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Rôle of oral Hygiene in Preventive Dentistry
RÔLE OF ORAL HYGIENE IN PREVENTIVE DENTISTRY B y G e o r g e E . M o r g a n , D .D .S., Milwaukee, Wis.
S
I N C E the inauguration of the first dental school in Am erica, in 1840, the mechanical aspect o f dentistry has enjoyed an overwhelming amount of concentrated study, with the result that, in m any practices, the preventive phase has been much neglected. Today, how ever, the prevention of dental disorders, and rightly so, is gradually taking pre cedence. This m ay be due to the natural biologic evolution of dentistry or to the addition of the dental hygienist to dental practice, or to both. T h e adoption of the slogan “ Preventive Dentistry in the In terest of Public Health” in 19 3 7 and “ Dental Health for American Youth” in 19 38 by the American Dental Association can be interpreted as a highly effective means for turning the attention o f the profession toward greater effort in pre ventive dentistry. Progressive health edu cators throughout the country are de manding more and more information on dental health. As m y practice for the past eleven years has been limited to pedodontia, and since it is generally acceded that preven tion begins with the child, I shall discuss the role of oral hygiene in preventive dentistry, covering only those hygienic measures essential for the mouth health of children from 2 to 16 years of age. O ral hygiene for children, in its broad est sense, should include not only pedoRead before the Section on Operative and Preventive Dentistry as a part of a symposium on preventive dentistry at the Seventy-Fourth Annual Midwinter Meeting of the Chicago Dental Society, February 15, 1938. Jour. A .D .A. & D. Cos., V ol. 25, September 1938
dontexesis, which means the scaling, cleaning and polishing o f the teeth of children, commonly known as dental prophylaxis, and definite instructions in home care, but also the removal of root fragments and abscessed teeth, the cor rection of overhanging fillings, the resto ration of proximal contacts and the gen eral elimination of all other conditions of the teeth that cannot be corrected by operative intervention. However, it is generally accepted among the profession that oral hygiene is synonymous with oral prophylaxis. T h e scaling, cleaning and polishing of the teeth o f children is looked on by m any dentists as a simple and unimpor tant procedure rather than an essential part of oral hygiene. It is, without ques tion, the dental health service which the parent is least inclined to seek at regular intervals for the child. This is due partly to the fact that there seem to be two schools of thought regarding when the child’s teeth should be cleaned : one, that it should be done at the initial visit of the child, provided the patient is not in need of relief from p a in ; the other, that it should be done at the final visit and combined with the polishing of the fill ings. I f dentists would stress the need for having the child’s teeth cleaned as a pre requisite for a thorough mouth examina tion before attempting restorative work, the problem of convincing the parent of its importance would be solved. T h e dentist or hygienist who gives the dental prophylactic treatment also has a better 1425
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opportunity to note the ordinary amount of home care given the teeth. T h e more visits the child makes to the office, the more interested in dental care the parent and child become. Then, too, m any of the pit and fissure areas are detectable with a sharp explorer only after the teeth have been thoroughly cleaned and dried with air. W hen the child patient is re called in three months for the periodic check-up, the parent will be educated to expect to have the child’s teeth cleaned before a thorough mouth examination is made. Parents will readily pay for a dental prophylaxis and examination for their children, but frequently are reluc tant to pay for the examination alone. T h e practice of combining dental prophylaxis with polishing of, the fillings at the final visit should be discouraged. It does not impress the parent nor the child with its importance and much of the instruction in home care, which would be retained if a definite rule o f dental prophylaxis at the initial visit were established, is lost. Before the dental prophylaxis is begun, the operator should have a systematized method of procedure. In every child’ s mouth, three conditions should be ob served : first, the occlusion of the teeth, to detect any malformation which m ay be due to a pernicious h abit; second, the degree o f home care, to determine what areas are missed in the toothbrushing, and, third, the masticating habits o f the child, to ascertain whether the child chews on both sides o f the mouth. I f the teeth are cleaner on one side than on the other, we can be quite certain that the child masticates only with the clean side. This m ay be due to habit, which can be corrected by calling the child’ s atten tion to it, or it m ay be caused by some thing that will require operative correc tion, such as a cavity, retained deciduous roots and food packing in the proximal areas, an abscessed condition or maloc clusion. A bugbear in pedodontexesis is the use
of a solution to disclose the accretions on the teeth of the child patient. A disclos ing solution is an unnecessary evil. It has a vile taste and tends to destroy the child’s pleasant reactions toward den tistry in general. Nine children out of ten are nauseated from it and nothing is gained by its use. It is just “ nasty” medicine to the average child, and the mother is too sympathetic to endeavor to understand w hy it is used. Abuse of the reward system with child patients is another evil that should be corrected. Children, generally, are very appreciative of rewards, and rewards can be made an educational part of one’s practice. Professional people should be very cautious as to what types o f re wards they give their patients. Some den tists have a tendency to belittle their pro fessional standing by handing out samples of this and that without any thought of what the effect m ay be. I f a reward sys tem is used, it should be first of all kind ness, consideration and good operative procedure; and, second, something of a dental health educational nature. M a terial in pamphlet form portraying opti mism and stressing the need for dental prophylaxis and examination at least every three months, the value o f good food habits and the need for proper home care and telling how dental health can be enjoyed by every child is very appro priate. O nly material that is prepared and distributed by official health organ izations should be given the child. Dis tribution of pamphlets and other material of a commercial nature destroys confi dence and reflects poor judgment. T h e prim ary purpose in a dental prophylaxis is to polish the teeth and make them more resistant to the form a tion of bacterial plaques and to caries. Therefore, the selection o f a cleansing paste should be given careful thought. N o preparation should be used that is abra sive enough to scratch the enamel even to the slightest degree. As a measure of safety, we might, in our everyday prac
Morgan— Rôle of Oral Hygiene in Preventive Dentistry tice, apply the simple test for abrasive ness developed by the United States Bu reau of Standards, which is as follow s: A piece of glass and a piece of alloy metal of the size and hardness of a five-cent piece are all that are needed for this test. First test the glass for hardness by rubbing the edge of the metal piece over it to be sure that the metal alone does not scratch the glass. Human enamel and glass both vary in hardness. The grade of soda-lime glass used in microscopic work was found to be harder than any of the enamel tested at the Bureau. Place some of the cleansing paste to be tested on the glass and rub again with the coin. If scratches result, then you may expect scratches on your teeth. This test is sensitive enough to detect one part of emery in one hundred thousand parts of paste. T h e years of childhood from 2 to 16 m ay be divided, from the standpoint of oral hygiene, into three distinct gro up s: first, the deciduous dentition period (2 to 6 ) ; second, the transitional dentition period (6 to n ) , and third, the perma nent dentition period ( 1 1 to 16 ). You m ay wonder w hy I did not make some mention of the prenatal as well as the period from birth to two years o f age. I can, I think, freely and rightly say that the responsibility for dental health during these periods of childhood rests with the pediatrician or with the expect ant mother’s dentist rather than with the pedodontist. Group 1. T h e deciduous dentition pe riod, covering the years of childhood from 2 to 6, is probably the most im pressionable habit training age even from the standpoint o f oral hygiene. During this period, the child usually makes his first contact with the dental office. There fore, his experiences should be pleasant, with the result that his reactions toward dentists and dentistry will be favorable. This type of reaction can be assured by establishing confidence through the use of psychology and patience on the part o f the office personnel. T w o distinct oral conditions, the black
and the green stains, are more frequently present in this age group. T h e cause for the formation of these stains is not defi nitely known. However, the green stain is most commonly found in mouths when the intake of carbohydrates is great and the home care is negligible. Th e use o f hydrogen peroxide assists immeasur ably in the removal of green stain, as it somehow tends to bleach the chromogenic accretions on the tooth surface. As for the black stain, there is no safe medicament that will assist in its removal. Fortunately, only a small minority of children have a susceptibility to black stain and, in a great m any of these cases, the condition persists only with the de ciduous teeth. It seems that black stain is, for some unknown reason, more com monly found in girls than in boys. In cer tain mouths, black stain possesses a pene trating power in that it embeds itself in the enamel and roughens the enamel sur face. In mouths in which this type o f black stain is found, the teeth usually are highly susceptible to d ecay; whereas the superficial type of black stain is often present in mouths practically immune to caries. A fter seating a child of from 2 to 6 years of age in the chair, it is well to note the number of teeth erupted and to make a general survey of the mouth, observing the occlusion, masticating habits and home care, then quietly introduce the various instruments necessary to begin the operative prophylactic procedures. T h e rubber cup polishers in the contraangle handpiece, with flour of pumice slightly flavored for the buccal, labial and lingual surfaces of the teeth, are most acceptable for the young child. During the deciduous dentition period, few chil dren have an accumulation of calculus on the lingual surfaces of the lower an terior teeth. However, if calculus is present, it should be removed with a scaler before the polishing is begun. T h e occlusal surfaces should be cleaned with midget brushes and cleansing paste. A
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fine linen strip or tape floss can be used to clean the proximal surfaces o f the teeth. T h e greatest problem encountered in giving a dental prophylaxis to a child for the first time is the use of the water and air syringes. N o operator should surprise a child by using either air or water unex pectedly. T h e child should be told as we proceed what we are going to do. He will submit to a dry field examination, not only for caries, but also as a means of detecting unremoved stains and un polished surfaces. W hen teaching a child home care of the mouth, it is well to invite the parent into the room. There are five major dental health habits to be stressed for home care during the deciduous denti tion p eriod: 1. E very child should be taught to brush the teeth after breakfast, after lunch and before going to bed at night without fail and the night brushing should be done by the parent or nurse. Th e mistake often made by mothers is that of teaching their children to brush the teeth before breakfast and m any mothers are reluctant about changing this practice. However, when the child is young, if the importance of brushing the teeth after breakfast is explained to the mother, she will usually change with out hesitation. T h e right dental health habits are essential if prevention is to be effective early in the life o f the child and early in the life of the tooth. 2. E very child should possess three toothbrushes of proper size and shape, one to be used after breakfast, one after lunch and the other before going to bed at n ig h t; thereby allowing them to thor oughly dry and regain their original stiff ness. Fo r the child of from 2 to 4 years, the single-row brush with from six to eight well-spaced tufts of bristles should be prescribed. This makes the brushing pro cedure more pleasant and, at the same time, is as effective as when the larger
brush is used. W hen there is normal spacing of the teeth, at about the age of 4, the regular two-row junior brush of average size should be used. Mothers should be instructed in the care of the toothbrush in order to preserve its stiff ness and some degree of sanitation by stressing the importance o f rinsing it with cold water only and allowing it to dry thoroughly in the open room, since the germs that grow in the mouth grow in darkness. This is especially important to mothers who have acquired a germ phobia and tend to accept the incubator type of toothbrush holders. .3. E very child should be instructed in the correct method for brushing the teeth. T h e generally accepted method of brushing the upper teeth down and the lower teeth up is a good technic for this age group. I f the hint regarding brushing all the teeth with a dry brush and allowing the saliva to moisten it well before using the toothpaste is carried out, the toothbrushing is usually done more thoroughly with out making it appear a long-drawn-out task. 4. Every child should have prescribed for him an accepted toothpaste rather than a toothpowder, because young chil dren tend to inhale the toothpowder, and for this reason alone the use o f toothpowder should be discouraged. Th e profession cannot be too cautious in the prescribing of a dentifrice and must prescribe one in which the content is known. W e must remember that any product of secret formula is classified as a patent medicine, and therefore should not be prescribed by dentists. In m y pedodontic practice, I have seen many deleterious effects of using an unsafe product. W e must remember that medica ments or any allergic products affect the child more readily than the adult be cause the child has not had an opportu nity to develop the same degree of im munity. T h e only safe method to follow in the selection of a dentifrice is to pre
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centuated by what appears to be an scribe, and caution the parent to use, orange-colored stain. Although this stain only those products bearing the seal of is easily removed with cleansing paste acceptance of the Council on Dental and rubber cup polishers, the child’s at Therapeutics of the Am erican Dental tention should be called to that particular Association. 5. Every child should establish the area when the home care o f the mouth habit of chewing on both sides o f the is stressed. Careful observation should jaws, thereby exercising all the teeth be made of the erupted teeth as com and allowing the jaws to develop sym pared to the normal, to prevent prolonged metrically if at all possible. retention; to the condition of the gin T h e establishment of good masticating gival tissues and the possibilities for focal habits early in life not only tends to pre infection; to overhanging fillings and the serve the oral health, but also enables the occlusion, and, again, to the importance child to enjoy his food and to profit from o f home care. good digestion and good assimilation. Polishing o f the proximal surfaces of Teaching health habits for home care the teeth with tape floss and cleansing of the mouth in the deciduous dentition paste or the regular prophylactic strips period involves more than the presenta is very effective in reducing the amount tion of facts. W e must develop the of decay and should be routine in pedo child’s imagination so that these facts dontexesis during the transitional denti tion period. A t the age when the exfolia will have meaning and interest. Group 2. T h e transitional dentition tion of the second deciduous molar is period, covering the years of childhood about to take place, as another preven from 6 to 1 1 , is probably the most trying tive oral hygiene measure the parent is in the child’s life. During this period instructed to bring the child in for an growth is rapid, activities are increased examination o f the mesial surfaces of and contact with contagious diseases is the first permanent molars immediately most frequent. T h e physical bodily after the loss of the second deciduous changes, including the exfoliation of the molars. I f this area gives any indication deciduous teeth and the eruption of the o f caries, the teeth can be filled without permanent teeth, all take place within the destruction of a great deal of tooth surface. I f no caries is present, the this five year period. In other words, we mesial surfaces o f the first permanent have an increased susceptibility and lowered immunity, making oral hygiene molars can be well polished to further of greater importance from the stand increase their immunity. point of preventive dentistry. Th e effectiveness of oral hygiene meas T h e technic of pedodontexesis between ures is greatly reduced during the transi the ages of 6 and 1 1 varies in only a few tional dentition period because the teeth are then more susceptible to caries and details from the technic employed during harder to brush, and the average child the deciduous dentition period, but, first of all, we have added hand polishing has not the time to care for his teeth consistently. However, some comprehen with the porte polisher, putting more sive effort should be made by the den effort on the careful polishing of the tists to supervise both the home care and permanent teeth. W e also have to re the eruption o f the teeth. T h e ectopic move with scalers increased accretions eruption of any one tooth in the mouth on the teeth, which are due to the ex reduces the possibilities of preventive foliation of the deciduous teeth, the erup care, not only from the standpoint of oral tion of the permanent teeth, impaired hygiene, but also from the standpoint of mastication and less vigorous toothbrushmastication, normal development and ing. These accretions are usually ac
T h e Journal of the American Dental Association and T h e Dental Cosmos growth. Likewise, prolonged retention buccal surfaces o f the first permanent often results in irritation around the molars is desirable. Th e benefits in mouth offending tooth, which m ay become health to be derived from having the child count the strokes while brushing very extensive within a short time. the teeth are surprising. Another oral hygiene hazard is the sub 2. E very child should have definitely merged deciduous tooth. W e must also prescribed for him three junior two-row bear in mind the fact that any condition shaped brushes. that impairs mastication impairs oral Dentists and hygienists make a grave health. N ext to dental caries, the most serious menace to mouth health is the mistake in allowing a child from 6 to 11 abscessed tooth. T h e child, like all other years’ to use an adult brush o f regular size. W e must remember that the size human beings, unconsciously seeks com of the jaws does not warrant this rapid fort during both mastication and home care. Abscessed teeth must be eliminated, change and that it is desirable for the child to learn to handle a junior brush not only for mouth health, but also for well before changing to an adult size. general health, because general health is a good index to increased possibilities Then, too, for this age group, our instruc for oral health. Unless some effort is tions must be detailed, even to the extent made to educate the parent as to the of indicating which brush is to be used at each brushing. N ow that colored value of increased dental supervision dur ing the transitional dentition period, handles are available, this should not be much is lost in the w ay of individual a problem, but we must be certain that mouth health even though the loss m ay the child understands the importance of be only temporary. allowing the brush to become thoroughly Presentation o f the subject o f home dry between brushings. care o f the teeth to children from 6 to 11 3. T h e method of brushing should be years is not necessarily a task, if the child the same as during the deciduous den is in a receptive mood. Th e important tition period. factors to stress besides dietary habits and T h e technic of brushing should not be the five m ajor health habits already out complicated by any form of interproxilined in the deciduous dentition period mal stimulation. Again, the importance o f the dry brush method before employ a re: i. T h e brushing of the teeth should ment o f the toothpaste is stressed. be done before a mirror and special care 4. E v e ry child should be instructed to should be exercised on the areas that massage the gums with the finger after show the results o f ineffective tooththe night brushing. brushing. This procedure increases the circula A fter the eruption of the first perma tion and reduces the possibility of sore nent molars, the general consensus of ness from exfoliation and eruption of opinion is that if the mouth is opened the teeth. wide during the brushing procedure, the In teaching home care during this tooth will be well brushed. T h a t is a period, it is evident that girls are more great fallacy because the contraction of precise in carrying out instructions, but the muscles tends to force the brush aw ay interest in tooth care increases in all from the buccal surface and it is there children with age. that added concentration is needed. Th e Group 3. Th e permanent dentition child should be instructed to close slightly period begins with, the child of 11 and, when brushing the posterior areas in the in most pedodontic practices, extends un mouth. O ften, for the child from 6 to til the close of the sixteenth year. N or 8, to assign a number of strokes on the mally, according to the newer theories of
M organ— Rôle of Oral Hygiene in Preventive Dentistry calcification and eruption, there are now only permanent teeth in the mouth, fully erupted or about to erupt. W hen consid ering the rôle of oral hygiene in preven tive dentistry during this period, we must remember that the child has emerged from childhood into adolescence and has a marked degree of susceptibility to dis eases, including oral disease. I f the mouth has suffered from inade quate dental supervision, we m ay be con fronted with the problems of impacted and unerupted teeth. Both these condi tions tend to decrease the possibilities of mouth health and impair home prophy laxis. W e m ay also have the other ex treme— prolonged retention of the decid uous teeth. T h e ectopic eruption of teeth as a result of prolonged retention reduces mouth cleanliness. T h e bicuspids and cuspids are more frequently malposed as the result of prolonged retention, a con dition which can largely be prevented by regular supervision supplemented with roentgen-ray examination and a working knowledge of tooth growth and develop ment. Closely related to the problem o f pro longed retention is that presented by the deciduous root fragment remaining in the ja w after the crown of the deciduous tooth has been exfoliated. These root fragments tend to destroy the contact and allow the food to pack in the interproximal space, thereby irritating the soft tissues. Frequently, the deciduous root fragments are not discovered until later in life and, if the bicuspids have been extracted, they are often mistaken for bicuspid root fragments. T h e loss of contact in the bicuspid area always war rants roentgenographic examination be fore any attempt is made to restore or provide normal contact by some artificial method. Therefore, the use of the roent gen rays is a necessary adjunct to all phases of dentistry for children during the dentition periods, and roentgeno grams must be utilized freely even in the
field of oral hygiene if the mouth is to be maintained in health. T h e procedure for giving a dental pro phylaxis for a child in the permanent dentition period does not differ greatly from the method employed during the transitional dentition period. However, polishing of the interproximal spaces with prophylactic strips or tape floss and cleansing paste should be carefully and thoroughly done. A ll calcareous and serumal deposits must be removed with out lacerating the soft tissues. A ll patients should again be instructed in home care of the mouth as outlined for the transitional dentition period, the dentist requesting more gum massage by finger pressure and increasing the mas saging requirements to both morning and night. It is also important to teach the child the use of tape dental floss, instruct ing the patient how to hold it and how to use it, besides cautioning him to avoid lacerating the gums. I f the child of n is instructed to use tape floss on the an terior teeth, first wiping the mesial sur face o f one tooth and then the distal surface of the proximate tooth, much can be done to prevent interproximal decay. A s the teeth erupt and grow into normal alinement, the tape floss measure can be extended to include all teeth. W e must implant uppermost in the child’s mind, the thought of the danger involved in the careless use of floss. However, the pos sibility for injury is considerably reduced with the tape type o f dental floss. During the permanent dentition period, w e are sometimes confronted with clean mouths in which caries is rampant. These patients probably have a glandular disturbance, and in such mouths caries cannot be appreciably re duced through mouth cleanliness alone. Procedures for the maintenance of mouth health for the child have been considered in detail that we m ay adopt a standard of value for oral hygiene in preventive dentistry. It is m y contention,
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after eleven years of private practice limited exclusively to dentistry for chil dren, that if the patient conscientiously strives to carry out instructions to keep the mouth clean and returns for periodic check-up at least every three months, oral hygiene can and will reduce the ravages of dental decay. It is true that the chil dren in private practice cannot be con sidered a control group from a scientific standpoint, yet each child responds ac cording to the degree of cooperation
given, in that those children who are more conscientious show greater benefits. Scientists up to the present time have not discovered any serum, vaccine or specific whereby one can be inoculated and thereafter be forever free from den tal disease. Until more definite and posi tive methods of control are discovered, we must rely on oral hygiene as one of the most important factors in the preven tion o f dental disorders. 2039 North Prospect Avenue.
PRACTICAL PHASES OF LOCAL ANESTHESIA B y H o w a r d C . M i l l e r , D .D .S., Chicago,
I
N any surgical procedure within the mouth, the selection of an anesthetic is an extremely important step. T h e decision as to the anesthetic to be used should be based upon the training and experience of the operator, the physical condition of the patient and the type of operation to be performed. There is no one anesthetic best suited to all cases, but there is generally one that is best suited to the individual and to the operation. The successful operator selects the anes thetic best adapted to the case, the one from which the patient will receive the maximum benefit. I f regional or block anesthesia is the anesthetic of choice, it must be remem bered that its successful administration calls for scrupulous asepsis, proper anes thetic solution, a thorough knowledge of the anatomy of the parts involved and an exact technic. Clinical investigation and research have revealed certain facts Read before the Section on Oral Surgery, Radiology and Anesthesia at the SeventyFourth Annual Midwinter Meeting of the Chicago Dental Society, February 15, 1938. Jour. A .D .A. & D. Cos., Vol. 25, September 1938
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that should be of value to the dental practitioner, some of which m ay be stated as follow s: i. Procaine (novocaine) is the most effective and the safest local anesthetic agent available at the present time. This conclusion is based not alone upon the wide clinical application o f procaine solu tions, but also upon the accepted methods for determining the concentration per cent, efficiency ratio and toxicity, and the duration of action of local anesthetic solutions. Th e methods usually employed for such tests a r e : (a) Nerve block; e.g., the standard frog sciatic nerve method. (b) Efficiency on mucous membrane; by application to the human cornea and to the rabbit cornea. (c) Injection efficiency; by the stand ard wheal test on man. (d) T o x icity; by subcutaneous and vein administration in guinea-pigs, rats, cats and dogs, which also furnishes an index on respiration, heart condition and circulation.
S
I N C E the inauguration of the first dental school in Am erica, in 1840, the mechanical aspect o f dentistry has enjoyed an overwhelming amount of concentrated study, with the result that, in m any practices, the preventive phase has been much neglected. Today, how ever, the prevention of dental disorders, and rightly so, is gradually taking pre cedence. This m ay be due to the natural biologic evolution of dentistry or to the addition of the dental hygienist to dental practice, or to both. T h e adoption of the slogan “ Preventive Dentistry in the In terest of Public Health” in 19 3 7 and “ Dental Health for American Youth” in 19 38 by the American Dental Association can be interpreted as a highly effective means for turning the attention o f the profession toward greater effort in pre ventive dentistry. Progressive health edu cators throughout the country are de manding more and more information on dental health. As m y practice for the past eleven years has been limited to pedodontia, and since it is generally acceded that preven tion begins with the child, I shall discuss the role of oral hygiene in preventive dentistry, covering only those hygienic measures essential for the mouth health of children from 2 to 16 years of age. O ral hygiene for children, in its broad est sense, should include not only pedoRead before the Section on Operative and Preventive Dentistry as a part of a symposium on preventive dentistry at the Seventy-Fourth Annual Midwinter Meeting of the Chicago Dental Society, February 15, 1938. Jour. A .D .A. & D. Cos., V ol. 25, September 1938
dontexesis, which means the scaling, cleaning and polishing o f the teeth of children, commonly known as dental prophylaxis, and definite instructions in home care, but also the removal of root fragments and abscessed teeth, the cor rection of overhanging fillings, the resto ration of proximal contacts and the gen eral elimination of all other conditions of the teeth that cannot be corrected by operative intervention. However, it is generally accepted among the profession that oral hygiene is synonymous with oral prophylaxis. T h e scaling, cleaning and polishing of the teeth o f children is looked on by m any dentists as a simple and unimpor tant procedure rather than an essential part of oral hygiene. It is, without ques tion, the dental health service which the parent is least inclined to seek at regular intervals for the child. This is due partly to the fact that there seem to be two schools of thought regarding when the child’s teeth should be cleaned : one, that it should be done at the initial visit of the child, provided the patient is not in need of relief from p a in ; the other, that it should be done at the final visit and combined with the polishing of the fill ings. I f dentists would stress the need for having the child’s teeth cleaned as a pre requisite for a thorough mouth examina tion before attempting restorative work, the problem of convincing the parent of its importance would be solved. T h e dentist or hygienist who gives the dental prophylactic treatment also has a better 1425
14 26
T h e Journal of the Am erican Dental Association and T h e Dental Cosmos
opportunity to note the ordinary amount of home care given the teeth. T h e more visits the child makes to the office, the more interested in dental care the parent and child become. Then, too, m any of the pit and fissure areas are detectable with a sharp explorer only after the teeth have been thoroughly cleaned and dried with air. W hen the child patient is re called in three months for the periodic check-up, the parent will be educated to expect to have the child’s teeth cleaned before a thorough mouth examination is made. Parents will readily pay for a dental prophylaxis and examination for their children, but frequently are reluc tant to pay for the examination alone. T h e practice of combining dental prophylaxis with polishing of, the fillings at the final visit should be discouraged. It does not impress the parent nor the child with its importance and much of the instruction in home care, which would be retained if a definite rule o f dental prophylaxis at the initial visit were established, is lost. Before the dental prophylaxis is begun, the operator should have a systematized method of procedure. In every child’ s mouth, three conditions should be ob served : first, the occlusion of the teeth, to detect any malformation which m ay be due to a pernicious h abit; second, the degree o f home care, to determine what areas are missed in the toothbrushing, and, third, the masticating habits o f the child, to ascertain whether the child chews on both sides o f the mouth. I f the teeth are cleaner on one side than on the other, we can be quite certain that the child masticates only with the clean side. This m ay be due to habit, which can be corrected by calling the child’ s atten tion to it, or it m ay be caused by some thing that will require operative correc tion, such as a cavity, retained deciduous roots and food packing in the proximal areas, an abscessed condition or maloc clusion. A bugbear in pedodontexesis is the use
of a solution to disclose the accretions on the teeth of the child patient. A disclos ing solution is an unnecessary evil. It has a vile taste and tends to destroy the child’s pleasant reactions toward den tistry in general. Nine children out of ten are nauseated from it and nothing is gained by its use. It is just “ nasty” medicine to the average child, and the mother is too sympathetic to endeavor to understand w hy it is used. Abuse of the reward system with child patients is another evil that should be corrected. Children, generally, are very appreciative of rewards, and rewards can be made an educational part of one’s practice. Professional people should be very cautious as to what types o f re wards they give their patients. Some den tists have a tendency to belittle their pro fessional standing by handing out samples of this and that without any thought of what the effect m ay be. I f a reward sys tem is used, it should be first of all kind ness, consideration and good operative procedure; and, second, something of a dental health educational nature. M a terial in pamphlet form portraying opti mism and stressing the need for dental prophylaxis and examination at least every three months, the value o f good food habits and the need for proper home care and telling how dental health can be enjoyed by every child is very appro priate. O nly material that is prepared and distributed by official health organ izations should be given the child. Dis tribution of pamphlets and other material of a commercial nature destroys confi dence and reflects poor judgment. T h e prim ary purpose in a dental prophylaxis is to polish the teeth and make them more resistant to the form a tion of bacterial plaques and to caries. Therefore, the selection o f a cleansing paste should be given careful thought. N o preparation should be used that is abra sive enough to scratch the enamel even to the slightest degree. As a measure of safety, we might, in our everyday prac
Morgan— Rôle of Oral Hygiene in Preventive Dentistry tice, apply the simple test for abrasive ness developed by the United States Bu reau of Standards, which is as follow s: A piece of glass and a piece of alloy metal of the size and hardness of a five-cent piece are all that are needed for this test. First test the glass for hardness by rubbing the edge of the metal piece over it to be sure that the metal alone does not scratch the glass. Human enamel and glass both vary in hardness. The grade of soda-lime glass used in microscopic work was found to be harder than any of the enamel tested at the Bureau. Place some of the cleansing paste to be tested on the glass and rub again with the coin. If scratches result, then you may expect scratches on your teeth. This test is sensitive enough to detect one part of emery in one hundred thousand parts of paste. T h e years of childhood from 2 to 16 m ay be divided, from the standpoint of oral hygiene, into three distinct gro up s: first, the deciduous dentition period (2 to 6 ) ; second, the transitional dentition period (6 to n ) , and third, the perma nent dentition period ( 1 1 to 16 ). You m ay wonder w hy I did not make some mention of the prenatal as well as the period from birth to two years o f age. I can, I think, freely and rightly say that the responsibility for dental health during these periods of childhood rests with the pediatrician or with the expect ant mother’s dentist rather than with the pedodontist. Group 1. T h e deciduous dentition pe riod, covering the years of childhood from 2 to 6, is probably the most im pressionable habit training age even from the standpoint o f oral hygiene. During this period, the child usually makes his first contact with the dental office. There fore, his experiences should be pleasant, with the result that his reactions toward dentists and dentistry will be favorable. This type of reaction can be assured by establishing confidence through the use of psychology and patience on the part o f the office personnel. T w o distinct oral conditions, the black
and the green stains, are more frequently present in this age group. T h e cause for the formation of these stains is not defi nitely known. However, the green stain is most commonly found in mouths when the intake of carbohydrates is great and the home care is negligible. Th e use o f hydrogen peroxide assists immeasur ably in the removal of green stain, as it somehow tends to bleach the chromogenic accretions on the tooth surface. As for the black stain, there is no safe medicament that will assist in its removal. Fortunately, only a small minority of children have a susceptibility to black stain and, in a great m any of these cases, the condition persists only with the de ciduous teeth. It seems that black stain is, for some unknown reason, more com monly found in girls than in boys. In cer tain mouths, black stain possesses a pene trating power in that it embeds itself in the enamel and roughens the enamel sur face. In mouths in which this type o f black stain is found, the teeth usually are highly susceptible to d ecay; whereas the superficial type of black stain is often present in mouths practically immune to caries. A fter seating a child of from 2 to 6 years of age in the chair, it is well to note the number of teeth erupted and to make a general survey of the mouth, observing the occlusion, masticating habits and home care, then quietly introduce the various instruments necessary to begin the operative prophylactic procedures. T h e rubber cup polishers in the contraangle handpiece, with flour of pumice slightly flavored for the buccal, labial and lingual surfaces of the teeth, are most acceptable for the young child. During the deciduous dentition period, few chil dren have an accumulation of calculus on the lingual surfaces of the lower an terior teeth. However, if calculus is present, it should be removed with a scaler before the polishing is begun. T h e occlusal surfaces should be cleaned with midget brushes and cleansing paste. A
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fine linen strip or tape floss can be used to clean the proximal surfaces o f the teeth. T h e greatest problem encountered in giving a dental prophylaxis to a child for the first time is the use of the water and air syringes. N o operator should surprise a child by using either air or water unex pectedly. T h e child should be told as we proceed what we are going to do. He will submit to a dry field examination, not only for caries, but also as a means of detecting unremoved stains and un polished surfaces. W hen teaching a child home care of the mouth, it is well to invite the parent into the room. There are five major dental health habits to be stressed for home care during the deciduous denti tion p eriod: 1. E very child should be taught to brush the teeth after breakfast, after lunch and before going to bed at night without fail and the night brushing should be done by the parent or nurse. Th e mistake often made by mothers is that of teaching their children to brush the teeth before breakfast and m any mothers are reluctant about changing this practice. However, when the child is young, if the importance of brushing the teeth after breakfast is explained to the mother, she will usually change with out hesitation. T h e right dental health habits are essential if prevention is to be effective early in the life o f the child and early in the life of the tooth. 2. E very child should possess three toothbrushes of proper size and shape, one to be used after breakfast, one after lunch and the other before going to bed at n ig h t; thereby allowing them to thor oughly dry and regain their original stiff ness. Fo r the child of from 2 to 4 years, the single-row brush with from six to eight well-spaced tufts of bristles should be prescribed. This makes the brushing pro cedure more pleasant and, at the same time, is as effective as when the larger
brush is used. W hen there is normal spacing of the teeth, at about the age of 4, the regular two-row junior brush of average size should be used. Mothers should be instructed in the care of the toothbrush in order to preserve its stiff ness and some degree of sanitation by stressing the importance o f rinsing it with cold water only and allowing it to dry thoroughly in the open room, since the germs that grow in the mouth grow in darkness. This is especially important to mothers who have acquired a germ phobia and tend to accept the incubator type of toothbrush holders. .3. E very child should be instructed in the correct method for brushing the teeth. T h e generally accepted method of brushing the upper teeth down and the lower teeth up is a good technic for this age group. I f the hint regarding brushing all the teeth with a dry brush and allowing the saliva to moisten it well before using the toothpaste is carried out, the toothbrushing is usually done more thoroughly with out making it appear a long-drawn-out task. 4. Every child should have prescribed for him an accepted toothpaste rather than a toothpowder, because young chil dren tend to inhale the toothpowder, and for this reason alone the use o f toothpowder should be discouraged. Th e profession cannot be too cautious in the prescribing of a dentifrice and must prescribe one in which the content is known. W e must remember that any product of secret formula is classified as a patent medicine, and therefore should not be prescribed by dentists. In m y pedodontic practice, I have seen many deleterious effects of using an unsafe product. W e must remember that medica ments or any allergic products affect the child more readily than the adult be cause the child has not had an opportu nity to develop the same degree of im munity. T h e only safe method to follow in the selection of a dentifrice is to pre
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centuated by what appears to be an scribe, and caution the parent to use, orange-colored stain. Although this stain only those products bearing the seal of is easily removed with cleansing paste acceptance of the Council on Dental and rubber cup polishers, the child’s at Therapeutics of the Am erican Dental tention should be called to that particular Association. 5. Every child should establish the area when the home care o f the mouth habit of chewing on both sides o f the is stressed. Careful observation should jaws, thereby exercising all the teeth be made of the erupted teeth as com and allowing the jaws to develop sym pared to the normal, to prevent prolonged metrically if at all possible. retention; to the condition of the gin T h e establishment of good masticating gival tissues and the possibilities for focal habits early in life not only tends to pre infection; to overhanging fillings and the serve the oral health, but also enables the occlusion, and, again, to the importance child to enjoy his food and to profit from o f home care. good digestion and good assimilation. Polishing o f the proximal surfaces of Teaching health habits for home care the teeth with tape floss and cleansing of the mouth in the deciduous dentition paste or the regular prophylactic strips period involves more than the presenta is very effective in reducing the amount tion of facts. W e must develop the of decay and should be routine in pedo child’s imagination so that these facts dontexesis during the transitional denti tion period. A t the age when the exfolia will have meaning and interest. Group 2. T h e transitional dentition tion of the second deciduous molar is period, covering the years of childhood about to take place, as another preven from 6 to 1 1 , is probably the most trying tive oral hygiene measure the parent is in the child’s life. During this period instructed to bring the child in for an growth is rapid, activities are increased examination o f the mesial surfaces of and contact with contagious diseases is the first permanent molars immediately most frequent. T h e physical bodily after the loss of the second deciduous changes, including the exfoliation of the molars. I f this area gives any indication deciduous teeth and the eruption of the o f caries, the teeth can be filled without permanent teeth, all take place within the destruction of a great deal of tooth surface. I f no caries is present, the this five year period. In other words, we mesial surfaces o f the first permanent have an increased susceptibility and lowered immunity, making oral hygiene molars can be well polished to further of greater importance from the stand increase their immunity. point of preventive dentistry. Th e effectiveness of oral hygiene meas T h e technic of pedodontexesis between ures is greatly reduced during the transi the ages of 6 and 1 1 varies in only a few tional dentition period because the teeth are then more susceptible to caries and details from the technic employed during harder to brush, and the average child the deciduous dentition period, but, first of all, we have added hand polishing has not the time to care for his teeth consistently. However, some comprehen with the porte polisher, putting more sive effort should be made by the den effort on the careful polishing of the tists to supervise both the home care and permanent teeth. W e also have to re the eruption o f the teeth. T h e ectopic move with scalers increased accretions eruption of any one tooth in the mouth on the teeth, which are due to the ex reduces the possibilities of preventive foliation of the deciduous teeth, the erup care, not only from the standpoint of oral tion of the permanent teeth, impaired hygiene, but also from the standpoint of mastication and less vigorous toothbrushmastication, normal development and ing. These accretions are usually ac
T h e Journal of the American Dental Association and T h e Dental Cosmos growth. Likewise, prolonged retention buccal surfaces o f the first permanent often results in irritation around the molars is desirable. Th e benefits in mouth offending tooth, which m ay become health to be derived from having the child count the strokes while brushing very extensive within a short time. the teeth are surprising. Another oral hygiene hazard is the sub 2. E very child should have definitely merged deciduous tooth. W e must also prescribed for him three junior two-row bear in mind the fact that any condition shaped brushes. that impairs mastication impairs oral Dentists and hygienists make a grave health. N ext to dental caries, the most serious menace to mouth health is the mistake in allowing a child from 6 to 11 abscessed tooth. T h e child, like all other years’ to use an adult brush o f regular size. W e must remember that the size human beings, unconsciously seeks com of the jaws does not warrant this rapid fort during both mastication and home care. Abscessed teeth must be eliminated, change and that it is desirable for the child to learn to handle a junior brush not only for mouth health, but also for well before changing to an adult size. general health, because general health is a good index to increased possibilities Then, too, for this age group, our instruc for oral health. Unless some effort is tions must be detailed, even to the extent made to educate the parent as to the of indicating which brush is to be used at each brushing. N ow that colored value of increased dental supervision dur ing the transitional dentition period, handles are available, this should not be much is lost in the w ay of individual a problem, but we must be certain that mouth health even though the loss m ay the child understands the importance of be only temporary. allowing the brush to become thoroughly Presentation o f the subject o f home dry between brushings. care o f the teeth to children from 6 to 11 3. T h e method of brushing should be years is not necessarily a task, if the child the same as during the deciduous den is in a receptive mood. Th e important tition period. factors to stress besides dietary habits and T h e technic of brushing should not be the five m ajor health habits already out complicated by any form of interproxilined in the deciduous dentition period mal stimulation. Again, the importance o f the dry brush method before employ a re: i. T h e brushing of the teeth should ment o f the toothpaste is stressed. be done before a mirror and special care 4. E v e ry child should be instructed to should be exercised on the areas that massage the gums with the finger after show the results o f ineffective tooththe night brushing. brushing. This procedure increases the circula A fter the eruption of the first perma tion and reduces the possibility of sore nent molars, the general consensus of ness from exfoliation and eruption of opinion is that if the mouth is opened the teeth. wide during the brushing procedure, the In teaching home care during this tooth will be well brushed. T h a t is a period, it is evident that girls are more great fallacy because the contraction of precise in carrying out instructions, but the muscles tends to force the brush aw ay interest in tooth care increases in all from the buccal surface and it is there children with age. that added concentration is needed. Th e Group 3. Th e permanent dentition child should be instructed to close slightly period begins with, the child of 11 and, when brushing the posterior areas in the in most pedodontic practices, extends un mouth. O ften, for the child from 6 to til the close of the sixteenth year. N or 8, to assign a number of strokes on the mally, according to the newer theories of
M organ— Rôle of Oral Hygiene in Preventive Dentistry calcification and eruption, there are now only permanent teeth in the mouth, fully erupted or about to erupt. W hen consid ering the rôle of oral hygiene in preven tive dentistry during this period, we must remember that the child has emerged from childhood into adolescence and has a marked degree of susceptibility to dis eases, including oral disease. I f the mouth has suffered from inade quate dental supervision, we m ay be con fronted with the problems of impacted and unerupted teeth. Both these condi tions tend to decrease the possibilities of mouth health and impair home prophy laxis. W e m ay also have the other ex treme— prolonged retention of the decid uous teeth. T h e ectopic eruption of teeth as a result of prolonged retention reduces mouth cleanliness. T h e bicuspids and cuspids are more frequently malposed as the result of prolonged retention, a con dition which can largely be prevented by regular supervision supplemented with roentgen-ray examination and a working knowledge of tooth growth and develop ment. Closely related to the problem o f pro longed retention is that presented by the deciduous root fragment remaining in the ja w after the crown of the deciduous tooth has been exfoliated. These root fragments tend to destroy the contact and allow the food to pack in the interproximal space, thereby irritating the soft tissues. Frequently, the deciduous root fragments are not discovered until later in life and, if the bicuspids have been extracted, they are often mistaken for bicuspid root fragments. T h e loss of contact in the bicuspid area always war rants roentgenographic examination be fore any attempt is made to restore or provide normal contact by some artificial method. Therefore, the use of the roent gen rays is a necessary adjunct to all phases of dentistry for children during the dentition periods, and roentgeno grams must be utilized freely even in the
field of oral hygiene if the mouth is to be maintained in health. T h e procedure for giving a dental pro phylaxis for a child in the permanent dentition period does not differ greatly from the method employed during the transitional dentition period. However, polishing of the interproximal spaces with prophylactic strips or tape floss and cleansing paste should be carefully and thoroughly done. A ll calcareous and serumal deposits must be removed with out lacerating the soft tissues. A ll patients should again be instructed in home care of the mouth as outlined for the transitional dentition period, the dentist requesting more gum massage by finger pressure and increasing the mas saging requirements to both morning and night. It is also important to teach the child the use of tape dental floss, instruct ing the patient how to hold it and how to use it, besides cautioning him to avoid lacerating the gums. I f the child of n is instructed to use tape floss on the an terior teeth, first wiping the mesial sur face o f one tooth and then the distal surface of the proximate tooth, much can be done to prevent interproximal decay. A s the teeth erupt and grow into normal alinement, the tape floss measure can be extended to include all teeth. W e must implant uppermost in the child’s mind, the thought of the danger involved in the careless use of floss. However, the pos sibility for injury is considerably reduced with the tape type o f dental floss. During the permanent dentition period, w e are sometimes confronted with clean mouths in which caries is rampant. These patients probably have a glandular disturbance, and in such mouths caries cannot be appreciably re duced through mouth cleanliness alone. Procedures for the maintenance of mouth health for the child have been considered in detail that we m ay adopt a standard of value for oral hygiene in preventive dentistry. It is m y contention,
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after eleven years of private practice limited exclusively to dentistry for chil dren, that if the patient conscientiously strives to carry out instructions to keep the mouth clean and returns for periodic check-up at least every three months, oral hygiene can and will reduce the ravages of dental decay. It is true that the chil dren in private practice cannot be con sidered a control group from a scientific standpoint, yet each child responds ac cording to the degree of cooperation
given, in that those children who are more conscientious show greater benefits. Scientists up to the present time have not discovered any serum, vaccine or specific whereby one can be inoculated and thereafter be forever free from den tal disease. Until more definite and posi tive methods of control are discovered, we must rely on oral hygiene as one of the most important factors in the preven tion o f dental disorders. 2039 North Prospect Avenue.
PRACTICAL PHASES OF LOCAL ANESTHESIA B y H o w a r d C . M i l l e r , D .D .S., Chicago,
I
N any surgical procedure within the mouth, the selection of an anesthetic is an extremely important step. T h e decision as to the anesthetic to be used should be based upon the training and experience of the operator, the physical condition of the patient and the type of operation to be performed. There is no one anesthetic best suited to all cases, but there is generally one that is best suited to the individual and to the operation. The successful operator selects the anes thetic best adapted to the case, the one from which the patient will receive the maximum benefit. I f regional or block anesthesia is the anesthetic of choice, it must be remem bered that its successful administration calls for scrupulous asepsis, proper anes thetic solution, a thorough knowledge of the anatomy of the parts involved and an exact technic. Clinical investigation and research have revealed certain facts Read before the Section on Oral Surgery, Radiology and Anesthesia at the SeventyFourth Annual Midwinter Meeting of the Chicago Dental Society, February 15, 1938. Jour. A .D .A. & D. Cos., Vol. 25, September 1938
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that should be of value to the dental practitioner, some of which m ay be stated as follow s: i. Procaine (novocaine) is the most effective and the safest local anesthetic agent available at the present time. This conclusion is based not alone upon the wide clinical application o f procaine solu tions, but also upon the accepted methods for determining the concentration per cent, efficiency ratio and toxicity, and the duration of action of local anesthetic solutions. Th e methods usually employed for such tests a r e : (a) Nerve block; e.g., the standard frog sciatic nerve method. (b) Efficiency on mucous membrane; by application to the human cornea and to the rabbit cornea. (c) Injection efficiency; by the stand ard wheal test on man. (d) T o x icity; by subcutaneous and vein administration in guinea-pigs, rats, cats and dogs, which also furnishes an index on respiration, heart condition and circulation.