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THE INEFFECTIVE TOOTHBRUSH
142 some
on the sole of the the time of the M.R.C.
response to touch stimuli
foot, compared with 27%
at
report.
deformity. With a mobile foot in a good position the patient will probably have satisfactory function no matter what the grade of neurological recovery.
No such
long-term improvement has occurred in popliteal nerve after suture, and at this later review only about a third of the patients could dorsiflex the foot against gravity and resistance. Clawson and Seddon show that with injuries to the lateral popliteal nerve the general standard of recovery was poor and was no better in cases where suture was undertaken early; whereas with injuries to the medial popliteal nerve,
recovery of the lateral
results are better where suture was prompt. The problem of gaps in the sciatic nerve following gunshot wounds has usually been overcome by mobilisation of the nerve and flexion of the knee, followed by gradual stretching for several weeks. There was at one time considerable scepticism about the value of a nerve suture which had to be followed by considerable stretching of the nerve, but this long-term follow-up shows that gaps of 12 cm. can be closed with as much motor recovery as after repair of smaller gaps. Indeed, the only alternative to direct suture is to insert a nerve graft; and, no matter what the technique of grafting, the results are
poor.
Clawson and Seddon2 mention several examples of patients with complete sciatic palsy who are engaged in strenuous occupations with virtually no disability. These workers have undertaken thedifficult but valuable task of correlating the usefulness of the limb with the grade of neurological recovery. Almost all the patients with palsy of the lateral popliteal nerve who had good motor recovery also had good function; but a surprisingly large proportion (83%) of those with poor motor recovery had satisfactory function. More than four-fifths of the patients with medial popliteal nerve palsy have a satisfactory functional result, whether the neurological recovery is good or bad, but on the whole those who have a better neurological recovery have a better grade of functional recovery in the limb. It is quite clear, therefore, that factors other than nerve regeneration play the most important part in giving the patient a useful limb. More than half the patients with lesions of the medial popliteal nerve are over-responsive to pinprick; this is a disabling state at first, but one which gradually becomes less important, and can be made less troublesome by wearing a thick rubber pad inside the shoe. 8 out of 12 patients who had a lesion of the posterior tibial nerve at the ankle exhibited over-response; and it is questionable whether suture of the posterior tibial nerve should be done at all, because over-response
THE INEFFECTIVE TOOTHBRUSH
THE design of the toothbrush has changed little in the past hundred and thirty years. A plate in Maury’s treatise on dentistry,l published in 1833, shows that almost every shape of brush had already been thought ofincluding one pattern that was reinvented in time for a recent dental congress. The figures for the number of toothbrushes sold in Great Britain are depressing-less than 25 million toothbrushes for 35 million potential users in 1956. Most people think of the toothbrush as a semipermanent article that remains useful until it is reduced to a splayed-out collection of disheartened bristles. The public are loath to pay more than about two shillings for a brush, thus restricting enterprise by the manufacturers. Advertising has little effect on sales; but branded makes by well-known firms sell more readily than those comparatively unknown, even if of equal merit. A few years ago, there was a move to rechristen the toothbrush a " mouthbrush " as a title more truly indicating its function. Proper brushing helps to keep the epithelium of the gingivae well keratinised, and will remove the bacterial plaque on the surface of the tooth2 " " (the yellow film beloved of the advertisers). This is, of course, an aesthetic and hygienic improvement; but if there is to be any real hope of preventing caries, thorough brushing must be carried out at least four times a day-for which few have either the time or the inclination. The various toothbrush-drills taught by dental surgeons are difficult to carry out correctly. The awkward up-anddown movements easily degenerate into narrow, elliptical loops, not far removed from the to-and-fro scrubbing action which leaves even the most accessible interdental spaces packed with food debris. Too much reliance is probably placed on medicated toothpastes : no dentifrice can ever be more than a detergent, in the true sense. The inclusion of hexachlorophene, sodium ricinoleate, or sodium fluoride is of negligible value.
disability than loss of sensibility. Perhaps the most serious complicating factor is deformity of the limb; for it is fixed deformity rather than loss of sensibility that is most likely to give rise to pressure sores-one of the most disabling complications that can arise from sciatic palsy. Amputation was sometimes required on account of pressure sores with fixed deformity, and in these cases the operation was worth while. Where amputation was done for pain there was little or no improvement, and it is noteworthy that amputation was done in only 10 patients out of a total of 329 with sciatic nerve.
may be more of a
lesions. This long-term follow-up provides evidence that one of the most important aspects of treatment is the maintenance of mobility in the limb and the prevention of
Obviously some new approach to tooth-cleaning is needed, and this has been made by Archer et a1.3 who have oroduced some interesting variants on the conventional brush. One design is for a portable brush in a cylindrical case which carries a supply of toothpaste; another is for a disposable brush, the semiflexible handle of which contains paste that can be forced through a small nozzle among the bristles. An even more unorthodox design has no bristles, the cleansing being done bya series of small-diameter nozzles supplied with water from the bathroom tap. Archer et al. suggest that a small block of detergent could be incorporated in the handle to make the instrument more pleasant and effective. Rubber or bristle gum stimulators could be fitted easily, anda mouth-spray based on these designs (which the authors admit are purely tentative) might prove acceptable and effective. Lord ADRIAN has been elected president of the Royal Society of Medicine in succession to Sir GEOFFREY MARSHALL. 1. 2. 3.
Maury, F. Complete Treatise on the Dental Art. Paris, 1853. Plate reproduced by R. Lucock Wilson. The Story of Dentistry; p. 20. London, 1958. Arnim, S. S., Williams, Q. E. Dent. Radiog. 1959, 32, 61. Archer, B. L., Bernaston, J., Grieves, J. Design, July, 1960, p. 24.
’
,
on the sole of the the time of the M.R.C.
response to touch stimuli
foot, compared with 27%
at
report.
deformity. With a mobile foot in a good position the patient will probably have satisfactory function no matter what the grade of neurological recovery.
No such
long-term improvement has occurred in popliteal nerve after suture, and at this later review only about a third of the patients could dorsiflex the foot against gravity and resistance. Clawson and Seddon show that with injuries to the lateral popliteal nerve the general standard of recovery was poor and was no better in cases where suture was undertaken early; whereas with injuries to the medial popliteal nerve,
recovery of the lateral
results are better where suture was prompt. The problem of gaps in the sciatic nerve following gunshot wounds has usually been overcome by mobilisation of the nerve and flexion of the knee, followed by gradual stretching for several weeks. There was at one time considerable scepticism about the value of a nerve suture which had to be followed by considerable stretching of the nerve, but this long-term follow-up shows that gaps of 12 cm. can be closed with as much motor recovery as after repair of smaller gaps. Indeed, the only alternative to direct suture is to insert a nerve graft; and, no matter what the technique of grafting, the results are
poor.
Clawson and Seddon2 mention several examples of patients with complete sciatic palsy who are engaged in strenuous occupations with virtually no disability. These workers have undertaken thedifficult but valuable task of correlating the usefulness of the limb with the grade of neurological recovery. Almost all the patients with palsy of the lateral popliteal nerve who had good motor recovery also had good function; but a surprisingly large proportion (83%) of those with poor motor recovery had satisfactory function. More than four-fifths of the patients with medial popliteal nerve palsy have a satisfactory functional result, whether the neurological recovery is good or bad, but on the whole those who have a better neurological recovery have a better grade of functional recovery in the limb. It is quite clear, therefore, that factors other than nerve regeneration play the most important part in giving the patient a useful limb. More than half the patients with lesions of the medial popliteal nerve are over-responsive to pinprick; this is a disabling state at first, but one which gradually becomes less important, and can be made less troublesome by wearing a thick rubber pad inside the shoe. 8 out of 12 patients who had a lesion of the posterior tibial nerve at the ankle exhibited over-response; and it is questionable whether suture of the posterior tibial nerve should be done at all, because over-response
THE INEFFECTIVE TOOTHBRUSH
THE design of the toothbrush has changed little in the past hundred and thirty years. A plate in Maury’s treatise on dentistry,l published in 1833, shows that almost every shape of brush had already been thought ofincluding one pattern that was reinvented in time for a recent dental congress. The figures for the number of toothbrushes sold in Great Britain are depressing-less than 25 million toothbrushes for 35 million potential users in 1956. Most people think of the toothbrush as a semipermanent article that remains useful until it is reduced to a splayed-out collection of disheartened bristles. The public are loath to pay more than about two shillings for a brush, thus restricting enterprise by the manufacturers. Advertising has little effect on sales; but branded makes by well-known firms sell more readily than those comparatively unknown, even if of equal merit. A few years ago, there was a move to rechristen the toothbrush a " mouthbrush " as a title more truly indicating its function. Proper brushing helps to keep the epithelium of the gingivae well keratinised, and will remove the bacterial plaque on the surface of the tooth2 " " (the yellow film beloved of the advertisers). This is, of course, an aesthetic and hygienic improvement; but if there is to be any real hope of preventing caries, thorough brushing must be carried out at least four times a day-for which few have either the time or the inclination. The various toothbrush-drills taught by dental surgeons are difficult to carry out correctly. The awkward up-anddown movements easily degenerate into narrow, elliptical loops, not far removed from the to-and-fro scrubbing action which leaves even the most accessible interdental spaces packed with food debris. Too much reliance is probably placed on medicated toothpastes : no dentifrice can ever be more than a detergent, in the true sense. The inclusion of hexachlorophene, sodium ricinoleate, or sodium fluoride is of negligible value.
disability than loss of sensibility. Perhaps the most serious complicating factor is deformity of the limb; for it is fixed deformity rather than loss of sensibility that is most likely to give rise to pressure sores-one of the most disabling complications that can arise from sciatic palsy. Amputation was sometimes required on account of pressure sores with fixed deformity, and in these cases the operation was worth while. Where amputation was done for pain there was little or no improvement, and it is noteworthy that amputation was done in only 10 patients out of a total of 329 with sciatic nerve.
may be more of a
lesions. This long-term follow-up provides evidence that one of the most important aspects of treatment is the maintenance of mobility in the limb and the prevention of
Obviously some new approach to tooth-cleaning is needed, and this has been made by Archer et a1.3 who have oroduced some interesting variants on the conventional brush. One design is for a portable brush in a cylindrical case which carries a supply of toothpaste; another is for a disposable brush, the semiflexible handle of which contains paste that can be forced through a small nozzle among the bristles. An even more unorthodox design has no bristles, the cleansing being done bya series of small-diameter nozzles supplied with water from the bathroom tap. Archer et al. suggest that a small block of detergent could be incorporated in the handle to make the instrument more pleasant and effective. Rubber or bristle gum stimulators could be fitted easily, anda mouth-spray based on these designs (which the authors admit are purely tentative) might prove acceptable and effective. Lord ADRIAN has been elected president of the Royal Society of Medicine in succession to Sir GEOFFREY MARSHALL. 1. 2. 3.
Maury, F. Complete Treatise on the Dental Art. Paris, 1853. Plate reproduced by R. Lucock Wilson. The Story of Dentistry; p. 20. London, 1958. Arnim, S. S., Williams, Q. E. Dent. Radiog. 1959, 32, 61. Archer, B. L., Bernaston, J., Grieves, J. Design, July, 1960, p. 24.
’
,