The Problems of Prevention*

BUREAU OF DENTAL HEALTH EDUCATION

THE PROBLEMS OF PREVENTION* B y FR A N K A . DELAB ARRE, A .B ., D. D. S., M . D ., F. A. C. D., Boston, Mass. is n o w p a s s i n g through a critical period of read­ justment of its purpose and ideals that broadens its field of endeavor and increases the responsibility greatly. The dream of many men for a long time is crystallizing in the conviction that, at last, to an appreciable extent, an effective means of prevention is possible. The brilliant progress made in the technical phases of our work and the overwhelm­ ing demand for our services blinded us to the real problem involved. e n t is t r y

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Sir W illiam Hunter’s vigorous arraign­ ment of “ Septic American Dentistry” in 1910 at M cG ill University forced the issue and compelled the study of the relationships of dental to general health and disease. The questions then aroused have not been settled yet, nor could they be by applying the old methods of cura­ tive effort. T he one item alone of focal infection following an abscessed tooth can best be eliminated by preventing the caries that is the exciting cause. The best of the in­ numerable methods devised for its cure are uncertain and disappointing. Fortunately, many minds turned to the idea of prevention, and from the leS: sons learned in the clinics for school children, there has developed a method that holds the greatest promise of con­ trolling or preventing dental caries. *R ead

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Caries is the most prevalent of all human pathologic conditions. It begins soon after the teeth erupt and is rampant during childhood and youth. Statistics show that 84 per cent of children at the age of 3 already suffer from it ; and within a few years, the percentage rises to 95. The Forsyth Infirmary, established in 1914, soon found that its policy of ad­ mitting any child up to the age of 16 afforded no diminution of “ repair” work 9 ffered. Gradually reducing the age limit for first admission to 7 pointed unmistakably to the solution and showed an amazing gain in effective control. Ultimately, no child over 2 years of age can gain admission and, as now, he will be ineligible after 16. T o this first practical advance was added Hyatt’s demonstration that many teeth erupted with existing physical de­ fects free from caries, and that these same locations showed by far the greatest number of cavities or fillings, later in life. Here, then, was the vulnerable area where caries most frequently started. This previously neglected field has, in a short time, taken a commanding place in our thoughts, efforts and literature, and the insistent demand today is for the establishment of preschool age clinics in order to take full advantage of the new method of attending to noncarious pits and fissures as soon as possible after eruption. Leaving the particular problems of children’s dentistry for the moment, let

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us face the whole idea of prevention of dental disorders in the wider aspects. The human organism must be studied as a unit. A ll of the organs and func­ tions are dependent on each other for their wellbeing. The vital organs are necessary for life, and impairment of any organ or function adversely affects the rest. Therefore, oral conditions must be studied from the standpoint of general health, and dentistry must be classed as a true “ health service,” when the general practitioner pays as much attention to children as he does to adults. The main thing now is to acknowledge the burden placed on our shoulders and assume the task of doing our work for the sake of maintaining or improving health. Compared with the whole, the dental problem occupies a minor place, but it is none the less important, because we know today that dental lesions may be the starting point of a chain of patho­ logic conditions that may result in pre­ mature death, through involvement of some vital organ. It is not necessary to determine the measure of its responsi­ bility at once; that will be developed along with increasing knowledge of cause and effect. Prevention may be secured in two ways: by finding the causes, both activat­ ing and contributory, and applying the appropriate remedy, i. e., prophylactic therapy; or by increasing the normal resistance and immunity of the body so that natural forces will render them in­ capable of harm. If the statement that “ dental preven­ tion is effective in inverse ratio to the age of the patient” is true, it is logical to exclude from this survey such condi­ tions as are not common in childhood, and to look for the solution in the means that can be applied to the masses rather than to individuals.

O f the two possible lines of attack, the greater result will come from the ef­ fort to improve the resistance and im­ munity of the bodily unit as a whole, which will have the greatest influence for general health. This is essentially a med­ ical problem but one in which we have great concern and to which we may ren­ der somfe small degree of aid, particularly by attention to the contributing causes of disease and by maintaining the integ­ rity of function in the oral cavity and closely related functions. Local hygienic measures are essential even if they fail to keep a “ clean” tooth free from decay be­ cause of their inability to reach the “ most vulnerable areas.” Growth and development are largely dependent, aside from hereditary influ­ ences, on the influences of the ductless glands and a proper diet, effectively assimilated and distributed. The oral function is closely concerned with the digestive function, and it is our task to maintain or restore its efficiency. W hile positive benefit may be ex­ pected from the further development of endocrine therapy, the application of diet­ ary measures offers the best results at present. Our profession can aid, by edu­ cational effort, to overcome the inertia and indifference of the public, confused by the variety and contradictions of the many food fads. Our relations with the public place us in a peculiarly fortunate position to do such educational work, since frequent and periodic appointments, particularly with children, give a con­ tact which medicine, as a whole, does not enjoy. Then, too, we can supplement the pediatrician’s effort to eliminate the con­ tributing causes of poor nutrition, such as an improper balance of daily activities in play, rest, work, sleep, exercise, fresh air and sunlight, without which the best

Bureau of D en tal H ealth Education

dietary is badly handicapped and inef­ fective. Education in mastication is indicated in many cases and the teachings of Fletcher should not be forgotten. Metabolism is a very complex prob­ lem, not to be solved by one line of ap­ proach, but which requires all the skill and knowledge that medicine and its re­ lated sciences can give. From our experience in age control, it is reasonable to expect that better, stronger, more resistant teeth will re­ sult from the intelligent medical care of the expectant mother, in regulating the diet and living conditions to maintain the desired balance of elements necessary to tooth formation. The Forsyth Infirm­ ary has had a prenatal clinic in operation for several years. Anything that medicine can do to im­ prove the health of the mother and child and raise the physical tone and vigor will tend to simplify our dental problems. T he earlier this help is given, the better the chance to provide immunity from caries. Even today, immunity to caries has not been entirely lost by the refinements of diet and manner of living that “ civiliza­ tion” has brought. There are individ■uals and races who show a relative im­ munity, and we know that age confers a measure of it to many. Therefore, we may hope to restore, by some such means, the immunity that mankind once enjoyed. It is entirely possible that the future will develop methods of arresting decay and prevent further occurrence by a combina­ tion of curative and preventive treatment. It is admitted that practically all dental effort results in a degree of prevention, but only for the individual and generally after childhood. Concerning caries, it must be admitted that dentistry’s effort at control by cura­

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tive procedure has been a relative fail­ ure, carrying little preventive benefit ; else why do we boast of a filling that has served for twenty or forty years ? W hat­ ever the active cause may be, whether chemical or due to micro-organisms or both or whatever combinations of con­ tributing factors are present, the fact re­ mains that caries has occurred, and it is too late for real prevention. T o supplement these efforts as out­ lined, there remains one practical means of the greatest importance that will give immediate results, and that is, dentistry for children, which is partly preventive and partly curative. It is truly preven­ tive if the remedy is applied before dis­ ease occurs, even though the mechanical technic is the same used in all our cura­ tive procedure; and the results of the curative effort for children are infinitely superior to any obtained in all our pre­ vious history. T he dentist does not see the child until the teeth appear. Much of the suc­ cess of his efforts depends on what has gone before, but the full measure of suc­ cess cannot be secured without the as­ sumption of his full responsibility. It should be unnecessary to emphasize the need of early, periodic and systematic visits for control and prevention, during all the years of development. Dentistry is not now so much a curative measure as a preventive health service. It is no longer a local problem, and its relation to general systemic conditions must be up­ permost in mind. There is need for a careful diagnosis in each case, based on a case history that supplements the medical case history. The common indices of health, such as the height-weight index, the color of the skin, the posture, the expression of the face and the mental attitude should be included, as well as the occurrence of

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disease. T he cooperation of the pediatri­ cian or the family physician is desirable in all cases, when indicated. The symptomatology of the mouth should be always noted at each visit in order to detect the signs of disease, par­ ticularly those that find entrance through the mouth and nose and often reveal their presence there first, such as the eruptive fevers, measles and scarlet fever. The technic in children’s dentistry is practically the same. The only modifica­ tions are occasioned by the differences in the structure of the deciduous teeth, the problems incident to the rapid growth and development of the dentition and the changes that occur in occlusion from infancy to adolescence. Elaboration of this newly adopted point of view is pre­ cluded by time, but its practical value cannot be overemphasized. Function is the basis on which to estimate the value of any organ. A mouth may be free from disease and yet not function efficiently because of m alocclusion. M a locclu sion appears early in life, in the majority of cases, and the child that does not show evi­ dences of normal growth and develop­ ment needs attention. A knowledge of such development is essential to any dentist handling children, and, more than that, an understanding of the causes of malocclusion, many of which could be eliminated. Particular emphasis is placed on the pernicious habits of infancy and childhood, such as sucking habits, faulty speech, mouth breathing and im­ proper posture. Breaking them may actually prevent malocclusion, and will in any event lessen the severity of com­ plications in a case due to other causes. It should also be appreciated that, later in life, malocclusion renders the individual more susceptible to caries and

pyorrhea in addition to his being func­ tionally handicapped. Dental Health Service for children is not complete without inclusion of ortho­ dontia, which is no longer undertaken for esthetic reasons alone, but mainly for the improvement in health that results from restored function. Our efforts to gain the acceptance of this line of procedure in practice intro­ duces into professional education new problems that are of greatest importance and require immediate attention. It is from this source that the most rapid progress may be expected. In spite of rapid advances, our educa­ tion and training do not qualify us as a profession to deal with the underlying fundamental causes. That is the province of medicine. Still, there is the increasing obligation resting on our professional schools to augment the teaching of med­ ical sciences to the point where the graduate will be equipped to understand and appreciate the single aim of the two professions, having gained sufficient knowledge of the dependence of all tissues on the laws of physiology and pathology to recognize the existence of general causative factors and injurious end re­ sults. Since children’s dentistry provides the best opportunity for realizing the highest attainable measure of prevention, more to be desired than any curative success, there are educational adjustments neces­ sary to insure the acceptance by the young graduate of this new point of view, which changes so radically the rela­ tive values and desirability for the patient of the various technical procedures as taught. W hile he still should be free to choose any specialty that he may desire, he must be made to appreciate the fact that better dental health can be assured more people

Bureau of D ental H ealth Education

by means of children’s dentistry than in any other way. If this is true, it must be given the place and dignity of a separate course under a qualified professor, and properly correlated with all other courses. In fact, this radical change in policy upsets the whole curriculum and forces a readjustment and balancing of hours and requirements all along the line. Better coordination with dental and medical teaching will be the result. If it is apportioned out among the vari­ ous departments, the subject will not be adequately presented and will suffer from lack of interest, unity and coordina­ tion, and will not carry conviction to the student mind. A separate clinic for children is im­ perative because the object is different, and the psychologic problem is more easily solved by handling the children alone. There remains another educational problem that is rather discouraging, but fortunately time will solve it. It relates to the acceptance of this whole idea by the profession at large. Organized den­ tistry has been educated to accept it as logical and inevitable; the individual dentist has not, and as a profession we are not prepared to give the service that the public will soon demand. O u r literature is givin g a good amount of space to the subject, and pro­ grams of societies and conventions list it in papers and teaching clinics. The Massachusetts State convention next M ay will feature children’s dentistry in its relation to all other branches. M ore study clubs should be formed everywhere to stimulate interest and explain the de­ tail. The medical profession should like­ wise be made acquainted with the fact that dentistry has awakened and wants to cooperate.

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Short informatory courses should be included in the medical schools, and the leaders of our profession should make every individual effort to bring the matter to their attention. In this connec­ tion, care should be taken to avoid extravagant statements; but it can be truthfully said that our help has been asked for, and we have now found a way and modestly offer to do what little we can to conserve public health. The task of educating the public should be easy because all parents love their children and want them to have advantages denied them in their own youth. But all effort in that direction should be supported and sponsored by resp on sible d enta l o rgan iza tion s and not left to individuals or unprofessional bodies. There is another outlet for the pro­ mulgation of this idea that is already in action in some states; that is, contact with state boards of health, either through committees or an individual ap­ pointment. Much can be done along this line in determining and standardizing the policies and conduct of existing or pro­ posed school clinics. Much confusion can be avoided and mistakes prevented by proper advice to communities from this source. There are already a number of spe­ cialists successfully practicing on children only and doing very remarkable work. And there has been formed a national society for the promotion of children’s dentistry. Specialization along this line will be advantageous in making progress in re­ search and improved technic, but it will never fulfil our obligation to the public. It will not solve the problem. That can only be done by having the bulk of the profession give this service to the chil­ dren. Such service is in no sense p er se

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a specialty of dentistry. It is merely dentistry applied to a particular group, and in this respect exactly parallels pedi­ atrics in medicine. The combined efforts of the pediatri­ cian and the dentist, whose aim is the

maintenance of health rather than the cure of existing disease, should secure for the child the best possible physical equip­ ment. 520 B e a c o n S treet.

TAKING INVENTORY OF OUR M OUTH HYGIENE PROGRESS* W ILLIAM R. DAVIS, A .B ., D .D .S .,f Lansing, Mich.

H E time of year suggests inventory. A ll going concerns today recognize the importance of taking stock at certain intervals, calculating losses and gains, and, from this survey, determining policies for the future. This is absolutely necessary today in successful business. Hit or miss methods cannot succeed. But it is also very essential to take inventory in o r g a n iz a tio n s and m ovem ents, although here profits and losses are more intangible and harder to evaluate. Honest attempts in this direction must be made if any movement is to continue to command respect and support, especially from those not directly connected with it and whom it wishes to ally to its cause, and also in order to accomplish its task most efficiently. Let us make a rather hasty attempt in this direction in regard to some phases of the mouth hygiene movement.

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W hile there were a few “ voices cry­ ing in the wilderness” in generations past, this movement really took its begin­ f D i r e c t o r o f th e B u r e a u o f M o u t h H y g ie n e , M i c h ig a n D e p a r t m e n t o f H e a lt h . * R e a d b e f o r e th e S e ctio n o n M o u t h H y ­ g ie n e at th e M i d w i n t e r C lin ic o f th e C h ic a g o D e n t a l S o c ie ty , J a n . 15, 1929.

Jour. A. D. A ., March, 1929

ning in the early part of the present century, when the efforts of B. Holly Smith and W . G . Ebersole first began to attract attention. It is just twenty years since Dr. Ebersole became chair­ man of the Oral Hygiene Committee of the National Dental Association, and one year later, he conducted the first real experiments to test the effects of mouth health on scholarship and general health, the now famous Marion School experiment in Cleveland. I think we can call this the first real impetus given to mouth hygiene as a part of public health. In 1911, Dr. Ebersole organized the National Mouth Hygiene Association, working indefatigably in behalf of this cause, until broken health and finally death took this great pioneer from our midst. T h e organization did not long survive its moving spirit. W hile mouth hygiene gained some attention and con­ verts, it had not yet begun to stir even many of the leaders of the medical or dental profession, to say nothing of the rank and file, public health organiza­ tions, or the general public. It remained for a physician of Eng­ land, Dr. Hunter, to “ fire the shot heard