Organization and Early Struggles (1913-30)

In 1913, Edward H. Angle was invited by his West Coast alumni to give a three-day course in Los Angeles on his recently developed pin-and-tube appliance. Following the course, the group organized an alumni society such as had been done by his eastern graduates. Thus was born the Pacific Coas t Society of Graduates of the Angle School of Orthodontia. There were nine charter members, including a woman, Genette Harbour. Robert Dunn was elected its first president and John R. McCoy its first secretary-treasurer. B. Frank Gray had already served a s president of the national organization, the American Society of Orthodontists (ASO) in 1910

Dues were but $5.00 a year. In 1917 its name was changed to the Pacific Coast Society of Orthodontists (PCSO) and non-Angle graduates were admitted as members. It did not become a constituent of the ASO until 1936, which itself underwent a name change two years later at its first West Coast meeting (in Los Angeles), to the American Association of Orthodontists (AAO).

The PCSO was divided into three sections: Washington-Oregon, Northern California, and Southern California. A constitution and bylaws, adopted in 1921, established a Board of Directors (BOD), consisting of the president, vice president, secretary, and a representative from each of the sections. After 1925, the president served two years, corresponding to the meetings.

In 1922, the first quarterly issue of the PCSO Bulletin was published. It was nothing like the slick, colorful magazine we have today. It was a 5-1/2 X 8-inch mimeographed pamphlet, having neither illustrations nor ads. In 77 years it has not missed an issue, though there were some in those early days who thought coverage of our society in the national journals was adequate. In fact, it came close to expiring in the early thirties before Reuben Blake took over as editor for 26 years.

Becoming an orthodontist before 1920 was limited to either becoming a preceptor or attending a six-week course at one of the three proprietary schools - Angle School (established 1900), International School (1907 ), or Dewey School (1911). In the early 1920s, a few universities opened graduate departments. By this time, Angle had moved to Pasadena, Calif., and was again holding forth in what was to become the first "college" devoted exclusively to the teaching of orthodontics. Although the Angle College of Orthodontia closed in 1927, the first university orthodontic training program on the West Coast, Curriculum II, opened three years later at the University of California in San Francisco ("Cal"), by which dental students could choose to specialize in orthodontics after their first year.

The most popular appliance of the day was Angle's ribbon arch, with the Crozat, the Mershon lingual, and the McCoy open tube also in general use. James D. McCoy (1884-1965), a 1905 Angle graduate, made important contributions in teaching, radiography, the literature, political leadership, and, with his brother, John, ran the "showcase" office of the '20s and '30s on L.A.'s Wilshire Boulevard.

Angle announced the edgewise in 1925, and four years later Spencer Atkinson came out with the universal appliance and Joseph Johnson introduced the twin wire. For bands and arch wires, one had the choice of gold. Bands were pinched and soldered. There were no orthodontic supply houses. Supplies were obtained from dental companies, notably S.S. White or gold manufacturers (such as Wilkinson or Dee Gold).

Annual meetings were held usually in San Francisco and, by 1924, were three days in length. Like today, sectional meetings took place two or three times a year. Appliances were the main topic, but etiology, rhinology, habits, and mixed dentition treatment were also featured.

In 1929, orthodontics became the first dental specialty with the formation of the American Board of Orthodontics (ABO). The PCSO boasted a membership of 72, including honorary members Albert Ketcham (who was the impetus behind the board), John Mershon, and Guy Millberry. We must have been doing something right to attract corresponding members Harold Chapman (England), Sheldon Friel (Ireland), Milo Hellman (New York), Axel Lundstrom (Sweden), Paul Rogers (Boston), and Bernhard W. Weinberger (New York).

Nineteen-thirty marked the death of Edward Angle, the birth of cephalometrics, and PCSO's annexation of Arizona, British Columbia, Idaho, and Nevada.

Depression Years to WWII (1931-45)

The following year PCSO sections were renamed Northern, Central, and Southern. There were no educational requirements for membership, but an applicant had to be a graduate of a recognized school of dentistry, be in the exclusive practice of orthodontics, and have the recommendation of two members.

As orthodontists began to feel the effects of the Great Depression, with its drop in patient starts and the cancellation of some annual meetings, those in California were buoyed by the opening in 1932 of the Crippled Children's Services (later, California Childrens Services [CCS]). Participants had to make do with a $150-per-patient annual fee but, then, the prevailing full-treatment fee was only $500.

In addition to James McCoy, other noteworthy society members were Spencer Atkinson, who founded the West's first graduate orthodontic department (University of Southern California [USC], 1934); George Hahn, who started the Curriculum II program and later head ed the national preceptor program; and Charles H. Tweed, who probably had the greatest influence on clinical orthodontics since Angle. The success of his courses attest to the fact that our membership had many doubts about the proper approach to treatment . Adherents of various appliances divided themselves into "camps," and it was common to hear the terms, edgewise man, universal man, and labiolingual man.

The first West Coast orthodontic supply company, Unitek, originated during the mid-30s in a small Pasadena machine shop that made parts for the universal appliance. As for practice management, conservatism reigned. Practices were not geared to production. The typical office had one or two chairs and a "girl Friday." Marketing was something you did at the local grocer's. Those who solicited patients were either reprimanded or expelled.

One of the main concerns of PCSO members of the 1930s was mail-order orthodontics, wherein dental laboratories urged practitioners, qualified or not, to send in their models and receive an appliance in return, complete with instructions for treatment. The other ethical concern was "advertisers," dentists who proclaimed in newspapers and yellow pages that teeth were "straightened."

These concerns were pushed aside by the onset of World War II. Practitioners who entered the armed services had to give up their hard-earned practices, only to learn that there was no orthodontics in the service. Those left behind found themselves swamped with patients. There were shortages of rubber, metals, and gasoline. After the war, returning service personnel were faced with a shortage of office space.

Postwar and the Golden Age (1945-65)

As the United States demobilized, rubber bands and other critical supplies again became available. A How pliers could be purchased for $4.85. Although dentistry hailed the advent of the country's first fluoridation (Kalamazoo, Mich.) in 1945, few could have foreseen its far-reaching effects on orthodontic practice.

Dentists returning home from the war in 1945, their practices having been disrupted and now in possession of educational benefits under the GI Bill, decided this would be a good time to take postgraduate education. They found, however, that there were only three orthodontic programs on the West Coast: Curriculum II, USC, and Cal's graduate program ('42). It would be another four years before the fourth program, at the University of Washington, would open.

The postwar prosperity, the baby boom, and the increased public awareness of the benefits of orthodontics created a demand for services that was beyond the capacity of available clinicians.

As a result, there was a call for the establishment of additional graduate programs. Orthodontists were enjoying what would later be called a golden age: They could practice without government interference, they could set their own fees, and there were more than enough patients to go around.

Yet CCS participants were still struggling with minimal fees arbitrarily imposed without orthodontist representation on its board. Those patients not qualified under CCS guidelines or unable to afford private fees sought treatment at one of the three univ ersity clinics (before 1960) or at one of the private "clinics" starting to appear in large metropolitan areas. These clinics were usually run by nonorthodontists, using untrained clinicians and multiple chairs, and charging low fees. At that time, PCSO members were more concerned about substandard treatment than they were about competition

The 1950s saw the first appearance of orthodontics under private health plans. By 1963, 18 major insurance companies were offering dental insurance. Seeing this as another threat to their standard of care, PCSO leaders urged third parties to limit providers to qualified orthodontists, give beneficiaries freedom of choice, and leave the orthodontist free to participate or not. But few companies specified the educational training of their providers, and we became concerned about control from outside the profession.

In 1955, when the first jet planes started flying, San Francisco played host to the AAO's second West Coast annual meeting. PCSO meetings were still biennial; however, a break with the traditional San Francisco location took place the following year when the Society convened in Seattle. "Sections" became "components," and dues were raised to $10 a year - the first raise in 42 years! With 330 active members, the PCSO was now the second largest AAO constituent ('56). Five years later we were augmented by the transfer of Alberta and Saskatchewan from the Central Section

Requirements for associate membership had recently been changed to include postdoctoral training at an American Dental Association (ADA)-approved university; in 1957, to become an active member, you needed five years of exclusive practice, 1,500 hours of advanced training (or three consecutive years' association with an AAO member having had at least eight years of practice). Beginning in 1965, prospective active members were required to submit five case reports.

In 1963 we approved a completely new constitution and bylaws providing for, among other things, a somewhat expanded BOD, consisting of a president, president-elect, past-president, vice president, secretary-treasurer, and three directors (one from each co mponent). Rev ised member categories included life, retired, and honorary ('69). Later, affiliate (for those not in exclusive practice) and academic were added ('75). The Board also OK'd the luxury of a part-time secretary, file cabinets, a telephone, and a Dictaphone ('60).

After 1964, presidents served only one year and now had 10 standing committees and one special committee to assist them. Our meetings were second to none. It was remarked that they were "as good as the AAO's." Some of the headliners of the 1965 meeting were Daniel Subtelny, Sam Weinstein, Charles Burstone, Ernest Hixon, and Egil Harvold. Other popular speakers of the day included Walter Straub, Cecil Steiner, Tom Graber, Bert Kraus, and Bob Ricketts.

Gold was phasing out, although Wilkinson was still offering precious metals ('55). Crozats were becoming more popular ('56); in the mid-60s, there was a revival of rapid palatal expansion. Most of the southern PCSO was universal until the time of Atkinson 's leaving USC ('56). Elsewhere, there was strong appeal for Begg's technic ('56) and his light round wire appliance ('65). Cephalometrics was the underlying theme of almost all essays. Up to now, the strong influence of conservative leaders had kept expectations modest, the use of ancillary personnel limited, and practice management courses almost unknown.

Responding to the need for more trained orthodontists, the AAO and the ADA Council on Dental Education established a supervised preceptorship program ('58), wherein the preceptee would spend three years under the supervision of a specially selected practitioner. By the time the last of the 266 preceptees had completed the program in 1967, there were five more graduate programs on the West Coast (including the reopening of USC), the birthrate had been on a 10-year decline, and practitioners were beginning to feel a drop in patient starts. Still, Pacific Coast members were optimistic. After all, hadn't the specialty enjoyed prosperity for the past quarter century? And what about all those insurance patients on the way?

General practitioners (GP's), too, began to feel the decrease in busyness due, in part, to the effects of fluoridation. They were also aware of specialists' prosperity; consequently, many dentists showed a renewed interest in orthodontics. They also complained that they were being denied membership in the PCSO, as well as access to orthodontic courses. Our group, in turn, complained that GP's were straightening teeth by following a cookbook treatment plan picked up at a meeting.

As a result of the unrest, several splinter groups, notably the International Association of Orthodontists (IAO), formed with the object of breaking down the barriers to unstructured orthodontic training and gaining recognition as specialists. Two of these "wannabes" even brought lawsuits against the PCSO (as well as the AAO), claiming they were denied membership. The cases were finally resolved to our satisfaction, but not without costly legal fees.

Challenges to the Status Quo (1966-80)

Starting in the early 1960s, the federal government became more and more involved in health care. Medicare and Medicaid were enacted in 1965, marking the beginning of the Great Society. Fully aware of a nationwide shortage of providers, politicians' initial efforts were directed to increase the opportunities for training of professional health personnel, passing laws to provide loans and other aid to students and schools. For example, the Health Economic Opportunity Act pressured universities to expand training by withholding grant money.

As time went on, however, legislation was geared less to relieving shortages and more to making health care accessible to lower income groups and to flood the market with enough practitioners to alleviate the shortage in remote areas and to bring down the cost of care. This proved to be moot in the case of orthodontics not only because of the "birth dearth,"" but because orthodontists do not thrive in "remote" areas.

By the late 1960s, the growth of prepaid dental programs had reached enormous proportions, to the extent that the orthodontic specialty was not prepared to deal with it. Words like HMO, capitation, and insurance girl entered the dental vocabulary. Prepaid plans, both insurance and union, were being established without consulting orthodontic specialists. Orthodontists were beginning to realize that third parties were here to stay and that to restrict them or to organize against them could lead to restraint of trade - even lawsuits ('76). Americans were becoming a society of litigants. In 1975, the PCSO was named in a $200,000 negligence suit.

The same year, our Society reported having the lowest ratio of 12-year-olds per orthodontist of all the constituents. Many practitioners, tempted to join a preferred provider organization (PPO), faced a "fight-em-or-join-em" dilemma. Furthermore, as a result of a 1977 Supreme Court ruling, the AAO had removed the ban on members' advertising.

Responding to pressures from members as well as local and state orthodontic societies, the AAO in 1979 launched a $2.125 million, major marketing effort. While the advertising portion of the budget focused on parents of children of orthodontic age, the primary public relations effort was on adult orthodontics. To finance the campaign, members were assessed $200 and saddled with a 77% dues increase. But conscientious practitioners agonized over adopting individual marketing methods they had long disdained. In an effort to attract more patients, many of our members opened branch offices or adopted some of the practice management techniques promulgated by more and more gurus on the lecture circuit.

During the 1970s many of our members played key roles in the development of major technological advances: bonded brackets (labial, then lingual), "straight wire," superelastic wire, and computerized research and diagnosis.

The Bulletin got a big boost when Bill Parker took over as editor in 1968. With its photographs, member profiles (revived later as "Portrait of a Professional"), and colorful covers, it so on gained nationwide attention, and in 1973, garnered the Golden Scroll award. Under Wayne Watson in 1975, our periodical underwent its first size change (to 6-1/2 by 9-1/2). When Watson took over the editorship of the American Journal of Orthodontics and Dentofacial Orthopedics in 1979, Dave Turpin was named the new Bulletin editor.

In order to deal more effectively with public health issues, dental service corporations, legislation, and public relations, the AAO urged its constituents to set up state societies. The PCSO had another reason to take this course: We wanted to prevent splinter organizations like the IAO from taking the names of state societies. By 1968, most Pacific Coast state components were in place (state societies were called "components ," components went back to "sections" ('73), and sections become "regions"

At about that time, the regional boards of directors were dissolved, placing all governing functions under the control of the PCSO Board of Directors. It wasn't long before the effectiveness of this reorganization became evident when the California component, largely through the efforts of Bill Coon, obtained the first significant CCS fee revision in 10 years ('70).

But this program, together with Denti-Cal (see below) would continue to vex orthodontists as it teetered under political and budgetary pressures.

In 1969 a part-time executive secretary (Ray Morris) was hired to handle the increasing complexity of PCSO business. Before long, members attending meetings would encounter NO SMOKING signs; wide ties and lapels, along with long sideburns, would be de rigueur. And all this was going on while our leaders were trying to quell a secessionist effort on the part of the Northern Component.

As part of the reorganization, the BOD was increased from 8 to 12 members in order to give each state equal representation ('77). Each Board member (except the trustee) would serve as a delegate to the AAO House of Delegates and the trustee would become a member of the Board ('68). In California, new legislation having a society-wide impact included a bill allowing health professionals to incorporate ('68), continuing education (CE) requirements, extended functions for auxiliaries ('74), and the Knox-Keene Act, enacted to promote delivery of he alth care to people under a service plan.

General dentists, upon whom we depend for most of our referrals, were a source of a major concern. They complained of exclusivity, an attitude of superiority, and lack of communication on our part. Ever since specialists had broken away from mainstream dentistry, relations had been strained. Now, with "unbusyness" affecting both groups, the strain became more acute. And AAO's recommendation that orthodontic problems be treated only by orthodontists wasn't helping matters.

The consumerism movement led to patients' complaints of high fees, inconvenient hours, and impersonalization. Assistants complained of low pay, lack of career paths, and lack of professional status (the first meeting of the Southern Component of Pacific Coast Orthodontic Assistant's Society took place in 1970). Rank-and-file orthodontists complained of inflation, needless CE courses, government regulations, third-party intrusion, GP orthodontics, cut-rate clinics, and, of course, graduate glut.

In 1971, PCSO membership passed the1,000 mark; five years later we became number one in constituent membership. Mandatory case presentation was finally dropped by the AAO in 1979, but we maintained the requirement in the face of arguments that membership should not be based on competence.

Part II of the History will appear in the Fall 2000 PCSO Bulletin

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