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The oral characteristics of Guamanians including the effects of betel chewing on the oral tissues
Research THE ORAL CHARACTERISTICS OF GUAMANIANS INCLUDING EFFECTS OF BETEL CHEWING ON THE ORAL TISSUES
THE
COMMANDER ROGER G. GERRY, DENTAL CORPS, UNITED STATES NAVY, STANLEP T. SMITH, D.D.S., BEAUMONT, TEXAS, AND LIEUTENANT (JG) M. LYLE CALTON, DENTAL CORPS, UNITED STATES NAVY
Part III Oral Anatomical Abnormalities.-Some time before this study was started. Commander Robert A. Wolcott (D.C., TT.S.N.)37 brought to our attention a condition which he had observed during his stay in Guam. He pointed out t)he existence of mesiodistal enamel checks on the lingual surfaces of t,he incisors of several patients and added that he had observed these only in the maxillary incisors of females. He further added that he had been unable to establish an etiology for this condition, During the course of this study we have attempted to learn more about the distribution, incidence, and etiology of these mesiodistal enamel checks. Mesiodistal Enamel G%ecLs.-Mesiodistal enamel checks were found on the lingual surfaces of the upper and lower incisors, and sometimes even on the cuspids (Figs. 16 and 1’7), and were more or less evenly distributed between both sexes. They were occasionally observed as early as the seventh year, but were usually not present in significant numbers until the eleventh year. They apparently never became secondarily involved with dental caries. In this series, a group of 1,199 subjects were examined for the presence of mesiodistal enamel checks. These included both male and female subjects between the ages of 11 and 59, who had been observed either as clinic patients or on the several field trips. Of this group 739, or 61.6 per cent, exhibit,ed mesiodistal enamel checks. At 11 years of age, 29.3 per cent of the snhjects examined had mesiodistal enamel checks. This proportion increased rapidly, until by the fifteenth year 67.1 per cent of bhose examined exhibited mcsiodistal enamel checks. This proportion remained at about ‘70 per cent until the twenty-ninth year. From the thirtieth year onward, the incidence declined and gradually fell to 50 per cent for the 50 to 59-year age group. This fall in the older age groups was probably due to the loss of anterior teeth as a result of periodontoclasia. The distribution of mesiodistal enamel checks in the several age groups is shown in Table XIV. Mesioclusion in Guamanians.--In an attempt to investigate the possible etiologies of mesiodistal enamel checks, the occlusions of the 1,215 subjects men100‘4
tioned were evaluated. Because eruption of the permanent teeth, of those individuals who had not Guamanians had only permanent, group of ll-year-old Guamanians had some degree of mesioclusion. group rind remained more or less
ing
Fig. evident. Fig.
l(i.-Mesiodistal l’i.-Mesiodistal
enamel enamel
checks checks
of the shedding of the deciduous teet,h and the no attempt was rnadc to cvalnate the occlusions rtnchctl their olc\-c>nt I-1year. I+y this age, mo~i: teeth in thci I( tlcni it ions. l3\-aluatioti of the indicated that, 17.2 ~CI* cult of their nun&~ This incidence doubled for the 1%year-o111 at, this level rlntil the early fift,ies (Tahlc XV) q Fig.
1F.
Fig.
li.
of
upper of
lower
wntml central
incisors.
No
~vi~icnre
of
twtcl
st:litl-
incisors.
when loss of teeth because of periodontoclasia made classification of occlusion difficult. In most instances the mesioclusion was not marked and was indicated by a disparity of only one or two millimeters from the normal relationship between the mesiobuccal cusp of the maxillary first molar and the buccal groove of the mandibular first molar. This very slight prognathism effected a virtual elimination of the normal overjet in such a large number of Guamanians that one of us (R. G. G.) was for a time inclined to believe that mesioclusion might have been responsible for the development of mesiodistal enamel checks. Actsally, the incidence of mesioclusion in Guamanians is probably higher than thilt
1006
GERRY, TABLE
XIV.
OF
NI’MBER GROUP
A(:E
-
INCIDENCE
11
--~-
SMITH,
AND
MESIODISTAL
IN
ENAMEL
40-49 50-59 Total
IN
GUAMANIANS PER CENT WITH MESIODISTAL ENAMEL CHECKS
17
67 71 77 76 87 81 52 75 314 152 69 20
30-39
CHECKS
NUMBER WITH MESIODISTAL ENAMEL CHECKS
58
12 13 14 15 16 17 1x 19 20-29
CALTON
29.3 34.3 52.1 64.9 67.1 75.9 66.7 73.1 69.3
23
37 50 51 A6 54 38 52 21 6
68.X
84 41
55.3 59.4 50.0 61.6
10
1,199
739
-
indicated in Table XV, as premature loss of permanent teeth, accompanied by drifting of the remaining teeth, made the slight degree of mesioclusion which might have been present extremely difficult to diagnose. TABLE
OF MESIOCLUSION
IN
GUAMANIANS’
NUMBER WITH MESIOCLUSION
PER CENT WITH MESIOCLUSION
:i
11
58 67 71
10 27 23
17.2 38.0 34.3
14 15 16 17
77 i6 87
38 27 19 27 14
49.4 35.5 21.8 33.3 26.9
ii 46 28 5
24.0 31.5 30.3 40.6 25.0 6.2 31.5yo
81
52
18
2F29 30-39 40-49 50-59 60-69
314 75 152 69 20 16 1,215
Total difficulties
INCIDENCE
NUMBER IN GROUP
AGE
a result
XV.
*Decreasing in
of
the
incidence diagnosis
of of
1
382 mesioclusion mesioclusion
in
as
older
increasing
age
groups
numbers
is
of
attributed
teeth
have
to
increasing
been
lost
as
periodontoclasia.
Relationship Between Mesiodistal Erulmel Checks, Mesioclusion, and Betel Use.-An attempt was made to evaluate the etiology of mesiddistal enamel checks and determine whether or not the prevalent mesioclusion was responsible for this abnormality, and further to determine whether the mastication of the hard, fibrous betel nut might be the causat,ive consideration in the development of mesiodistal enamel checks and/or mesioclusion. For these reasons, it was decided to evaluate the coincidence of these findings in the group of 1,215 Guamanians whose incidence of mesioclusion and mesiodistal enamel checks had already been noted. Mesioclusion was present, alone, in 382 subjects, an incidence of 31.5 per cent in a group of 1,212. Mesiodistal enamel checks were present in 739 subjects, or 61.6 per cent of the same group. Mesiodistal enamel
ORAL
CHARACTERTSTICS
OF
GI-AMASIASS
lO(l.7
checks and mesioclusion were found together in Z87 subjects, or 23.7 per (WI’ of the entire group. However, of the 739 subjects having mesiodistal enamp Tt has been mentiont>i checks, 39.5 per cent concurrently showed mesioclusion. here t,hat the recorded incidence of mrsioclusion was probably low, and tlr:lt most, likely, a greater number of individuals who exhibited mesiodistal euam(’ On the other hand, 95 cases of mc>si checks also had associated mesioclusion. oclusion, or 24.3 per cent of t,he 382 casesof mesioclusion, presented no csoexist ing mesiodistal enamel checks. On the hasis of these findings, there is insnfficicnl rvidence to assume that the development of mtsiodistal enamel checks iq WII tingent on the presence of mesioclusion. 1Tesiodistal enamel cheeks were prestnj in ‘739 cases,which represented 61.6 per cent of the entire group. OL’ the 7:s Guamanians who exhibited mesiodistal enamel checks. 163, or 62.7 per cent, als( chewed betel nut. Actually this percentage is probably also low, as the presenc*( of mesiodistal enamel checks is a posit,ive finding, while the evaluation ot’ h~lc nut, use is dependent, to a certain extent, on thr subject’s 1listor.v. It has alye:lti! been mentioned that many (yruamanians, especially those practicing good ora hygiene, who chew betel nut will deny its use. Nevertheless, on the hnsis 01 these findings, it cannot he affirmed that mastic*ation of the hetP1 nut \\ras th( etiologic factor in the development of mesiotlistal ellatnel checks. This itnl’r(hs sion may be further substantiated by the considerat ion that 262 Guamania n! having mesiodistal enamel checks, an incitlenc~r of 36.1 per cent, denied heicl USC In addition, we examined a small number of iVla.rshallcse who exhibit,rd msio distal enamel checks, but, in whose native islands betel is not chewed. On the same basis, it, was established that of the 382 Guamanians in when mesioclusion was diagnosed, 307, or 80.4 per cent, also chewed betel. Howevrr of the 701 betel chewers in the group, 394, or 56.2 prr cent, did not exhibit mclsi oclusion. In addition, since such a large numl)cr of all C:uamanians are 1)&e! users, it, would be anticipated that this characteristic would accompany almo~i any other oral finding. 0n the basis of these findings, it probably can be assumedthat, mesiocluxion betel use, and mesiodistal enamel checks exist concurrently, but without inflnt~lrc~t on each other. It is probable that the high inc~idence of mesioclusion can h+ explained on an anthropologic basis, and the developmental factor in the incidcnce of mesiodistal enamel checks should not be overlooked. Xuch c*o~lltl 1~ learned from investigating the incidence of mesiodistal enamel checks in those islands of Micronesia in which betel is not chewed, and evaluations of occlusiot should be performed in a more carefully selected group of subjects than WI! available in this study. Three-Rooted Lower Molars.-A consideration which might have heck : factor in the development of mesioclusion in Guamanians was the presence ot a fairly high incidence of three-rooted mandibular first and second molars. IT! a series of 127 teeth in this category, eight, or 6.3 per cent, had three roots. Tht patients were almost equally divided between the sexes, 64 male and 63 fem;d~~ and of t,he 8 three-rooted molars, five were found in males and three in females Actual crown dimensions of these teeth were not measured. We recognize thai
1008
GERRY,
SMITH,
AND
CALTON
an extremely small series such as this is not of statistical significance. In addition, it has not been possible to compare the incidence of three-rooted mandibular molars in Guamanians with the incidences in other groups, as, to our knowledge, similar series elsewhere have not been reported. However, in the light of our personal observations in exodontia in the IJnited Stat,es, it was felt that the incidence of three-rooted mandibular molars in Guam was unusually high. This finding, with the frequency of mesioclusion in Guamanians, might be of anthropologic interest. Temporomandibulw Joint Disease in Guanzanians.-The high incidence of neutro- and mesioclusion, or rather the low incidence of distoclusion with overbite, and the extremely low incidence of trauma, i.e., during a period of eighteen months no Guamanians were t,reated for maxillary or mandibular fractures, probably accounts for the extremely low incidence of temporomandibular joint. problems.38 Only two Guamanians presented with positive temporomandibular joint findings. One of these was a young girl who gave a history of having been beaten several times by her father, with accompanying acute mandibular dislocation. The other was a 52-year-old Guamanian man with missing posterior teeth and with accompanying bilaterally excessive condylar excursion and disc derangement.38 Cleft Lip and Palate irt Guanaanians.--In a total of 2,004 Guamanians esamined, there were no cases of cleft lip or palate. Occurrence of these deformities was also not observed during the examination of additional Guamanians who were not included in this series. Coope+ reported approximately one cleft lip or palate in 750 live births in Denmark, Pennsylvania, and Wisconsin. Actually, the two sets of figures are not comparable, and it cannot be advised that the incidence of these defects is lower in Guam than in other areas listed, as the Guam series was taken entirely from patients who more or less voluntarily presented themselves for dental examination or treatment. Guamanians, as a group, are somewhat shy and, for the large part, completely incognizant of the benefits which dentistry can offer the cleft palate patient. On this basis, it was assumed that those Guamanians having either cleft lip, or palate, or both, would not be likely to present themselves for examination in a series of this sort. This impression has been substantiated by the Obstetrical Service of the Guam Memorial Hospital in which there were approximately 400 live births between July 1, 1949 and June 30, 1950. During this period three live babies with cleft lip or palate were delivered.40
Summary 1. The history, vital statistics, dietary habits, dental treatment, and oral hygiene habits of the natives of the island of Guam have been discussed. 2. The incidence of use and the pharmacology of the bct,el nut, and especially its effect on the human saliva, have been described. 3. The incidence and chronologic distribution of dental caries in Guamanians have been evaluated and the effect of betel nut use on the dental caries incidence discussed.
4. The incidence and chronologic distril)ut ion of gingivitis and period?,ntoelasia in Guamanians hecn supporting dental tissues dcscrihctl. 5. The existcmc ol’ the oral I’orn~s 01’ I~~~~ko~~hl~i;~, ~‘aws, ;III(I \.~~~IWPOIIS l~apilloma in Gnamaniatni has been dcscril~etl. 6. The incidence of carcinomas of all loc*alit,ies in Guamanians has been computed, and the effect of hetcl c~hewing as an oral canrcinogcnic considera.tion discussed. 7. Various anatomical characteristics of Guamanians, as mesioclusion aild its effect on temporomandibular joint disease, mesiodistal enamel checks on incisor teeth, and the incidences of three-rooted mandibular molars and cleft lip and palate have been described. IliVC
(!ValliltPtl,
ant1
lhc
dfcc’t,
of
htcl
use
011
t11c
Conclusions 1. The Guamanian diet is extremely ric+h in carbohydrates and especially” refined sugars, and has deteriorated in this respect since before the war. 2. almost no Guamanians receive routine dental care, and, while satisfaetory toothbrushes are not available, a large majority of Guamanians own some sort of toothbrush. 3. Forty-one and one-tenth per cent of the Guamanians questioned, from 11 to 69 years of age, were frequent chewers of betel nut,. The pH of their salivary secretions averaged 0.4 pH u&s higher than those Guamanians who were not frequent betel chewers. Chewing betel nut for a period of two minutes increases the pH of saliva an average of 1.2 pH units and will maintain an elevated saliva pH for an average of seventy-three minutes. 4. Guamanians between the ages of 5 and 19 years have an average of 4 diseased, missing, or filled teeth each. This incidence is decidedly lower t,han that in the United States, the United Kingtlom, or the Virgin Islands. Hawever, the deciduous caries rate in Guam is very high, and the average DJlF for children under 5 years of age is 8.6 per subject. 5. Guamanians who are frequent betel nut chewers average 2.5 DMF’s per subject less than those who do not chew betel. Betel chewers average 36 ‘per cent less dental caries than those who are not betel chewers. 6. The incidence of gingivitis in Guamanians is low, averaging 24 per cent for all ages. The incidence of gingivitis among betel chewers is somewhat higher than among nonusers. This increase is attributed to the more rapid precipitation of dental calculus among betel users as the resnlt of the elevation of the salivary pII. 7. The incidence of periodontoclasia in Guamanians under 30 is negligible, but in the older age groups approaches 90 per cent. The incidence for betel chewers is almost twice that of nonchewers. This condition is attributed to the more rapid calculus formation on the teeth of betel-using individuals a.s described previously. It is felt that betel chewing Guamanians practicing good oral hygiene would have no higher incidence of periodontoclasia than similarly practicing nonchewers.
1010
GERRY,
SMITH,
AND
CALTON
8. The incidence of oral disease other than dental caries, gingivitis, and periodontoclasia is generally very low in Guam. Only four cases of leukoplakia were seen which were not complicated by other abnormal processes, as carcinoma, verrucous papilloma, etc. Only one primary yaws lesion of t,he oral tissues was observed in a series of over 1,800 yaws patients. 9. The incidence of carcinomas of all types among Guamanians is extremely low. This circumstance is attributed to the low life expectancy of Guamanians. The incidence of oral carcinomas, among carcinomas of other locations, is probably about the same in Guam as in the United States. On this basis it is considered that the betel nut is not a carcinogenic factor. 10. Malignant oral neoplasms other than carcinomas were not observed in Guamanians. 11. Mesiodistal enamel checks on the lingual surfaces of the incisor teeth are present in about 60 per cent of all Guamanians between the ages of 11 and 69. 12. Mesioclusion is present in more than 30 per cent of all Guamanians beThis condition, plus the remarkably low twee.n the ages of 11 and 69 years. incidence of mandibular trauma, is credited with being responsible for the very low incidence of temporomandibular joint disease. 13. No correlation can bc demonstrated between the existence of mesiodistal enamel checks, mesioclusion, and/or betel use. 14. The incidence of three-rooted mandibular first and second molars is apparently high in Guam. The incidence of cleft lip and palate is apparently not remarkable. The writers wish to express their sincere thanks to Sami Leioto, Pio F. Misa, Setoga Setoga, Jr., Tutuila, Pago Pago, American Samoa ; Teoho Oiph, Koror, Palau Islands; and Enta Peter, Ebon Atoll, Marshall Islands; all senior students at the School of Dental Assistants, Guam, M. l., for their assistance in the collection of the data in this report; and to Lieutenants (jg), D. C., IT. S. N. R., Harold R. Englander, Bernard Malberg, and Clifford J. Raimist, all of the United States Naval Hospital, St. Albans, N. Y., for their assistance in the preparation of the tables presented.
References 1. Thompson, I,.: Guam and Its People, San Francisco, 1941, Institute of Pacific Relations, p. 4. 2. Garcia, Francisco : Vida y martirio de el venerable Padre Diego Luis de Sanvitores, Madrid, lG83; translated by Margaret Higgins in the Guam Recorder, April, 1937, p. 21. 3. Thompson, L.: Guam and Its People, San Francisco, 1941, Institute of Pacific Relations, p. 27. Government of Guam, Department of Public Health: Personal communication. 2 Pretty, F. : Sir Francis Drake’s Famous Voyage Round the World, in Voyages and Travels, Ancient and Modern, New York, 1910; cited by Thompson, L.: The Native Cultures of the Marianas Islands, Bernice P. Bishop Museum Bulletin No. 185, Honolulu, 1945, p. 10. 6. Government of Guam, Department of Public Health: Personal communication. Underwood, R. F.: Personal communication. i: Annual Report of the Government of Guam, 1924, p. 17. of Guam, Department of Customs and Immigration: Personal communication. 9. Government 10. Wood, H. C., Jr., 0801, A., Youngken, H. W., and Gershenfeld, L.: The Dispensatory of the U. S. A., ed. 23, Philadelphia, 1943, J. B. Lippincott Company, pp. 157-158. 11. Goodman, L., and Gilman, A.: The Pharmacologic Basis of Therapeutics, New York, 1941, The Macmillan Company, p. 393. Tests to Determine Suitability of 12. Wheatcroft, M. G., Schlack, C. A., and Taylor, 13. W.: Burnt Coral as a Dentifrice: Report I, Mail. Surgeon 107: 124, 1950.
ORAL
CHARACTERISTICS
OF
1011
CrIi.\MANIANS
13. Best,
C. H., and Taylor, N. B. : The Physiological Basis of Medical Practice, I:;lltiruclr~~. 1950, Williams & Wilkins Company, pp. 127-128. 14. Blackerby, P. E., Jr.: Intrastate Geographic Variations in Dental Caries Ratrs. .I. ..llr:. Dent. A. 30: 1241; cited by Shourie and Marshall-Day, Reference 16. 15. Weaver, R.: Fluorine and Dental Caries; Further Investigations on Tyneside and 111 Sunderland, Brit. D. 5. 77: 185, 1944; cite11 by PlinuricL and Marshall-I)ay, Refrrw~ I’ 11;.
16. Shouric, K. W., and Marshall-Day, C. 1). : Dental Vxriw TCxpcrienre in the Virgil1 Td:r~~ci~ J. Am. Dent. A. 40: 319, 1950. 17. Knutson, J. W.: Pub. Health Rep. 59: 253-263, 1944, cited by T’olker, Refrrenw 19. 18. Hollander, F., and Dunning, J. M.: ,T. D. Res. 18: 4X-60. 1X:9; (‘ited 1,~ Yolkw. ll~~frwn~~~~ 19.
19. Volker, 20. 21. 22. 23.
J. F.: What Is the Scope of Our Present Knowledge of’ the lht:~l (‘:?I+ Process? J. California State D. A. 26: 10.11, 1950. Miller, S. C.: Oral Diagnosis and Treatment, rd. ‘:. T’l~il:~tl~~lphin, 1946. Thr Hlakistlirr Company, pp. 106-107. Urban. K. L.: Personal communication. Shourie, K. L.: The Possible Effe(% of Betel Chewin:: 011 thr Inridt~nc*c~ of Thl:~l (‘:lri~~ in Indian Children, J. D. Res. 27: 770, IRIS. Weisbewer. 0. : A Role of Glucosr in tlw Pw~lurtion of A’wt,ificaial C;tGrs. ,I, I). Rt,s. 29:-26,
1950.
24. Fosdic>k, L. 8.: The Reduction of the Inridcnw of I)ental Caries. I. Lmme~liate TootItBrushing With a Neutral Dentifrice. ,J. Am. T>ent,. A. 40: l?Al34. 19.X. 25. Marshall-Day; C. D., and Shourie, K. L.: Gingiwl l)is:ea:c in thr Vir&n Islnntl~, .I. .11n. Dent. A. 40: 179, 1950. 26. Marshall-Day, C. D., and Shourie, K. I,. : A Roentgenographic Rurl-qof’ I’(>rio(lonl:tl I)israse in India, J. Am. Dent. A. 39: 575, 1949. 27. Gurney, B. F., and Huschart, ,T. II.: A Dietary Asp& of C:~l~ulus, .l. I). Rcs. 29: I;&:;, 1950. 28. Colby, R. A.: Personal communication. 29. Mackie, T. T., Hunter, G. W,., III., and Worth. C. H.: Manual ol’ Tropical Medic*inch, National Research Council, Phdadelphia, 1945, TV. B. Saunders Compa?y. pp. 7X-79. Annual Narratlre Report 10 30. Department of Public Health, Naval Government of Guam: the Governor of Guam, Dec. 31, 1949. Cancer: Diagnosis, Treatment, and I’wgno~is, 31. Ackerman, L. V., and de1 Regato, J. A.: St. Louis, 1947, The C. V. Mosby Company, pp. 251-252. 32. Balendra, W.: The Effect of Betel Chewing on the Dental and Oral Tissue an<1 It: Possible Relationship to Buccal Carcinoma, Rrit. D. .T. 87: S7, 1949. 33. Khanolkar, V. R.: Oral Cancer in Bombay, Imlia. .\ Review of 1,000 Consevuiiw C:IWS Cancer Research 4: 318-319, 1944. 34. Eisen, M. J.: Betel Chewing Among Natives of the! Southxwt Pavific .Tslands. (‘ancer Research 6: 140-141, 1943. 35. Levin, M. L.: Cancer Renortinn II in New York State. Sew York State M. *T. 44: SWq:43. 1944.
36. Martin, H.: Cancer of the Head and Neck, 1. .i. R. 37. Wolcott, R. A.: Personal communication. 38. Markowitz, H. A., and Gerry, R. G.: Temporomandibular MED.,
AIW
OR~I,
PATH.
39. Cooper, H. K. : Cleft Lip 40. Lingrnfelder. .T. : Personal
3:
32-36,
.I. 137:
1:X%, 1948.
.I oint
TXseasr,
23:
41. 19.50.
1950.
and Palate, D. Radio. rommunication.
&z Photog.
O~:,\zr, Hr‘~:c,
01: .\ I,
THE
COMMANDER ROGER G. GERRY, DENTAL CORPS, UNITED STATES NAVY, STANLEP T. SMITH, D.D.S., BEAUMONT, TEXAS, AND LIEUTENANT (JG) M. LYLE CALTON, DENTAL CORPS, UNITED STATES NAVY
Part III Oral Anatomical Abnormalities.-Some time before this study was started. Commander Robert A. Wolcott (D.C., TT.S.N.)37 brought to our attention a condition which he had observed during his stay in Guam. He pointed out t)he existence of mesiodistal enamel checks on the lingual surfaces of t,he incisors of several patients and added that he had observed these only in the maxillary incisors of females. He further added that he had been unable to establish an etiology for this condition, During the course of this study we have attempted to learn more about the distribution, incidence, and etiology of these mesiodistal enamel checks. Mesiodistal Enamel G%ecLs.-Mesiodistal enamel checks were found on the lingual surfaces of the upper and lower incisors, and sometimes even on the cuspids (Figs. 16 and 1’7), and were more or less evenly distributed between both sexes. They were occasionally observed as early as the seventh year, but were usually not present in significant numbers until the eleventh year. They apparently never became secondarily involved with dental caries. In this series, a group of 1,199 subjects were examined for the presence of mesiodistal enamel checks. These included both male and female subjects between the ages of 11 and 59, who had been observed either as clinic patients or on the several field trips. Of this group 739, or 61.6 per cent, exhibit,ed mesiodistal enamel checks. At 11 years of age, 29.3 per cent of the snhjects examined had mesiodistal enamel checks. This proportion increased rapidly, until by the fifteenth year 67.1 per cent of bhose examined exhibited mcsiodistal enamel checks. This proportion remained at about ‘70 per cent until the twenty-ninth year. From the thirtieth year onward, the incidence declined and gradually fell to 50 per cent for the 50 to 59-year age group. This fall in the older age groups was probably due to the loss of anterior teeth as a result of periodontoclasia. The distribution of mesiodistal enamel checks in the several age groups is shown in Table XIV. Mesioclusion in Guamanians.--In an attempt to investigate the possible etiologies of mesiodistal enamel checks, the occlusions of the 1,215 subjects men100‘4
tioned were evaluated. Because eruption of the permanent teeth, of those individuals who had not Guamanians had only permanent, group of ll-year-old Guamanians had some degree of mesioclusion. group rind remained more or less
ing
Fig. evident. Fig.
l(i.-Mesiodistal l’i.-Mesiodistal
enamel enamel
checks checks
of the shedding of the deciduous teet,h and the no attempt was rnadc to cvalnate the occlusions rtnchctl their olc\-c>nt I-1year. I+y this age, mo~i: teeth in thci I( tlcni it ions. l3\-aluatioti of the indicated that, 17.2 ~CI* cult of their nun&~ This incidence doubled for the 1%year-o111 at, this level rlntil the early fift,ies (Tahlc XV) q Fig.
1F.
Fig.
li.
of
upper of
lower
wntml central
incisors.
No
~vi~icnre
of
twtcl
st:litl-
incisors.
when loss of teeth because of periodontoclasia made classification of occlusion difficult. In most instances the mesioclusion was not marked and was indicated by a disparity of only one or two millimeters from the normal relationship between the mesiobuccal cusp of the maxillary first molar and the buccal groove of the mandibular first molar. This very slight prognathism effected a virtual elimination of the normal overjet in such a large number of Guamanians that one of us (R. G. G.) was for a time inclined to believe that mesioclusion might have been responsible for the development of mesiodistal enamel checks. Actsally, the incidence of mesioclusion in Guamanians is probably higher than thilt
1006
GERRY, TABLE
XIV.
OF
NI’MBER GROUP
A(:E
-
INCIDENCE
11
--~-
SMITH,
AND
MESIODISTAL
IN
ENAMEL
40-49 50-59 Total
IN
GUAMANIANS PER CENT WITH MESIODISTAL ENAMEL CHECKS
17
67 71 77 76 87 81 52 75 314 152 69 20
30-39
CHECKS
NUMBER WITH MESIODISTAL ENAMEL CHECKS
58
12 13 14 15 16 17 1x 19 20-29
CALTON
29.3 34.3 52.1 64.9 67.1 75.9 66.7 73.1 69.3
23
37 50 51 A6 54 38 52 21 6
68.X
84 41
55.3 59.4 50.0 61.6
10
1,199
739
-
indicated in Table XV, as premature loss of permanent teeth, accompanied by drifting of the remaining teeth, made the slight degree of mesioclusion which might have been present extremely difficult to diagnose. TABLE
OF MESIOCLUSION
IN
GUAMANIANS’
NUMBER WITH MESIOCLUSION
PER CENT WITH MESIOCLUSION
:i
11
58 67 71
10 27 23
17.2 38.0 34.3
14 15 16 17
77 i6 87
38 27 19 27 14
49.4 35.5 21.8 33.3 26.9
ii 46 28 5
24.0 31.5 30.3 40.6 25.0 6.2 31.5yo
81
52
18
2F29 30-39 40-49 50-59 60-69
314 75 152 69 20 16 1,215
Total difficulties
INCIDENCE
NUMBER IN GROUP
AGE
a result
XV.
*Decreasing in
of
the
incidence diagnosis
of of
1
382 mesioclusion mesioclusion
in
as
older
increasing
age
groups
numbers
is
of
attributed
teeth
have
to
increasing
been
lost
as
periodontoclasia.
Relationship Between Mesiodistal Erulmel Checks, Mesioclusion, and Betel Use.-An attempt was made to evaluate the etiology of mesiddistal enamel checks and determine whether or not the prevalent mesioclusion was responsible for this abnormality, and further to determine whether the mastication of the hard, fibrous betel nut might be the causat,ive consideration in the development of mesiodistal enamel checks and/or mesioclusion. For these reasons, it was decided to evaluate the coincidence of these findings in the group of 1,215 Guamanians whose incidence of mesioclusion and mesiodistal enamel checks had already been noted. Mesioclusion was present, alone, in 382 subjects, an incidence of 31.5 per cent in a group of 1,212. Mesiodistal enamel checks were present in 739 subjects, or 61.6 per cent of the same group. Mesiodistal enamel
ORAL
CHARACTERTSTICS
OF
GI-AMASIASS
lO(l.7
checks and mesioclusion were found together in Z87 subjects, or 23.7 per (WI’ of the entire group. However, of the 739 subjects having mesiodistal enamp Tt has been mentiont>i checks, 39.5 per cent concurrently showed mesioclusion. here t,hat the recorded incidence of mrsioclusion was probably low, and tlr:lt most, likely, a greater number of individuals who exhibited mesiodistal euam(’ On the other hand, 95 cases of mc>si checks also had associated mesioclusion. oclusion, or 24.3 per cent of t,he 382 casesof mesioclusion, presented no csoexist ing mesiodistal enamel checks. On the hasis of these findings, there is insnfficicnl rvidence to assume that the development of mtsiodistal enamel checks iq WII tingent on the presence of mesioclusion. 1Tesiodistal enamel cheeks were prestnj in ‘739 cases,which represented 61.6 per cent of the entire group. OL’ the 7:s Guamanians who exhibited mesiodistal enamel checks. 163, or 62.7 per cent, als( chewed betel nut. Actually this percentage is probably also low, as the presenc*( of mesiodistal enamel checks is a posit,ive finding, while the evaluation ot’ h~lc nut, use is dependent, to a certain extent, on thr subject’s 1listor.v. It has alye:lti! been mentioned that many (yruamanians, especially those practicing good ora hygiene, who chew betel nut will deny its use. Nevertheless, on the hnsis 01 these findings, it cannot he affirmed that mastic*ation of the hetP1 nut \\ras th( etiologic factor in the development of mesiotlistal ellatnel checks. This itnl’r(hs sion may be further substantiated by the considerat ion that 262 Guamania n! having mesiodistal enamel checks, an incitlenc~r of 36.1 per cent, denied heicl USC In addition, we examined a small number of iVla.rshallcse who exhibit,rd msio distal enamel checks, but, in whose native islands betel is not chewed. On the same basis, it, was established that of the 382 Guamanians in when mesioclusion was diagnosed, 307, or 80.4 per cent, also chewed betel. Howevrr of the 701 betel chewers in the group, 394, or 56.2 prr cent, did not exhibit mclsi oclusion. In addition, since such a large numl)cr of all C:uamanians are 1)&e! users, it, would be anticipated that this characteristic would accompany almo~i any other oral finding. 0n the basis of these findings, it probably can be assumedthat, mesiocluxion betel use, and mesiodistal enamel checks exist concurrently, but without inflnt~lrc~t on each other. It is probable that the high inc~idence of mesioclusion can h+ explained on an anthropologic basis, and the developmental factor in the incidcnce of mesiodistal enamel checks should not be overlooked. Xuch c*o~lltl 1~ learned from investigating the incidence of mesiodistal enamel checks in those islands of Micronesia in which betel is not chewed, and evaluations of occlusiot should be performed in a more carefully selected group of subjects than WI! available in this study. Three-Rooted Lower Molars.-A consideration which might have heck : factor in the development of mesioclusion in Guamanians was the presence ot a fairly high incidence of three-rooted mandibular first and second molars. IT! a series of 127 teeth in this category, eight, or 6.3 per cent, had three roots. Tht patients were almost equally divided between the sexes, 64 male and 63 fem;d~~ and of t,he 8 three-rooted molars, five were found in males and three in females Actual crown dimensions of these teeth were not measured. We recognize thai
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AND
CALTON
an extremely small series such as this is not of statistical significance. In addition, it has not been possible to compare the incidence of three-rooted mandibular molars in Guamanians with the incidences in other groups, as, to our knowledge, similar series elsewhere have not been reported. However, in the light of our personal observations in exodontia in the IJnited Stat,es, it was felt that the incidence of three-rooted mandibular molars in Guam was unusually high. This finding, with the frequency of mesioclusion in Guamanians, might be of anthropologic interest. Temporomandibulw Joint Disease in Guanzanians.-The high incidence of neutro- and mesioclusion, or rather the low incidence of distoclusion with overbite, and the extremely low incidence of trauma, i.e., during a period of eighteen months no Guamanians were t,reated for maxillary or mandibular fractures, probably accounts for the extremely low incidence of temporomandibular joint. problems.38 Only two Guamanians presented with positive temporomandibular joint findings. One of these was a young girl who gave a history of having been beaten several times by her father, with accompanying acute mandibular dislocation. The other was a 52-year-old Guamanian man with missing posterior teeth and with accompanying bilaterally excessive condylar excursion and disc derangement.38 Cleft Lip and Palate irt Guanaanians.--In a total of 2,004 Guamanians esamined, there were no cases of cleft lip or palate. Occurrence of these deformities was also not observed during the examination of additional Guamanians who were not included in this series. Coope+ reported approximately one cleft lip or palate in 750 live births in Denmark, Pennsylvania, and Wisconsin. Actually, the two sets of figures are not comparable, and it cannot be advised that the incidence of these defects is lower in Guam than in other areas listed, as the Guam series was taken entirely from patients who more or less voluntarily presented themselves for dental examination or treatment. Guamanians, as a group, are somewhat shy and, for the large part, completely incognizant of the benefits which dentistry can offer the cleft palate patient. On this basis, it was assumed that those Guamanians having either cleft lip, or palate, or both, would not be likely to present themselves for examination in a series of this sort. This impression has been substantiated by the Obstetrical Service of the Guam Memorial Hospital in which there were approximately 400 live births between July 1, 1949 and June 30, 1950. During this period three live babies with cleft lip or palate were delivered.40
Summary 1. The history, vital statistics, dietary habits, dental treatment, and oral hygiene habits of the natives of the island of Guam have been discussed. 2. The incidence of use and the pharmacology of the bct,el nut, and especially its effect on the human saliva, have been described. 3. The incidence and chronologic distribution of dental caries in Guamanians have been evaluated and the effect of betel nut use on the dental caries incidence discussed.
4. The incidence and chronologic distril)ut ion of gingivitis and period?,ntoelasia in Guamanians hecn supporting dental tissues dcscrihctl. 5. The existcmc ol’ the oral I’orn~s 01’ I~~~~ko~~hl~i;~, ~‘aws, ;III(I \.~~~IWPOIIS l~apilloma in Gnamaniatni has been dcscril~etl. 6. The incidence of carcinomas of all loc*alit,ies in Guamanians has been computed, and the effect of hetcl c~hewing as an oral canrcinogcnic considera.tion discussed. 7. Various anatomical characteristics of Guamanians, as mesioclusion aild its effect on temporomandibular joint disease, mesiodistal enamel checks on incisor teeth, and the incidences of three-rooted mandibular molars and cleft lip and palate have been described. IliVC
(!ValliltPtl,
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of
htcl
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011
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Conclusions 1. The Guamanian diet is extremely ric+h in carbohydrates and especially” refined sugars, and has deteriorated in this respect since before the war. 2. almost no Guamanians receive routine dental care, and, while satisfaetory toothbrushes are not available, a large majority of Guamanians own some sort of toothbrush. 3. Forty-one and one-tenth per cent of the Guamanians questioned, from 11 to 69 years of age, were frequent chewers of betel nut,. The pH of their salivary secretions averaged 0.4 pH u&s higher than those Guamanians who were not frequent betel chewers. Chewing betel nut for a period of two minutes increases the pH of saliva an average of 1.2 pH units and will maintain an elevated saliva pH for an average of seventy-three minutes. 4. Guamanians between the ages of 5 and 19 years have an average of 4 diseased, missing, or filled teeth each. This incidence is decidedly lower t,han that in the United States, the United Kingtlom, or the Virgin Islands. Hawever, the deciduous caries rate in Guam is very high, and the average DJlF for children under 5 years of age is 8.6 per subject. 5. Guamanians who are frequent betel nut chewers average 2.5 DMF’s per subject less than those who do not chew betel. Betel chewers average 36 ‘per cent less dental caries than those who are not betel chewers. 6. The incidence of gingivitis in Guamanians is low, averaging 24 per cent for all ages. The incidence of gingivitis among betel chewers is somewhat higher than among nonusers. This increase is attributed to the more rapid precipitation of dental calculus among betel users as the resnlt of the elevation of the salivary pII. 7. The incidence of periodontoclasia in Guamanians under 30 is negligible, but in the older age groups approaches 90 per cent. The incidence for betel chewers is almost twice that of nonchewers. This condition is attributed to the more rapid calculus formation on the teeth of betel-using individuals a.s described previously. It is felt that betel chewing Guamanians practicing good oral hygiene would have no higher incidence of periodontoclasia than similarly practicing nonchewers.
1010
GERRY,
SMITH,
AND
CALTON
8. The incidence of oral disease other than dental caries, gingivitis, and periodontoclasia is generally very low in Guam. Only four cases of leukoplakia were seen which were not complicated by other abnormal processes, as carcinoma, verrucous papilloma, etc. Only one primary yaws lesion of t,he oral tissues was observed in a series of over 1,800 yaws patients. 9. The incidence of carcinomas of all types among Guamanians is extremely low. This circumstance is attributed to the low life expectancy of Guamanians. The incidence of oral carcinomas, among carcinomas of other locations, is probably about the same in Guam as in the United States. On this basis it is considered that the betel nut is not a carcinogenic factor. 10. Malignant oral neoplasms other than carcinomas were not observed in Guamanians. 11. Mesiodistal enamel checks on the lingual surfaces of the incisor teeth are present in about 60 per cent of all Guamanians between the ages of 11 and 69. 12. Mesioclusion is present in more than 30 per cent of all Guamanians beThis condition, plus the remarkably low twee.n the ages of 11 and 69 years. incidence of mandibular trauma, is credited with being responsible for the very low incidence of temporomandibular joint disease. 13. No correlation can bc demonstrated between the existence of mesiodistal enamel checks, mesioclusion, and/or betel use. 14. The incidence of three-rooted mandibular first and second molars is apparently high in Guam. The incidence of cleft lip and palate is apparently not remarkable. The writers wish to express their sincere thanks to Sami Leioto, Pio F. Misa, Setoga Setoga, Jr., Tutuila, Pago Pago, American Samoa ; Teoho Oiph, Koror, Palau Islands; and Enta Peter, Ebon Atoll, Marshall Islands; all senior students at the School of Dental Assistants, Guam, M. l., for their assistance in the collection of the data in this report; and to Lieutenants (jg), D. C., IT. S. N. R., Harold R. Englander, Bernard Malberg, and Clifford J. Raimist, all of the United States Naval Hospital, St. Albans, N. Y., for their assistance in the preparation of the tables presented.
References 1. Thompson, I,.: Guam and Its People, San Francisco, 1941, Institute of Pacific Relations, p. 4. 2. Garcia, Francisco : Vida y martirio de el venerable Padre Diego Luis de Sanvitores, Madrid, lG83; translated by Margaret Higgins in the Guam Recorder, April, 1937, p. 21. 3. Thompson, L.: Guam and Its People, San Francisco, 1941, Institute of Pacific Relations, p. 27. Government of Guam, Department of Public Health: Personal communication. 2 Pretty, F. : Sir Francis Drake’s Famous Voyage Round the World, in Voyages and Travels, Ancient and Modern, New York, 1910; cited by Thompson, L.: The Native Cultures of the Marianas Islands, Bernice P. Bishop Museum Bulletin No. 185, Honolulu, 1945, p. 10. 6. Government of Guam, Department of Public Health: Personal communication. Underwood, R. F.: Personal communication. i: Annual Report of the Government of Guam, 1924, p. 17. of Guam, Department of Customs and Immigration: Personal communication. 9. Government 10. Wood, H. C., Jr., 0801, A., Youngken, H. W., and Gershenfeld, L.: The Dispensatory of the U. S. A., ed. 23, Philadelphia, 1943, J. B. Lippincott Company, pp. 157-158. 11. Goodman, L., and Gilman, A.: The Pharmacologic Basis of Therapeutics, New York, 1941, The Macmillan Company, p. 393. Tests to Determine Suitability of 12. Wheatcroft, M. G., Schlack, C. A., and Taylor, 13. W.: Burnt Coral as a Dentifrice: Report I, Mail. Surgeon 107: 124, 1950.
ORAL
CHARACTERISTICS
OF
1011
CrIi.\MANIANS
13. Best,
C. H., and Taylor, N. B. : The Physiological Basis of Medical Practice, I:;lltiruclr~~. 1950, Williams & Wilkins Company, pp. 127-128. 14. Blackerby, P. E., Jr.: Intrastate Geographic Variations in Dental Caries Ratrs. .I. ..llr:. Dent. A. 30: 1241; cited by Shourie and Marshall-Day, Reference 16. 15. Weaver, R.: Fluorine and Dental Caries; Further Investigations on Tyneside and 111 Sunderland, Brit. D. 5. 77: 185, 1944; cite11 by PlinuricL and Marshall-I)ay, Refrrw~ I’ 11;.
16. Shouric, K. W., and Marshall-Day, C. 1). : Dental Vxriw TCxpcrienre in the Virgil1 Td:r~~ci~ J. Am. Dent. A. 40: 319, 1950. 17. Knutson, J. W.: Pub. Health Rep. 59: 253-263, 1944, cited by T’olker, Refrrenw 19. 18. Hollander, F., and Dunning, J. M.: ,T. D. Res. 18: 4X-60. 1X:9; (‘ited 1,~ Yolkw. ll~~frwn~~~~ 19.
19. Volker, 20. 21. 22. 23.
J. F.: What Is the Scope of Our Present Knowledge of’ the lht:~l (‘:?I+ Process? J. California State D. A. 26: 10.11, 1950. Miller, S. C.: Oral Diagnosis and Treatment, rd. ‘:. T’l~il:~tl~~lphin, 1946. Thr Hlakistlirr Company, pp. 106-107. Urban. K. L.: Personal communication. Shourie, K. L.: The Possible Effe(% of Betel Chewin:: 011 thr Inridt~nc*c~ of Thl:~l (‘:lri~~ in Indian Children, J. D. Res. 27: 770, IRIS. Weisbewer. 0. : A Role of Glucosr in tlw Pw~lurtion of A’wt,ificaial C;tGrs. ,I, I). Rt,s. 29:-26,
1950.
24. Fosdic>k, L. 8.: The Reduction of the Inridcnw of I)ental Caries. I. Lmme~liate TootItBrushing With a Neutral Dentifrice. ,J. Am. T>ent,. A. 40: l?Al34. 19.X. 25. Marshall-Day; C. D., and Shourie, K. L.: Gingiwl l)is:ea:c in thr Vir&n Islnntl~, .I. .11n. Dent. A. 40: 179, 1950. 26. Marshall-Day, C. D., and Shourie, K. I,. : A Roentgenographic Rurl-qof’ I’(>rio(lonl:tl I)israse in India, J. Am. Dent. A. 39: 575, 1949. 27. Gurney, B. F., and Huschart, ,T. II.: A Dietary Asp& of C:~l~ulus, .l. I). Rcs. 29: I;&:;, 1950. 28. Colby, R. A.: Personal communication. 29. Mackie, T. T., Hunter, G. W,., III., and Worth. C. H.: Manual ol’ Tropical Medic*inch, National Research Council, Phdadelphia, 1945, TV. B. Saunders Compa?y. pp. 7X-79. Annual Narratlre Report 10 30. Department of Public Health, Naval Government of Guam: the Governor of Guam, Dec. 31, 1949. Cancer: Diagnosis, Treatment, and I’wgno~is, 31. Ackerman, L. V., and de1 Regato, J. A.: St. Louis, 1947, The C. V. Mosby Company, pp. 251-252. 32. Balendra, W.: The Effect of Betel Chewing on the Dental and Oral Tissue an<1 It: Possible Relationship to Buccal Carcinoma, Rrit. D. .T. 87: S7, 1949. 33. Khanolkar, V. R.: Oral Cancer in Bombay, Imlia. .\ Review of 1,000 Consevuiiw C:IWS Cancer Research 4: 318-319, 1944. 34. Eisen, M. J.: Betel Chewing Among Natives of the! Southxwt Pavific .Tslands. (‘ancer Research 6: 140-141, 1943. 35. Levin, M. L.: Cancer Renortinn II in New York State. Sew York State M. *T. 44: SWq:43. 1944.
36. Martin, H.: Cancer of the Head and Neck, 1. .i. R. 37. Wolcott, R. A.: Personal communication. 38. Markowitz, H. A., and Gerry, R. G.: Temporomandibular MED.,
AIW
OR~I,
PATH.
39. Cooper, H. K. : Cleft Lip 40. Lingrnfelder. .T. : Personal
3:
32-36,
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1:X%, 1948.
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1950.
and Palate, D. Radio. rommunication.
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