Orthodontics in communal settlements kibbutxim) in Israel

Abraham Golden, B.D.S.(Randl, H.D.D., D.Orth. R.C.S.(Eng.)* London, E?tgland

C ommunal settlements, or kibbutzim, form the main basis for agricul- ture in Israel’ ; they number well over 300 and are scattered throughout the country. The population of a kibbutz may vary from 100 men, \vomen, and chil- dren to more than 1,000.

The center of a kibbutz reminds one of a modern village. At the entrance are the sheds where the agricultural equipment is stored, large workshops where machinery is repaired and serviced, and the carpentry shop where the kibbutz furniture is made and repaired. In addition to fields, orchards, and fish ponds, most of the established kibbutzim have factories which may produce anything from plastic toys to sophisticated electronic equipment. The heart of the kibbutz is generally a complex of strikingly modern concrete and glass buildings which house the dining room, communal center, and other recreational rooms. Radiating from this center are the single- or double-story apartments in which the kibbutz members (or kibbutzniks) live. Between all are well-tended lawns, flower gardens, and trees. The children’s houses, playrooms, and classrooms catch the eye with their decorative appearance and brightly colored playground equipment. The roads and paths within the kibbutz are generally asphalted and well lit, but motor-driven vehicles are forbidden.

Meals are prepared in large, well-run kitchens and eaten in the communal dining room. The self-service style is popular. Enormous mechanical dishwashers take care of the mountains of dirty crockery. In the evenings, the kibbutz provides films, concerts, plays, and musical entertainments; well-known actors and musi- cians from the city often include the kibbutzim in their itinerary. Or one may spend the evening in the library, the television room, or simply chatting with friends in the kibbutz coffee bar. The consumption of alcohol, although not offi- cially forbidden, is usually reserved for the odd festive occasion. Young volunteer workers from abroad occasionally break, at least temporarily, the accepted social patterns of the kibbutz.

*Formerly Senior Orthodontist, Tel Hashomer Hospital, Tel Aviv, Israel.

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The kibbutz thus provides its members with board, accommodation, food, clothing, and all other facilities; it expects, in return, that the members do their share of the work. The men are engaged in agriculture (the cultivation of fruit, vegetables, flowers, and cotton, dairy farming, and chicken raising) and also work in the kibbutz-based industries. The women are generally employed as teachers, nurses, and seamstresses ; they also engage in certain branches of agriculture and work in the kitchen and the laundry.

From the income derived from agriculture and local industry, the kibbutz is able to provide for its members. The primary aim of the kibbutz, through its communal way of life, is to raise the quality of life for the individual, and in this regard strict business considerations in the management of the kibbutz are some- times laid aside.

Kibbutz children

The rearing and education of children constitute a very special feature of kibbutz life, and its uniqueness has aroused a great deal of interest among edu- cationalists and psychologists.*

Unlike the city child, the kibbutz child is brought up with a group of children of the same age. Apart from a few hours per day, which is spent in the company of his parents, most of the child’s time is spent with his own group. The children eat and sleep away from their parents, in their own quarters (the children’s houses), and are cared for by specially trained women-the mitapelets, who com- bine the qualities of child-minder, teacher, psychologist, and mother.

Thus, from the age of a few weeks to the age of 18 years, the child lives with his own peer group. The children visit their parents in the afternoon, when the parents have rested after their working day, and the hours spent together are often in circumstances more favorable than those which prevail in the average city home. Parents are free from economic and household cares and are able to devote themselves more fully to their children. Nevertheless, it is claimed by some observers that the child’s most intense loyalty is to the other members of his own group and not to his parents. Generally the children do have a different attitude toward adults and toward the traditionally respected figures, such as the phy- sician or dentist.

Education and schooling are provided either on the kibbutz itself or at a neighboring regional school which serves three or four kibbutzim. Music lessons and art classes are made available for the talented. Some young people are sent to the universities to study teaching or engineering. The traditional professions of law and medicine seem to have little attraction for the kibbutz school graduate. From an early age, the children usually spend several hours per week working in the fields, as the ultimate aim is that they should become useful members of the kibbutz, which is primarily a farm in spite of its many unusual features.

Kibbutz dentistry

Medical care is provided for kibbutz members by physicians who may live on the kibbutz or visit it several times per week, traveling from a nearby town or city. Each kibbutz has a well-constructed and well-equipped polyclinic which has a

suite of dental offices attached to it. The dentist is usually a practitioner from a neighboring town who pays several visits to the kibbutz during the week; OF casionally, a dentist is an actual resident of the kibbutz.

I was orthodontist to a group of fifteen kibbutzim in the Jczrcel and Beisalr Valleys in the northwestern part of Israel for a period of 5 years from 1970 to 1975.

The facilities providecl on most kibbut,zim for dental treatment range from adeyua,te to very good, depending very much on the dentist in charge. Two of the kibbutzim had American-trained dentists who were resident, and the standard there was extremely high. These dentists were refreshingly progressive and cn thusiastic in their approach, and, among other projects, they managed to institute a fluoride tablet scheme on their kibbutzim; in a matter of a few years, these two kibbutzim should become models of good dental cart.

The dental assistant plays a key role. In addition to routine chairside assist- ance and administrative duties, slit acts as a liaison between the orthodontist, the parents, the children, and other interested persons, such as the teacher and the mitapelef. Payments are approved by t,hc Kibbutz Medical Committee, and the assistant, as a member of the kibbutz, may be called upon to explain cxccp- tional procedures to the Committee-especially those which involve the expendi- ture of large sums of money. At the beginning, T found the dental assistants of particular help t,o me, in riew of my initial unfamiliarity with the language, manners, and customs.

The standard of these dental assistants varied enormously. Some were full- time assistants, whereas others were employed only part time and were engaged in a. variety of other occupations, such as cosmeticians or cooks. A few had corn- pleted formal courses at a university dental school; others had attcndecl annual short refresher courses and lectures provided by the Ministry of Health. As I visited each kibbutz only once every 4 weeks, some degree of responsibility de- volved on the assistants, who had to see to it that the patients wore their ap- pliances and kept their teeth clean.

I traveled from Tel Aviv to the kibbut,zim once a week, treating children from three or four different kibbutzim on each weekly visit. In this manner, I visited each kibbutz once every 1 weeks. The attitude of the children initially puzzled, interested, and occasionally irritated me. I-Tow different they appeared from the London children with whom I had formerly worked! They were noisy and out- spoken, asked innumerable questions, and correctecl my Hebrew. With time, my Hebrew improved, as did my understanding of my new patients and their environment. The traditional authoritarian relationship between doctor and pa- tient was simply not applicable, given the totally different patterns of child rearing. T answered their questions as patiently as I could, and as the months passed, I succeeded in building up a good working relationship with the children. Their responsiveness and liveliness more than medc up for their informalit and unconvent,ional behavior.

A kibbutz is run by various committees which are elected by its members; in- clividuals are given a small personal allowance but otherwise seldom handle money. The idea of money was also somewhat foreign to the children. Thus,

Orthodontics iv& commurwl settlemeflts i,b Isrnel 681

parents and children were often oblivious of the costs involved in orthodontic treatment. This no doubt was in part responsible for the fact that removable ap- pliances were carelessly handled and often lost on some of the kibbutzim. Al- though the cooperation of children and parents was generally good, one felt that it might have been even better if they had been more involved with the financial aspects of treatment.

Early problems

RIJ- first few months were spent in sorting out and re-assessing about 200 casts in various stages of treatment. In the majority of these cases, patients were being treated with removable appliances, consisting mainly of expansion screw plates.

Israeli orthodontics was influenced to a large extent by the European con- cepts of the 1920’s and 1930’s. According to certain of these schools, space in crowded arches could be created by bilateral expansion; activators were used on the basis that they influence the growth of the jaws and could cause a favorable repositioning of the mandible. Multiband and extraoral appliance therapy was seldom, if ever, employed.

Although I favored the use of the edgewise mechanism, it was apparent that it. would be impractical and unacceptable to substitute multiband appliances for removable appliances in a short space of time.

Three factors had to be taken into account : 1. Eco?zon~ics. The inability and understandable unwillingness of most of

the kibbutzim to pay for the quadrupling in costs of orthodontic treat- ment, which the general use of multiband appliances would entail.

2. Ti?)le. Ny own time was limited and I therefore had to curtail, at that stage, the use of the more time-consuming multiband techniques.

3. Traditions. Removable appliances were very much the accepted mode of treatment in Israel, whereas bands had been regarded with suspicion and even distaste. However, in addition to the fact that the society is mobile and susceptible to new ideas, the use of banded techniques was given a fillip with the immigration of several English-speaking ortho- dontists in the early 1970’s. As a consequence, the public gradually ac- cepted banded techniques and came to recognize that, with their use, treatments could be rapidly and effectively completed.

On the kibbutzim on which I worked, this process was facilitated by the cooperation of some of the dental assistants, who had either witnessed the use of modern orthodontic techniques at the university dental schools or had attended short courses. Given the limitations imposed by these factors, I was obliged to evolve some reasonable system that would conform to my preferred methods of treatment and would yield acceptable and pleasing results. I therefore decided, during the initial period of my work on the kibbutzim, that I would use simple removable appliances wherever possible and resort to multiband appliances only in those cases where a reasonable result was beyond the scope of the former. I intended to introduce the use of banded techniques gradually and expected that, in the course of time, the progress achieved with the banded cases would provide

682 Golderl

positive proof of the efficacy of the technique. At the same time, fears that the teeth might be harmed by the bands would be allayed.

The use of extraoral appliances also met with some initial opposition, and the cooperation of the children was disappointing. It was found, however, that when grozbps of three or four children on a particular kibbutz wore the extraoral or any other appliance unfamiliar to them, they became more cooperative. Most orthodontic appliances are, to some extent, esthetically objectionable and uncom- fortable, but it is fair to say that, once the group accepts them, the individual child is more ready to accept them too. When one remembers that kibbutz chil- dren always lire in groups, this approach was obviously the better course to adopt.

Orthodontic procedures

The selection of CUSBS. I examined the children at least once a year, starting from the age of 8, and younger children were occasionally referred by the kibbutz dentist for an opinion. At other times, I consulted the dentist about certain cases. In this way, the majority of children were screened and treatment could be started at the optimum time.

On the kibbutz, the potential cooperation and readiness for treatment of the child was assessed in conjunction with the dental assistant; occasionally, the parents or mitapelet were also called in.

In Israel, bimaxillary protrusions are fairly common and, therefore, more acceptable; the decision to treat such cases was often a very fine one, requiring more than one consultation with the child and parents. (In some cases the deci- sion to treat was clearly not a difficult one.)

The ethos of masculinity, which prevails on the kibbutz, not infrequently affects the teen-age boy in his attitude toward orthodontic treatment and was a factor that had to be taken into account in the selection of cases. A boy who is apparently unconcerned about his appearance and is skeptical of orthodontic treatment is not a potentially good patient. In some cases, the wiser course was the indefinite postponement of treatment. \Vhatever ultimate decision was reached, I had to explain, as simply and as clearly as possible (with the aid of models and pictures), what the implications of treatment or nontreatment were.

li=arly freatnumt. Protracted orthodontic treatment, beginning at a very early age and continuing for 4 or more years, was not uncommon in Israel. In spite of parental pressure, 1 confined treatment in the deciduous dentition to a minority of cases and regarded such early treatments as only the preliminary stage of the main procedures to be carried out in the permanent dentition.

The main examples of this type of treatment are : 1. Anterior and posterior cross-bites treated with a simple plate. 2. Simple Class III cases requiring the proclination of the upper incisors

and combined occasionally with the retroclination of the lower incisors. 3. Certain types of Class II, Division 1 malocclusion, which were consid-

ered aincllahle to ~~rdreSS~~l1 appliance th(>rapF and which wt’rt’ selected according to the following criteria :

Volume71 Number 6 Orthodontics in communal settlements in Israel 683

(a) Skeletal dysplasia deemed to be due more to a postnormal mandible than to a maxillary protrusion.

(b) Upper incisors proclined and spaced. (c) Uncrowded or spaced arches. (d) Low FMA. (e) Patient assessed as being above average in potential cooperative-

ness. 4. The incidence of thumb-sucking is relatively high, as shown on a survey

which I conducted in July-August, 1975, on more than 600 kibbutz children, between 7 and 12 years of age. Fifty-one per cent of this group had sucked their thumbs at least until the age of 4. Biittner3 found an in- cidence of 55 per cent in a group of Swiss children, but in three other countries the incidence was found to be less. Popovitch4 reported an incidence of 41.9 per cent in a group of Canadian children ; Bralack and Frisk” found an incidence of 30.7 per cent in Swedish children; and Gardiner” reported an incidence of 27.2 per cent in English children. The thumb-sucking problem on the kibbutz has several interesting psy- chological aspects, which will be dealt with in another article. Of pri- mary practical interest, however, is the fact that thumb-sucking is a main or contributory etiologic factor in many cases of malocclusion on the kibbutzim. The most prevalent type of malocclusion is the Class II, Division 1, with proclined, spaced incisors frequently associated with some degree of open-bite. The fitting of a simple removable appliance to retract the upper incisors effectively improved facial esthetics, pre- vented possible injury to the incisors, and frequently discouraged thumb-sucking.

5. Mild Class II, Division 1 cases requiring the initial correction of the molar relationship often responded well to extraoral appliance therapg in the deciduous-dentition stage.

Apart from the foregoing examples, treatment was usually postponed until the permanent-dentition stage. Multiband appliances were generally used in the more complicated cases, which presented the following features :

Class I (a) Crowded cases involving extractions and space closure. (b) Cases involving the apical root movement of canines. (c) Treatment of lower incisor crowding involving the extraction of one

lower incisor. (d) Correction of incisor rotations and midline discrepancies. Class II (a) The correction of deep overbites. (b) The retraction of vertically inclined or retroclined incisors. (c) Cases involving upper and lower arch treatment. True Class III These cases were ext,remely rare. As the majority of cases which presented themselves for treatment were USU-

ill,,. ,I. O??hod. .Juw 19ii

ally amenable to simple procedures the use of complicated techniques was limited, by and large, to cases of the types enumerated above.

The reasonable compromise in public health orthodontics

Bccausc of the nature of the kibbutz and its unique system of bringing up children, orthodont,ics on the kibbutzim does present several unusual features. However, the problems which the ort,hodontist generally faces arc the same as those he would encounter in a public clinic, hospital, or other public service in- stitution, that is, in all practice other than the priyate office.

The limitations which exist, in public health orthodontics arc not usudly associated with private practice, but thr> lat>ter can meet only a relatively small proportion of the orthodontic needs of the majority of communities. Outside the private practice, the orthodontist is faced with the problem of having to strike a balance between what he would like to achieve and the limitations imposed by time, money, and the social structure of the community in which he works. On the other hand, the popularity of more complicated, expensive, and time-coa- suming techniques is on the increase, and orthodontists are aspiring to achieve a higher standard of results,

Taking all these factors into account, a reasonable compromise is possible; there must be a rational selection of cases and a separat,ion of those which can be successfully treated by simple appliances from those in which it is essential to employ more complicated techniques. In treating orthodontic cases on the kibbutzim, this was the compromise that I at,temptrd to reach.

The questions raised 1),x- my esperience on the kibbutzim, although confined to a very particular society, pose problems for all orthodontists working in public health situations. Our attention must be directed to these questions in order to create a. service which can meet the requirements of the institution for which the orthodontist, works and, at the same time, enable him to achieve the best possible results for his patients.

Due ncknon-lrdgrment is made to Aviva Golden for invaluahle assistance in the prqaration of this manuscript.

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1975, Encyclopedia Brittanica, Inc., vol. 9, p. 1OOlh. 2. Bettelheim, B. : Children of the dream, London, 1969, Thames & Hudson. 3. Biittncr, M.: fiber die Haufigheit des Lutschens im Schulpflichtigen, Alter. Schwriz. Jfonats-

s&r. Zahnheilkd. 79: 58-584, 1969. -1. Popovitch, F. : Tile prevalence of the sucking habit and its relationship to malocclusion, Oral

Health 57: 498-505, 1967. 5. Bralack, I.-B., and Frisk, A-K.: Fingersugning has 12.Gingar, Sren. ‘l’andlak. Tidskr. 60:

201-214, 1967. 6. Gardiner, .J. H.: A survey of malocclusion and some aetiological factors in 1,000 Sheffield

who01 children, Trans. Br. Sot. Orthod., pp. 114-125, 1955.