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Caries Control in Pediatric Practice
CARIES CONTROL IN PEDIATRIC PRACTICE MAURY MASSLER, D.D.S.
More than 90 per cent of the grade school children and approximately 50 per cent of the preschool children between three and six years of age, visiting the pediatrician for preventive care, have one or more carious teeth. Most of these teeth are unfilled. Many mothers are unaware of the tooth decay, and will remain unaware of it unless the pediatrician calls it to their attention. Parents often do not seek dental care for children until a toothache develops. Parents are usually quite surprised when the decay reaches the pulp, causing extreme pain and infection of the jaw. This is hardly a good introduction of the child to the dentist, and certainly not in keeping with sound principles of preventive medicine. Prevention of disease is the primary goal of the pediatrician. He carefully examines the throat, the tonsils and the tongue at every visit even when there are no complaints. But many pediatricians feel that dental disease is not within their province and leave the examination and care of the teeth to the dentist. This clinic will attempt to clarify the role of the pediatrician in the control of dental caries and indicate how he can help the pedodontist implement a successful program of caries prevention. PEDIATRIC TEETH EXAMINATION
The following steps applied to daily pediatric practice would do more to help prevent dental decay and tooth loss than all the dentifrices now sold to the American public. The technique is neither difficult nor time consuming. I. Examine the teeth of every child coming to the office. Do this just before looking at the throat and tonsils. The average time required From the Department of Pedodontics, University of Illinois College of Dentistry, Chicago.
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is 50 seconds. The equipment is a tongue blade and intraoral light. Place the child in a comfortable position and proceed as for a throat examina tion. Begin with the lower left last molar and proceed around the lower arch to the right side. Touch each tooth with the tip of the tongue blade. It is well to count aloud as you proceed to gain the child's cooperation and to allay his fears. Count from one to 10 for the preschool child and from one to 12 for the grade school child. (There are 10 primary or deciduous teeth in each arch from ages two and one half to six. The first permanent molars appear behind the last deciduous molars at age six.) Repeat with the upper arch, going from the child's left to right. Inspect the molar teeth again with special care, since dental caries always begins in the occlusal pits and fissures of these teeth. 2. If the child has no cavities, a referral should be made to a pedodontist or dentist with an interest in caring for children for early introduction and a program of preventive dental care. A notation of the name of the dentist should be entered in the record. 3. If the child has one or two small cavities, insist that he be taken to a dentist at once for fillings. Check for fillings at the next visit. 4. If the child shows numerous cavities, institute caries control measures and refer to a competent dentist at once. The most effective method of arresting active dental decay (at present) consists in minimizing the excessive intake of sugars between meals. After reviewing the diet, suggestions for substituting cold cuts, cheeses, fruits and other more healthful foods for the cariogenic confections consumed in large quantities by many American children between meals are indicated. The pediatrician should guide the dietary habits of his preschool and grade school children with the same care that he shows the infant. When the child is healthy and vigorous and growing well, the tendency is to omit dietary supervision. But when dental disease becomes evident, the pediatrician has the responsibility to review the diet with a view towards better systemic as well as dental health. DENTAL CARIES
In order to bring the problem of dental caries into better focus, it would be appropriate to review briefly the major characteristics of dental caries, since this disease too often receives only superficial attention in most medical school curricula. Once the main features of the disease are understood, it is not difficult to apply the various methods of caries control.
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The Caries Process
Dental caries is the result of bacterial attack of the hard substance of the tooth, beginning on the surface and progressing inward towards the pulp and resulting in the formation of a cavity. The primary attack on the enamel or dentin is made by acid metabolites produced by acidogenic organisms (lactobacilli, streptococci and others) living on a fermentable carbohydrate substrate on the surface of the tooth. Acid decalcification is followed by proteolysis of the organic matter with the result that dental caries is a slowly progressive and intermittent process. Incidence
Dental caries is primarily a disease of childhood. It begins early in childhood as soon as the molar teeth are erupted and accumulates rapidly, with acute exacerbations between four and eight years and 12 and 16 years of age. The rate decreases substantially after the age of 30 years. Dietary Factors
The most important contributory factors in the initiation and progression of dental decay are the readily fermentable carbohydrates (particularly the sugars) which adhere to the surface of the teeth. 2 These can be metabolized by the acidogenic organisms within a few minutes. The pH on the tooth surface (as measured by an antimony electrode) will drop from 7.0 to 5.4 within two minutes after a single glucose or sucrose rinse. 6 Effective caries control depends on preventing the accumulation of fermentable sugars on the tooth surfaces. This can be accomplished by (a) restricting the sugar intake to mealtimes when the natural cleansing action of detergent foods and saliva prevents the accumulation of sugars on the tooth surface or (b) by brushing the teeth immediately after sweets have been ingested. Other dietary or nutritional factors do not appear to play any significant role in the production or prevention of human caries. In this respect it should be pointed out that the role of calcium and vitamin D in caries prevention is practically nil. Genetic Factors
There is reasonably good evidence from both animal and human studies to suggest that genetic factors may also influence susceptibility to decay. Approximately 5 to 7 per cent of the population are cariesimmune in spite of dietary indiscretions and poor oral hygiene. Caries immunity can often be traced through family groups. The mechanism
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of this immunity is not known. It may lie in a potent bacteriostatic property of the saliva. . Extreme susceptibility to dental decay (rampant caries) afflicts approximately 7 per cent of the population. These persons suffer severe attacks of decay even when they practice good oral hygiene and sugar restriction. In them, dietary indiscretions and poor oral hygiene are catastrophic and result in a complete destruction of all the teeth in the mouth so that they become edentulous before the age of 25 years. Rampant caries seems to follow a definite familial pattern and is probably the result of an inherent susceptibility to dental decay aggravated by excessive consumption of sugars and poor oral hygiene. Pattern of Caries Attack
Dental caries begins in the pits and fissures on the occlusal (biting) surfaces of the molar teeth. These are the most susceptible areas, and the pediatrician should always examine the occlusal surfaces of the posterior teeth for signs of decay. The second site for caries attack are the proximal contact surfaces between the molar teeth. These are difficult to examine, even by the dentist-who usually obtains intraoral roentgenograms to make his inspection more complete. The third (and least frequent) site for caries attack are the necks of the teeth (cervical areas) near the gingivae. Dental caries spreads from the molar teeth anteriorly. As long as only the posterior teeth are affected, the disease may be considered mild. When the bicuspid teeth become involved, the disease is considered to be moderate. When decay spreads to the approximal surfaces between the upper anterior teeth, it is considered severe and the child rates as being caries-susceptible. If the lower anterior teeth become involved, the condition is called "rampant caries." By this time, too, the cervical areas of the molar, bicuspid and sometimes also the incisor teeth are attacked by caries. Caries Control
Caries control (i.e., limitation of the spread of the lesions, once the lesion has appeared) may be achieved by (a) early and regular visits to the dentist and (b) elimination of fermentable sugars between meals. Caries Prevention
In the average child a significant degree of caries prevention (preventing the appearance of new lesions) can be achieved by the following: (1) elimination of fermentable sugars between meals, (2) tooth-
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brushing immediately after each meal, (3) topical application of fluorides to the enamel as soon as the teeth erupt, (4) the addition of one part per million of fluorides to the communal drinking water supply. The pediatrician can do a great deal towards implementing a program of caries control in his patients by insisting that children under his care visit the dentist regularly and that they begin to do so before the teeth show gross evidence of decay. The pediatrician can also do a great deal to help the pedodontist to arrest the decay, once it becomes apparent, by introducing the parent and the child to the concept of caries control by sugar control. The pediatrician is regarded as the authority in matters of the child's health. He can encourage the mother and child to cooperate with the pedodontists' program or nullify these efforts by a too casual attitude concerning dental health. Caries prevention and caries control measures are especially indicated for children who would suffer excessive hazards from tooth extraction (the child with rheumatic heart disease, kidney disease or hemophilia). CARIES CONTROL VIA SUGAR CONTROL
An extensive scientific literature has accumulated during the past two decades which proves beyond reasonable doubt that the consumption of excessive amounts of refined sugars, particularly in the form of rapidly fermentable carbohydrates (especially sugars) which stick tenaciously to tooth surfaces, leads to a marked increase in the caries attack rate. Thousands of caries-active children and adults have had the disease completely arrested by a drastic reduction in sugar intake, i.e., the elimination of sugars which are consumed in excess of nutritional needs. During the war these clinical observations were duplicated in almost an experimental fashion in large groups living in Europe. As the annual consumption of sugars decreased during the war in The Netherlands, Norway, Sweden and England, the average caries attack rate fell in proportion. After the war, when sugar in the form of candies, cookies and the like again became freely available, the incidence of caries rose again, in proportion. 7 Other Effects of Excessive Sugar Intake
Excessive sugar intake between meals (above nutritional needs) constitutes a hazard not only to the teeth. Excessive consumption of between-meal sugars is an important factor in the loss of appetite at mealtimes for essential foodstuffs such as meats and vegetables. The common complaint by parents that their children have no appetite and fail to eat at mealtimes may often be traced to the enormous consumption of refined sugars between meals. In this way excessive sugar con-
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sumption predisposes to poor nutritional balance, since it literally pushes out from the dietary the other necessary proteins, minerals and fats. The consumption of sweets in excessive amounts during early childhood may be a reflection of a psychologic problem which causes the child to seek gratification from eating because his needs are not being met in other ways. Thus the sugar appetite in the child and the alcohol appetite in the adult have many points in common from both the metabolic and psychologic viewpoints. Small amounts of sugar or alcohol may stimulate the appetite and lead to obesity. Excessive amounts lead to malnutrition by depressing the appetite. It is interesting to note that rampant caries has its highest incidence in the thin, undernourished child who subsists largely on between-meal snacks or sweets. The obese child tends to have a lower than average caries attack rate. 3 Snack Habits and Dental Caries
If a person were to consume sugars only at mealtimes, the caries attacks would be minimized by the buffering and detergent action of the saliva and alkaline foodstuffs. However, when refined sugars are ingested between meals and at frequent intervals, the teeth are subjected to an almost continuous series of assaults by the acids formed on the tooth surfaces. The caries attack rate thus becomes enormously increased by the habitual consumption of sugars between meals. It is not so much the total quantity of sugars consumed during the day that is important as the number of times a sugar meal was taken. An occasional "candy binge" is not as injurious as the habitual daily consumption of caramels or chewing gum. Correcting the Diet
Caries control via sugar control should be initiated by the pediatrician as early as possible. Correcting the diet and eliminating excessive amounts of between-meal sugars are not difficult if the physician will first obtain a careful history of the daily intake of the child for a period of approximately one week. Careful review of the diet often reveals peculiarities in eating habits. Individual caries susceptibility determines to a large extent the amount of fermentable carbohydrate which is cariogenic. A very susceptible child may suffer great destruction of the teeth from what appear to be only "normal" amounts of sugars. Other children may consume large amounts of candies without severe damage. The degree of caries susceptibility of the child must be pointed out to the parents
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when they object to suggestions that the destruction of the child's teeth may be due to overindulgence in sweets. Many parents find it difficult to limit between-meal snacks and sweets to their children. A more effective technique is to offer an apple or potato chips instead of candies or cookies or a sandwich containing meat or cheese instead of one containing jams or jellies. A healthy child will enjoy an apple with as much gusto as a piece of cake, and will accept noncariogenic popcorn or potato chips instead of caramels with no loss in caloric intake. A lunch consisting of a meat-sandwich and milk is just as satisfying as and far more healthful than one made up of a sweet-roll and soda-pop. In fact, if given a free choice, most young children will select the fruit and the sandwich over the cake and caramel as a steady diet. Only those with already conditioned appetites prefer the sweets. If parents are considerable consumers of candies, cookies and chewing gum, one cannot expect the child to deny himself these confections. It is important that the physician recognize the impact of family food habits upon the child. Often parents will make a sincere effort to change their own dietary habits in the interests of their children's health. It would be pertinent here to point out that the appetite for sweets is acquired early. The pediatrician can do his part in discouraging the excessive consumption of candies by offering his patients a toy balloon or trinket as a reward instead of a lollipop. CALCIUM. VITAMIN D AND CARIES
Vitamin D and calcium compounds have often been invoked as therapeutic agents for the control and even prevention of dental decay. Thousands of calcium tablets, vitamin D pills and gallons of milk have been consumed by children and pregnant females toward this end. However, the past two decades have indicated clearly that such therapeutic measures are not effective, since the caries attack rate has increased steadily during that period. There is certainly no rational basis, at present, for the continuation of these empiric and ineffective therapeutic measures. This does not in any sense negate the value of calcium and vitamin D in the growth and calcification of bone. However, they seem to have no value in caries prevention. FLUORIDES AND CARIES Fluorides in Water
It has been demonstrated that the caries attack rate is much less in areas where the fluoride content of the water supply is one part per
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million or more than in non fluoride areas. It has therefore been proposed that fluorides be added to communal water supplies to reduce the incidence of caries. This hypothesis has been subjected to careful and intensive testing over a 10 year period in Newburgh and Kingston, New York; Grand Rapids, Michigan; Evanston, Illinois; and other cities. The inverse relation between water-borne fluorides and dental caries is now one of the most thoroughly tested and authenticated relationships in all modern medicine. These studies have demonstrated conclusively that the addition of minute amounts of fluorides (one to two parts per million) regularly reduces the caries attack rate approximately 40 to 60 per cent with perfect safety and absolutely no systemic effects and at a low cost (approximately eight to ten cents per person per year). Inevitably there have been objections to this procedure by small but vocal groups. Some object to the fluoridation of water as "socialized medicine" or "mass medication," forgetting that the chlorination of water, the pasteurization of milk and the addition of iodides to table salt are similar preventive measures. The addition of fluorides to the water is not a therapeutic procedure (it does not heal the carious lesion); it is a preventive measure. Other groups object to the fluoridation of water on religious ground-s. Still others object on the basis that fluorides are protoplasmic poisons. In powder form or as strong solution, fluorides are poisons and have been used as insecticides. In a concentration of one to two parts per million fluorides are not at all poisonous. Chlorine is also poisonous when concentrated as a gas, but not when used in weak dilutions to purify the water. The objections offered by small groups against the addition of fluorides to drinking water are primarily emotional and not based on any real evidence'. These groups will unfortunately delay the fluoridation of the drinking water in some communities, but will not, in the long run, stop progress in the mass reduction of caries by water fluoridation, because the scientific evidence to support the use of water fluoridation as a public health measure for the reduction of dental caries is now overwhelming. Fluorides in Foods
Many foods (fish, tea, many vegetables) contain relatively large amounts of fluorides (40 to 100 parts per million). These fluorides have no effect in reducing the incidence of caries probably because the fluorides in foods are in insoluble combinations and not available for action on the teeth. Apparently fluorides must be in water solution and in a soluble, ionic form to act in caries reduction.
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Fluoride Tablets
Though there is excellent evidence to show that the addition of fluorides to the communal water supply is effective in reducing the prevalence of dental caries, there is no evidence to support the suggestion that fluorides in the form of tablets or lozenges would be similarly effective. Commercial preparations which contain calcium fluorides plus multiple vitamins have nonetheless been offered for the control of dental caries. There have been no acceptable studies made to support such claims. Such tablets contain insoluble calcium fluorides which are not absorbed from the intestinal tract and are therefore nontoxic. They are also inactive against caries. Topical Applications of Fluorides
The relation between fluorides in the water supply and reduced caries experience in children has led directly to experimental studies on the effect of topical applications of fluorides to the teeth. Knutson and Armstrong (1942), Cheyne (1942), Bibby (1944) and many others have demonstrated conclusively that the topical application of fluorides to the teeth of children is an effective method of preventing the initiation of new enamel caries. Solutions of sodium fluoride 2 per cent were applied only to the teeth on one side of the mouth. The untreated side in the same child served as the control. This procedure showed are· duction of 25 to 40 per cent in the incidence of new caries in the treated side over the untreated side after one to three years of observation. The topical application of fluorides has none of the objections offered to its systemic administration, since the material is not swallowed and is therefore not toxic. The accepted method of sodium fluoride applications consists in an initial, thorough dental prophylaxis followed by a minimum of four treatments within a relatively short period (two to three weeks). Fluorides are effective when applied to the recently erupted teeth of children, but not in adults. Newly erupted enamel is receptive to the fluoride ion, the apatite molecule changing from the soluble hydroxyapatite to the less soluble fluor-apatite. The adult enamel surface is impregnated over a period of years by ions derived from the saliva and is no longer receptive to the fluoride ion. Topical applications of fluoride solutions to the teeth of children are not contraindicated in areas where fluorides have been added to the drinking water. The added fluorides are not ingested and will not cause mottling, but may further increase the resistance of the enamel surface to acid etching.
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Fluoride Dentifrices
On the basis of the efficacy of topical applications of sodium fluoride solutions to the surface of the newly erupted enamel in reducing the incidence of new lesions, it was logical to assume that sodium fluoride might be effective if added to dentifrices or mouthwashes. Unfortunately repeated trials have shown that sodium fluoride in the form of a dentifrice or mouthwash is not effective in reducing dental caries (Bibby et aI., 1946). The fluoride ion probably combines with the calcium or other metallic ions present in the dentifrice and becomes unavailable to the enamel. Recently, Muhler et aJ.5 demonstrated that stannous fluoride is more effective than sodium fluoride solutions when applied to the enamel of hamsters' teeth or human teeth. He showed also that when stannous fluoride is added to a noncalcium dentifrice, it is effective in protecting the enamel against attack by caries. Although a vast advertising campaign has already sold millions of dentifrices containing stannous fluoride, it is still too early to say with certainty that these are effective in reducing dental decay. Muhler's results have not yet been duplicated by other investigators. ORAL HYGIENE AND CARIES
There is no doubt that brushing the teeth immediately after each meal would significantly reduce the incidence of dental decay, probably by reason of removing the carbohydrate substrate before bacterial action produces significant amounts of acids. Fosdick! showed that regular brushing of the teeth immediately after meals reduced the caries attack rate by as much as 40 per cent. The amount of toothbrushing and its timing are far more important than the material contained in the dentifrices. Unfortunately toothbrushing immedately after each meal is not practical in modern society. In fact, it is rare to discover any person who brushes his teeth at other times than on arising or before retiring. Toothbrushing performed at the beginning or end of the day serves a cosmetic function, but has no effect in preventing dental caries because it does not remove the acids on the tooth surfaces at the time they are formed. Nonetheless, the search continues for a magic toothpaste which will prevent dental caries. Ammonium, chlorophyll, penicillin and a variety of antienzymes have been recently added to dentifrices with many promises by the manufacturers that these would halt all decay. This has sold millions of dentifrices, but has not yet significantly reduced the incidence of dental decay. It is generally agreed that the main in-
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gredient in good oral hygiene is the toothbrush and the "elbow-grease" used rather than the dentifrice. EARLY DENTAL CARE
Removal of the decay by the dentist and filling the cavity are still the most certain methods of arresting the progress of the lesion. Unfortunately, few patients visit the dentist early enough or regularly enough so that early lesions can be detected and filled. Towards this end the pedodontist must have the active cooperation of the pediatrician. Somewhat less than 20 per cent of all children requiring dental treatment receive it at an early age. In all too many instances the child's first visit is made only after there has been pulpal infection, with periapical pain. This is hardly a good introduction to dentistry. The child's first experience with the dentist conditions his attitude towards dentistry and dental procedures. In general, the three year old is ready to make the acquaintance of the dentist. If the first experience is a pleasant one, and nonpainful, the child will be better prepared to accept dental procedures when they become necessary. Most dentists complain that they do not see the child early enough and are therefore confronted with emergency problems initially rather than a healthy cooperative child. The pediatrician can do a great deal to help overcome the tremendous loss of teeth caused by dental caries if he would refer his young patients to the dentist before severe pain occurs. The primary dentition is completed between two and two and onehalf years of age. In susceptible children dental decay usually begins in the molar teeth before the age of three, and even in the average child at least four carious lesions can be expected before the age of six. It is therefore suggested that the pediatrician refer the patient to a dentist for examination and careful inspection of early lesions at approximately two and one-half to three years of age. When cavitation is observed, the pediatrician should insist upon immediate treatment by a pedodontist, lest extension of infection through the pulp and into the periapical bone result in loss of the tooth. Referral to the Dentist
The admonition to "Go see your dentist" does not constitute a referral. All too many do not go to the dentist. Some encounter dentists who do not care to treat children. It is not uncommon for pediatricians to complain that they have sent patients to a dentist only to find that the dentist would not or could not take care of the child. This is frustrating. The pediatrician would do well, therefore, to discover and
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become acquainted with the local dentists and/or pedodontists who are able and willing to treat children. The referral should be definite and as precise as the referral to an otolaryngologist. Perhaps the simplest approach is first to obtain a list of names (from the local dental society or local American Society of Dentistry for Children) of practitioners who are accustomed to treat child patients. A further responsibility of the pediatrician lies in finding a dentist who is able to care for the handicapped child. In those cases cooperation with the pedodontist in providing a bed at the hospital and a competent anesthesiologist would extend dental services to many more handicapped children than now receive them. SUMMARY AND CONCLUSIONS
The responsibility of treating and repairing the teeth rests with the pedodontist. However, the pediatrician can do a great deal to promote and implement a program of preventive dental care and caries control in the preschool and grade school children. The pediatrician should insist that the child see the dentist some time before his third birthday, before extensive dental repair becomes necessary. It is not wise to wait until decay becomes clinically evident any more than one waits for disease before instituting a preventive program of immunization. The pedodontist would like to see the child early in order (a) to institute preventive measures by dietary control of sugars, the application of topical fluorides and teaching good oral hygiene, and (b) to minimize the development of fear of the dentist. There is nothing more frustrating to the dentist than to be presented with 10 deep and painful cavities in a child who is extremely fearful of the dental procedures and therefore uncooperative. The greatest cause for dental neglect is fear. This can be prevented primarily by early introduction of the child to the dentist before he needs painful treatment. The pediatrician can do a great deal to reduce the caries attack rate in the American child by discouraging the habitual consumption of cariogenic sugars above the nutritional needs of the child. Dental caries is primarily a bacterial attack upon the hard tissues of the tooth by acidogenic organisms. These organisms produce acid metabolites on the surface of the teeth, using fermentable carbohydrates (sugars) as the substrate. Adherent foodstuffs containing sugar which remain on the tooth surface for more than 20 minutes lead to a marked production of acids on the tooth surface with enamel decalcification and initiation of the caries lesion. The American child leads the world in the consumption of sweets and in dental caries. Good dietary habits like hygienic habits must begin early in child-
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hood. Supervision of the child's dietary should not cease at infancy. The child's diet should be the joint responsibility of both the pediatrician and the pedodontist. The fluoridation of water has been demonstrated to safely reduce the caries attack rate. Increasing acceptance of this public health practice by communities is destined to enhance caries control. Dental health is part of the total health picture. No child can be considered perfectly well if he is suffering from extensive and destructive dental decay. Dental health is therefore a part of pediatric care. REFERENCES
1. Fosdick, L. S.: Reduction of the Incidence of Dental Caries. I. Immediate Toothbrushing with a Neutral Dentifrice. J. Am. Dent. A, 40:133,1950. 2. Jay, P., and Bennett, A. S.: Role of Diet in the Control of Dental Caries. J. Am. Dent. A, 52:18, 1956. 3. MassIer, M., and Zwemer, J.: Rampant Caries: Its Clinical Management. Ill. Dent. J., 20 :407, 1951. 4. Muhler, J. C., and others: Effect of a Stannous Fluoride-Containing Dentifrice on Caries Reduction in Children. J. Dent. Res., 33:606, 1954; J. Am. Dent. A, 50:163, 1955_ 5. Muhler, J. C., Radike, A. W., Nebergall, W. H., and Day, H. G.: A Comparison between the Anticariogenic Effects of Dentifrices Containing Stannous Fluoride and Sodium Fluoride. J. Am. Dent. A., 51:556, 1955. 6. Stephan, R. M.: Changes in H+ Ion Concentration on Tooth Surfaces in Carious Lesions. J. Am. Dent. A., 27:718,1940. 7. Sognnaes, R. F.: Analysis of Wartime Reduction of Dental Caries in European Children. Am. J. Dis. Child., 75 :792, 1948. 808 South Wood Street Chicago 12, Illinois
More than 90 per cent of the grade school children and approximately 50 per cent of the preschool children between three and six years of age, visiting the pediatrician for preventive care, have one or more carious teeth. Most of these teeth are unfilled. Many mothers are unaware of the tooth decay, and will remain unaware of it unless the pediatrician calls it to their attention. Parents often do not seek dental care for children until a toothache develops. Parents are usually quite surprised when the decay reaches the pulp, causing extreme pain and infection of the jaw. This is hardly a good introduction of the child to the dentist, and certainly not in keeping with sound principles of preventive medicine. Prevention of disease is the primary goal of the pediatrician. He carefully examines the throat, the tonsils and the tongue at every visit even when there are no complaints. But many pediatricians feel that dental disease is not within their province and leave the examination and care of the teeth to the dentist. This clinic will attempt to clarify the role of the pediatrician in the control of dental caries and indicate how he can help the pedodontist implement a successful program of caries prevention. PEDIATRIC TEETH EXAMINATION
The following steps applied to daily pediatric practice would do more to help prevent dental decay and tooth loss than all the dentifrices now sold to the American public. The technique is neither difficult nor time consuming. I. Examine the teeth of every child coming to the office. Do this just before looking at the throat and tonsils. The average time required From the Department of Pedodontics, University of Illinois College of Dentistry, Chicago.
953
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is 50 seconds. The equipment is a tongue blade and intraoral light. Place the child in a comfortable position and proceed as for a throat examina tion. Begin with the lower left last molar and proceed around the lower arch to the right side. Touch each tooth with the tip of the tongue blade. It is well to count aloud as you proceed to gain the child's cooperation and to allay his fears. Count from one to 10 for the preschool child and from one to 12 for the grade school child. (There are 10 primary or deciduous teeth in each arch from ages two and one half to six. The first permanent molars appear behind the last deciduous molars at age six.) Repeat with the upper arch, going from the child's left to right. Inspect the molar teeth again with special care, since dental caries always begins in the occlusal pits and fissures of these teeth. 2. If the child has no cavities, a referral should be made to a pedodontist or dentist with an interest in caring for children for early introduction and a program of preventive dental care. A notation of the name of the dentist should be entered in the record. 3. If the child has one or two small cavities, insist that he be taken to a dentist at once for fillings. Check for fillings at the next visit. 4. If the child shows numerous cavities, institute caries control measures and refer to a competent dentist at once. The most effective method of arresting active dental decay (at present) consists in minimizing the excessive intake of sugars between meals. After reviewing the diet, suggestions for substituting cold cuts, cheeses, fruits and other more healthful foods for the cariogenic confections consumed in large quantities by many American children between meals are indicated. The pediatrician should guide the dietary habits of his preschool and grade school children with the same care that he shows the infant. When the child is healthy and vigorous and growing well, the tendency is to omit dietary supervision. But when dental disease becomes evident, the pediatrician has the responsibility to review the diet with a view towards better systemic as well as dental health. DENTAL CARIES
In order to bring the problem of dental caries into better focus, it would be appropriate to review briefly the major characteristics of dental caries, since this disease too often receives only superficial attention in most medical school curricula. Once the main features of the disease are understood, it is not difficult to apply the various methods of caries control.
MAURY MASSLER
955
The Caries Process
Dental caries is the result of bacterial attack of the hard substance of the tooth, beginning on the surface and progressing inward towards the pulp and resulting in the formation of a cavity. The primary attack on the enamel or dentin is made by acid metabolites produced by acidogenic organisms (lactobacilli, streptococci and others) living on a fermentable carbohydrate substrate on the surface of the tooth. Acid decalcification is followed by proteolysis of the organic matter with the result that dental caries is a slowly progressive and intermittent process. Incidence
Dental caries is primarily a disease of childhood. It begins early in childhood as soon as the molar teeth are erupted and accumulates rapidly, with acute exacerbations between four and eight years and 12 and 16 years of age. The rate decreases substantially after the age of 30 years. Dietary Factors
The most important contributory factors in the initiation and progression of dental decay are the readily fermentable carbohydrates (particularly the sugars) which adhere to the surface of the teeth. 2 These can be metabolized by the acidogenic organisms within a few minutes. The pH on the tooth surface (as measured by an antimony electrode) will drop from 7.0 to 5.4 within two minutes after a single glucose or sucrose rinse. 6 Effective caries control depends on preventing the accumulation of fermentable sugars on the tooth surfaces. This can be accomplished by (a) restricting the sugar intake to mealtimes when the natural cleansing action of detergent foods and saliva prevents the accumulation of sugars on the tooth surface or (b) by brushing the teeth immediately after sweets have been ingested. Other dietary or nutritional factors do not appear to play any significant role in the production or prevention of human caries. In this respect it should be pointed out that the role of calcium and vitamin D in caries prevention is practically nil. Genetic Factors
There is reasonably good evidence from both animal and human studies to suggest that genetic factors may also influence susceptibility to decay. Approximately 5 to 7 per cent of the population are cariesimmune in spite of dietary indiscretions and poor oral hygiene. Caries immunity can often be traced through family groups. The mechanism
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of this immunity is not known. It may lie in a potent bacteriostatic property of the saliva. . Extreme susceptibility to dental decay (rampant caries) afflicts approximately 7 per cent of the population. These persons suffer severe attacks of decay even when they practice good oral hygiene and sugar restriction. In them, dietary indiscretions and poor oral hygiene are catastrophic and result in a complete destruction of all the teeth in the mouth so that they become edentulous before the age of 25 years. Rampant caries seems to follow a definite familial pattern and is probably the result of an inherent susceptibility to dental decay aggravated by excessive consumption of sugars and poor oral hygiene. Pattern of Caries Attack
Dental caries begins in the pits and fissures on the occlusal (biting) surfaces of the molar teeth. These are the most susceptible areas, and the pediatrician should always examine the occlusal surfaces of the posterior teeth for signs of decay. The second site for caries attack are the proximal contact surfaces between the molar teeth. These are difficult to examine, even by the dentist-who usually obtains intraoral roentgenograms to make his inspection more complete. The third (and least frequent) site for caries attack are the necks of the teeth (cervical areas) near the gingivae. Dental caries spreads from the molar teeth anteriorly. As long as only the posterior teeth are affected, the disease may be considered mild. When the bicuspid teeth become involved, the disease is considered to be moderate. When decay spreads to the approximal surfaces between the upper anterior teeth, it is considered severe and the child rates as being caries-susceptible. If the lower anterior teeth become involved, the condition is called "rampant caries." By this time, too, the cervical areas of the molar, bicuspid and sometimes also the incisor teeth are attacked by caries. Caries Control
Caries control (i.e., limitation of the spread of the lesions, once the lesion has appeared) may be achieved by (a) early and regular visits to the dentist and (b) elimination of fermentable sugars between meals. Caries Prevention
In the average child a significant degree of caries prevention (preventing the appearance of new lesions) can be achieved by the following: (1) elimination of fermentable sugars between meals, (2) tooth-
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brushing immediately after each meal, (3) topical application of fluorides to the enamel as soon as the teeth erupt, (4) the addition of one part per million of fluorides to the communal drinking water supply. The pediatrician can do a great deal towards implementing a program of caries control in his patients by insisting that children under his care visit the dentist regularly and that they begin to do so before the teeth show gross evidence of decay. The pediatrician can also do a great deal to help the pedodontist to arrest the decay, once it becomes apparent, by introducing the parent and the child to the concept of caries control by sugar control. The pediatrician is regarded as the authority in matters of the child's health. He can encourage the mother and child to cooperate with the pedodontists' program or nullify these efforts by a too casual attitude concerning dental health. Caries prevention and caries control measures are especially indicated for children who would suffer excessive hazards from tooth extraction (the child with rheumatic heart disease, kidney disease or hemophilia). CARIES CONTROL VIA SUGAR CONTROL
An extensive scientific literature has accumulated during the past two decades which proves beyond reasonable doubt that the consumption of excessive amounts of refined sugars, particularly in the form of rapidly fermentable carbohydrates (especially sugars) which stick tenaciously to tooth surfaces, leads to a marked increase in the caries attack rate. Thousands of caries-active children and adults have had the disease completely arrested by a drastic reduction in sugar intake, i.e., the elimination of sugars which are consumed in excess of nutritional needs. During the war these clinical observations were duplicated in almost an experimental fashion in large groups living in Europe. As the annual consumption of sugars decreased during the war in The Netherlands, Norway, Sweden and England, the average caries attack rate fell in proportion. After the war, when sugar in the form of candies, cookies and the like again became freely available, the incidence of caries rose again, in proportion. 7 Other Effects of Excessive Sugar Intake
Excessive sugar intake between meals (above nutritional needs) constitutes a hazard not only to the teeth. Excessive consumption of between-meal sugars is an important factor in the loss of appetite at mealtimes for essential foodstuffs such as meats and vegetables. The common complaint by parents that their children have no appetite and fail to eat at mealtimes may often be traced to the enormous consumption of refined sugars between meals. In this way excessive sugar con-
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sumption predisposes to poor nutritional balance, since it literally pushes out from the dietary the other necessary proteins, minerals and fats. The consumption of sweets in excessive amounts during early childhood may be a reflection of a psychologic problem which causes the child to seek gratification from eating because his needs are not being met in other ways. Thus the sugar appetite in the child and the alcohol appetite in the adult have many points in common from both the metabolic and psychologic viewpoints. Small amounts of sugar or alcohol may stimulate the appetite and lead to obesity. Excessive amounts lead to malnutrition by depressing the appetite. It is interesting to note that rampant caries has its highest incidence in the thin, undernourished child who subsists largely on between-meal snacks or sweets. The obese child tends to have a lower than average caries attack rate. 3 Snack Habits and Dental Caries
If a person were to consume sugars only at mealtimes, the caries attacks would be minimized by the buffering and detergent action of the saliva and alkaline foodstuffs. However, when refined sugars are ingested between meals and at frequent intervals, the teeth are subjected to an almost continuous series of assaults by the acids formed on the tooth surfaces. The caries attack rate thus becomes enormously increased by the habitual consumption of sugars between meals. It is not so much the total quantity of sugars consumed during the day that is important as the number of times a sugar meal was taken. An occasional "candy binge" is not as injurious as the habitual daily consumption of caramels or chewing gum. Correcting the Diet
Caries control via sugar control should be initiated by the pediatrician as early as possible. Correcting the diet and eliminating excessive amounts of between-meal sugars are not difficult if the physician will first obtain a careful history of the daily intake of the child for a period of approximately one week. Careful review of the diet often reveals peculiarities in eating habits. Individual caries susceptibility determines to a large extent the amount of fermentable carbohydrate which is cariogenic. A very susceptible child may suffer great destruction of the teeth from what appear to be only "normal" amounts of sugars. Other children may consume large amounts of candies without severe damage. The degree of caries susceptibility of the child must be pointed out to the parents
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when they object to suggestions that the destruction of the child's teeth may be due to overindulgence in sweets. Many parents find it difficult to limit between-meal snacks and sweets to their children. A more effective technique is to offer an apple or potato chips instead of candies or cookies or a sandwich containing meat or cheese instead of one containing jams or jellies. A healthy child will enjoy an apple with as much gusto as a piece of cake, and will accept noncariogenic popcorn or potato chips instead of caramels with no loss in caloric intake. A lunch consisting of a meat-sandwich and milk is just as satisfying as and far more healthful than one made up of a sweet-roll and soda-pop. In fact, if given a free choice, most young children will select the fruit and the sandwich over the cake and caramel as a steady diet. Only those with already conditioned appetites prefer the sweets. If parents are considerable consumers of candies, cookies and chewing gum, one cannot expect the child to deny himself these confections. It is important that the physician recognize the impact of family food habits upon the child. Often parents will make a sincere effort to change their own dietary habits in the interests of their children's health. It would be pertinent here to point out that the appetite for sweets is acquired early. The pediatrician can do his part in discouraging the excessive consumption of candies by offering his patients a toy balloon or trinket as a reward instead of a lollipop. CALCIUM. VITAMIN D AND CARIES
Vitamin D and calcium compounds have often been invoked as therapeutic agents for the control and even prevention of dental decay. Thousands of calcium tablets, vitamin D pills and gallons of milk have been consumed by children and pregnant females toward this end. However, the past two decades have indicated clearly that such therapeutic measures are not effective, since the caries attack rate has increased steadily during that period. There is certainly no rational basis, at present, for the continuation of these empiric and ineffective therapeutic measures. This does not in any sense negate the value of calcium and vitamin D in the growth and calcification of bone. However, they seem to have no value in caries prevention. FLUORIDES AND CARIES Fluorides in Water
It has been demonstrated that the caries attack rate is much less in areas where the fluoride content of the water supply is one part per
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million or more than in non fluoride areas. It has therefore been proposed that fluorides be added to communal water supplies to reduce the incidence of caries. This hypothesis has been subjected to careful and intensive testing over a 10 year period in Newburgh and Kingston, New York; Grand Rapids, Michigan; Evanston, Illinois; and other cities. The inverse relation between water-borne fluorides and dental caries is now one of the most thoroughly tested and authenticated relationships in all modern medicine. These studies have demonstrated conclusively that the addition of minute amounts of fluorides (one to two parts per million) regularly reduces the caries attack rate approximately 40 to 60 per cent with perfect safety and absolutely no systemic effects and at a low cost (approximately eight to ten cents per person per year). Inevitably there have been objections to this procedure by small but vocal groups. Some object to the fluoridation of water as "socialized medicine" or "mass medication," forgetting that the chlorination of water, the pasteurization of milk and the addition of iodides to table salt are similar preventive measures. The addition of fluorides to the water is not a therapeutic procedure (it does not heal the carious lesion); it is a preventive measure. Other groups object to the fluoridation of water on religious ground-s. Still others object on the basis that fluorides are protoplasmic poisons. In powder form or as strong solution, fluorides are poisons and have been used as insecticides. In a concentration of one to two parts per million fluorides are not at all poisonous. Chlorine is also poisonous when concentrated as a gas, but not when used in weak dilutions to purify the water. The objections offered by small groups against the addition of fluorides to drinking water are primarily emotional and not based on any real evidence'. These groups will unfortunately delay the fluoridation of the drinking water in some communities, but will not, in the long run, stop progress in the mass reduction of caries by water fluoridation, because the scientific evidence to support the use of water fluoridation as a public health measure for the reduction of dental caries is now overwhelming. Fluorides in Foods
Many foods (fish, tea, many vegetables) contain relatively large amounts of fluorides (40 to 100 parts per million). These fluorides have no effect in reducing the incidence of caries probably because the fluorides in foods are in insoluble combinations and not available for action on the teeth. Apparently fluorides must be in water solution and in a soluble, ionic form to act in caries reduction.
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Fluoride Tablets
Though there is excellent evidence to show that the addition of fluorides to the communal water supply is effective in reducing the prevalence of dental caries, there is no evidence to support the suggestion that fluorides in the form of tablets or lozenges would be similarly effective. Commercial preparations which contain calcium fluorides plus multiple vitamins have nonetheless been offered for the control of dental caries. There have been no acceptable studies made to support such claims. Such tablets contain insoluble calcium fluorides which are not absorbed from the intestinal tract and are therefore nontoxic. They are also inactive against caries. Topical Applications of Fluorides
The relation between fluorides in the water supply and reduced caries experience in children has led directly to experimental studies on the effect of topical applications of fluorides to the teeth. Knutson and Armstrong (1942), Cheyne (1942), Bibby (1944) and many others have demonstrated conclusively that the topical application of fluorides to the teeth of children is an effective method of preventing the initiation of new enamel caries. Solutions of sodium fluoride 2 per cent were applied only to the teeth on one side of the mouth. The untreated side in the same child served as the control. This procedure showed are· duction of 25 to 40 per cent in the incidence of new caries in the treated side over the untreated side after one to three years of observation. The topical application of fluorides has none of the objections offered to its systemic administration, since the material is not swallowed and is therefore not toxic. The accepted method of sodium fluoride applications consists in an initial, thorough dental prophylaxis followed by a minimum of four treatments within a relatively short period (two to three weeks). Fluorides are effective when applied to the recently erupted teeth of children, but not in adults. Newly erupted enamel is receptive to the fluoride ion, the apatite molecule changing from the soluble hydroxyapatite to the less soluble fluor-apatite. The adult enamel surface is impregnated over a period of years by ions derived from the saliva and is no longer receptive to the fluoride ion. Topical applications of fluoride solutions to the teeth of children are not contraindicated in areas where fluorides have been added to the drinking water. The added fluorides are not ingested and will not cause mottling, but may further increase the resistance of the enamel surface to acid etching.
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Fluoride Dentifrices
On the basis of the efficacy of topical applications of sodium fluoride solutions to the surface of the newly erupted enamel in reducing the incidence of new lesions, it was logical to assume that sodium fluoride might be effective if added to dentifrices or mouthwashes. Unfortunately repeated trials have shown that sodium fluoride in the form of a dentifrice or mouthwash is not effective in reducing dental caries (Bibby et aI., 1946). The fluoride ion probably combines with the calcium or other metallic ions present in the dentifrice and becomes unavailable to the enamel. Recently, Muhler et aJ.5 demonstrated that stannous fluoride is more effective than sodium fluoride solutions when applied to the enamel of hamsters' teeth or human teeth. He showed also that when stannous fluoride is added to a noncalcium dentifrice, it is effective in protecting the enamel against attack by caries. Although a vast advertising campaign has already sold millions of dentifrices containing stannous fluoride, it is still too early to say with certainty that these are effective in reducing dental decay. Muhler's results have not yet been duplicated by other investigators. ORAL HYGIENE AND CARIES
There is no doubt that brushing the teeth immediately after each meal would significantly reduce the incidence of dental decay, probably by reason of removing the carbohydrate substrate before bacterial action produces significant amounts of acids. Fosdick! showed that regular brushing of the teeth immediately after meals reduced the caries attack rate by as much as 40 per cent. The amount of toothbrushing and its timing are far more important than the material contained in the dentifrices. Unfortunately toothbrushing immedately after each meal is not practical in modern society. In fact, it is rare to discover any person who brushes his teeth at other times than on arising or before retiring. Toothbrushing performed at the beginning or end of the day serves a cosmetic function, but has no effect in preventing dental caries because it does not remove the acids on the tooth surfaces at the time they are formed. Nonetheless, the search continues for a magic toothpaste which will prevent dental caries. Ammonium, chlorophyll, penicillin and a variety of antienzymes have been recently added to dentifrices with many promises by the manufacturers that these would halt all decay. This has sold millions of dentifrices, but has not yet significantly reduced the incidence of dental decay. It is generally agreed that the main in-
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gredient in good oral hygiene is the toothbrush and the "elbow-grease" used rather than the dentifrice. EARLY DENTAL CARE
Removal of the decay by the dentist and filling the cavity are still the most certain methods of arresting the progress of the lesion. Unfortunately, few patients visit the dentist early enough or regularly enough so that early lesions can be detected and filled. Towards this end the pedodontist must have the active cooperation of the pediatrician. Somewhat less than 20 per cent of all children requiring dental treatment receive it at an early age. In all too many instances the child's first visit is made only after there has been pulpal infection, with periapical pain. This is hardly a good introduction to dentistry. The child's first experience with the dentist conditions his attitude towards dentistry and dental procedures. In general, the three year old is ready to make the acquaintance of the dentist. If the first experience is a pleasant one, and nonpainful, the child will be better prepared to accept dental procedures when they become necessary. Most dentists complain that they do not see the child early enough and are therefore confronted with emergency problems initially rather than a healthy cooperative child. The pediatrician can do a great deal to help overcome the tremendous loss of teeth caused by dental caries if he would refer his young patients to the dentist before severe pain occurs. The primary dentition is completed between two and two and onehalf years of age. In susceptible children dental decay usually begins in the molar teeth before the age of three, and even in the average child at least four carious lesions can be expected before the age of six. It is therefore suggested that the pediatrician refer the patient to a dentist for examination and careful inspection of early lesions at approximately two and one-half to three years of age. When cavitation is observed, the pediatrician should insist upon immediate treatment by a pedodontist, lest extension of infection through the pulp and into the periapical bone result in loss of the tooth. Referral to the Dentist
The admonition to "Go see your dentist" does not constitute a referral. All too many do not go to the dentist. Some encounter dentists who do not care to treat children. It is not uncommon for pediatricians to complain that they have sent patients to a dentist only to find that the dentist would not or could not take care of the child. This is frustrating. The pediatrician would do well, therefore, to discover and
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become acquainted with the local dentists and/or pedodontists who are able and willing to treat children. The referral should be definite and as precise as the referral to an otolaryngologist. Perhaps the simplest approach is first to obtain a list of names (from the local dental society or local American Society of Dentistry for Children) of practitioners who are accustomed to treat child patients. A further responsibility of the pediatrician lies in finding a dentist who is able to care for the handicapped child. In those cases cooperation with the pedodontist in providing a bed at the hospital and a competent anesthesiologist would extend dental services to many more handicapped children than now receive them. SUMMARY AND CONCLUSIONS
The responsibility of treating and repairing the teeth rests with the pedodontist. However, the pediatrician can do a great deal to promote and implement a program of preventive dental care and caries control in the preschool and grade school children. The pediatrician should insist that the child see the dentist some time before his third birthday, before extensive dental repair becomes necessary. It is not wise to wait until decay becomes clinically evident any more than one waits for disease before instituting a preventive program of immunization. The pedodontist would like to see the child early in order (a) to institute preventive measures by dietary control of sugars, the application of topical fluorides and teaching good oral hygiene, and (b) to minimize the development of fear of the dentist. There is nothing more frustrating to the dentist than to be presented with 10 deep and painful cavities in a child who is extremely fearful of the dental procedures and therefore uncooperative. The greatest cause for dental neglect is fear. This can be prevented primarily by early introduction of the child to the dentist before he needs painful treatment. The pediatrician can do a great deal to reduce the caries attack rate in the American child by discouraging the habitual consumption of cariogenic sugars above the nutritional needs of the child. Dental caries is primarily a bacterial attack upon the hard tissues of the tooth by acidogenic organisms. These organisms produce acid metabolites on the surface of the teeth, using fermentable carbohydrates (sugars) as the substrate. Adherent foodstuffs containing sugar which remain on the tooth surface for more than 20 minutes lead to a marked production of acids on the tooth surface with enamel decalcification and initiation of the caries lesion. The American child leads the world in the consumption of sweets and in dental caries. Good dietary habits like hygienic habits must begin early in child-
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hood. Supervision of the child's dietary should not cease at infancy. The child's diet should be the joint responsibility of both the pediatrician and the pedodontist. The fluoridation of water has been demonstrated to safely reduce the caries attack rate. Increasing acceptance of this public health practice by communities is destined to enhance caries control. Dental health is part of the total health picture. No child can be considered perfectly well if he is suffering from extensive and destructive dental decay. Dental health is therefore a part of pediatric care. REFERENCES
1. Fosdick, L. S.: Reduction of the Incidence of Dental Caries. I. Immediate Toothbrushing with a Neutral Dentifrice. J. Am. Dent. A, 40:133,1950. 2. Jay, P., and Bennett, A. S.: Role of Diet in the Control of Dental Caries. J. Am. Dent. A, 52:18, 1956. 3. MassIer, M., and Zwemer, J.: Rampant Caries: Its Clinical Management. Ill. Dent. J., 20 :407, 1951. 4. Muhler, J. C., and others: Effect of a Stannous Fluoride-Containing Dentifrice on Caries Reduction in Children. J. Dent. Res., 33:606, 1954; J. Am. Dent. A, 50:163, 1955_ 5. Muhler, J. C., Radike, A. W., Nebergall, W. H., and Day, H. G.: A Comparison between the Anticariogenic Effects of Dentifrices Containing Stannous Fluoride and Sodium Fluoride. J. Am. Dent. A., 51:556, 1955. 6. Stephan, R. M.: Changes in H+ Ion Concentration on Tooth Surfaces in Carious Lesions. J. Am. Dent. A., 27:718,1940. 7. Sognnaes, R. F.: Analysis of Wartime Reduction of Dental Caries in European Children. Am. J. Dis. Child., 75 :792, 1948. 808 South Wood Street Chicago 12, Illinois