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Research and the prevention of Dental Caries
PUBLIC HEALTH.
422
SEPTEMBER,
Research and the Prevention of Dental Caries By
J.
SIM WALLACE, M.D. ,
n.sc.,
L.D.S.
In this, which is the secondof the very useful and informatioe .. casual communications " submitted at meetings of the Dental Officers' Group, Dr. Sim Wallace, to whom the Group and the Society are indebted for the suggestion that such "casual communications" should be prepared, summarises certain American studies on the all· important subject of dental caries from the bacteriological, chemical and nutritional points of view.
T
HIS is an extract from the summary of the" Bacteriological, Chemical, and Nutritional Studies of Dental Caries by the Michigan Research Group," conducted in the School of Dentistry of the University of Michigan under the auspices of the Children's Fund of Michigan, presented at the twelfth general meeting of the International Association for Dental Research: .. In the study of the orphanage group, as reported by Koehne, 169 children were observed over periods of from one to four and a half years. This group was selected because all children in this institution, numbering about 300, had been examined by members of the Research Group at least once a year during the preceding six years and found to have a remarkably low degree of caries. From 75 to 80 per cent. were entirely caries-free, and only 5 to 6 per cent. had an appreciable amount of dental disease. A study of the dietary conditions of these children was, therefore, undertaken to determine whether any apparent nutritional factor could be related to the freedom from caries. It was found that the diet, which had been fairly uniform throughout the period of observation, did not meet standard requirements for adequate nutrition. It was below the minimum standard requirement for calories in each agegroup, and also inadequate in Ca, P, and vitamin D contents. It contained little milk and no butter. A small amount of meat was served daily. No oranges were available, except at Christmas, but various vegetables were provided throughout the year, many of which were fed raw. Dessert consisted mostly of raw apple. Cookies and sweet dessert were fed only on Sunday. Of the total caloric intake, 40 to 45 per cent. was in the form of starch and cereals. No candy was allowed at any time. Only minimum amounts of sugar were used to sweeten foods, and no sugar was placed on the table. Certainly the freedom from caries among these children could not be attributed to adequacy of diet, nor correlated with any consistent increase in COz content of saliva, nor to
intake of Ca, P, or vitamin 0."1 Perhaps the most important points to which attention was drawn were " low sugar content" and " hard fibrous raw fruit eaten at the ends of meals." Reference was made to this research in the British Dental Journal, but chiefly with regard to the large amount of cereals. So far as I remember the general conclusions in the summary were not given. The following were the first four: .. (1) No consistent correlation could be found between amounts of salivary total solids, ash, Ca, P, CI, diastatic activity. pH, CO2 capacity, or total alkalinity, and activity of dental caries. (2) No relationship could be found between intake of Ca. P, and vitamin D, or acid base dietary values, and activity of dental caries. (3) Evidence is submitted indicating that sugar is a very important consideration in dental caries. (4) A remarkably low degree of dental caries was observed in children on a low sugar diet deficient in Ca, P, and vitamin 0."1 I will give just one other summary of another research bearing on a point raised by Dr. Andrew Davidson and Mr. Frederick Breese at a recent meeting of our Society.a It is of special interest because it elucidates very satisfactorily the contentions of Mr. Breese. who is "a convinced believer in the theory of dental caries generally held in this country and elsewhere in the world,'" and indicates how the important conclusions of a useful piece of work may easily be made in a casual communication. I shall simply read the greater part of the best summary! of this research which I have seen. It ran as follows: .. This is a significant and interesting contribution to the literature on the experimental control of caries in children by the exhibition of vitamins A and D, by C. D. Marshall Day and H. J. Sedwick, who undertook this investigation to test decisively the effect of fat-soluble vitamins on arresting or retarding dental caries by superimposing a generous supply of fat-soluble vitamins upon the ordinary home diets of a grout-'
1935.
PUBLIC HEALTH.
of school children. The work was carried out in the seventh grade of one of the public schools in Rochester, U.~.A. The children averaged 13 years of age, and 430 were selected. Of these, 220, with their parents, were willing to cooperate for the necessary length of time. The remaining 210 constituted the controls. It was found that the two groups were as nearly as possible of the same economic status with about equal proportions of various nationalities, while the original dental conditions were almost identical. Each child in the experimental group received a daily ration of a fat-soluble vitamin concentrate in tablet form. The tablets were physiologically standardised and readily assimilable. Each tablet consisted of not less than 1,000 U-S.P. units of vitamin A and 245 Steenbock units of vitamin D. The daily ration for each child was six tablets equivalent to three teaspoonsful of cod-liver oil reinforced with viosterol. These were delivered to the homes periodically by an assistant who was employed throughout the investigation to maintain constant contact with the children and parents in their homes. It was realised that this was the crucial factor in the test, and the experiment owes much to the enthusiasm of this assistant. Various reasons, such as absence from school, transference or flagging interest, caused the number of children to be reduced to 147 children in the experimental group and 171 in the control group. Three detailed inspections were made at six monthly intervals. Individual charts were made and the actual location and extent of each cavity marked. Each child was submitted to a thorough prophylactic cleaning before each examination. A complete radiographic survey was made in the first and final examination and numerous incipient cavities revealed at or just below the contact point which could not have been discovered by the finest explorer . . . . The results of the examinations are recorded in a series of tables. These may be summarised as follows: no beneficial effects could be observed in the incidence of dental caries when the two groups were compared, as judged by the average increase in percentage of affected teeth, the average percentage increase in the number of cavities per month, and also the percentage increase in the average caries figure. Furthermore, the percentage of teeth which erupted and became carious subsequent to the first examination was just as high in the group receiving vitamins as in the control group. The caries process seemed just as active
423
between the first and second examination and between the second and third examination . An interesting point brought out in this research is that there was a continued tendency for those children showing an originally low incidence of caries to maintain a lower absolute increase in the average caries figure than those children with a high caries figure at the commencement of the investigation. The caries figure of hypoplastic teeth showed no greater tendency to increase than teeth with no evidence of gross hypoplasia. "6 REFERENCES .
IBunting, R. W. Bacteriological, Chemical and Nutritional Studies of Dental Caries by the Michigan Research Group. Journal of Dental Research, April, 1934, p. 102. 'Ibid, p, 104. 'The School Dental Service. PUBLIC HEALTH, March, 1935, p, 210, et seq. (Breese, F. Diet and the Teeth. Brit. Dent. Jrnl., February Ist, 1934, p. 120. 5Notes on Dental Periodical Literature. Brit. Dent. Jrni., January 15th, 1935, p. 65. SThe Fat-soluble Vitamins and Dental Caries in Children. Journal of Nutrition , September, 1934.
THE Royal Sanitary Institute announces that the autumn session of training courses for candidates desiring to enter for the examinations held by the Institute for sanitary inspectors, inspectors of meat and other foods, and smoke inspectors, for Associateship (in general hygiene and sanitation) and in sanitary science, will commence on September 16th. Details of the lecture courses and syllabuses of the examinations are obtainable from the Secretary of the Institute, 90, Buckingham Palace Road, London, S.W.I. THE Midwives' Institute desires to thank, through the columns of this journal, the medical officers of local supervising authorities in England and Wales who have sent lists of midwives giving notice of intention to practise in their areas, or information regarding independent midwives. These lists have enabled the Institute to send some 7,000 questionnaires to midwives in private practice asking for information on their conditions of practice. Lady Forber (Dr. Janet Lane Claypon) has generously promised to tabulate and analyse the information received, and the Institute hope that this may provide valuable assistance in connection with the settlement of the many questions which will be raised if a salaried service of midwives is set up.
422
SEPTEMBER,
Research and the Prevention of Dental Caries By
J.
SIM WALLACE, M.D. ,
n.sc.,
L.D.S.
In this, which is the secondof the very useful and informatioe .. casual communications " submitted at meetings of the Dental Officers' Group, Dr. Sim Wallace, to whom the Group and the Society are indebted for the suggestion that such "casual communications" should be prepared, summarises certain American studies on the all· important subject of dental caries from the bacteriological, chemical and nutritional points of view.
T
HIS is an extract from the summary of the" Bacteriological, Chemical, and Nutritional Studies of Dental Caries by the Michigan Research Group," conducted in the School of Dentistry of the University of Michigan under the auspices of the Children's Fund of Michigan, presented at the twelfth general meeting of the International Association for Dental Research: .. In the study of the orphanage group, as reported by Koehne, 169 children were observed over periods of from one to four and a half years. This group was selected because all children in this institution, numbering about 300, had been examined by members of the Research Group at least once a year during the preceding six years and found to have a remarkably low degree of caries. From 75 to 80 per cent. were entirely caries-free, and only 5 to 6 per cent. had an appreciable amount of dental disease. A study of the dietary conditions of these children was, therefore, undertaken to determine whether any apparent nutritional factor could be related to the freedom from caries. It was found that the diet, which had been fairly uniform throughout the period of observation, did not meet standard requirements for adequate nutrition. It was below the minimum standard requirement for calories in each agegroup, and also inadequate in Ca, P, and vitamin D contents. It contained little milk and no butter. A small amount of meat was served daily. No oranges were available, except at Christmas, but various vegetables were provided throughout the year, many of which were fed raw. Dessert consisted mostly of raw apple. Cookies and sweet dessert were fed only on Sunday. Of the total caloric intake, 40 to 45 per cent. was in the form of starch and cereals. No candy was allowed at any time. Only minimum amounts of sugar were used to sweeten foods, and no sugar was placed on the table. Certainly the freedom from caries among these children could not be attributed to adequacy of diet, nor correlated with any consistent increase in COz content of saliva, nor to
intake of Ca, P, or vitamin 0."1 Perhaps the most important points to which attention was drawn were " low sugar content" and " hard fibrous raw fruit eaten at the ends of meals." Reference was made to this research in the British Dental Journal, but chiefly with regard to the large amount of cereals. So far as I remember the general conclusions in the summary were not given. The following were the first four: .. (1) No consistent correlation could be found between amounts of salivary total solids, ash, Ca, P, CI, diastatic activity. pH, CO2 capacity, or total alkalinity, and activity of dental caries. (2) No relationship could be found between intake of Ca. P, and vitamin D, or acid base dietary values, and activity of dental caries. (3) Evidence is submitted indicating that sugar is a very important consideration in dental caries. (4) A remarkably low degree of dental caries was observed in children on a low sugar diet deficient in Ca, P, and vitamin 0."1 I will give just one other summary of another research bearing on a point raised by Dr. Andrew Davidson and Mr. Frederick Breese at a recent meeting of our Society.a It is of special interest because it elucidates very satisfactorily the contentions of Mr. Breese. who is "a convinced believer in the theory of dental caries generally held in this country and elsewhere in the world,'" and indicates how the important conclusions of a useful piece of work may easily be made in a casual communication. I shall simply read the greater part of the best summary! of this research which I have seen. It ran as follows: .. This is a significant and interesting contribution to the literature on the experimental control of caries in children by the exhibition of vitamins A and D, by C. D. Marshall Day and H. J. Sedwick, who undertook this investigation to test decisively the effect of fat-soluble vitamins on arresting or retarding dental caries by superimposing a generous supply of fat-soluble vitamins upon the ordinary home diets of a grout-'
1935.
PUBLIC HEALTH.
of school children. The work was carried out in the seventh grade of one of the public schools in Rochester, U.~.A. The children averaged 13 years of age, and 430 were selected. Of these, 220, with their parents, were willing to cooperate for the necessary length of time. The remaining 210 constituted the controls. It was found that the two groups were as nearly as possible of the same economic status with about equal proportions of various nationalities, while the original dental conditions were almost identical. Each child in the experimental group received a daily ration of a fat-soluble vitamin concentrate in tablet form. The tablets were physiologically standardised and readily assimilable. Each tablet consisted of not less than 1,000 U-S.P. units of vitamin A and 245 Steenbock units of vitamin D. The daily ration for each child was six tablets equivalent to three teaspoonsful of cod-liver oil reinforced with viosterol. These were delivered to the homes periodically by an assistant who was employed throughout the investigation to maintain constant contact with the children and parents in their homes. It was realised that this was the crucial factor in the test, and the experiment owes much to the enthusiasm of this assistant. Various reasons, such as absence from school, transference or flagging interest, caused the number of children to be reduced to 147 children in the experimental group and 171 in the control group. Three detailed inspections were made at six monthly intervals. Individual charts were made and the actual location and extent of each cavity marked. Each child was submitted to a thorough prophylactic cleaning before each examination. A complete radiographic survey was made in the first and final examination and numerous incipient cavities revealed at or just below the contact point which could not have been discovered by the finest explorer . . . . The results of the examinations are recorded in a series of tables. These may be summarised as follows: no beneficial effects could be observed in the incidence of dental caries when the two groups were compared, as judged by the average increase in percentage of affected teeth, the average percentage increase in the number of cavities per month, and also the percentage increase in the average caries figure. Furthermore, the percentage of teeth which erupted and became carious subsequent to the first examination was just as high in the group receiving vitamins as in the control group. The caries process seemed just as active
423
between the first and second examination and between the second and third examination . An interesting point brought out in this research is that there was a continued tendency for those children showing an originally low incidence of caries to maintain a lower absolute increase in the average caries figure than those children with a high caries figure at the commencement of the investigation. The caries figure of hypoplastic teeth showed no greater tendency to increase than teeth with no evidence of gross hypoplasia. "6 REFERENCES .
IBunting, R. W. Bacteriological, Chemical and Nutritional Studies of Dental Caries by the Michigan Research Group. Journal of Dental Research, April, 1934, p. 102. 'Ibid, p, 104. 'The School Dental Service. PUBLIC HEALTH, March, 1935, p, 210, et seq. (Breese, F. Diet and the Teeth. Brit. Dent. Jrnl., February Ist, 1934, p. 120. 5Notes on Dental Periodical Literature. Brit. Dent. Jrni., January 15th, 1935, p. 65. SThe Fat-soluble Vitamins and Dental Caries in Children. Journal of Nutrition , September, 1934.
THE Royal Sanitary Institute announces that the autumn session of training courses for candidates desiring to enter for the examinations held by the Institute for sanitary inspectors, inspectors of meat and other foods, and smoke inspectors, for Associateship (in general hygiene and sanitation) and in sanitary science, will commence on September 16th. Details of the lecture courses and syllabuses of the examinations are obtainable from the Secretary of the Institute, 90, Buckingham Palace Road, London, S.W.I. THE Midwives' Institute desires to thank, through the columns of this journal, the medical officers of local supervising authorities in England and Wales who have sent lists of midwives giving notice of intention to practise in their areas, or information regarding independent midwives. These lists have enabled the Institute to send some 7,000 questionnaires to midwives in private practice asking for information on their conditions of practice. Lady Forber (Dr. Janet Lane Claypon) has generously promised to tabulate and analyse the information received, and the Institute hope that this may provide valuable assistance in connection with the settlement of the many questions which will be raised if a salaried service of midwives is set up.