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Proper Dental Care for the Child Patient*
2320
T he Journal of the American D en ta l Association
profit through proper education of the public. By removing, correcting or pre venting handicaps in the young which might otherwise be so serious as to in fluence in a great degree their success in
later life, we shall raise the standard of health in the community. And lastly, it would be just another stepping stone to raise our profession just a little higher on the health plane.
PROPER DEN TA L CARE FOR T H E CHILD PATIENT* B y T H O M A S A. G A R D N E R , B.A ., D.D.S., Iow a City, Iow a H E essays on children’s dentistry presented before this section during the last several years have thoroughly and effectively covered the field. I t ap pears that little might be added, but there are certain items that can bear fre quent repetition. I shall attem pt to touch on those phases of children’s den tistry that are most puzzling to the aver age dentist: children as patients, abscessed deciduous teeth and roots, exposed pulps and filling materials.
T
CHILDREN AS PATIENTS I have occasionally met some older practitioners who felt that they could not handle children, that all child patients were difficult to w ork for and that a dentist in order to be successful with chil dren must be blessed w ith a supernatural power of persuasion or have at his com mand some form of hypnosis; that fillings could be inserted or teeth extracted only when the patient was taken unawares, that children’s dentistry is unprofitable and that deciduous teeth cannot be ex pected to hold fillings satisfactorily. Such beliefs are entirely erroneous. Children, on the whole, make excellent patients, a *Read before the Section on M outh H ygiene and P re v e n tiv e D entistry at the Seventy-Second A n n u al Session of the A m eri can D ental A ssociation, D enver, Colo., July 23, 1930. Jo u r. A . D . A ., D ecem ber, 1930
fact which we have demonstrated to many practitioners in Iow a during the last few years of our state wide dental program. M any dentists have delightedly told me of their experiences and the reve lations that had come to them. T h e chief prerequisites to the success ful handling of children a re : (1 ) an in finite supply of patience and (2 ) an un derstanding sympathetic attitude. If we can foresee the good th at is being done for the child, the normal development of the facial bones, the prevention of maloc clusion, the elimination of possible focal infection, the maintenance of a higher systemic resistance to all disease, and can visualize an active robust happy young ster, it is possible to tu rn w hat might ordinarily be considered an unpleasant task into a privilege and a pleasurable duty. If the proper psychologic ap proaches are utilized, practically any den tist can work successfully with children.
ABSCESSED DECIDUOUS TEETH AND ROOTS T h e universal question that dentists ask a public health dental w orker is, “W h a t should I do w ith deciduous teeth th at are too badly broken down to be filled ?” T his question is too general to be answered w ithout further qualifica tion. Such a tooth could be abscessed, putrescent or have an exposed pulp or merely the roots be present. Each condi
B ureau of D e n ta l H e a lth E ducation.
tion merits a distinct treatm ent. Abscessed deciduous molars and roots should be dealt w ith in children much as the den tist would dispose of them for his adult patients. T his, in most cases, means extraction; yet operators frequently rec ommend to parents th at these diseased teeth remain in the mouths of children in order th at the space may be maintained. It is not difficult to correlate the presence of abscessed teeth w ith certain systemic infections. W hich is more desirable, a pathologic condition of the heart or muti lated facial features? In answering for your own child, it is not difficult to decide on the course of procedure. If the den tist w ill perform his professional duty, the child should suffer from neither the injured heart nor m utilation of the face. Space maintainers should be used whereever deciduous teeth are extracted pre maturely, i. e., six months or more previ ous to eruption. Perhaps the only contra indication to the extraction of such teeth is the involvement of the second decidu ous m olar previous to the eruption of the first perm anent molar, in which case the tooth may be treated even though a fis tula is present. T hree successive treat ments w ith formocresol will usually clarify the canals and pulp chamber, which then may be filled w ith a paste of beechwood creosote and zinc oxid. It may be necessary to cauterize the fistula slightly w ith 95 per cent phenol or wipe out the tract w ith camphor and phenol in order to induce healing. A fter the eruption of the first permanent molar, the deciduous tooth may be extracted and space maintainers applied. Putrescent teeth have been effectively treated by many child specialists, but these teeth can always be considered a possible source of infection. W ith ju d i cious selection of cases, considering the child’s health, age and family history,
2321
some of these teeth may be kept in posi tion w ith safety. T hey assist in the nor mal development of the arch, jaws, facial bones, sinuses and contour and expression of the face. B ut we must remember that these physiologic processes are possible only when the tooth is healthy and the normal occlusion and approximal contact have been restored. T o leave a broken down putrescent tooth in the mouth w ithout any operative treatm ent, tru st ing that N ature w ill maintain the above mentioned functions, is a questionable procedure. Yet, this is frequently done by dentists who hold up their hands in horror at the thought of treating putres cent deciduous teeth or am putating pulps. F o r clarifying putrescent teeth, formo cresol or beechwood creosote may be used. T h e use of the latter eliminates any possibility of injury to the soft tis sues, but more treatm ents are required. A paste of beechwood creosote and zinc oxid may be forced into the canals and pulp chamber. W hen only the roots of a deciduous molar remain in position, little can be expected of them as space maintainers. Norm al proximal contact is not present and, in most cases, serious loss of space w ill occur despite the roots, w ith result ing malocclusion. T hen, too, roots are a source of infection to the child. In my experience, it is a rare instance th at pus cannot be expressed from the tissues sur rounding them. T h e roots should be removed and space maintainers applied. T h e overlay space maintainer advocated by W ille tt of Peoria is quite satisfactory.
EXPOSED PULPS IN DECIDUOUS TEETH ■ A pulp exposure in deciduous teeth offers two courses of procedure: (1 ) pulp am putation; (2 ) extraction. Pulp cap ping is not an alternative. I know of no operator who has successfully and con
2322
T he Journal of the American D e n ta l Association
sistently capped pulps of deciduous teeth. Pulp amputation, th at is, the removal of the bulbous portion of the pulp, has been practiced on deciduous teeth for a sufficient num ber of years to prove its merit. T h e splendid case histories pre sented before this section last October by D r. Sweet, the testimony of other workers and the life long experience of D r. Jordan are convincing evidence of the success of this procedure. Pressure anesthesia offers the most satisfactory method of anesthesia for am putation of the pulp. A t the children’s clinic of the D ental College of the State University of Iowa, pulverized procain tablets dis solved in distilled w ater are used for this purpose. Slow, gradual pressure w ith a blunt-end instrum ent on unvulcanized rubber inserted in the cavity will prom pt ly produce anesthesia. If sufficient time is given to this operation, the child will suffer little pain. T h e pulp may be am putated by means of a large, sharp steril ized round bur. H em orrhage may be con trolled by formocresol or 95 per cent phenol. These medicaments also serve to cauterize the tissue remaining in the canals; which is conducive to prompt healing. Phenol compound should be sealed in the pulp chamber for forty-eight hours previous to filling. T h e paste for the pulp chamber is the same as th at used for putrescent teeth. A t the time of its insertion, all coagulated blood should be removed from the cavity and especially from over the stumps of the pulps. I t is needless to state that the cavities should be kept free of saliva while putrescent teeth are being treated or a pulp amputation is being performed. A rubber dam need not be applied if the operator perfects himself in the manipu lation of cotton rolls. W ith lower teeth, this may be accomplished by holding the rolls w ith the first tw o fingers, one on the
buccal aspect w ith one roll, the other on the lingual w ith tw o rolls, and the assistance of a saliva ejector, if the patient does not object too seriously. Numerous case histories have been re ported dem onstrating th at normal shed ding of these and properly treated putrescent teeth occurs. Some operators m aintain that they will usually be shed approximately one year prematurely.
P U L P EXPOSURE IN T H E FIRST PERM A NENT MOLAR In her book on “ Children’s D entistry,” Jordan outlines a technic for amputation of the bulbous portion of pulps in first permanent molars. T his procedure has been followed in the children’s clinic of the Cook County Hospital for several years, w ith careful follow-up observa tions. I t is th at group’s opinion that if a large apical foramen is present, the prognosis is excellent for the successful treatm ent of the tooth and that the grow th of the tooth continues w ith an apparent normal development of the apical portion of the root.
FILLING MATERIALS W h at filling m aterials should be used for children is a puzzle to many dentists. M anufacturers offer alluring cements and other preparations th at supposedly can be inserted w ith success under very unfavorable conditions. These materials are thus designed with the thought that fillings in deciduous teeth are inherently temporary and relatively of little impor tance. In order to emphasize the need for permanent w ork for deciduous teeth, let us select a second deciduous molar in the mouth of a 5-year-old child. T his tooth is normally shed between the tenth and tw elfth years. If a proximoclusal cavity is present in such a tooth at 5 years of age, the inserted filling must last for from five to seven years, which is suffi
B ureau o f D e n ta l H ea lth E ducation
cient indication that the cavity prepara tion should be carefully made and the filling constructed of the best materials available. T h is filling must be of service to the patient for possibly seven years, and no temporary measure should be em ployed, any more than if the filling were to be inserted in the mouth of an adult. I find that many dentists underestimate the shedding time for the deciduous molars. Copper amalgam may be called the ideal filling m aterial for children’s den tistry. T h is substance has advantages and disadvantages, but the form er are sufficiently outstanding to counterbalance the latter. T h e principal disadvantages are its color, slow setting time and tensile strength. T h e chief advantages are a low coefficient of expansion and contraction, germicidal action and a low coefficient of conductivity. T h e low coefficient of expansion and contraction prevents the amalgam from contracting away from the margins of the cavity, it frequently remaining in cavities that have but very slight reten tion. T h e germicidal action prevents recurrence of caries, but must not be relied on to arrest active decay. T h e low coefficient of conductivity is an extremely valuable asset, as so many fillings inserted in deciduous teeth closely approximate the pulps. Use of an alloy w ith a high coefficient of conductivity, such as silver or gold, is apt to cause the death of the pulp. Copper amalgam largely overcomes this objection. Another advantage frequently Qffered for copper amalgam is that it may be in serted in a w et cavity. I t is to my mind very doubtful that a filling inserted in a w et cavity w ill be so successful as one inserted under more nearly ideal condi tions. I t has been my experience that the child who cannot be managed to the
2323
extent of keeping the cavity dry for the insertion of the filling is extremely rare. If the copper amalgam becomes wet, it may be dried over the flame or on a paper towel and used w ithout danger of having the filling fail. T h e setting time for copper amalgam can be greatly reduced by decreasing the quantity of the mercury. Reduction in the amount of mercury also seems to in crease the strength of the alloy. One m anufacturer has recently devised an ex cellent method for heating copper amal gam pellets. T hey are placed in a small glass tube and then heated over the flam e; which gives a uniform expression of the mercury, prevents overheating and avoids loss of the mercury, thus assuring a proper mix of alloy. T h e frame of a discarded m irror also makes an excellent heating tray. T h e amalgam should never be heated over the open flame in a pair of pliers. Copper amalgam should be as carefully triturated as silver amalgam. W hen a smooth uniform mix has been secured, the excess mercury should be expressed by means of pliers and chamois skin. T his produces apparently a dry substance and one seemingly unsuitable for use, but when it is manipulated in the palm of the hand, it again becomes plastic. Copper amalgam in such a state can be readily condensed into a hard dense filling th at w ill set w ithin three or four hours. T h e operator should caution the parent and the child that hard food should not be eaten during the next meal and that no chewing should be done for twenty-four hours on the side of the mouth containing the new filling.
CEMENTS T his type of filling material was, in former years, most commonly recom mended for children’s dentistry. Experi ence has taught us th at cements are
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T h e Journal of the A m erican D e n ta l Association
largely makeshifts, giving on the whole unsatisfactory resu lts; yet they are useful for filling cavities in teeth th at will shed w ithin a few months. Some brands of copper cements have been advertised as possessing extensive germicidal action. Bacteriologic tests indicate th at they have some such action, but not to the extent supposed, the action being much less than with copper amalgam. Some operators claim to have used germicidal silicate cements w ith success, especially for pits and fissures. If this material proves to be as useful as is claimed by the manufacturers, a very valuable filling material is available for children’s dentistry.
CONCLUSION I cannot that pioneer D r. Fones. consider the he said :
refrain from quoting from in the field of dental hygiene, In urging the profession to child patient more seriously,
B ut m ost im p o rtan t of all, the appeal for conscientious attention to ch ild ren ’s dentistry should certainly arouse the interest of the most indifferent. T h is im p o rtan t w ork is undertaken today, no doubt a t a financial loss to the dentist, but a t a g re a t g a in to the c h ild ; but c h ildren a re not young and squirm ing and p erhaps unprofitable for long. T o m o r row they a re the lea d in g citizens of your tow n. From a purely selfish standpoint there can be no g re a te r insurance th a t a p riv ate practice w ill g ro w continuously over a long period of y ears th an fo r the d entist to estab lish him self firm ly in the m inds and hearts of the c hildren in his com m unity by careful attention to th e ir needs. T h e re w ard s of such professional service, especially to children, are h a rd ly to be m easured in term s like these, still it is freq u en tly a form of appeal th a t m ust be used. M
outh
H y g ie n e
(T h is a rticle is fu rn ish ed T h e J o u r n a l by the P ub licatio n D e p artm en t of the Russell Sage Foundation. It w ill a p p e a r la te r as the a u th o ritativ e article on the subject in the
Social W o rk Y e a r Book fo r 1929, shortly to be published, a review of w hich w ill ap p ea r in T h e J o u r n a l .) M outh hygiene, as now understood, em braces sev eral fields of e n d ea v o r: Instruction in the principles and practice of m outh hygiene by the dental hygienist ; the teaching of m outh hygiene in public schools; the in struction of lay groups— such as R o tary or K iw a n is Clubs, and P a re n t-T e a c h e r A ssocia tions— by lecture m ethods; and prophylactic trea tm e n t given by the dentist and hygienist in schools, in d u stria l organizations, and p r i vate dental practice.«. A t least 95 p e r cent of the c hildren of school age in the U nited States a re in need of dental treatm en t. A com m unity mouth health p ro g ra m takes into account the pro spective m other, h e r diet and m outh hygiene d u rin g p re g n an c y ; the preschool child, its diet and hab its— such as thum b sucking, and m outh b re ath in g — and the care of its tem p o ra ry teeth ; the school child, w ith attention to re g u la r dental care, periodic cleansing of the teeth, m ethods of p re se rv in g dental health, and tra in in g in the home care of the teeth as a form of tra in in g fo r parenthood. T h e in struction of p a ren ts is also essential in ord er to establish the im portance of m outh hygiene, and to w in th e ir support fo r any clinics o r g anized to care fo r those otherw ise unable to obtain dental treatm ent. HISTORY AND PRESENT STATUS
T h e m ovem ent to fu rth e r m outh hygiene ha d its inception in the days follow ing H u n te r ’s declaratio n th a t the teeth m ay be a p rim a ry source of focal infection. T h e con ception th a t young wom en m ay be tra in e d as dental hygienists is a ttrib u te d to D r. A. C. Fones, w ho in 1915 established the first tra in ing school fo r dental hygienists to prep are them fo r service in the public schools of B ridgeport. T h e m outh hygiene m ovem ent has now become w o rld -w id e and mouth hygiene itself is an accepted b ranch of pub lic health. A s such it is prom oted by social organizations, schools, and industry. T h a t the m ovem ent has cap tu red the im agination of the public is m anifested by the extent and influence of dental clinics in v a rio u s com m unities, such as those e stab lished by p h ilanthropists in Boston and Rochester, N. Y., to care solely for children
B ureau of D en ta l H ea lth E ducation u n d e r 16 years. T h e re is a noticeable increase in the num ber of dental clinics fo r adults w hich a re supported by local benefactors, or by d en tal societies, com m unity chests, or f r a te rn a l groups. T h ese serve as resto rativ e ra th e r th a n p re v en tiv e agencies. T h e num ber of hospitals h a v in g dental in tern s is also in creasin g rapidly, and the sentim ent of den tal students is increasingly in fa v o r of accepting institutional p o stg ra d u ate train in g . In m ost state institutions it is the practice to have dental interns. One of the m ost im p o rtan t recent advances is the inclusion of a dentist, to direct mouth hygiene activities, in the bo ard of health or the b o a rd of education in some tw enty states and in an increasin g num ber of m unicipali ties, and the licensing of dental hygienists to practice prophylaxis, or a t least to teach m outh hygiene in about the sam e num ber of states. T h e state departm ents in these states have the teach in g of m outh hygiene un d er th eir supervision and a re fu rth e rin g the w ork, as o pportunity affords, in cooperation w ith local authorities. In some states, on the other h and, the m outh hygiene m ovem ent w as o rig in a lly sponsored by local groups, and from sm all beginnings has sp re ad until it em braces considerable areas. Several natio n al agencies h ave as th eir p rim a ry purpose the p ro p ag atio n of mouth health principles ; am ong these a re the A m eri can M outh H ealth A ssociation, D ental E d u ca tional Council of A m erica, and the In te rn a tional D ental H ealth Foundation fo r C hil dren. O th er health agencies are interested in m outh hygiene because the condition of the teeth affects the success or fa ilu re of th eir efforts along other lines. Such a re the U nited States P ublic H e alth Service, A m erican C hild H ealth A ssociation, N atio n al T uberculosis A ssociation, and the A m erican M edical A sso ciation. M uch space has been given of late to a r ticles on m outh hygiene in o utstanding m a g a zines and new spapers, w ritte n by w ell-know n practitio n ers or groups in the dental p ro fession and sponsored by reputable local organ izatio n s. L ead in g m an u fa ctu re rs’ and p roducers’ associations, such as the N a tional D a iry Council, h ave also included m outh h ealth in th e ir educational publicity; and in d iv id u a l firms h ave p re p are d and d is tributed posters and charts and h ave p re p a red lectures fo r the use of health w orkers. Business concerns th a t preach m outh health
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include larg e food corporations, den tifrice and X -ra y equipm ent m an u fa ctu re rs, and life insurance com panies. T h ese all benefit in directly from th e ir p ro p a g an d a fo r m outh health and preventive dentistry. P ra c tica lly everyone w ho reads or listens to the ra d io has received some in fo rm atio n as to the neces sity for m outh hygiene. DEVELOPMENTS AND EVENTS, 1929 D u rin g the y e a r there w as a g en eral a d vance in the m outh hygiene m ovem ent, p a r tic u larly in the inclusion of dentists on the state boards of education and health, the m ore g en eral acceptance of the dental hygienist as a dental h ealth teacher, and a m ore general recognition of the valu e of prophylaxis in relation to the health of the school child, his tra in in g , habits, and scholarship. T h e most significant event of the y e a r w as the active cam paign w hich com m ercial institutions c a r ried on in accordance w ith the best professional ethics to popularize m outh hygiene through p rin te d adv ertisem en t and ra d io b roadcasting. T h e in terest show n by the professional groups in d issem inating in form ation on this subject, p a rtic u la rly at th e ir state and natio n al m eet ings, w as also m arked. A fu rth e r noticeable developm ent w as the inclusion of good m o tion picture films re la tin g to m outh hygiene in the health series of a prom inent ed u ca tional film lib ra ry , and the increasin g use of such films in public schools. D u rin g 1929 announcem ent w as m ade of the build in g of larg e dental clinics for New Y ork City, C hicago and Providence, and the C h ild re n ’s Fund of M ichigan announced th a t one of its aim s w ould be the prom otion of m outh h ealth program s. T h e establishm ent of research along purely dental lines in the lead in g m edical schools by the Rockefeller F oundation w as an e n couraging in dication th a t m outh hygiene had been accepted as a fa c to r in the public h ealth field. P rogress w as also m ade d u rin g the y e a r in research re la tin g to the prevention of dental decay by m eans of bacterial control and d ie ta ry m easures. C o n s u l t : B u rk h a rt, H. J .: Care of M outh and Teeth, 1928; “T h e D en tal H ygienist as an E d u cato r,” in Dental Item s of Interest, A ugust, 1927; O w re, A lfre d : “ G ive Y our T e e th a Chance,” in W om an’s Home Com panion, July, 1930; issyes of Journal of American D ental Association (D e p artm en t on D ental H ealth E ducation) ; and Black, A. D .: Index to Dental Periodical Literature. R. S. V o o r h e e s , J r .
T he Journal of the American D en ta l Association
profit through proper education of the public. By removing, correcting or pre venting handicaps in the young which might otherwise be so serious as to in fluence in a great degree their success in
later life, we shall raise the standard of health in the community. And lastly, it would be just another stepping stone to raise our profession just a little higher on the health plane.
PROPER DEN TA L CARE FOR T H E CHILD PATIENT* B y T H O M A S A. G A R D N E R , B.A ., D.D.S., Iow a City, Iow a H E essays on children’s dentistry presented before this section during the last several years have thoroughly and effectively covered the field. I t ap pears that little might be added, but there are certain items that can bear fre quent repetition. I shall attem pt to touch on those phases of children’s den tistry that are most puzzling to the aver age dentist: children as patients, abscessed deciduous teeth and roots, exposed pulps and filling materials.
T
CHILDREN AS PATIENTS I have occasionally met some older practitioners who felt that they could not handle children, that all child patients were difficult to w ork for and that a dentist in order to be successful with chil dren must be blessed w ith a supernatural power of persuasion or have at his com mand some form of hypnosis; that fillings could be inserted or teeth extracted only when the patient was taken unawares, that children’s dentistry is unprofitable and that deciduous teeth cannot be ex pected to hold fillings satisfactorily. Such beliefs are entirely erroneous. Children, on the whole, make excellent patients, a *Read before the Section on M outh H ygiene and P re v e n tiv e D entistry at the Seventy-Second A n n u al Session of the A m eri can D ental A ssociation, D enver, Colo., July 23, 1930. Jo u r. A . D . A ., D ecem ber, 1930
fact which we have demonstrated to many practitioners in Iow a during the last few years of our state wide dental program. M any dentists have delightedly told me of their experiences and the reve lations that had come to them. T h e chief prerequisites to the success ful handling of children a re : (1 ) an in finite supply of patience and (2 ) an un derstanding sympathetic attitude. If we can foresee the good th at is being done for the child, the normal development of the facial bones, the prevention of maloc clusion, the elimination of possible focal infection, the maintenance of a higher systemic resistance to all disease, and can visualize an active robust happy young ster, it is possible to tu rn w hat might ordinarily be considered an unpleasant task into a privilege and a pleasurable duty. If the proper psychologic ap proaches are utilized, practically any den tist can work successfully with children.
ABSCESSED DECIDUOUS TEETH AND ROOTS T h e universal question that dentists ask a public health dental w orker is, “W h a t should I do w ith deciduous teeth th at are too badly broken down to be filled ?” T his question is too general to be answered w ithout further qualifica tion. Such a tooth could be abscessed, putrescent or have an exposed pulp or merely the roots be present. Each condi
B ureau of D e n ta l H e a lth E ducation.
tion merits a distinct treatm ent. Abscessed deciduous molars and roots should be dealt w ith in children much as the den tist would dispose of them for his adult patients. T his, in most cases, means extraction; yet operators frequently rec ommend to parents th at these diseased teeth remain in the mouths of children in order th at the space may be maintained. It is not difficult to correlate the presence of abscessed teeth w ith certain systemic infections. W hich is more desirable, a pathologic condition of the heart or muti lated facial features? In answering for your own child, it is not difficult to decide on the course of procedure. If the den tist w ill perform his professional duty, the child should suffer from neither the injured heart nor m utilation of the face. Space maintainers should be used whereever deciduous teeth are extracted pre maturely, i. e., six months or more previ ous to eruption. Perhaps the only contra indication to the extraction of such teeth is the involvement of the second decidu ous m olar previous to the eruption of the first perm anent molar, in which case the tooth may be treated even though a fis tula is present. T hree successive treat ments w ith formocresol will usually clarify the canals and pulp chamber, which then may be filled w ith a paste of beechwood creosote and zinc oxid. It may be necessary to cauterize the fistula slightly w ith 95 per cent phenol or wipe out the tract w ith camphor and phenol in order to induce healing. A fter the eruption of the first permanent molar, the deciduous tooth may be extracted and space maintainers applied. Putrescent teeth have been effectively treated by many child specialists, but these teeth can always be considered a possible source of infection. W ith ju d i cious selection of cases, considering the child’s health, age and family history,
2321
some of these teeth may be kept in posi tion w ith safety. T hey assist in the nor mal development of the arch, jaws, facial bones, sinuses and contour and expression of the face. B ut we must remember that these physiologic processes are possible only when the tooth is healthy and the normal occlusion and approximal contact have been restored. T o leave a broken down putrescent tooth in the mouth w ithout any operative treatm ent, tru st ing that N ature w ill maintain the above mentioned functions, is a questionable procedure. Yet, this is frequently done by dentists who hold up their hands in horror at the thought of treating putres cent deciduous teeth or am putating pulps. F o r clarifying putrescent teeth, formo cresol or beechwood creosote may be used. T h e use of the latter eliminates any possibility of injury to the soft tis sues, but more treatm ents are required. A paste of beechwood creosote and zinc oxid may be forced into the canals and pulp chamber. W hen only the roots of a deciduous molar remain in position, little can be expected of them as space maintainers. Norm al proximal contact is not present and, in most cases, serious loss of space w ill occur despite the roots, w ith result ing malocclusion. T hen, too, roots are a source of infection to the child. In my experience, it is a rare instance th at pus cannot be expressed from the tissues sur rounding them. T h e roots should be removed and space maintainers applied. T h e overlay space maintainer advocated by W ille tt of Peoria is quite satisfactory.
EXPOSED PULPS IN DECIDUOUS TEETH ■ A pulp exposure in deciduous teeth offers two courses of procedure: (1 ) pulp am putation; (2 ) extraction. Pulp cap ping is not an alternative. I know of no operator who has successfully and con
2322
T he Journal of the American D e n ta l Association
sistently capped pulps of deciduous teeth. Pulp amputation, th at is, the removal of the bulbous portion of the pulp, has been practiced on deciduous teeth for a sufficient num ber of years to prove its merit. T h e splendid case histories pre sented before this section last October by D r. Sweet, the testimony of other workers and the life long experience of D r. Jordan are convincing evidence of the success of this procedure. Pressure anesthesia offers the most satisfactory method of anesthesia for am putation of the pulp. A t the children’s clinic of the D ental College of the State University of Iowa, pulverized procain tablets dis solved in distilled w ater are used for this purpose. Slow, gradual pressure w ith a blunt-end instrum ent on unvulcanized rubber inserted in the cavity will prom pt ly produce anesthesia. If sufficient time is given to this operation, the child will suffer little pain. T h e pulp may be am putated by means of a large, sharp steril ized round bur. H em orrhage may be con trolled by formocresol or 95 per cent phenol. These medicaments also serve to cauterize the tissue remaining in the canals; which is conducive to prompt healing. Phenol compound should be sealed in the pulp chamber for forty-eight hours previous to filling. T h e paste for the pulp chamber is the same as th at used for putrescent teeth. A t the time of its insertion, all coagulated blood should be removed from the cavity and especially from over the stumps of the pulps. I t is needless to state that the cavities should be kept free of saliva while putrescent teeth are being treated or a pulp amputation is being performed. A rubber dam need not be applied if the operator perfects himself in the manipu lation of cotton rolls. W ith lower teeth, this may be accomplished by holding the rolls w ith the first tw o fingers, one on the
buccal aspect w ith one roll, the other on the lingual w ith tw o rolls, and the assistance of a saliva ejector, if the patient does not object too seriously. Numerous case histories have been re ported dem onstrating th at normal shed ding of these and properly treated putrescent teeth occurs. Some operators m aintain that they will usually be shed approximately one year prematurely.
P U L P EXPOSURE IN T H E FIRST PERM A NENT MOLAR In her book on “ Children’s D entistry,” Jordan outlines a technic for amputation of the bulbous portion of pulps in first permanent molars. T his procedure has been followed in the children’s clinic of the Cook County Hospital for several years, w ith careful follow-up observa tions. I t is th at group’s opinion that if a large apical foramen is present, the prognosis is excellent for the successful treatm ent of the tooth and that the grow th of the tooth continues w ith an apparent normal development of the apical portion of the root.
FILLING MATERIALS W h at filling m aterials should be used for children is a puzzle to many dentists. M anufacturers offer alluring cements and other preparations th at supposedly can be inserted w ith success under very unfavorable conditions. These materials are thus designed with the thought that fillings in deciduous teeth are inherently temporary and relatively of little impor tance. In order to emphasize the need for permanent w ork for deciduous teeth, let us select a second deciduous molar in the mouth of a 5-year-old child. T his tooth is normally shed between the tenth and tw elfth years. If a proximoclusal cavity is present in such a tooth at 5 years of age, the inserted filling must last for from five to seven years, which is suffi
B ureau o f D e n ta l H ea lth E ducation
cient indication that the cavity prepara tion should be carefully made and the filling constructed of the best materials available. T h is filling must be of service to the patient for possibly seven years, and no temporary measure should be em ployed, any more than if the filling were to be inserted in the mouth of an adult. I find that many dentists underestimate the shedding time for the deciduous molars. Copper amalgam may be called the ideal filling m aterial for children’s den tistry. T h is substance has advantages and disadvantages, but the form er are sufficiently outstanding to counterbalance the latter. T h e principal disadvantages are its color, slow setting time and tensile strength. T h e chief advantages are a low coefficient of expansion and contraction, germicidal action and a low coefficient of conductivity. T h e low coefficient of expansion and contraction prevents the amalgam from contracting away from the margins of the cavity, it frequently remaining in cavities that have but very slight reten tion. T h e germicidal action prevents recurrence of caries, but must not be relied on to arrest active decay. T h e low coefficient of conductivity is an extremely valuable asset, as so many fillings inserted in deciduous teeth closely approximate the pulps. Use of an alloy w ith a high coefficient of conductivity, such as silver or gold, is apt to cause the death of the pulp. Copper amalgam largely overcomes this objection. Another advantage frequently Qffered for copper amalgam is that it may be in serted in a w et cavity. I t is to my mind very doubtful that a filling inserted in a w et cavity w ill be so successful as one inserted under more nearly ideal condi tions. I t has been my experience that the child who cannot be managed to the
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extent of keeping the cavity dry for the insertion of the filling is extremely rare. If the copper amalgam becomes wet, it may be dried over the flame or on a paper towel and used w ithout danger of having the filling fail. T h e setting time for copper amalgam can be greatly reduced by decreasing the quantity of the mercury. Reduction in the amount of mercury also seems to in crease the strength of the alloy. One m anufacturer has recently devised an ex cellent method for heating copper amal gam pellets. T hey are placed in a small glass tube and then heated over the flam e; which gives a uniform expression of the mercury, prevents overheating and avoids loss of the mercury, thus assuring a proper mix of alloy. T h e frame of a discarded m irror also makes an excellent heating tray. T h e amalgam should never be heated over the open flame in a pair of pliers. Copper amalgam should be as carefully triturated as silver amalgam. W hen a smooth uniform mix has been secured, the excess mercury should be expressed by means of pliers and chamois skin. T his produces apparently a dry substance and one seemingly unsuitable for use, but when it is manipulated in the palm of the hand, it again becomes plastic. Copper amalgam in such a state can be readily condensed into a hard dense filling th at w ill set w ithin three or four hours. T h e operator should caution the parent and the child that hard food should not be eaten during the next meal and that no chewing should be done for twenty-four hours on the side of the mouth containing the new filling.
CEMENTS T his type of filling material was, in former years, most commonly recom mended for children’s dentistry. Experi ence has taught us th at cements are
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T h e Journal of the A m erican D e n ta l Association
largely makeshifts, giving on the whole unsatisfactory resu lts; yet they are useful for filling cavities in teeth th at will shed w ithin a few months. Some brands of copper cements have been advertised as possessing extensive germicidal action. Bacteriologic tests indicate th at they have some such action, but not to the extent supposed, the action being much less than with copper amalgam. Some operators claim to have used germicidal silicate cements w ith success, especially for pits and fissures. If this material proves to be as useful as is claimed by the manufacturers, a very valuable filling material is available for children’s dentistry.
CONCLUSION I cannot that pioneer D r. Fones. consider the he said :
refrain from quoting from in the field of dental hygiene, In urging the profession to child patient more seriously,
B ut m ost im p o rtan t of all, the appeal for conscientious attention to ch ild ren ’s dentistry should certainly arouse the interest of the most indifferent. T h is im p o rtan t w ork is undertaken today, no doubt a t a financial loss to the dentist, but a t a g re a t g a in to the c h ild ; but c h ildren a re not young and squirm ing and p erhaps unprofitable for long. T o m o r row they a re the lea d in g citizens of your tow n. From a purely selfish standpoint there can be no g re a te r insurance th a t a p riv ate practice w ill g ro w continuously over a long period of y ears th an fo r the d entist to estab lish him self firm ly in the m inds and hearts of the c hildren in his com m unity by careful attention to th e ir needs. T h e re w ard s of such professional service, especially to children, are h a rd ly to be m easured in term s like these, still it is freq u en tly a form of appeal th a t m ust be used. M
outh
H y g ie n e
(T h is a rticle is fu rn ish ed T h e J o u r n a l by the P ub licatio n D e p artm en t of the Russell Sage Foundation. It w ill a p p e a r la te r as the a u th o ritativ e article on the subject in the
Social W o rk Y e a r Book fo r 1929, shortly to be published, a review of w hich w ill ap p ea r in T h e J o u r n a l .) M outh hygiene, as now understood, em braces sev eral fields of e n d ea v o r: Instruction in the principles and practice of m outh hygiene by the dental hygienist ; the teaching of m outh hygiene in public schools; the in struction of lay groups— such as R o tary or K iw a n is Clubs, and P a re n t-T e a c h e r A ssocia tions— by lecture m ethods; and prophylactic trea tm e n t given by the dentist and hygienist in schools, in d u stria l organizations, and p r i vate dental practice.«. A t least 95 p e r cent of the c hildren of school age in the U nited States a re in need of dental treatm en t. A com m unity mouth health p ro g ra m takes into account the pro spective m other, h e r diet and m outh hygiene d u rin g p re g n an c y ; the preschool child, its diet and hab its— such as thum b sucking, and m outh b re ath in g — and the care of its tem p o ra ry teeth ; the school child, w ith attention to re g u la r dental care, periodic cleansing of the teeth, m ethods of p re se rv in g dental health, and tra in in g in the home care of the teeth as a form of tra in in g fo r parenthood. T h e in struction of p a ren ts is also essential in ord er to establish the im portance of m outh hygiene, and to w in th e ir support fo r any clinics o r g anized to care fo r those otherw ise unable to obtain dental treatm ent. HISTORY AND PRESENT STATUS
T h e m ovem ent to fu rth e r m outh hygiene ha d its inception in the days follow ing H u n te r ’s declaratio n th a t the teeth m ay be a p rim a ry source of focal infection. T h e con ception th a t young wom en m ay be tra in e d as dental hygienists is a ttrib u te d to D r. A. C. Fones, w ho in 1915 established the first tra in ing school fo r dental hygienists to prep are them fo r service in the public schools of B ridgeport. T h e m outh hygiene m ovem ent has now become w o rld -w id e and mouth hygiene itself is an accepted b ranch of pub lic health. A s such it is prom oted by social organizations, schools, and industry. T h a t the m ovem ent has cap tu red the im agination of the public is m anifested by the extent and influence of dental clinics in v a rio u s com m unities, such as those e stab lished by p h ilanthropists in Boston and Rochester, N. Y., to care solely for children
B ureau of D en ta l H ea lth E ducation u n d e r 16 years. T h e re is a noticeable increase in the num ber of dental clinics fo r adults w hich a re supported by local benefactors, or by d en tal societies, com m unity chests, or f r a te rn a l groups. T h ese serve as resto rativ e ra th e r th a n p re v en tiv e agencies. T h e num ber of hospitals h a v in g dental in tern s is also in creasin g rapidly, and the sentim ent of den tal students is increasingly in fa v o r of accepting institutional p o stg ra d u ate train in g . In m ost state institutions it is the practice to have dental interns. One of the m ost im p o rtan t recent advances is the inclusion of a dentist, to direct mouth hygiene activities, in the bo ard of health or the b o a rd of education in some tw enty states and in an increasin g num ber of m unicipali ties, and the licensing of dental hygienists to practice prophylaxis, or a t least to teach m outh hygiene in about the sam e num ber of states. T h e state departm ents in these states have the teach in g of m outh hygiene un d er th eir supervision and a re fu rth e rin g the w ork, as o pportunity affords, in cooperation w ith local authorities. In some states, on the other h and, the m outh hygiene m ovem ent w as o rig in a lly sponsored by local groups, and from sm all beginnings has sp re ad until it em braces considerable areas. Several natio n al agencies h ave as th eir p rim a ry purpose the p ro p ag atio n of mouth health principles ; am ong these a re the A m eri can M outh H ealth A ssociation, D ental E d u ca tional Council of A m erica, and the In te rn a tional D ental H ealth Foundation fo r C hil dren. O th er health agencies are interested in m outh hygiene because the condition of the teeth affects the success or fa ilu re of th eir efforts along other lines. Such a re the U nited States P ublic H e alth Service, A m erican C hild H ealth A ssociation, N atio n al T uberculosis A ssociation, and the A m erican M edical A sso ciation. M uch space has been given of late to a r ticles on m outh hygiene in o utstanding m a g a zines and new spapers, w ritte n by w ell-know n practitio n ers or groups in the dental p ro fession and sponsored by reputable local organ izatio n s. L ead in g m an u fa ctu re rs’ and p roducers’ associations, such as the N a tional D a iry Council, h ave also included m outh h ealth in th e ir educational publicity; and in d iv id u a l firms h ave p re p are d and d is tributed posters and charts and h ave p re p a red lectures fo r the use of health w orkers. Business concerns th a t preach m outh health
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include larg e food corporations, den tifrice and X -ra y equipm ent m an u fa ctu re rs, and life insurance com panies. T h ese all benefit in directly from th e ir p ro p a g an d a fo r m outh health and preventive dentistry. P ra c tica lly everyone w ho reads or listens to the ra d io has received some in fo rm atio n as to the neces sity for m outh hygiene. DEVELOPMENTS AND EVENTS, 1929 D u rin g the y e a r there w as a g en eral a d vance in the m outh hygiene m ovem ent, p a r tic u larly in the inclusion of dentists on the state boards of education and health, the m ore g en eral acceptance of the dental hygienist as a dental h ealth teacher, and a m ore general recognition of the valu e of prophylaxis in relation to the health of the school child, his tra in in g , habits, and scholarship. T h e most significant event of the y e a r w as the active cam paign w hich com m ercial institutions c a r ried on in accordance w ith the best professional ethics to popularize m outh hygiene through p rin te d adv ertisem en t and ra d io b roadcasting. T h e in terest show n by the professional groups in d issem inating in form ation on this subject, p a rtic u la rly at th e ir state and natio n al m eet ings, w as also m arked. A fu rth e r noticeable developm ent w as the inclusion of good m o tion picture films re la tin g to m outh hygiene in the health series of a prom inent ed u ca tional film lib ra ry , and the increasin g use of such films in public schools. D u rin g 1929 announcem ent w as m ade of the build in g of larg e dental clinics for New Y ork City, C hicago and Providence, and the C h ild re n ’s Fund of M ichigan announced th a t one of its aim s w ould be the prom otion of m outh h ealth program s. T h e establishm ent of research along purely dental lines in the lead in g m edical schools by the Rockefeller F oundation w as an e n couraging in dication th a t m outh hygiene had been accepted as a fa c to r in the public h ealth field. P rogress w as also m ade d u rin g the y e a r in research re la tin g to the prevention of dental decay by m eans of bacterial control and d ie ta ry m easures. C o n s u l t : B u rk h a rt, H. J .: Care of M outh and Teeth, 1928; “T h e D en tal H ygienist as an E d u cato r,” in Dental Item s of Interest, A ugust, 1927; O w re, A lfre d : “ G ive Y our T e e th a Chance,” in W om an’s Home Com panion, July, 1930; issyes of Journal of American D ental Association (D e p artm en t on D ental H ealth E ducation) ; and Black, A. D .: Index to Dental Periodical Literature. R. S. V o o r h e e s , J r .