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Preventive dentistry for pre-school children
Pub/. tt/th. Lomt. (1969) 83, 245-250
Preventive Dentistry for Pre-schooi Children* P. M. C. ,IAMBS M.D.S., 1.,.D.S., I).P.D.
Professor o/' Dental Heahh. U)Tiversio, of Birmingham, The Dental School, St. ~ l(lrvs Ro,', Birmineham DF.NTAL CARE and supervision o f pre-school children are extremely important. During the tirst five years of life three processes are taking place which t-rove considerable significance in determining the future dental health of the individual. First, the deciduous dentition is erupting into the mouth, and the primary teeth are exposed to the oral environment with all its attendant dangers: second, tooth formation Js proceeding li)r the permanent dentition and this is the time to increase its caries resistance by systemic means" and third, the child's dietary habits, so intimately related to the oral environment, are being established, for better or for worse, in each indMduat, tt is entirely within the capabilities of every mother, during this vital period of time, to make or mar her child's dentition, both present and future, and it is the responsibility or" the dental profession to aid her in every way possible. This group is a difficult one to reach. Even basic information about the extent to which it is attacked by caries is lacking. Once children are conveniently assembled in schools they are available for the investigations of the inquisiti,,,e epidemiologist, but the examination of younger children presents a problem. Some idea o f their caries prevalence can be obtained by calling for volunteers and e x a m M n g those who are presented, but this is not a randomly-selected group and the findings cannot be extrapolated to the pre-school population as a whole. It seems likely however that the average pre-school child experiences a d.e.f, of about one for each year of" life" that is, a three-year old has approximately three decayed, extracted o r filled deciduous teeth; a four-year old four. and so on. These are only average figures" the range of d.e.f, prevalence in three-year olds can vary fl'om 0 to 20. It is often the case that the first dental expo. ur¢: of the five year otd is a school inspection, when the ravages of the deciduous dentition may be discovered for the first time; too late for prevention and sometimes too late even for conservative treatment. In passing it might be mentioned that at least there is a dental advantage in having school entry at live years. In some countries children do not go to school uutii they are seven, so when they receive tne~r fir.~ dental examination it is sometimes the case that not only the primary dentition but also the four first permanent molars are beyond redemptiol~. *This paper was originally given as a lecture at a Refresher Course f¢.~r Local Amhority DentaI OlIicers at Cowley Manor, Gloucester in May 1968.
246
P U B L I C H E A L T H VOL. 83 NO. 5
Our objective must be somehow to apply preventive dentistry methods to a group which is itself unco-operative because of its tender age, the majority of which is quite inaccessible, and whose mothers are often apathetic about such things as dental care. At present there is only one realistic solution to the problem and that is by the mliversal fluoridation of water. We have certain knowledge that by this inethod the problem would almost disappear. The present three-year old, witii',three carious teeth, would, as has happened in llirmingham, become a three year-old with one and a half carious teeth; and moreover, the progression of caries through these teeth would be much slower tiaan otherwise, taking the urgency out of the operative requirement. If nothing else was done except water fluoridation the average child would arrive at school at five years old with only minimal caries in two or three teeth. The fact that tluoridation is not universally adopted is a measure of public apathy, and many town and city Councils are neglecting an important public health duty. Fluoridation of water is tile best way of introducing this magic ion into the tooth substance, but there are others. Fluoride tablets and fluoridated salt are sometimes suggested as alternatives. Are fluoride tablets a useful substitute for water tiuoridation ? The answer is both yes and no; yes they are, if people would administer them regularly and conscientiously to their children: otherwise not. There is evidence that the dosing of a child with I m g o1"fluoride a day by tablet, preferably crushed and mixed with water, is as effective as water fluoridation in preventing dental caries. Arnold, McClure & White (1960)reported the result of a fluoride tablet trial. The children in this trial were mostly of the pre-school age so the methods and results are of some relevence. Most of the test subjects were a selected group; their parents were physicians, dentists, or other professional employees of tile public health service who "wanted their chitdren to have the best dental care, and these children and parents were considered capable of following instructions consistently and exactly." A three-month supply of tablets was given to each family. Parents of children aged up to two years were instructed to dissolve ~t tab~let (1 mg F) in a quart o f water and to use this for making up baby foods or for drinking purposes. Children between two and three years old were to have one tablet every other day, taken directly with water, or dissolved in a suitable drink. Those between the ages of three and ten years were to receive a tablet every day, given in the Sallle n l a . n n e r .
The results, alter varying exposure to the table'~s, by children aged from one to o v e r eight years, showed that the effect was comparable with reductions that could be expected from water fluoridation, although the authors wei'e under no ilhzsions that this was a properly cont,roHed investigation because of the very selective nature of the test group. From a public health point of view the most interesting and significant paragraph in the paper was the last one: "Although t h e persons involved in the study were, on the whole, a highly
PREVENTIVE DENTISTRY FOR PRI5-SCHOOI. CH~LDR EN
247
educated group, only about half of them actually continued to give their children tablets for the necessary number of years.'" If this educated and enthusiastic group failed, what chance is there for the general population ? Ten years is a long time to expect unflagging zea!. and it should not be forgotten that many mothers are too disinterested even to take their children to clinics for immunization against killing diseases, There is little likelihood of tablets ever becoming of public health significance, hov~e~,er useful they may be in occasional selected families. There is concrete evidence for this massive indifference. Calgary, Canada. launched a fluoride tablet programme, with much publicity, in November [966. as an alternative to a water fluoridation scheme. Under this programme chiidren under 16 could receive a three-months supply oF fluoride tablets on prescription. After the initial impact it was Found that two out o f three Ca|garians did not bother to get their free fluoride suppliments re-prescribed, and although the Health Authorities are continuing the scheme for the moment its future is in doubt. A similar scheme in Saskatchewan, started earlier, has been discontinued. A better method of instituting systemic fluoride is by the fluoridation of table salt. In 1955 such salt, containing 200 mg of sodium fluoride/kg, was introduced into the canton of Zurich, Switzerland; and by t965 the consumption of fluoridated salt was about 65 ('' of the total usaee o f domestic salt in the whole country (Muhlemann, t967). Allowing for some loss of satt during food preparation the daily fluoride supplement given by this method is approximately 0.5 rag, or only about one-half the optimum dose. In younger children there is a lower consumption of salt, so the actual fluoride ingested woutd be even less. Reductions in caries following salt fluoridation reported by Marthaler (i962) show a reduction in eight- and nine-year old chi!dren of about 22".~;. The concentration of 200 mg of sodium fluoride/kg is not now considered high enough and a higher concentration of 300 mg/kg is recommended. Some workers have r&:narked on the diCficulty of establishing an optimum concentration of fluoride in salt that would allow for age differences in its consumption, There is no doubt that of all fluoridation methods so far attempted the t]uoridation of water is the method of choice. Although systemic fluoride is the best way to use the protective effect to the full, it still has its uses after tooth eruption. All pre-school children should have topical applications of fluoride at yearly intervals, This is a bald statement, and there are considerable difticulties in implementing such a suggestion, because of the general lack of availability of pre-school children. It is quite easy to instal a hygienist in a welfare clinic, and the applications themselves are very easy, quick and painless. The difficulty will be to persuade parents that atter> dance for this purpose is useful, and there should be wide-spread propaganda both inside and outside the mother and child welfare clinics, directed towards expectant mothers as well as those with inRants already. If mothers of pre 7 school children wou[d attend with their charges l\~r this prophylactic treatment
2-1a
PUt3LIC H E A I . T I ! V(-)t.. g3 N(). 5
there would be lkmr advantages. First, tile advantage that the treatment itself affords: second, the introduction of the child to dental treatment by a quick and painless operation: third, the year)yinspection of tile teeth and fol)ow-up of conservative treatment where necessary: and l~)urth, the opportunity that the visit allows for educating parents in matters of diet and more particularly into the more harmful contents of die(. Mothers of young children, are subjected to all sorts of pressures. There is the pressure of the confectionary, advertising, aimed at convincing the public that sucrose is not on)y nice. but necessary for life and heahh and energy. The chief sweet manufacturing tirms spend about 7 million pounds per year on promotion and advertising. There is the pressure of the manufaeiurers <,f Vitamin C syrups. There is the social pressure often induced by' overerowd{ag the necessity for keeping a child quiet. A n d what better way is there of keeping him quie{ than by giving him a comforter bottle or a dinky feeder containirag a fruit syrup if he is sma)), and a supply of sucrose comestibles if he is older? They are cheap and ef)i~ctive purchasers of temporary silence. The giving of sweets in large quantities to small children has two altendant dental risks, as weli as the other hea)th risks involved. The first dental risk is the obvious one: t.he effect of sugar on the teeth and the production of caries in the deciduous denlition, The second is the habit tk)rmation, the sweet tooth, that may ultimately .ruin the permaneni dentition as well. [.eft to themselves children will enjoy savoury foods, as anyone who provides these at a children's party tinds out. But if sweets play a prominent part of their lives and are ofli:red always as a reward for virtue (and conversely, the deprivation of them as punishment [br vice.) then they become a mental as welt as a physical habit. it has been observed that the caries rate is higher in only and tirst-born children than in later children (Berk. t943; Mansbridge, t960), and there are a number o f theories to account for this. My theory is that the eldest child receives the most attention during the first tiaw years of life, especially From grandparents. It woutd be interesting to conduct an epidemiological study looking at dental caries in relation io yet another dental health index, the James index o f g r a n d motl',er exposure! It is the responsibility of the various branches of the medical profession to counter these pressures; uphill work, but not always unsuccessful. Much. health education c a n be done in the maternity and child welfare clinics, both anteand post-nata); a t the suggested topical fluoride visits; and most i m p o r t a n t o f all, b y district nurses and health visitors, w h e r e such education should be a part of their total health instruction and supervision. W i t h o u t substantial support from the medical services, which have more contact with parenCs during the pre-scimol years, educational plans are n o t likely to be effective. The message c oncmining sugar restriction is a familiar one, and it is unnecessary to repeat it at the present time. l t i s psychologically unwise to b e t o o prohibitive; dental health education should attempt to guide total diet rather
PREVENTI.VE DFNTISTRY FOR PRE-SCHOOL CHII_DRF.N
249
ihan attempting to forbid a few items. One item that should of course be totally condemned is the sugar comforter whether in the form of the dipped dummy, the dinky feeder, or the propped bottle. It is worth noting that one manuE~cturcr of vitamin syrups has recently produced a new product which is less erosive and contains glucose, not sucrose. Although one cannot say that it is l.n nalcs. it is probably tess harnfful, as it is generally recognized that sucrose is ~he most dentally dangerous of" the sugars because of the properly of certain oral streptococci to synthesize sticky polysaccharides from it. Nevertheless. administrmion by the metimds mentioned should be a mauer of warning. As far as sweets ave concerned the important piece of coucat~¢ h to eel over is that the quantity token is not as important as their consistency and the frequency of eating them. Toffees are probably the most dangerous to the teclh and 'tt~e eating of them should be strictly conlrolled. Chocolalc is probably tl~c least oi" the evils" it ~9 soluble, rapidly eaten, and relativeb,' expensive in relati~m ~o I o c l h - c x p c ) s u l c
t{t33f~.
Oral hygiene is another factor that presents certain dilticulties in small children. They are usually not capable of corrcct and e.q'ectivc too~hbruslfing and the mother's attempts, when they are made at all, are inclined to be cursory and infrequent, tn a programme of dental health education the importance of oral hygiene should be stressed but ahhough hopeful of success (especially with an dectric toothbrush) a better result would probably be obtained by the use of fibrous tbods. Apples will clean the teeth of this age group more effectively than artiiicial means, as well as being a valuable salivary stimulant, and all meals should end with a slice of apple or raw carrot. Adults are not ofte!a enthusiastic about raw carrot, but there is no doubt that most small ch.iktren eat it with relish. Apples, carrots, nuts, crisps, cheese and tlie like are useful for between-meal snacks, as a substitute for cariogenic items. To sum up--the most effective protection fi'om dental caries is systemic fluoride, preferably in the water, when it is an involuntary benefit. The results of all fluoridation trials show us this clearly. In Birmingham where the water was fluoridated in 1964 the benefits to three-year old children are clear to see clinically as well as statistically. Mothers who have attended the Birnqingham Dental Hospital for some years with successive children h a v e been surprised and pleased to find that their youngest pre-school offspring, unlike the others, are either free from caries at three years old or with only minimal attack, ll" Birmingham follows the experience of American dental s c h o o l s i n fluoride areas there will soon be a shortage of child patients ort whom to demonstrate the manifestations of rampant dental caries to the students, and difficulty in producing children on whom they can practice the operation of pulpotomy. After systemic fluoride, topical application of fluoride salts should be carried out routinely in maternity and child welfare clinics, together with at1 the educational effort mentioned: Very i m p o r t a n t , and worth repeating, is the necessity for the support of the physicians and their representatives, especially
250
PUBLIC HEALTH VOL. 83 NO. 5
those who actually call at the homes. One of the main difficulties in educating the pre-school group is the communication problem; health visitors can probably make, after water fluoridation, the biggest contribution of all. References ARNOLD. F A., MCCLURE, F. J. ~: WHITE, C. L. (1960). Dent. Prog. 1, 12. BEAK, H. (1943). J. Am. dent. Ass'. 30, 1749. MANStmlDGE, J. N. (1960). A:'chs oral Biol. 2, 209. MARTHALER, T. M. (1962). Schweiz. Alschr. Zahnheilk, 71,671. MUttLEMANN, H. R. (1967). hit. dent. J., Lond. 17, I0.
Preventive Dentistry for Pre-schooi Children* P. M. C. ,IAMBS M.D.S., 1.,.D.S., I).P.D.
Professor o/' Dental Heahh. U)Tiversio, of Birmingham, The Dental School, St. ~ l(lrvs Ro,', Birmineham DF.NTAL CARE and supervision o f pre-school children are extremely important. During the tirst five years of life three processes are taking place which t-rove considerable significance in determining the future dental health of the individual. First, the deciduous dentition is erupting into the mouth, and the primary teeth are exposed to the oral environment with all its attendant dangers: second, tooth formation Js proceeding li)r the permanent dentition and this is the time to increase its caries resistance by systemic means" and third, the child's dietary habits, so intimately related to the oral environment, are being established, for better or for worse, in each indMduat, tt is entirely within the capabilities of every mother, during this vital period of time, to make or mar her child's dentition, both present and future, and it is the responsibility or" the dental profession to aid her in every way possible. This group is a difficult one to reach. Even basic information about the extent to which it is attacked by caries is lacking. Once children are conveniently assembled in schools they are available for the investigations of the inquisiti,,,e epidemiologist, but the examination of younger children presents a problem. Some idea o f their caries prevalence can be obtained by calling for volunteers and e x a m M n g those who are presented, but this is not a randomly-selected group and the findings cannot be extrapolated to the pre-school population as a whole. It seems likely however that the average pre-school child experiences a d.e.f, of about one for each year of" life" that is, a three-year old has approximately three decayed, extracted o r filled deciduous teeth; a four-year old four. and so on. These are only average figures" the range of d.e.f, prevalence in three-year olds can vary fl'om 0 to 20. It is often the case that the first dental expo. ur¢: of the five year otd is a school inspection, when the ravages of the deciduous dentition may be discovered for the first time; too late for prevention and sometimes too late even for conservative treatment. In passing it might be mentioned that at least there is a dental advantage in having school entry at live years. In some countries children do not go to school uutii they are seven, so when they receive tne~r fir.~ dental examination it is sometimes the case that not only the primary dentition but also the four first permanent molars are beyond redemptiol~. *This paper was originally given as a lecture at a Refresher Course f¢.~r Local Amhority DentaI OlIicers at Cowley Manor, Gloucester in May 1968.
246
P U B L I C H E A L T H VOL. 83 NO. 5
Our objective must be somehow to apply preventive dentistry methods to a group which is itself unco-operative because of its tender age, the majority of which is quite inaccessible, and whose mothers are often apathetic about such things as dental care. At present there is only one realistic solution to the problem and that is by the mliversal fluoridation of water. We have certain knowledge that by this inethod the problem would almost disappear. The present three-year old, witii',three carious teeth, would, as has happened in llirmingham, become a three year-old with one and a half carious teeth; and moreover, the progression of caries through these teeth would be much slower tiaan otherwise, taking the urgency out of the operative requirement. If nothing else was done except water fluoridation the average child would arrive at school at five years old with only minimal caries in two or three teeth. The fact that tluoridation is not universally adopted is a measure of public apathy, and many town and city Councils are neglecting an important public health duty. Fluoridation of water is tile best way of introducing this magic ion into the tooth substance, but there are others. Fluoride tablets and fluoridated salt are sometimes suggested as alternatives. Are fluoride tablets a useful substitute for water tiuoridation ? The answer is both yes and no; yes they are, if people would administer them regularly and conscientiously to their children: otherwise not. There is evidence that the dosing of a child with I m g o1"fluoride a day by tablet, preferably crushed and mixed with water, is as effective as water fluoridation in preventing dental caries. Arnold, McClure & White (1960)reported the result of a fluoride tablet trial. The children in this trial were mostly of the pre-school age so the methods and results are of some relevence. Most of the test subjects were a selected group; their parents were physicians, dentists, or other professional employees of tile public health service who "wanted their chitdren to have the best dental care, and these children and parents were considered capable of following instructions consistently and exactly." A three-month supply of tablets was given to each family. Parents of children aged up to two years were instructed to dissolve ~t tab~let (1 mg F) in a quart o f water and to use this for making up baby foods or for drinking purposes. Children between two and three years old were to have one tablet every other day, taken directly with water, or dissolved in a suitable drink. Those between the ages of three and ten years were to receive a tablet every day, given in the Sallle n l a . n n e r .
The results, alter varying exposure to the table'~s, by children aged from one to o v e r eight years, showed that the effect was comparable with reductions that could be expected from water fluoridation, although the authors wei'e under no ilhzsions that this was a properly cont,roHed investigation because of the very selective nature of the test group. From a public health point of view the most interesting and significant paragraph in the paper was the last one: "Although t h e persons involved in the study were, on the whole, a highly
PREVENTIVE DENTISTRY FOR PRI5-SCHOOI. CH~LDR EN
247
educated group, only about half of them actually continued to give their children tablets for the necessary number of years.'" If this educated and enthusiastic group failed, what chance is there for the general population ? Ten years is a long time to expect unflagging zea!. and it should not be forgotten that many mothers are too disinterested even to take their children to clinics for immunization against killing diseases, There is little likelihood of tablets ever becoming of public health significance, hov~e~,er useful they may be in occasional selected families. There is concrete evidence for this massive indifference. Calgary, Canada. launched a fluoride tablet programme, with much publicity, in November [966. as an alternative to a water fluoridation scheme. Under this programme chiidren under 16 could receive a three-months supply oF fluoride tablets on prescription. After the initial impact it was Found that two out o f three Ca|garians did not bother to get their free fluoride suppliments re-prescribed, and although the Health Authorities are continuing the scheme for the moment its future is in doubt. A similar scheme in Saskatchewan, started earlier, has been discontinued. A better method of instituting systemic fluoride is by the fluoridation of table salt. In 1955 such salt, containing 200 mg of sodium fluoride/kg, was introduced into the canton of Zurich, Switzerland; and by t965 the consumption of fluoridated salt was about 65 ('' of the total usaee o f domestic salt in the whole country (Muhlemann, t967). Allowing for some loss of satt during food preparation the daily fluoride supplement given by this method is approximately 0.5 rag, or only about one-half the optimum dose. In younger children there is a lower consumption of salt, so the actual fluoride ingested woutd be even less. Reductions in caries following salt fluoridation reported by Marthaler (i962) show a reduction in eight- and nine-year old chi!dren of about 22".~;. The concentration of 200 mg of sodium fluoride/kg is not now considered high enough and a higher concentration of 300 mg/kg is recommended. Some workers have r&:narked on the diCficulty of establishing an optimum concentration of fluoride in salt that would allow for age differences in its consumption, There is no doubt that of all fluoridation methods so far attempted the t]uoridation of water is the method of choice. Although systemic fluoride is the best way to use the protective effect to the full, it still has its uses after tooth eruption. All pre-school children should have topical applications of fluoride at yearly intervals, This is a bald statement, and there are considerable difticulties in implementing such a suggestion, because of the general lack of availability of pre-school children. It is quite easy to instal a hygienist in a welfare clinic, and the applications themselves are very easy, quick and painless. The difficulty will be to persuade parents that atter> dance for this purpose is useful, and there should be wide-spread propaganda both inside and outside the mother and child welfare clinics, directed towards expectant mothers as well as those with inRants already. If mothers of pre 7 school children wou[d attend with their charges l\~r this prophylactic treatment
2-1a
PUt3LIC H E A I . T I ! V(-)t.. g3 N(). 5
there would be lkmr advantages. First, tile advantage that the treatment itself affords: second, the introduction of the child to dental treatment by a quick and painless operation: third, the year)yinspection of tile teeth and fol)ow-up of conservative treatment where necessary: and l~)urth, the opportunity that the visit allows for educating parents in matters of diet and more particularly into the more harmful contents of die(. Mothers of young children, are subjected to all sorts of pressures. There is the pressure of the confectionary, advertising, aimed at convincing the public that sucrose is not on)y nice. but necessary for life and heahh and energy. The chief sweet manufacturing tirms spend about 7 million pounds per year on promotion and advertising. There is the pressure of the manufaeiurers <,f Vitamin C syrups. There is the social pressure often induced by' overerowd{ag the necessity for keeping a child quiet. A n d what better way is there of keeping him quie{ than by giving him a comforter bottle or a dinky feeder containirag a fruit syrup if he is sma)), and a supply of sucrose comestibles if he is older? They are cheap and ef)i~ctive purchasers of temporary silence. The giving of sweets in large quantities to small children has two altendant dental risks, as weli as the other hea)th risks involved. The first dental risk is the obvious one: t.he effect of sugar on the teeth and the production of caries in the deciduous denlition, The second is the habit tk)rmation, the sweet tooth, that may ultimately .ruin the permaneni dentition as well. [.eft to themselves children will enjoy savoury foods, as anyone who provides these at a children's party tinds out. But if sweets play a prominent part of their lives and are ofli:red always as a reward for virtue (and conversely, the deprivation of them as punishment [br vice.) then they become a mental as welt as a physical habit. it has been observed that the caries rate is higher in only and tirst-born children than in later children (Berk. t943; Mansbridge, t960), and there are a number o f theories to account for this. My theory is that the eldest child receives the most attention during the first tiaw years of life, especially From grandparents. It woutd be interesting to conduct an epidemiological study looking at dental caries in relation io yet another dental health index, the James index o f g r a n d motl',er exposure! It is the responsibility of the various branches of the medical profession to counter these pressures; uphill work, but not always unsuccessful. Much. health education c a n be done in the maternity and child welfare clinics, both anteand post-nata); a t the suggested topical fluoride visits; and most i m p o r t a n t o f all, b y district nurses and health visitors, w h e r e such education should be a part of their total health instruction and supervision. W i t h o u t substantial support from the medical services, which have more contact with parenCs during the pre-scimol years, educational plans are n o t likely to be effective. The message c oncmining sugar restriction is a familiar one, and it is unnecessary to repeat it at the present time. l t i s psychologically unwise to b e t o o prohibitive; dental health education should attempt to guide total diet rather
PREVENTI.VE DFNTISTRY FOR PRE-SCHOOL CHII_DRF.N
249
ihan attempting to forbid a few items. One item that should of course be totally condemned is the sugar comforter whether in the form of the dipped dummy, the dinky feeder, or the propped bottle. It is worth noting that one manuE~cturcr of vitamin syrups has recently produced a new product which is less erosive and contains glucose, not sucrose. Although one cannot say that it is l.n nalcs. it is probably tess harnfful, as it is generally recognized that sucrose is ~he most dentally dangerous of" the sugars because of the properly of certain oral streptococci to synthesize sticky polysaccharides from it. Nevertheless. administrmion by the metimds mentioned should be a mauer of warning. As far as sweets ave concerned the important piece of coucat~¢ h to eel over is that the quantity token is not as important as their consistency and the frequency of eating them. Toffees are probably the most dangerous to the teclh and 'tt~e eating of them should be strictly conlrolled. Chocolalc is probably tl~c least oi" the evils" it ~9 soluble, rapidly eaten, and relativeb,' expensive in relati~m ~o I o c l h - c x p c ) s u l c
t{t33f~.
Oral hygiene is another factor that presents certain dilticulties in small children. They are usually not capable of corrcct and e.q'ectivc too~hbruslfing and the mother's attempts, when they are made at all, are inclined to be cursory and infrequent, tn a programme of dental health education the importance of oral hygiene should be stressed but ahhough hopeful of success (especially with an dectric toothbrush) a better result would probably be obtained by the use of fibrous tbods. Apples will clean the teeth of this age group more effectively than artiiicial means, as well as being a valuable salivary stimulant, and all meals should end with a slice of apple or raw carrot. Adults are not ofte!a enthusiastic about raw carrot, but there is no doubt that most small ch.iktren eat it with relish. Apples, carrots, nuts, crisps, cheese and tlie like are useful for between-meal snacks, as a substitute for cariogenic items. To sum up--the most effective protection fi'om dental caries is systemic fluoride, preferably in the water, when it is an involuntary benefit. The results of all fluoridation trials show us this clearly. In Birmingham where the water was fluoridated in 1964 the benefits to three-year old children are clear to see clinically as well as statistically. Mothers who have attended the Birnqingham Dental Hospital for some years with successive children h a v e been surprised and pleased to find that their youngest pre-school offspring, unlike the others, are either free from caries at three years old or with only minimal attack, ll" Birmingham follows the experience of American dental s c h o o l s i n fluoride areas there will soon be a shortage of child patients ort whom to demonstrate the manifestations of rampant dental caries to the students, and difficulty in producing children on whom they can practice the operation of pulpotomy. After systemic fluoride, topical application of fluoride salts should be carried out routinely in maternity and child welfare clinics, together with at1 the educational effort mentioned: Very i m p o r t a n t , and worth repeating, is the necessity for the support of the physicians and their representatives, especially
250
PUBLIC HEALTH VOL. 83 NO. 5
those who actually call at the homes. One of the main difficulties in educating the pre-school group is the communication problem; health visitors can probably make, after water fluoridation, the biggest contribution of all. References ARNOLD. F A., MCCLURE, F. J. ~: WHITE, C. L. (1960). Dent. Prog. 1, 12. BEAK, H. (1943). J. Am. dent. Ass'. 30, 1749. MANStmlDGE, J. N. (1960). A:'chs oral Biol. 2, 209. MARTHALER, T. M. (1962). Schweiz. Alschr. Zahnheilk, 71,671. MUttLEMANN, H. R. (1967). hit. dent. J., Lond. 17, I0.