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Can Human Life Be Prolonged by Dental Prophylaxis?*
DEPARTMENT OE DENTAL HEALTH EDUCATION CAN HUMAN LIFE BE PROLONGED BY DENTAL PROPHYLAXIS ? * By GRACE ROGERS SPALDING, D .D.S., F.A .A .P ., Birmingham, Michigan
N spite o f the fact that “the love o f life is a universal instinct” and that any suggestions fo r prolonging our earthly life seem to have a popular ap peal, when it comes to a practical appli cation o f such measures, humanity as a whole is totally indifferent. A nation ally prominent member o f the medical profession states that the greatest ob stacle met in the campaign fo r longer life is the widespread indifference thereto; that while life is our most precious possession, it is also the most neglected. W illiam Cowper once wrote:
In our consideration o f this question, let us understand life to mean, not mere existence as measured in years, but vitality, energy, activity, recalling the epigram “L ife is not mere living, but the enjoyment o f health,” and that it is “not years but deeds that count.” T here are many ways o f prolonging human life and an endless number o f ways o f shortening it. By the evidence we are about to submit, we hope to be
able to decide whether dental prophy laxis may be considered as belonging to the group o f those measures which pro mote health, thereby lengthening life . In 19 0 4 , D r. D. D. Smith described the purpose o f oral prophylaxis as: 1. T he freeing o f the oral cavity o f conditions o f tooth decay * * * 2. T he eradication o f infection from the oral cavity. 3. Conserving human health. 4. Prolonging human life. D r. Fones,1 defines dental prophy laxis as “that scientific effort, either operative or therapeutic, which tends to prevent diseases o f the teeth and their surrounding tissues.” D r. Fones then adds that this includes practically all the operations in dentistry i f properly done, but states that “true prevention o f disease is, in its broader conception, a matter o f education rather than an operative or a therapeutic procedure.” I should like, fo r this discussion, to define dental prophylaxis as that scien tific effort, educational, operative or therapeutic, which tends to prevent dis eases o f the teeth and periodontium. I place the educational feature o f dental prophylaxis first, since that is, in my opinion, o f first importance, because o f
*R ead b e fo re the M id w in te r C lin ic o f the C h ica g o D en tal Society, Jan. 27, 1926.
1. p. 81.
I
M en deal w ith life , as ch ild ren w ith their p la y , W h o first misuse, then cast their toys aw ay.
1482
Fones,
A.
C .:
P reven tive
Dentistry,
Department of Dental Health Education
the fact that the extent o f its applica tion, as w ell as its results, are practically unlimited. D r. John Harvey Kellogg, who is 73 years o f age (the oldest living member o f the American Public Health Asso ciation), gives practically all o f his in come to support, in his own words, “not doctoring, not surgery, but education,” particularly as it pertains to hygiene and prevention o f disease. T he dentist’s own time has lim ita tions, and since, as Poor Richard says, “Tim e is the stuff that life is made o f,” it is best that we invest time ( life ) in such a way as to bring the greatest re turns in health ( life ) to our patients; we can therefore use education as a means o f broadening our sphere o f in fluence in dentistry. W e are prone to undervalue the pos sible eifect o f the patient’s efforts in this field o f dental prophylaxis, at the same time unconsciously exaggerating our own, when, as a matter o f fact, the dentist’s efforts are futile without the cooperation o f his patient. W h at the intelligent, w ell-trained patient can do fo r the health o f his own mouth is o f inestimable value. W e must needs en list as many co-workers in dental pro phylaxis as is possible in order to extend its benefits. T o repair lost tooth struc ture and to fa il to guard against further destruction o f tooth structure, to the very lim it o f our present enlightenment and with all the weapons at our com mand, educational, operative and thera peutic, is not taking advantage o f our opportunities, or making the best use o f our time ( life ) in dentistry. W hen we fa il to include the educa tional phase o f dental prophylaxis in our practice, we place a definite lim ita tion on our services, which is a positive handicap and which helps to make o f
14 8 3
dentistry a luxury beyond the reach o f the average patient in the average dental practice. In this connection, an unusual dis cussion on “ Good Dentistry fo r the Poor”2 is suggestive and o f importance to our profession. The educational part o f dental prophylaxis is referred to by D r. Ottolengui as the Ford o f modern dentistry, while the operative part it is said is apt to be the RollsRoyce. T he educational division is best dealt with as two separate topics: 1. Instruc tion in mouth hygiene. 2. Instruction in personal hygiene. In reality, o f course, the latter includes the former. A s D r. A lfre d O w re says: “It is futile to regard an organ or set o f organs as an entity pathologically or otherwise. The body is the entity. W ithin it, Nature’s forces play and interplay irresistably. W e can help or we can hinder, but we cannot at a single spot check the sweep o f these forces. W e cannot detach the questiony say, o f oral health fr o m the question o f health as a w hole.”
In order to play an effectual part in this game o f prolonging life , it is essen tial that we, as members o f a healing profession, be enthusiastic teachers o f hygiene, believing, especially, in our own specific message: mouth hygiene. A thorough understanding o f mouth hygiene, together with the mastering o f the necessary technic, w ill enable pa tients to provide a complete change o f environment fo r their teeth; to remove soft, visible deposits from exposed tooth surfaces; to break up bacterial films on the teeth, tongue and gingivae at fre quent intervals; to disturb interproximal 2. G o o d D en tistry f o r the P o o r j ed i torials, D en t. Items In t., N ovem b er and D ecem ber, 1925.
1484
The Journal of the American Dental Association
stasis; to stimulate circulation in the capillaries and periodontium; to p ro lif erate epithelial cells on the surface o f the gums, which act as guards against infection and injury o f the underlying tissues, and to improve the health tone o f the periodontium. T here are many earnest dentists whose patients are ob taining these results, some with totally different methods. A n y method which produces the above mentioned benefits, without injury to the teeth or their in vesting tissues, is a good one. W e find, however, that time is the one constant, invaluable and indispensable factor, in a ll really effectual methods, yet we are bound to admit that the best o f them are but artificial and accessory means fo r producing oral health. The second division o f our instruc tion deals with personal hygiene, its object being to stimulate an interest in and obedience to the laws o f health which tend to prevent diseases o f the degenerative type, such as those asso ciated with circulation, nutrition, elimi nation and the central nervous system; at the same time also increasing resist ance to infectious diseases. W hen we lim it our activities to the treatment o f results, without at least attempting to treat the cause, we are on a par with a medical man who, finding his patient anemic, gives him a course o f iron in jections without inquiring into the con ditions that may have produced the anemia, having their correction also in mind. How limited in value is such service, how short lived and how costly! Can we conscientiously ignore funda mentals ? I f we would prolong human life , we cannot ignore certain basic health laws, mental and physical, in spite o f all the advancement made in modern dental and medical science. D r. Harvey
W iley, him self an inspiring example, says that i f we are to attain longevity, w e must work fo r it, and “ the surest way to possess this great blessing is to turn aside from our artificial diet and en vironment and come back as nearly as we can to Nature.” Again, D r. O w re says: “How are we to get back? W e cannot wipe out civilization; but we can , I am convinced, prevent it from wiping us out. I have no hesitation in stating that the most necessary step is the return to a more primitive diet.” D r. Thomas B. Hartzell writes: “ O ur best weapons are cleanliness and proper food.” A t this point, it is w ell to re member that diet is but one factor. Digestion, assimilation and elimination are important, as w ell as the glands o f internal secretion, about which we know so little yet which are a part o f the mechanism controlling metabolism, the central nervous system, which in large part controls these glands; and finally that force, mental or spiritual, which invigorates the central nervous system. In short we must get back, albeit it step by step, to the ultimate factors in the etiology o f disease. T o teach personal hygiene success fu lly, we must acquire learning in this science. W e need to study and prac tice it until we are enthusiastic advocates o f the laws o f health o f mind and body, associated with diet, nutrition, elimina tion, exercise, work, recreation, en vironment, rest, right thinking and other allied subjects. T o keep up one’s own enthusiasm and that o f the pa tient’s, we can read new books on any phase o f hygiene, or read old books, or magazines. Establishing a small library o f this literature fo r our patients’ use is also a means o f enlisting their interest. T here are some who may question our prerogative in teaching the subject
Department of Dental Health Education
o f personal hygiene. But since we see patients more frequently when w ell than does any other group o f the heal ing professions, and since the perma nent success o f our efforts in dentistry depends in large measure on the main tenance o f health, who can question our right, provided our instruction is intelli gent and conservative? T he medical man and his aid, the medical nurse, are preoccupied with the sick and dying; hence, we have an opportunity second to none fo r the personal enlistment o f in terest in and cooperation with the laws o f health. T he annual complete physi cal examination is too prodigal o f time and expense fo r the average patient, and, fo r the value o f its information, too dependent on accuracy o f detail on the part o f the examining physician. T he reports are all too often fu ll o f destructive suggestions (often broad cast) to be a measure fo r universal application. W e must evolve an addi tional method whereby those ills which so frequently shorten life may be averted. Does it not appeal to you that we can best do this through education in appreciation o f the value o f life and observance o f the laws o f right living? W e are inclined to think o f the re lationship existing between the dental and medical profession in terms o f dis ease, specifically focal infection. Could we not perhaps cultivate a most con genial association with the medical man i f we met him more often in the fields o f hygiene and prophylaxis? In these delightful and constructive fields, “ Health, mental and physical” would be our mutual slogan, and we would be met as co-workers; not as criminals re sponsible fo r most o f the ills o f man kind, as often occurs in the realms o f disease. As in the health maintenance o f the
1485
mouth, so with the health maintenance o f the body, in order to achieve the utmost good fo r the greatest number, we must enlist many co-workers. Those most interested are the individ uals themselves whose teeth and health are in question, and who have the potentiality o f real helpers in the effort fo r their own health promotion, when once enlisted. W e shall only briefly take into ac count the operative division o f dental prophylaxis, not that it lacks impor tance, but because it is impossible to do more, owing to lack o f time. T he m anifold operative procedures in dental prophylaxis must have as their objective the removal o f all irritation, together with its cause, and the restora tion o f function to the teeth and perio dontal tissues. The irritants that are a menace to the health o f the dental organs and supporting tissues may be classified as mechanical, pathologic and chemical. Among those irritants which are me chanical, we may have calcareous deposits; overhanging margins o f fill ings; badly fitting clasps, bands, crowns, bridges or partial dentures; traumatic occlusion; food impactions, and incor rect use o f toothbrush, dental floss or toothpicks. The pathologic irritants are infections o f pulp or periodontium; the chemical may be bacterial toxins or fermenting carbohydrate food rem nants. It is manifestly not enough, fo r the purpose o f dental prophylaxis, merely to remove all such irritants. It is o f equal importance that we remove the cause and restore function to these den tal structures and tissues, whenever practical, by correct dental restorations, and stimulation, both natural and arti ficial.
1 4 8 6
The Journal of the American Dental Association
T he operative technic here demanded is w ell known and it would appear needless to dwell on it, except, perhaps, to attempt to m odify, in a measure, our evaluation o f certain technical pro cedures. For example, we have laid great emphasis on the importance o f high polishing o f the tooth surfaces, without apparently heeding the fact that the smoothest enamel becomes quickly coated when there is a disturbance o f metabolism, having, fo r example, so simple an etiology as overeating, incor rect eating or poor elimination. Recog nition o f this fact is fundamental. Let us at least make the effort to understand the causes, other than local, fo r accumu lations on the teeth. W e have learned, at no little expense o f time and effort on the part o f some o f our confreres, that traumatic occlu sion is the chief bete noir o f dental and periodontal health. Some o f us have been driven into a state o f nervous ex citement in our effort to keep pace with the experts in trauma detection and correction, and, in our hurried grind ing, have merely shifted the area o f trauma from one tooth to another. W e need to learn to be discerning as w ell as conservative, in all the details o f dental prophylaxis, else our remedial efforts may become destructive. Again, in our zeal to restore contacts and contours, and in our enthusiasm over modern restorative dentistry, we remove a 30 or 4 0 year old malleted gold filling, sans contour, sans contact, but which, nevertheless, may have guarded the tooth against further inva sion o f dental caries and the pulp against infection. W e may be sincere in our efforts, but defective in judg ment, or perhaps lacking in skill and experience, or careless o f detail in our
technic, if, within a year or so, under the new gold inlay, with its beautifully carved cusps, perfect contour and con tact restorations, we have a diseased pulp, with its potential trail o f focal infection. This may have occurred because we were too radical in our cavity preparation fo r inlay retention; or failed effectively to protect the pulp against shock or the dentin against in fection. Perchance, we neglected to check up on our occlusion with suffi cient accuracy, and we had a resultant trauma. W hatever the cause, it would have been better dental prophylaxis to have le ft the old filling over a healthy pulp. W e sometimes need to choose the lesser o f two evils. Let us “make haste slow ly” and employ the best o f judgment and technic in our replace ment o f old restorations, since the pa tient, fo r whose benefit the changes are made, may have his life history un favorably altered by the operation. Since we have suggested a slight modification o f our enthusiasm about a few o f the many important operations in dental prophylaxis, may we now em phasize the need fo r greater zeal in putting into pra;tice several m ajor and vital principles? In order to do the greatest good, and avert the most evil, in the operative field o f dental prophylaxis, we must bring our greatest force o f action to bear on the detection o f dental caries and periodontal lesions in their incipiency. Both, with the minimum o f effort, are easily controlled at this early stage, yet, in more advanced stages, each may have a most uncertain prog nosis as regards the life history o f the involved teeth as w ell as that o f the patient. Hippocrates, the “Father o f Medicine,” living in the fifth century, B. C ., recognized the fact that, in his
Department of Dental Health Education
own words, “Diseases must be com bated in their origin.” Because o f the technical difficulties, experience and judgment required o f the dentist and the possible danger to life and expense involved fo r the pa tient in treating successfully the results o f advanced dental caries and perio dontal lesions, it is impractical, unwise and inexpedient not to check these con ditions in the beginning. In order to bestow the greatest blessings on hu manity from the angle o f dentistry, we must practice prevention in all its aspects, since we are told upon authority that this is the only means by which we can effectively check the inroads made by dental caries and periodontoclasia on the masticating machine o f mankind. The radiogram is an invaluable aid fo r disclosing the presence o f dental and periodontal lesions, in their incipiency. The systematic, periodic treatment o f the mouth as outlined and promulgated by the late D r. D. D. Smith, nearly thirty years ago, remains an important and distinct feature o f the operative section o f dental prophylaxis. It is worthy o f note that little advance in the technic o f the treatment has been made since its introduction. Such treat ment is ideal, i f the operator is w ell trained, skilful, experienced and fu lly appreciative o f the complete benefits and qualifications embodied in true oral prophylaxis treatment. Since this treatment is an ideal one, nothing short o f a faultless technic, ac companied by a high and genuine esteem fo r the value o f such treatment, is worthy the name. One important technical procedure in the treatment is the subgingival exploration, which, i f sk ilfu lly per formed, uncovers a wealth o f inform a
1487
tion as regards both the patient’s health and his personal care o f the mouth. The tone o f the soft tissues o f the periodon tium is noticeably affected by personal care and bodily health. I f the tissue tone o f the gingivae is good, the sub gingival space is practically obliterated, and the operator finds little, i f any, ex cretions or concretions; while i f the tissues lack tone, this space is increased in dimensions, and we may find the fo l lowing as enumerated by D r. Smith: “Concretions, calcic deposits, semi solids, bacterial plaques, and inspissated secretions and excretions.” W hether the cause o f these accumulations is local or systemic, their removal is essential to a production o f health in the gingival tissues. A universally approved operative procedure o f far-reaching benefit is the sterilization and protection o f pits and fissures in erupting bicuspids and molars, particularly until they come into occlusion. This should include all the molars, even the much maligned thirds. The method o f protection may be conservative or radical, but, in any case, it must be adequate as a protection, and not interfere with occlusion. Some good and wise members o f our profession say that therapeusis as a pro phylactic measure in dentistry is valu able; some equally wise and good ones say it is o f questionable value. But before dismissing the subject too abruptly, I cannot resist calling atten tion to the rather amusing situation that obtains in the digestive tract. The upper portion, or mouth, is the scene o f w arfare between the dentist and Bacil lus acidophilus. The dentist wields his weapon o f metaphan, iodin, orange wood, and abrasives, determined on the extermination o f this bacillus and all
1488
The Journal of the American Dental Association
his progeny. Throughout the intestinal tract, the medical man is caring fo r the refugees, endeavoring to cause their in crease and propagation by lactodextrim and the free use o f fruits and vege tables. W h o is right and who w ill win? Is it ( Bacillus acidofhilus') our friend or our enemy? I f it is a poten tial enemy in the mouth, would it" not be good prophylaxis, by means o f cor rect eating, to produce an environment so inviting throughout the intestinal tract that, o f its volition, it would fo r sake the mouth, the field o f danger, fo r a safer and more congenial habitat? T he use o f sodium ricinoleate is rec ommended by D r. H artzell fo r neu tralizing bacterial poisons in the mouth, especially those formed by the strepto coccus group. But do we not concern ourselves overmuch with matters fa r beyond the pale o f our understanding, at the same time neglecting to avail ourselves o f pow erful aids, close at hand, which are effective weapons fo r guarding against disease, such as basic laws conducive to health? A re we not inclined, unconsciously, to oppose prevention, because so large a part o f it, such as the treatment o f in cipient lesions, as w ell as its educational phase, lacks the intricate technic on which our minds so naturally and easily center? Do we not, too often, gladly shift these responsibilities to other groups with less training perhaps, thereby admitting our lack o f regard fo r this vital work? M ay we widen our circle o f understanding o f dental prophylaxis until we can appreciate and respond to all its varied interests! Dental prophylaxis is the most compre hensive subject in dentistry; in fact, it embraces all o f dentistry, and is de
manding the best thought o f the great est minds in our profession. Through the follow ing three main divisions o f dental prophylaxis, we be lieve that we can promote the health, not only o f the teeth and supporting structures, but o f the body as w ell: 1. The educational division: It is our duty to impart knowledge and en thusiasm on the subject o f personal hygiene, which tends to prevent disease o f the degenerative type and to raise our innate resistance against infectious diseases; also, specifically, through in struction in mouth hygiene, to promote the health o f the teeth and periodon tium and through study and unpreju diced investigation extend our vision indefinitely until it is all inclusive o f the primary factors in the etiology o f disease. 2. T he operative division: Focal infection is a recognized and frequent cause o f premature deaths, and such foci o f infection are often associated with diseases o f the teeth or periodon tium, and these are known to be pre ventable, in large measure, by the operative procedure called fo r in dental prophylaxis. 3. The therapeutic division: W e have authority fo r believing that we can counteract virulent bacterial toxins es pecially those o f the streptococcus group, and, i f advisable, discourage the growth o f Bacillus acidofhilus in the mouth by therapeutics o f known value. In our original premise, life was meant to imply not mere existence, as measured in years, but the enjoyment o f health. W e are convinced that, by means o f a comprehensive understand ing and application o f the truths and principles o f dental prophylaxis, den tists can prolong not only existence, but also the enjoy.ment o f health, life.
N spite o f the fact that “the love o f life is a universal instinct” and that any suggestions fo r prolonging our earthly life seem to have a popular ap peal, when it comes to a practical appli cation o f such measures, humanity as a whole is totally indifferent. A nation ally prominent member o f the medical profession states that the greatest ob stacle met in the campaign fo r longer life is the widespread indifference thereto; that while life is our most precious possession, it is also the most neglected. W illiam Cowper once wrote:
In our consideration o f this question, let us understand life to mean, not mere existence as measured in years, but vitality, energy, activity, recalling the epigram “L ife is not mere living, but the enjoyment o f health,” and that it is “not years but deeds that count.” T here are many ways o f prolonging human life and an endless number o f ways o f shortening it. By the evidence we are about to submit, we hope to be
able to decide whether dental prophy laxis may be considered as belonging to the group o f those measures which pro mote health, thereby lengthening life . In 19 0 4 , D r. D. D. Smith described the purpose o f oral prophylaxis as: 1. T he freeing o f the oral cavity o f conditions o f tooth decay * * * 2. T he eradication o f infection from the oral cavity. 3. Conserving human health. 4. Prolonging human life. D r. Fones,1 defines dental prophy laxis as “that scientific effort, either operative or therapeutic, which tends to prevent diseases o f the teeth and their surrounding tissues.” D r. Fones then adds that this includes practically all the operations in dentistry i f properly done, but states that “true prevention o f disease is, in its broader conception, a matter o f education rather than an operative or a therapeutic procedure.” I should like, fo r this discussion, to define dental prophylaxis as that scien tific effort, educational, operative or therapeutic, which tends to prevent dis eases o f the teeth and periodontium. I place the educational feature o f dental prophylaxis first, since that is, in my opinion, o f first importance, because o f
*R ead b e fo re the M id w in te r C lin ic o f the C h ica g o D en tal Society, Jan. 27, 1926.
1. p. 81.
I
M en deal w ith life , as ch ild ren w ith their p la y , W h o first misuse, then cast their toys aw ay.
1482
Fones,
A.
C .:
P reven tive
Dentistry,
Department of Dental Health Education
the fact that the extent o f its applica tion, as w ell as its results, are practically unlimited. D r. John Harvey Kellogg, who is 73 years o f age (the oldest living member o f the American Public Health Asso ciation), gives practically all o f his in come to support, in his own words, “not doctoring, not surgery, but education,” particularly as it pertains to hygiene and prevention o f disease. T he dentist’s own time has lim ita tions, and since, as Poor Richard says, “Tim e is the stuff that life is made o f,” it is best that we invest time ( life ) in such a way as to bring the greatest re turns in health ( life ) to our patients; we can therefore use education as a means o f broadening our sphere o f in fluence in dentistry. W e are prone to undervalue the pos sible eifect o f the patient’s efforts in this field o f dental prophylaxis, at the same time unconsciously exaggerating our own, when, as a matter o f fact, the dentist’s efforts are futile without the cooperation o f his patient. W h at the intelligent, w ell-trained patient can do fo r the health o f his own mouth is o f inestimable value. W e must needs en list as many co-workers in dental pro phylaxis as is possible in order to extend its benefits. T o repair lost tooth struc ture and to fa il to guard against further destruction o f tooth structure, to the very lim it o f our present enlightenment and with all the weapons at our com mand, educational, operative and thera peutic, is not taking advantage o f our opportunities, or making the best use o f our time ( life ) in dentistry. W hen we fa il to include the educa tional phase o f dental prophylaxis in our practice, we place a definite lim ita tion on our services, which is a positive handicap and which helps to make o f
14 8 3
dentistry a luxury beyond the reach o f the average patient in the average dental practice. In this connection, an unusual dis cussion on “ Good Dentistry fo r the Poor”2 is suggestive and o f importance to our profession. The educational part o f dental prophylaxis is referred to by D r. Ottolengui as the Ford o f modern dentistry, while the operative part it is said is apt to be the RollsRoyce. T he educational division is best dealt with as two separate topics: 1. Instruc tion in mouth hygiene. 2. Instruction in personal hygiene. In reality, o f course, the latter includes the former. A s D r. A lfre d O w re says: “It is futile to regard an organ or set o f organs as an entity pathologically or otherwise. The body is the entity. W ithin it, Nature’s forces play and interplay irresistably. W e can help or we can hinder, but we cannot at a single spot check the sweep o f these forces. W e cannot detach the questiony say, o f oral health fr o m the question o f health as a w hole.”
In order to play an effectual part in this game o f prolonging life , it is essen tial that we, as members o f a healing profession, be enthusiastic teachers o f hygiene, believing, especially, in our own specific message: mouth hygiene. A thorough understanding o f mouth hygiene, together with the mastering o f the necessary technic, w ill enable pa tients to provide a complete change o f environment fo r their teeth; to remove soft, visible deposits from exposed tooth surfaces; to break up bacterial films on the teeth, tongue and gingivae at fre quent intervals; to disturb interproximal 2. G o o d D en tistry f o r the P o o r j ed i torials, D en t. Items In t., N ovem b er and D ecem ber, 1925.
1484
The Journal of the American Dental Association
stasis; to stimulate circulation in the capillaries and periodontium; to p ro lif erate epithelial cells on the surface o f the gums, which act as guards against infection and injury o f the underlying tissues, and to improve the health tone o f the periodontium. T here are many earnest dentists whose patients are ob taining these results, some with totally different methods. A n y method which produces the above mentioned benefits, without injury to the teeth or their in vesting tissues, is a good one. W e find, however, that time is the one constant, invaluable and indispensable factor, in a ll really effectual methods, yet we are bound to admit that the best o f them are but artificial and accessory means fo r producing oral health. The second division o f our instruc tion deals with personal hygiene, its object being to stimulate an interest in and obedience to the laws o f health which tend to prevent diseases o f the degenerative type, such as those asso ciated with circulation, nutrition, elimi nation and the central nervous system; at the same time also increasing resist ance to infectious diseases. W hen we lim it our activities to the treatment o f results, without at least attempting to treat the cause, we are on a par with a medical man who, finding his patient anemic, gives him a course o f iron in jections without inquiring into the con ditions that may have produced the anemia, having their correction also in mind. How limited in value is such service, how short lived and how costly! Can we conscientiously ignore funda mentals ? I f we would prolong human life , we cannot ignore certain basic health laws, mental and physical, in spite o f all the advancement made in modern dental and medical science. D r. Harvey
W iley, him self an inspiring example, says that i f we are to attain longevity, w e must work fo r it, and “ the surest way to possess this great blessing is to turn aside from our artificial diet and en vironment and come back as nearly as we can to Nature.” Again, D r. O w re says: “How are we to get back? W e cannot wipe out civilization; but we can , I am convinced, prevent it from wiping us out. I have no hesitation in stating that the most necessary step is the return to a more primitive diet.” D r. Thomas B. Hartzell writes: “ O ur best weapons are cleanliness and proper food.” A t this point, it is w ell to re member that diet is but one factor. Digestion, assimilation and elimination are important, as w ell as the glands o f internal secretion, about which we know so little yet which are a part o f the mechanism controlling metabolism, the central nervous system, which in large part controls these glands; and finally that force, mental or spiritual, which invigorates the central nervous system. In short we must get back, albeit it step by step, to the ultimate factors in the etiology o f disease. T o teach personal hygiene success fu lly, we must acquire learning in this science. W e need to study and prac tice it until we are enthusiastic advocates o f the laws o f health o f mind and body, associated with diet, nutrition, elimina tion, exercise, work, recreation, en vironment, rest, right thinking and other allied subjects. T o keep up one’s own enthusiasm and that o f the pa tient’s, we can read new books on any phase o f hygiene, or read old books, or magazines. Establishing a small library o f this literature fo r our patients’ use is also a means o f enlisting their interest. T here are some who may question our prerogative in teaching the subject
Department of Dental Health Education
o f personal hygiene. But since we see patients more frequently when w ell than does any other group o f the heal ing professions, and since the perma nent success o f our efforts in dentistry depends in large measure on the main tenance o f health, who can question our right, provided our instruction is intelli gent and conservative? T he medical man and his aid, the medical nurse, are preoccupied with the sick and dying; hence, we have an opportunity second to none fo r the personal enlistment o f in terest in and cooperation with the laws o f health. T he annual complete physi cal examination is too prodigal o f time and expense fo r the average patient, and, fo r the value o f its information, too dependent on accuracy o f detail on the part o f the examining physician. T he reports are all too often fu ll o f destructive suggestions (often broad cast) to be a measure fo r universal application. W e must evolve an addi tional method whereby those ills which so frequently shorten life may be averted. Does it not appeal to you that we can best do this through education in appreciation o f the value o f life and observance o f the laws o f right living? W e are inclined to think o f the re lationship existing between the dental and medical profession in terms o f dis ease, specifically focal infection. Could we not perhaps cultivate a most con genial association with the medical man i f we met him more often in the fields o f hygiene and prophylaxis? In these delightful and constructive fields, “ Health, mental and physical” would be our mutual slogan, and we would be met as co-workers; not as criminals re sponsible fo r most o f the ills o f man kind, as often occurs in the realms o f disease. As in the health maintenance o f the
1485
mouth, so with the health maintenance o f the body, in order to achieve the utmost good fo r the greatest number, we must enlist many co-workers. Those most interested are the individ uals themselves whose teeth and health are in question, and who have the potentiality o f real helpers in the effort fo r their own health promotion, when once enlisted. W e shall only briefly take into ac count the operative division o f dental prophylaxis, not that it lacks impor tance, but because it is impossible to do more, owing to lack o f time. T he m anifold operative procedures in dental prophylaxis must have as their objective the removal o f all irritation, together with its cause, and the restora tion o f function to the teeth and perio dontal tissues. The irritants that are a menace to the health o f the dental organs and supporting tissues may be classified as mechanical, pathologic and chemical. Among those irritants which are me chanical, we may have calcareous deposits; overhanging margins o f fill ings; badly fitting clasps, bands, crowns, bridges or partial dentures; traumatic occlusion; food impactions, and incor rect use o f toothbrush, dental floss or toothpicks. The pathologic irritants are infections o f pulp or periodontium; the chemical may be bacterial toxins or fermenting carbohydrate food rem nants. It is manifestly not enough, fo r the purpose o f dental prophylaxis, merely to remove all such irritants. It is o f equal importance that we remove the cause and restore function to these den tal structures and tissues, whenever practical, by correct dental restorations, and stimulation, both natural and arti ficial.
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T he operative technic here demanded is w ell known and it would appear needless to dwell on it, except, perhaps, to attempt to m odify, in a measure, our evaluation o f certain technical pro cedures. For example, we have laid great emphasis on the importance o f high polishing o f the tooth surfaces, without apparently heeding the fact that the smoothest enamel becomes quickly coated when there is a disturbance o f metabolism, having, fo r example, so simple an etiology as overeating, incor rect eating or poor elimination. Recog nition o f this fact is fundamental. Let us at least make the effort to understand the causes, other than local, fo r accumu lations on the teeth. W e have learned, at no little expense o f time and effort on the part o f some o f our confreres, that traumatic occlu sion is the chief bete noir o f dental and periodontal health. Some o f us have been driven into a state o f nervous ex citement in our effort to keep pace with the experts in trauma detection and correction, and, in our hurried grind ing, have merely shifted the area o f trauma from one tooth to another. W e need to learn to be discerning as w ell as conservative, in all the details o f dental prophylaxis, else our remedial efforts may become destructive. Again, in our zeal to restore contacts and contours, and in our enthusiasm over modern restorative dentistry, we remove a 30 or 4 0 year old malleted gold filling, sans contour, sans contact, but which, nevertheless, may have guarded the tooth against further inva sion o f dental caries and the pulp against infection. W e may be sincere in our efforts, but defective in judg ment, or perhaps lacking in skill and experience, or careless o f detail in our
technic, if, within a year or so, under the new gold inlay, with its beautifully carved cusps, perfect contour and con tact restorations, we have a diseased pulp, with its potential trail o f focal infection. This may have occurred because we were too radical in our cavity preparation fo r inlay retention; or failed effectively to protect the pulp against shock or the dentin against in fection. Perchance, we neglected to check up on our occlusion with suffi cient accuracy, and we had a resultant trauma. W hatever the cause, it would have been better dental prophylaxis to have le ft the old filling over a healthy pulp. W e sometimes need to choose the lesser o f two evils. Let us “make haste slow ly” and employ the best o f judgment and technic in our replace ment o f old restorations, since the pa tient, fo r whose benefit the changes are made, may have his life history un favorably altered by the operation. Since we have suggested a slight modification o f our enthusiasm about a few o f the many important operations in dental prophylaxis, may we now em phasize the need fo r greater zeal in putting into pra;tice several m ajor and vital principles? In order to do the greatest good, and avert the most evil, in the operative field o f dental prophylaxis, we must bring our greatest force o f action to bear on the detection o f dental caries and periodontal lesions in their incipiency. Both, with the minimum o f effort, are easily controlled at this early stage, yet, in more advanced stages, each may have a most uncertain prog nosis as regards the life history o f the involved teeth as w ell as that o f the patient. Hippocrates, the “Father o f Medicine,” living in the fifth century, B. C ., recognized the fact that, in his
Department of Dental Health Education
own words, “Diseases must be com bated in their origin.” Because o f the technical difficulties, experience and judgment required o f the dentist and the possible danger to life and expense involved fo r the pa tient in treating successfully the results o f advanced dental caries and perio dontal lesions, it is impractical, unwise and inexpedient not to check these con ditions in the beginning. In order to bestow the greatest blessings on hu manity from the angle o f dentistry, we must practice prevention in all its aspects, since we are told upon authority that this is the only means by which we can effectively check the inroads made by dental caries and periodontoclasia on the masticating machine o f mankind. The radiogram is an invaluable aid fo r disclosing the presence o f dental and periodontal lesions, in their incipiency. The systematic, periodic treatment o f the mouth as outlined and promulgated by the late D r. D. D. Smith, nearly thirty years ago, remains an important and distinct feature o f the operative section o f dental prophylaxis. It is worthy o f note that little advance in the technic o f the treatment has been made since its introduction. Such treat ment is ideal, i f the operator is w ell trained, skilful, experienced and fu lly appreciative o f the complete benefits and qualifications embodied in true oral prophylaxis treatment. Since this treatment is an ideal one, nothing short o f a faultless technic, ac companied by a high and genuine esteem fo r the value o f such treatment, is worthy the name. One important technical procedure in the treatment is the subgingival exploration, which, i f sk ilfu lly per formed, uncovers a wealth o f inform a
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tion as regards both the patient’s health and his personal care o f the mouth. The tone o f the soft tissues o f the periodon tium is noticeably affected by personal care and bodily health. I f the tissue tone o f the gingivae is good, the sub gingival space is practically obliterated, and the operator finds little, i f any, ex cretions or concretions; while i f the tissues lack tone, this space is increased in dimensions, and we may find the fo l lowing as enumerated by D r. Smith: “Concretions, calcic deposits, semi solids, bacterial plaques, and inspissated secretions and excretions.” W hether the cause o f these accumulations is local or systemic, their removal is essential to a production o f health in the gingival tissues. A universally approved operative procedure o f far-reaching benefit is the sterilization and protection o f pits and fissures in erupting bicuspids and molars, particularly until they come into occlusion. This should include all the molars, even the much maligned thirds. The method o f protection may be conservative or radical, but, in any case, it must be adequate as a protection, and not interfere with occlusion. Some good and wise members o f our profession say that therapeusis as a pro phylactic measure in dentistry is valu able; some equally wise and good ones say it is o f questionable value. But before dismissing the subject too abruptly, I cannot resist calling atten tion to the rather amusing situation that obtains in the digestive tract. The upper portion, or mouth, is the scene o f w arfare between the dentist and Bacil lus acidophilus. The dentist wields his weapon o f metaphan, iodin, orange wood, and abrasives, determined on the extermination o f this bacillus and all
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his progeny. Throughout the intestinal tract, the medical man is caring fo r the refugees, endeavoring to cause their in crease and propagation by lactodextrim and the free use o f fruits and vege tables. W h o is right and who w ill win? Is it ( Bacillus acidofhilus') our friend or our enemy? I f it is a poten tial enemy in the mouth, would it" not be good prophylaxis, by means o f cor rect eating, to produce an environment so inviting throughout the intestinal tract that, o f its volition, it would fo r sake the mouth, the field o f danger, fo r a safer and more congenial habitat? T he use o f sodium ricinoleate is rec ommended by D r. H artzell fo r neu tralizing bacterial poisons in the mouth, especially those formed by the strepto coccus group. But do we not concern ourselves overmuch with matters fa r beyond the pale o f our understanding, at the same time neglecting to avail ourselves o f pow erful aids, close at hand, which are effective weapons fo r guarding against disease, such as basic laws conducive to health? A re we not inclined, unconsciously, to oppose prevention, because so large a part o f it, such as the treatment o f in cipient lesions, as w ell as its educational phase, lacks the intricate technic on which our minds so naturally and easily center? Do we not, too often, gladly shift these responsibilities to other groups with less training perhaps, thereby admitting our lack o f regard fo r this vital work? M ay we widen our circle o f understanding o f dental prophylaxis until we can appreciate and respond to all its varied interests! Dental prophylaxis is the most compre hensive subject in dentistry; in fact, it embraces all o f dentistry, and is de
manding the best thought o f the great est minds in our profession. Through the follow ing three main divisions o f dental prophylaxis, we be lieve that we can promote the health, not only o f the teeth and supporting structures, but o f the body as w ell: 1. The educational division: It is our duty to impart knowledge and en thusiasm on the subject o f personal hygiene, which tends to prevent disease o f the degenerative type and to raise our innate resistance against infectious diseases; also, specifically, through in struction in mouth hygiene, to promote the health o f the teeth and periodon tium and through study and unpreju diced investigation extend our vision indefinitely until it is all inclusive o f the primary factors in the etiology o f disease. 2. T he operative division: Focal infection is a recognized and frequent cause o f premature deaths, and such foci o f infection are often associated with diseases o f the teeth or periodon tium, and these are known to be pre ventable, in large measure, by the operative procedure called fo r in dental prophylaxis. 3. The therapeutic division: W e have authority fo r believing that we can counteract virulent bacterial toxins es pecially those o f the streptococcus group, and, i f advisable, discourage the growth o f Bacillus acidofhilus in the mouth by therapeutics o f known value. In our original premise, life was meant to imply not mere existence, as measured in years, but the enjoyment o f health. W e are convinced that, by means o f a comprehensive understand ing and application o f the truths and principles o f dental prophylaxis, den tists can prolong not only existence, but also the enjoy.ment o f health, life.