrial service, but which do not as yet interfere withtheir present civilian occupations... Because of widespread shifting ofpopulation during and after the National Emergency, the responsibilityis national as well as local. In order to meet the situation realisticallyit is recommended that Congress enact legislation to defray the cost...Without federal legislation of this nature, it can be predicted that littleprogress in voluntary rehabilitation is to be expected.
108Rowntree, L. G. : Dentistry and SelectiveService. 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.
227
The Commission stated that:
... the alternative to such a program is lower physicalstandards of eligibility for selective service and compulsory physicalrehabilitation after induction into the Army. Action is required alongthe lines of one or the other of these alternatives, for the present standardsof physical eligibility have reduced the nation's reservoir of eligibleregistrants to a number far lower than had been expected.
In August 1941 the President of the American Dental Association urgedconsideration of the problem of dental rehabilitation in the followingdiscussion: 111
It is well-known, of course, that many registrants underthe, Selective Service and Training Act of 1940 have been rejected foractive military service because of dental defects. The large number ofsuch rejections has been a matter of grave concern to officials of theAmerican Dental Association as well as to our military authorities. A gooddeal of study has been devoted to the development of a practicable planthrough which the correction of dental defects, either before or afterthe registrant has been examined by his local draft board, can be promoted.
The problem of rehabilitation, in its initial stage, proposedcertain questions of a jurisdictional nature in addition to many others.Was a program of rehabilitation to be set up by the Selective Service Systemor was such a program to be developed by the American Dental Associationin consultation with the proper governmental agencies? What types of dentalcare would be made available under such a program?
By whom and under what conditions was dental care to beprovided for a deficient registrant? Was the financial burden of such arehabilitation 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 thatthe National Health Program Committee of that organization had been directedto cooperate with the governmental agencies and that the American DentalAssociation had officially offered its services to the Coordinator of Health,Welfare, and Related Activities in the National Defense Program, to TheSurgeon General of the United States Public Health Service, and to theDirector of the Selective Service System.
On 3 August 1941 the President of the American Dental Association calleda joint meeting of the board of trustees and members of the committeeson Dental Preparedness, Legislation, and the National Health Program. Afteran all-day session this group made the following recommendations:112
1. It was believed that dental rehabilitation would be most effectivelyaccomplished by inducting deficient registrants into the Armed Forces underlowered physical standards, necessary treatment to be rendered subsequentto induction by dental officers of the respective services.
2. If a "prehabilitation" program was considered necessaryby Selective Service, consideration should be given to a plan Similar tothat proposed by the Commission on Physical Rehabilitation. If the latterprogram were
111Robinson, W. H. : President's Page. J. Am.Dent. A. 28: 1332-1333, Aug 1941.
112Program for rehabilitation of registrants rejected for dentaldefects under the Selective Service Act. J. Am. Dent. A. 28: 1518-1519,Sep 1941.
228
adopted, however, it was recommended that the state rehabilitation committeescontemplated in the proposed plan should be headed by the ranking dentalofficer in the state government as executive officer and that they shouldinclude representatives of the appropriate state agencies, the organizeddental profession, and such other groups and agencies as were deemed necessary.The American Dental Association also recommended that the majority of themem-bers of these committees should be dentists nominated by the organizeddental profession. Local committees would be organized along similar linesunder the jurisdiction of the state committees. Standards of fees, methodsof payment, and the designation of the agencies to render treatment wouldbe largely the responsibility of the local committees.
On 9 October 1941, the President told a conference of the Secretaryof War, the Chief of Staff , and Selective, Service officials, that hedesired action to effect the rehabilitation of an estimated 100,000 menwith correctable dental defects out of a total of 188,000 rejected.113The following day the, President announced a, program to "salvage"200,000 men out of 1,000,000 rejected for all causes. He stated that treatmentwould be made available by the registrant's own dentist or physician, withthe cost borne by the Government through funds made available to SelectiveService.114 The President also stated that it was believed thatcare could be provided by local medical personnel at less cost than bythe Armed Forces.
In February 1942 the Selective Service System inaugurated a test rehabili-tationprogram in the states of Maryland and Virginia. From February to Septemberabout 300 men received medical care, but reports from the pilot test headquartersdid not distinguish between medical and dental cases, so the number ofinductees who had dental defects corrected is not known.115Average time required for dental cases was 38.5 days.116 Reportson 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, butas early as June 1942 General Lewis B. Hershey, Director of the, SelectiveService System, told the annual meeting of the American Medical Associationthat "results of the pilot test did not justify the current adoptionof a rehabilitation program on a nation-wide basis. . . ."119In July 1944 a representative of Selective Service told a SenateSubcommittee on Wartime Health and Education that:
It appears that dental rehabilitation by the armed forcesduring the basic training period of personnel offered a more logical methodthan the slower method contemplated
113Wells, C. R.: Role of dentistry in the wareffort. 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 Educationand Labor, United States Senate, Seventy-eighth Congress. Washington, GovernmentPrinting Office, 1944, pt. 5.
117Ibid.
118See footnote 115, above.
119Ibid.
229
in the offices of civilian dentists, particularly sincethe ranks of civilian dentists were becoming rapidly depleted due to thedemand for thousands of dentists by the Armed Forces and the lowering ofdental standards made more men available for military service without priordental rehabilitation.120
The Senate Subcommittee itself found that:
Early in the war, test rehabilitation programs were undertakenby the Selective Service System, but yielded meager results and were abandoned.In sharp contrast to the results of the Selective Service efforts are thoseof the Army rehabilitation program. Here remarkable success has been achieved.Approximately one and one-half million men with major defects have beeninducted and rendered fit for duty, including 1,000,000 men with majordental defects.121
It has been hinted, but not specifically stated, that the civilian prehabilitationprogram was unsatisfactory because:
1. Selective Service was too deeply involved in other matters to beable to devote the time and effort necessary.122
2. The time required for treatment in busy civilian offices Was toolong.123
3. Civilian dentists were already working at top capacity and couldnot accept new patients without neglecting essential civilian need.124
In any event, it seems clear that if the Armed Form take approximatelyone-third of the dentists in the country, the remaining dentists will betoo busy to assume responsibility for preinduction care of Selective Serviceregistrants.
The poor results attained in the Selective Service test program discouragedfurther efforts to promote large-scale dental rehabilitation by civilianagencies. The American Dental Association, which had from the first favoredrehabilitation by the Army, continued to sponsor a "Victory"program to encourage high school students to maintain dental health ona voluntary basis, but the care of inductees became the sole responsibilityof the Armed Forces.
DENTAL CRITERIA FOR OVERSEAS SERVICE
The Dental Service of World War II was organized to provide approximatelytwice as many dental officers per capita in the United States as were allottedto overseas theaters. This ratio was justified by the obvious fact thatit would be more satisfactory to carry on dental rehabilitation duringtraining rather than after the soldier had assumed his military dutiesin the field. The basic authorization of 1 dentist for each 1,200 men intactical units was expected to provide only routine maintenance care oftroops 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 definitedental standard for foreign service led to the shipment overseas during1942 and 1943 of large numbers of men with serious dental defects. Thereports of almost all theaters during this period note that their dentalfacilities were unable to cope with the unexpected demand. The SouthwestPacific Area, for instance, found that up to 80 percent of the men arrivingin Australia early in the war needed some form of dental treatment.125The Director of Training, ASF, stated as late as May 1943 that men werestill leaving replacement training centers and replacement depots for subsequentshipment overseas prior to the completion of apparently necessary dentalwork."126
On 20 June 1942 the War Department directed that all enlisted men designatedfor combat units overseas must meet physical standards prescribed in MR1-9, though limited service categories could be sent to overseas hospitalsand other Zone of lnterior-type installations.127 However, thispublication was rescinded in November of the same year.128 InOctober of 1942 it was provided that nonprogressive dental defects wouldnot bar shipment of officers overseas, implying, though not stating specifically,that other serious dental defects would prevent transfer to a foreign theater.129Neither of these directives was sufficiently explicit in respect to dentaldeficiencies.
On 26 March 1943 War Department Circular No. 85 provided that "allreplacements so ordered [overseas] will be mentally and physically qualifiedfor service in an overseas combat theater"; limited service categorieswere not to be shipped outside the continental United States.130A subsequent War Department circular stated that officers were still arrivingfor overseas shipment with Class I dental conditions and that the provisionsof the previous circular were not being complied with, so it would appearthat Circular No. 85 was intended to prevent shipment of Class I dentalcases 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 wasbeing experienced because of differences of opinion as to what constituted"dental fitness." He recommended that "definite standardsof dental requirements relative to overseas eligibility be established."131This recommendation was forwarded to The Surgeon General for comment, andon 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, forACofs, 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 priorto departure for staging areas and ports of embarkation for service overseas:"Dental correction of all Class I cases to include those with 'insufficientteeth to masticate the Army ration' as outlined in Change 1, dated September10, 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, recommendedto the Assistant Chief of Staff G-1 that approximately the same provisionsbe published as a change to War Department Circular No. 85.133This request was disapproved on technical grounds as it was desired tokeep War Department Circular No. 85 couched in general terms, with specificrequirements on any individual point to be published separately.134Definite requirements for dental health of personnel ordered overseas werefinally established in "Preparations for Overseas Movement,"in August 1943, as follows:135
All necessary dental treatment, from a health and functionalstandpoint, will be provided troops prior to their departure from homestation. The following policy will govern dental qualifications for overseasservice: 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 CircularNo. 189, published 21 August 1943.136 These directives remainedin effect during the remainder of the war, though a slight modificationwas made in June 1945 when the suspicion that some men were intentionallydestroying their dental appliances to delay shipment caused the War Departmentto direct that soldiers requiring dentures were not to be withheld fromshipments if they had been able to perform their military duties previouslyand if their history indicated that replacement was not absolutely essential.137
It will be noted that the published standard did not make, mandatorythe completion of all dental treatment. In fact, the Director of the DentalDivision stated in September 1943 that it was physically impossible tocomplete all work prior to shipment.138 Routine care of nonemergeneyconditions was to be rendered whenever possible, but a man was not to bekept from shipment overseas for such treatment.
The order directing that essential dental care would be rendered beforedeparture for a combat area was aimed more directly at commanding officersthan at dentists. Prior to its publication, unit commanders had been extremelyreluctant to release men from training schedules for dental appointments;now
1321st ind, SG, 5 May 43, on memo cited infootnote 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 overseasreplacements. SG: 702.-1.
134Memo, R. W. Berry, Exec Off, ACofS, G-1, for TAG, 17 May43, 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]
232
they knew that they would lose the men anyway if the latter did notmeet required standards when the unit went overseas, and they vigorouslysupported the dental surgeon's efforts to provide urgent treatment.
As a result of improvements in dental facilities, and the establishmentof definite standards for foreign service, men received as replacementsoverseas after 1943 were in much better dental condition than those whopreceded them. The change was so marked, in fact, that the Southwest PacificArea, which had claimed that 80 percent of new troops needed dental care,now reported that 85 percent were in Class IV on arrival.139 Ingeneral the shipment of men in poor dental condition ceased to be a seriousproblem in the latter part of 1943.
USE OF CIVILIAN DENTISTS
The amount of dental care rendered military personnel by civilian dentistsduring World War II was not important in spite of the fact that such attend-ancehad been authorized, in an emergency, for many years. In October 1925,AR 40-510 provided that when no dental officer was available, emergencycivilian dental treatment could be obtained by military personnel on aduty status at Government expense and without prior authority. Routinedental care could be provided with the prior authorization of The SurgeonGeneral.140 Military personnel on duty overseas without troopscould procure civilian dental attendance without prior authority, subjectto later approval by The Surgeon General. In July 1942, it was furtherauthorized that personnel on leave or furlough could procure emergencydental care at Government expense.141
The cited regulations were not interpreted to authorize civilian dentaltreatment as a routine procedure when Army facilities were inadequate dueto shortages of equipment or personnel, though such an interpretation waspossible and it was actually the basis for the use of civilian dental laboratorieson 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 annoyingproblem throughout the war. Varying circumstances led to this waste ofeffort and materials. In many cases dentures were lost through simple failureto observe normal precautions in caring for a fragile and expensive appliance.The soldier who daily saw millions of dollars worth of property destroyedwas not likely to be impressed with his responsibility for such a smallitem as a denture. In time of stress the denture often went into a hippocket, where it suffered irreparable damage when its owner rode in a truckor hit a fox-
139See footnote 34, p. 206.
140AR 40-510, 10 Oct 25.
141See footnote 31, p. 205.
233
hole. Some were lost because soldiers neglected to remove them whenthey became nauseated on a sea-crossing. Also, since the appliance costthe soldier nothing, he was likely to be very impatient of defects. Itwas reported that in some cases men discarded dentures if a single toothwas broken because they knew that a new one would be forthcoming withoutdelay.142 It has also been stated that partial dentures containinggold were occasionally sold in France, where they brought a good price.143
Even more serious in its effect on morale was the intentional destructionof dental appliances to avoid dangerous duty or to delay departure foran overseas theater. The Commanding General of the Army Ground Forces statedin April 1943:
Although it is not possible to obtain positive evidencein any considerable number of cases, this headquarters has observed indicationsthat individual enlisted men in proper dental condition upon departurefrom Replacement Training Centers have destroyed their dental fittingsand rendered themselves unsuitable for overseas shipment, with a view toshirking hazardous duty.144
The North African theater reported in January 1944:
It is impossible to say that men break or lose their denturesintentionally, but the incidence of this type of accident is so high thatthe suspicion seems warranted.145
The Seventh Army, in the Mediterranean area, noted that:
Accurate figures were not available as to the deliberate loss or breakageof dentures in order to be evacuated from combat, but it was believed thatthe rate was highest just before and during amphibious operations.146
One step recommended to give dental surgeons information on past prosthetictreatment was to record dental appliances in individual service records.147The Dental Division did not concur in this plan since it was believed thateven with a clear record that a denture had existed, it would be impossibleto prove intent in case of loss or destruction.148 The furthercourse of this recommendation is not certain, but a War Department directiveof 1 August 1943 provided that dentures would be listed in the servicerecords of enlisted men going overseas.149 In October 1943 itwas further provided that prosthetic appliances of officers be listed inthe Immunization Register.150 In January 1945 the War
142The fact that soldiers discarded dentureson slight provocation was reported by the 5th Auxiliary Surgical Groupin Europe. This report was seen by the author in 1946 but it was subsequentlylost 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 surgeonin Europe during the war.
144See footnote 142, above.
145Essential Technical Medical Data Report, Headquarters, NorthAfrican 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.
234
Department finally directed that a record of all prosthetic appliancesbe entered in the individual's Immunization Register.151
Late in 1943 the question of charging military personnel for dentalappliances lost through carelessness or intent was brought up by the ArmyGround Forces Replacement Depot No. 1, at Fort George G. Meade, Md. Thisstation reported that men who had been given replacements were arrivingwithout them and stated its intention to enter a statement of charges insuch cases.152 At about the same time the Army Service ForcesReplacement Depot at Camp Reynolds, Pa., reported that in a recent shipmentto that station 18 men were found not to meet dental requirements for overseasduty. Investigation showed that 9 of these men had been supplied dentureswithin the past 3 months. One had been given his replacement only a fewdays before. None had any reasonable excuse for the shortage. This stationtherefore recommended that dentures be entered on the individual soldier'srecord of personal equipment and that a charge be made in case of negligentloss.153 On the basis of these recommendations the CommandingGeneral, Army Ground Forces, asked The Adjutant General for an opinionas to the legality of making a charge for dentures and spectacles lostthrough carelessness. Noting that "There have been cases where itis apparent that enlisted men have willfully destroyed or wrongfully disposedof dentures and spectacles in order to forestall their shipment overseas"and that "such acts are highly prejudicial to good order and militarydiscipline" AGF recommended that "in the event that soldierscannot be penalized under present regulations for loss or destruction ofthe subject items . . . regulations be changed so that punitive actionmay be sustained, at least to the extent of requiring enlisted men to payfor such losses."154 The Adjutant General referred thematter to The Surgeon General for comment and the latter stated that inthe opinion of his Legal Division dentures and spectacles became the personalproperty of the soldier and that there was no basis for a charge even ifthe man deliberately destroyed the appliances. He stated further that hisOffice would be opposed to establishing property accountability for denturessince it was believed that the procedures involved would be too cumbersometo justify the effort. The Surgeon General recommended, as an alternative,that court martial action be taken to punish offenders.155 TheAdjutant General concurred in the recommendations of The Surgeon Generaland notified the Commanding General, AGF, that men could not be chargedfor 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.
235
of The Judge Advocate General's Office confirmed the opinion of theLegal Division, SGO, that military personnel could not be charged for dentalappliances under existing regulations.157
As a result of the above opinions no further attempt was made to penalizesoldiers for the loss or destruction of dental appliances. It was truethat a man could be tried for such action, but the burden of proof wason the prosecution and the very nature of the offense was such that nomatter how strong the presumptive evidence it was practically impossibleto prove intent to the degree required for conviction before a court martial.
The chief of the Operations Service, SGO, suggested in 1944 that portmedical officers should hold as few men as possible for the replacementof dentures;158 and a War Department circular of June 1945 providedthat Class I dental patients who needed only replacement of missing teethwould not be held back when they had previously performed their militaryduties satisfactorily and if their history indicated that restoration wasnot necessary.159 In May 1944 it was directed that all dentureswould carry the names and serial numbers of their owners, partly to assistin the return of lost appliances and partly to aid in identification ofthe patient in case of accident.160 All of these measures didnot greatly deter the few men who were inclined to use any means to avoidshipment overseas, or any other dangerous assignment, from "losing"or destroying their dentures.
It would appear that a practical solution to this problem would be toenter dental appliances on the list of articles for which the soldier isresponsible, to be paid for if lost through negligence. Under such circumstances,a commanding officer could collect the cost of a denture through a simpleadministrative action. No charge would have to be made if negligence werenot involved, but the soldier would have the same responsibility for adental appliance as for any other valuable piece of equipment issued forhis 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 shortageof satisfactory artificial eyes. Replacements were needed for the casualtieswhich were arriving from the battle zones and physical requirements hadbeen lowered to permit the induction of men with only one eye. At the sametime, the normal supply of glass eyes from Europe had been cut off. Ordinaryglass eyes had many disadvantages for military use. They were extremelyfragile and even
157Bulletin of the Judge Advocate General ofthe 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 ConsultantsDivision, in 1947, in a statement to the author said that he favored somesystem for property accountability for dental appliances.
236
small factors like sudden changes in temperature might result in breakage;they became etched in the fluids of the socket so that they required frequentreplacement; custom-fitted eyes for difficult conditions required as muchas 2 months for construction and some men lost up to 8 months' duty ina single year while getting successive eye replacements; stocks of as manyas a hundred thousand eyes were required for the proper fitting of onlya thousand patients.162 As a result of this situation whichwas almost as serious for the civilian population as for the military,several agencies undertook investigations to develop an artificial eyewhich would readily be available and which would be superior to the glasseye in common use.
A clear synthetic resin (methyl methacrylate) had been in use for someyears for the construction of artificial dentures. It was strong, welltolerated by human tissues, and easy to form into irregular shapes. Itis not surprising, therefore, that the idea of using this material forocular prostheses suggested itself to several persons at approximatelythe same time.163 As early as 1941 the pink acrylic resin usedin denture work was made up into temporary eyes to maintain socket formuntil a permanent appliance could be placed.164
Captain Stanley F. Erpf, DC, on duty with the 30th General Hospitalin England, was probably the first Army officer to produce a satisfactoryacrylic eye; Captain Erpf 's own statement of his work is as follows:165
May 1943 to December 1943. Initial research begun. Forty prosthesesconstructed for patients of the 30th General Hospital. December 1943.Research report and training manual written and submitted to the Officeof the Chief Surgeon, ETOUSA. January 1944 to May 1944. Trainingprogram conducted at the 30th General Hospital for 40 U.S. Army and 10British Army dental officers.
June 1944. Training center at 30th General Hospital terminated andCapt. Erpf en route to the United States to aid in setting up center atValley Forge General Hospital in the United States.
July 1944 to December 1944. Research and training program conductedat Valley Forge General Hospital in collaboration with Major Victor Dietzand Major Milton Wirtz, who had also been working independently on developmentof the acrylic prosthesis.
At approximately the same time that Captain Erpf was doing his workin England, Major Victor H. Dietz and Major Milton S. Wirtz were experiment-ingalong similar lines at Thomas M. England General Hospital, Atlantic City,N.J., and at Camp Crowder, Mo.166 It appears that these twoofficers of the Dental Corps produced acrylic eyes for patients somewhatlater than Captain
162Randolph, M. E. : History of the artificialeye program (glass and plastic), 2 Jan 46. HD: 314.7-2.
163At least three Army Dental Corps officers and an unknownnumber of Naval officers and civilian investigators apparently worked independentlyalong similar lines.
164Holmes, A. G. : Use of acrylic resins in the constructionof temporary artificial eyes. Dental Bulletin, supp. to Army Medical Bulletin12: 265-266, Oct 1941.
165Personal letter from Dr. Stanley F. Erpf to the author, 9Oct 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 UnitedStates Patent Office. In any event, each worked on his own initiative andeach was awarded the Legion of Merit for his contribution. In July 1944both officers joined Captain Erpf in developing a standard technique.
The acrylic eye proved so superior in every respect that it was eventuallyadopted as the exclusive type of replacement by the Army. In October 1944it was announced that 12 Eye Centers would accept patients for acryliceyes, though glass eyes were still furnished on request.167By August 1945, 29 general hospitals and 1 regional hospital were renderingthis service.168 The exact number of acrylic eyes constructedis not known, though 7,500 appliances had been made in the United Statesalone by October 1945.169 170 Captain Erpf estimated that about10,000 eyes were made in the first 18 months of the program.171 TheArmy technique was adopted by the Veterans Administration when it tookover responsibility for the continued care of former soldiers. The partplayed by dental officers in developing and staffing the artificial eyeprogram 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 efficiencyof hearing-aids depended to an important extent on the accuracy with whichthe receiver was adapted to the external auditory canal. An ear mold custom-fittedto the individual case eliminated outside noise, prevented "feedback"to the receiver, and channeled sound waves directly to the tympanum withoutloss of intensity. At the start of the war, ear molds were being constructedby civilian laboratories from individual impressions of the canal, butthis system was not altogether satisfactory for the following reasons:173
1. Patients had to be held in the hospital while time was lost in mailingwork to commercial laboratories.
2. Impressions were subject to distortion or breakage in the mail.
3. Commercial laboratories could not take chances on their ear moldsimpinging on the tympanum so they habitually shortened the mold to a degreewhich 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 Administrationwhen 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 acryliceye is not considered in detail in this discussion because it is believedthat only the U.S. Patent Office can evaluate claims of the military andcivilian personnel involved.
173McCracken, G. A. : Construction of ear molds for hearing-aidappliances. 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 ina. laboratory established in the hospital itself. The project appearedpractical and it was presented to the Dental Division and The Surgeon Generalfor approval. The Surgeon General not only concurred in the plan but alsodirected that laboratories be established at Borden General, Hospital (Chickasha,Okla.) and Hoff General Hospital (Santa Barbara, Calif.).174The laboratories were supervised and operated by dental personnel becauseof their experience in taking impressions and handling plastics. Improvementswere made in the techniques commonly used by the commercial laboratoriesand the work produced was eminently satisfactory. While it is not yet knownhow many ear molds were fabricated, it was reported that Deshon GeneralHospital alone employed 6 technicians on 2 shifts to turn out from 250to 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 theArmy in September 1942. They were found to be strong and well-tolerated,but the fabrication of a plate with irregular outline and contour offeredconsiderable difficulty. Lt. Col. Arthur J. Hemberger, of the Dental Serviceat Walter Reed General Hospital, suggested that dental procedures mightbe applicable to the problem and thereafter dental officers were giventhe responsibility for taking impressions of cases before operation andforming appliances which could he adapted with a minimum of alterationat 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 thismodel dies were formed which were used to mold the sheet of tantalum underhigh pressure. The plate was then trimmed to the desired outline on themodel and was ready for insertion after cleaning and sterilization.
This technique was described to Army neurosurgeons at the annual meetingat Walter Reed General Hospital in 1943. Motion pictures of the processwere distributed throughout the Army and Navy and the method was reportedin the Journal of Neurosurgery in 1945.176 177
174Ibid.
175Ibid.
176Hemberger, A. J. : The fabrication of tantalum plates forthe repair of skull defects. HD 314.7-2.
177Hemberger, A. J. ; Whitcomb, B. B. ; and Woodhall, B.: Thetechnique 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 importantdental diseases during the period 1 January 1942 through 31 August 1945.Tables 7 through 14 show the more significant treatments rendered in thesame period. (In some instances, reports on the incidence of dental diseases,and the amount of treatment rendered, contained no breakdown for militaryand "other" personnel; however, the number of "others"treated was generally so small that the rates for military personnel werenot greatly affected.) The incidence of five important dental diagnosesare shown graphically in Charts 2 through 6. Considerable confusion hasexisted in the dental profession concerning the diagnosis of Vincent'sinfection. It is probable that the rates reported for this disease wereexcessive and included many cases which should properly have been listedas "gingivitis." The statistics shown for Vincent's stomatitisare probably no more nor less accurate than those which would have beenobtained from a similar group of civilian dentists.
CHART 2. INCIDENCE* OF CELLULITIS OFDENTAL 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 statisticaldata 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 receivedin the Dental Division, SGO.
240
CHART 3. INCIDENCE* OF FRACTURED MANDIBLESIN THE UNITED STATES ARMY, 1938-1945.
*Includes new cases, readmissions, and both in- and out-patients.
Source: Bar graphs (1938-40), prepared from statisticaldata 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 receivedin the Dental Division, SGO.
241
CHART 4. INCIDENCE* OF FRACTURED MAXILLAEIN THE UNITED STATES ARMY, 1938-1945.
*Includes new cases, readmissions, and both in- and out-patients.
Source : Bar graphs (1938-40), prepared from statisticaldata 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 receivedin the Dental Division, SGO.
242
CHART 5. INCIDENCE* OF OSTEOMYELITISOF 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 statisticaldata 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 receivedin the Dental Division, SGO.
243
CHART 6. INCIDENCE* OF VINCENT'S STOMATITISIN THE UNITED STATES ARMY, 1938-1945.
*Includes new cases, readmissions, and both in- and out-patients.
Source : Bar graphs (1938-40), prepared from statisticaldata 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 receivedin 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 bothinpatients and outpatients.
2Except where otherwise indicated, consists of Army personneland 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 notreported separately from "Army" personnel. The statistics shownfor "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 inthe Dental Division, SGO.
245
TABLE 5. INCIDENCE1 OF VINCENT'S STOMATITIS, UNITEDSTATES 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 bothinpatients and outpatients.
2Except where otherwise indicated, consists of Army personneland 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 notreported separately from "Army" personnel. The statistics shownfor "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 inthe 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 bothinpatients and outpatients.
2Except where otherwise indicated, consists of Army personneland 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 notreported separately from "Army" personnel. The statistics shownfor "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 inthe Dental Division, SGO.
247
TABLE 7. PERMANENT FILLINGS PLACED BY THE UNITED STATES ARMYDENTAL 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, consistsof 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 greatincrease in treatment after 1943 largely represents care given prisonersof war.
3Data are for 1 January-31 August only.
Source: Compiled by the author from reports received inthe Dental Division, SGO.
248
TABLE 8. EXTRACTIONS PERFORMED BY THE UNITED STATES ARMY DENTALSERVICE,
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, consistsof 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 inthe Dental Division, SGO.
249
TABLE 9. FULL DENTURES CONSTRUCTED BY THE UNITED STATES ARMYDENTAL 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 ofdependents, civilian employees, and a negligible number of Navy and Alliedmilitary personnel.
2Data are for 1 January-31 August only.
Source: Compiled by the author from reports received inthe Dental Division, SGO.
250
TABLE 10. PARTIAL DENTURES CONSTRUCTED BY THE UNITED STATESARMY 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, consistsof 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 inthe Dental Division, SGO.
251
TABLE 11. DENTURES REPAIRED BY THE UNITED STATES ARMY DENTALSERVICE,
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, consistsof 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 inthe Dental Division, SGO.
252
TABLE 12. FIXED BRIDGES CONSTRUCTED BY THE UNITED STATES ARMYDENTAL 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, consistsof 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 inthe 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 per100 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 ofdependents, civilian employees, and a negligible number of Navy and Alliedmilitary personnel.
2"Others" include prisoners of war, in addition tothose listed in footnore 1.
3Data are for 1 January-31 August only.
Source: Compiled by the author from reports received inthe Dental Division, SGO.
254
TABLE 14. DENTAL PROPHYLAXES PERFORMED BY THE UNITED STATESARMY 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, consistsof 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 inthe Dental Division, SGO.
255
DISCHARGES FOR DENTAL DEFECTS
Discharges for physical disability due to dental defects were negligibleduring the war. Of 956,232 enlisted men separated from the Army for disabilityfrom January 1942 through December 1945, only 312 were separated due topathology of the teeth.178 This figure, however, does not, coverother possible losses due to dental or oral defects since oral structuresmay have been involved for some of the men reported as separated for otherdiseases or traumatic injuries.
CASH VALUE OF TREATMENT RENDERED BY DENTAL OFFICERS
Table 15 gives the average number of five of the more important operationscompleted per dental officer per year in the continental United States,overseas, and in the Army as a whole, for the period 1 January 1942 through31 August 1945. Under Veterans Administration fee-schedules published inMay 1946 the average yearly work of each dentist, for these five itemsonly, would be valued at over $16,000 a year. The value of the other miscellaneouscare given cannot be determined with accuracy, but since it constitutednumerically more than half of all treatments rendered, an estimate of $4,000a year would seem conservative, bringing the gross value of the dentalofficer's yearly work to about $20,000.
178Separations from the Army for Physical andMental Reasons, Health of the Army, Vol 1, No. 2, Aug 1946, pp. 20-23.
256
TABLE 15. AVERAGE NUMBER OF FIVE PRINCIPAL OPERATIONS COMPLETEDPER 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 thenumber of dental officers overseas and in the continental United States.
2Average based on figures for the period 1January-31 August1945.
3Averaged based on figures for the period 1 January 1943-31August 1945.
