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The relation of periodontal diseases to public health
The relation of periodontal diseases to public health
C lifton O. D u m m ett, D .D .S ., M .S .D ., M .P .H ., U. S. A ir F orce
a m ajor concern in present-day dentistry, and as one o f the health problem s in need o f support by the public health profes sion.
Public health is defined1 as the science and art o f preventing disease, prolonging life and prom oting physical and mental efficiency through organized comm unity effort. K nutson2 observes that this defini tion, despite its comprehensiveness, is not sufficiently practical. T h e specific o b je c tives3 o f public health as they affect den tistry encompass the prevention, early diagnosis and treatment o f dental caries, malocclusion, oral clefts and other anomalies, cancer and traumatic injuries o f the teeth and maxilla. In addition there are instructions in acceptable oral hygiene, the prevention and treatment of gingival and periodontal diseases, the production o f scientifically accurate in form ation, the m otivation o f proper oral health habits and attitudes on the part of the public, and the developm ent o f lec tures for dental public health programs. Periodontics is that specialty o f dental science w hich is concerned with the study, prevention and treatment o f dis eases o f the supporting tissues o f the teeth. In origin or in effect, periodontal diseases may include those local or sys temic disturbances o f the supporting tissues which may be m orphologic, in fec tious, traumatic or degenerative. A fter 35 years o f age patients lose more teeth as a result o f periodontal disease than from any other single dental dis ease.4,5 Affections o f the periodontium must therefore be reckoned with, both as
P U B L IC H E A L T H A S P E C T S OF P E R IO D O N T A L D IS E A S E
A n inspection of the teeth and their sup porting tissues and an evaluation o f other oral and systemic conditions are essentials in the examination o f patients fo r perio dontal disease. These examinations con stitute the basis o f diagnosis and should enable the periodontist to determine the distinctive nature o f periodontal diseases. A thorough examination is a prerequisite fo r effective treatment. Indispensable requirements fo r perio dontal diagnosis include an over-all ap-
Presented before the Section on Periodontics, ninetyseventh annual session, Am erican Dental Association, A tla n tic City, N. J., O ctober I, 1956. The opinions expressed herein are solely those o f the author and do not necessarily reflect policies o f the U. S. A ir Force M edical Service. Major, Dental Corps, U. S. A ir Force, 5005th U. S. A ir Force Hospital, A . P. O . 942, Seattle, Wash. 1. Winslow, C. E. A . U nfilled fields of p ublic health. M od. Med. 2:183 March 1920. 2. Pelton, W . J., and Wisan, J. M . Dentistry In public health, ed. 2. Philadelphia, W . B. Saunders Co., 1955. 3. Proposed re po rt on educational qualifications of pub lic health dentists. Am .J. Pub. Health 42:188 Feb. 1952. 4. Allen, E. F. Statistical study o f the prim ary causes o f extractions. J.D. Res. 23:453 Dec. 1944. 5. Brekhus, P. J. Dental disease and its relation to the loss of human teeth. J.A .D .A . 16:2237 Dec. 1929. 49
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praisal o f the patient, a consideration o f the principal com plaint, examination of the oral cavity, local and systemic case histories, history o f dietary intake and nutritional status, roentgenographic ex amination, study casts and the numerous laboratory aids utilized in the diagnosis o f oral and systemic diseases.6 T h e cor rectness o f the diagnosis is in proportion to the completeness o f these specific steps. It is in the area o f early diagnosis o f periodontal disease that there is an im portant relationship o f periodontics to public health. T h e incipient signs o f periodontal diseases can be detected by careful systematic oral examination, and dentists should not be satisfied until such examinations have uncovered the etiologic factors. T h e early diagnosis o f gingival and periodontal disease— a specific o b je c tive o f dental pu blic health— enables treatment to be instituted as soon as pos sible. T h e diagnosis o f varying types o f perio dontal diseases is dependent on an ac ceptable classification. Several classifica tions o f periodontal conditions have been proposed. T h e most generally accepted ones today are based on O rban ’s w ork7 which classifies periodontal diseases on the basis o f inflammatory, degenerative, atrophic, hypertrophic, traumatic and neoplastic entities. Such a classification is necessary to investigate the epidem i ology o f periodontal disease. Frost8 defines epidem iology as the science w hich considers the occurrence, distribution and types o f diseases o f m an kind in distinct epochs o f time at varying points on the earth’s surface. E pidem i ology presents the relations o f these dis eases to inherent characteristics o f the individual and to the external conditions which surround him and w hich determine his manner o f life. Ever since the examination o f ancient skulls showed that periodontal diseases are probably as old as man, there has been m uch interest in gathering data about the types o f periodontal disease,
the persons most affected and the regions in w hich varying conditions occurred. These studies of early m an indicate that some form o f periodontal disease has ex isted in practically every part o f the world. Surveys o f contem porary m an re veal a greater prevalence o f the m ore severe form s o f periodontal disturbances in some countries than in others. For exam ple, the natives o f W est A frica have been fou n d to have a higher incidence of periodontal disease than those o f East Africa. Generalized gingival hyperplasia affects practically 100 per cent o f the Australian aborigines.9 In Europe, south ern and Dinaric races are affected m ore severely with periodontal disease than those living in Finland and L aplan d.10 In Bombay, India, the disease is m ore prevalent and severe, with as high as 93 per cent o f children (11 to 16 years old ) being affected.11 Akhter reports12 that 95 per cent o f Punjab school children 10 to 16 years old showed signs o f perio dontal disease, chiefly hypertrophic gin givitis. Considerable evidence from A us tralasia indicates that the prevalence of periodontal disease increases with age.9 M any o f these epidem iologic studies record opinions and observations that are primarily subjective, and are frequently based only on visual inspection o f the gingiva. M oreover, a w ide variation in methods o f diagnostic technics and ap proaches to surveys has rendered co l lected data difficult o f confirm ation, un-
6. Thoma, K. H., and Robinson, H. B. G . O ral and dental diagnosis, ed. 4. Philadelphia, W . B. Saunders Co., 1955. 7. O rban, B. Classification and nomenclature o f perio dontal diseases. J. Periodont. 13:88 July 1942. 8. Frost, Wade Ham pton. Papers; a contribution to epidem iological method. Edited by K. F. Maxcy. New York, Commonwealth Fund, 1941. 9. Cunningham, W . M . Prevalence o f periodontal dis ease. 2. In Australasia. Internat. D.J. 5:200 June 1955. 10. Loos, S. Prevalence of periodontal disease: 3. Europe. Internat. D.J. 5:319 Sept. 1955. 1!. Mehta, F. S.; Sanjana, M . K., and Shroff, B. C. Prevalence o f periodontal disease. 5. Epidem iology in Indian child population in relation to their socio-eco nomic status. Internat. D.J. 6:31 March 1956. 12. Akhter, H. Incidence o f periodontal diseases in the Punjab. Pakistan D. Rev. 5:109 July 1955.
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reliable in com parison and, therefore, limited in value. T h e epidem iologic studies o f K ing, Schour, Massler and M arshall-Day evalu ated gingival diseases in children. K in g’s13 objective differentiation o f forms o f gingivitis was expressed quantitatively. M arshall-Day and Shourie assessed14 the severity o f gingivitis on the basis o f changes in gingival surface margins and papillae. F or their evaluations, Schour and Massler15 used the P M A index, a quantitative clinical measurement in which the location o f gingival inflam m a tion provides an estimate o f the degree of gingivitis in individual instances. A ll o f these investigators fou n d that inflam matory gingival conditions occurred in m ore than 90 per cent o f the persons examined. In a m ore recent study on the incidence o f gingivitis in Brisbane school children (age 3 to 12 years), K ru ger16 utilized the P M A index and fou n d that the per centage o f children with gingivitis ranged from 49 per cent (3 year age grou p) to 90.5 per cent (9 year age g ro u p ). T here was a definite correlation between dental caries attack and the incidence and severity o f gingivitis. Studies o f the more advanced stages o f periodontal disease frequently have uti lized roentgenographic estimations o f bone loss or evaluations o f the occurrence o f the disease without regard to degree o f severity. In using the amount o f bone loss as a determinant o f the advancement o f periodontal disease, M arshall-Day17 found that the prevalence o f periodontal diseases with roentgenographic evidence o f bone loss around on e or m ore teeth ranged from 4 per cent (age 13 to 15) to 100 per cent (age 6 5 ). A bove 35 years o f age, the prevalence o f bone loss was practically universal. In addition, tooth mortality increased from 6 per cent (age 19 to 20) to 60 per cent (age 6 0 ). Stahl, Wisan and M iller,18 after taking into account the alveolar resorptive changes which accom pany aging, re
ported a greater severity o f bone loss in Veterans Administration patients suffer ing from diseases in w hich general cellu lar metabolism was affected, than in p a tients admitted for local ills. M ehta, Grainger and W illiam s19 ex amined 670 Canadian civil servants (302 men and 368 w om en) aged 15 to 24 and fou n d that periodontitis simplex was the most com m on form o f the disease, affect ing 79.4 per cent o f the men and 79.6 per cent o f the wom en. Periodontitis com plex was diagnosed fo r 16.3 per cent o f the men and 9.4 per cent o f the wom en. T h e pockets per person and per tooth were significantly higher in men after age 35. O ral hygiene retrogressed with age and was poorer in m en than in women. A study by Belting, Massler and Schour20 forecasts that 50 per cent o f all males will have some clinical or roent genographic evidence o f periodontal dis ease by the time they are 45 years old. An alternative possibility w ould be the loss o f all teeth from periodontal disease. A promising quantitative m ethod o f scoring periodontal disease fo r field population studies recently has been d e vised by Russell,21 w ho accepted only positive signs as an indication o f disease, thus limiting reporting to late stages of the disease. T h e supporting tissues are
13. King, J. D. Vincent's disease treated with nicotinic acid. Lancet 2:32 July 13, 1940. 14. M arshall-Dayt C. D., and Shourie, K. L. H yper tro p h ic g in g ivitis in Indian children and adolescents. Indian J. M. Research 35 (4): 261, 1947. 15. Schour, Isaac, and Massler, Maury. Prevalence of g in g ivitis in young adults. J. D. Res. 27:733 Dec. 1948. 16. Kruger, B. J. Incidence of g in g ivitis among a sample of Brisbane school and pre-school children. Aus tra l. J. Den. 59:237 Aug. 1955. 17. Marshall-Day, C. D. The epidem iology of p erio dontal disease. J. Periodont. 22:13 Jan. 1951. 18. Stahl, S. S.; Wisan, J. M., and M ille r, S. C. In fluence of systemic diseases on alveolar bone. J.A .D .A. 45:277 Sept. 1952. 19. Mehta, M . M .; G rainger, R. M., and W illiam s, C. H. M. Periodontal disease among adults. J. Canad. D.A. 21:617 Nov. 1955. 20. Belting, C. M .; Massler, M., and Schour, I. Prev alence and incidence o f alveolar bone disease in men. J.A .D .A . 47:190 Aug. 1953. 21. Russell, A . L. System of classification and scoring fo r prevalence surveys of periodontal disease. J.D. Res. 35:350 June 1956.
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estimated individually fo r each tooth in a m outh and are scored accordin g to a progressive scale w hich weighs soft tissue inflammation lightly and bone involve ment heavily. T h e score for an individual patient is the arithmetic average o f scores for all teeth and reflects the status o f that patient’s periodontal tissues. T here is no reference to type or etiology o f perio dontal disease. Russell’s m ethod o f scor ing permits quantitative comparisons within hum an populations. In essence, existing epidem iologic in form ation shows that periodontal disease is widely prevalent, is probably influenced by systemic disease, is likely to occu r in creasingly with advancing age in both sexes and affects m en earlier in life than wom en. T here is a need fo r indexes o f perio dontal activity to procure statistically re liable inform ation fo r an accurate por trayal o f the m agnitude and charac teristics o f the periodontal problem . T h e present need can be attributed to the absence o f standardized systems o f exam i nation and diagnosis, and a lack o f uni form ity in survey methods w hich makes comparisons difficult if not impossible. P U B L IC H E A L T H A S P E C T S OF P E R IO D O N T A L T R E A T M E N T
A correct diagnosis is a prerequisite to effective treatment. T o avoid conflict or duplication o f therapeutic procedures, some form o f blueprint o f treatment plan ning is necessary. T h e blueprint may con tain several variations o f a specific plan or different plans o f treatment fo r a specific patient. T h e factors w hich influence treatment planning are many and m ay include the anticipated cooperation o f the patient, the circumstances under w hich therapy is instituted, the ability o f the operator, the psychologically negative attitude o f the patient and the patient’ s econom ic status. Should periodontal therapy include re storative or prosthodontic adjunctive
treatment, the increased costs may be com e a hindrance to periodontal care. Alternative measures, therefore, must be kept in mind. From the public health viewpoint, it is essential to know the factors which in fluence the acceptance or rejection o f in dividual periodontal therapy, since in a larger sense these factors will influence the planning o f treatment programs on a com m unity-wide basis. Few com m unity periodontal care programs exist because the problem o f periodontal disease has been eclipsed by the im portance im puted to dental caries and the attention given that disorder by both private and public health dentists. O n e o f the requirements for an effective com m unity periodontal program is extensive com m unity partici pation in fact finding. Inform ation must be collected, analyzed and interpreted. O nly after this has been accom plished can the com m unity plan an intelligent preventive and remedial program. Various periodontal treatment plans have been proposed, all o f which in clu d e : (1 ) the elimination o f doubtful teeth ; (2 ) the im plem entation o f periodontal treatment; (3 ) the removal o f irritating agents; (4 ) the correction o f injurious habits; (5 ) the adjustment o f occlusion; (6 ) instruction in oral hygiene; (7 ) ac com plishm ent o f associated rehabilitative technics, and (8 ) the initiation of sys tem ic therapeusis. M ost o f these processes must be carried out on an individual basis. O n a com m unity-wide basis, however, the correc tion o f injurious habits and the im prove m ent o f standards o f oral hygiene can be accom plished through public health edu cation technics. P U B L IC H E A L T H A S P E C T S O F P R E V E N T IO N
A program o f prevention o f periodontal disease can be effective only if it is based on a knowledge o f the factors causing the disease and also on an understanding of
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its epidem iologic characteristics. M any o f the local factors that contribute to periodontal disease are so well known that, on a com m unity scale, prevention o f the disorder can be prom oted through the application o f recognized dental health measures. M any o f the systemic factors w hich aggravate or produce periodontal disease are still little known or understood. In these instances, prevention must await future disclosures by the researcher. T here is every reason to believe that eventually rational systemic therapy will supplement present-day local therapeutic measures. Some difference in emphasis m ay be m ade between preventing the occurrence o f periodontal diseases in those persons w ho have never experienced the con d i tion and in preventing a recurrence of the condition in patients w h o have been treated successfully. Patients in the latter category should be cautioned to maintain constant vigilance, since it is necessary for such persons to observe a m ore strict m outh hygiene regime than it is fo r per sons w h o have never experienced the disorder. In a recent study, M arshall-Day, Stephens and Quigley2^ fou n d that only 9 per cent o f 1,279 Boston men and wom en (age 13 to 65) were aware o f the presence o f periodontal disease, and only 7 per cent received treatment fo r the co n dition, despite the fact that the incidence o f gingival disease ranged from 80 per cent at age 13 to 95 per cent at age 65. T h e author estimates that as high as 40 per cent o f the periodontal patients under his care over the past 18 months have never received any instruction from a dentist in proper oral health care. Education appears, therefore, to be o f m ajor im portance. Periodontists as well as other dentists must educate b oth the private patient and the public in matters o f oral hygiene and preventive dentistry. M u ch progress is being m ade in this field. In most dental schools, students are m ade
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familiar with the aims and objectives o f preventive dentistry and dental public health and with the social aspects and responsibilities o f the dental profession. Schools emphasize the responsibility of the dental practitioner to the com m unity; this is well, as dentistry will continue to progress in direct proportion to the a c ceptance o f these ideas. O ther members o f the health profes sions also need to be m ade aware o f the im portance pf periodontal preventive and corrective treatment, and to participate actively in dental com m unity health p ro grams. Despite the pessimism displayed in some quarters o f the profession regarding the value o f dental health education, it has been demonstrated that prescribed instruction in dental hygiene does p ro duce beneficial results. T h e Baltimore toothbrushing study23 showed a measur able salutary effect on tooth cleanliness in upper elementary grade children in that city. A public health program fo r the pre vention o f periodontal disease can suc ceed if the health education aspect o f the project is supported by increased availability o f periodontal care.24 A re cent report25 on trends in public health dentistry by the dental health section o f the Am erican Public Health Association states: T he new concern of dental research has been with prevalence and relative risk— the epidemiology— and the evolution of survey methods which will permit the comparison of different populations, studied with different examiners. Already differences in risk be tween and within the populations are bein
22. Marshali-Day, C. D., Stephens, R. G., and Ç>uîgley, L. F., Jr. Periodontal disease: prevalence and incidence. J. Periodont. 26:185 Juiy 1955. 23. McCauley, H. B.; Davis, L. B., and Frazier, T. M. Effect on oral cleanliness produced by dental health in struction and brushing the teeth in the class room: The 1953-54 Baltimore toothbrushing study. J. School Health 25:250 Nov. 1955. 24. Dummett, C. O . Public health aspects of perio dontics. J.D. Med. 10:28 Jan. 1955. 25. Trends in p ublic health dentistry. Am . J. Pub. Health 46:353 March 1956.
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to specific causative factofs, mass preventive methods may be indicated.
Periodontics, especially, has been the victim o f a profusion o f misleading state ments and misconceptions. Periodontal health inform ation must be subjected to critical scrutiny. O nly the inform ation that is accurate and scientifically proved should be utilized. T h e presentation of such inform ation to the public is an im portant phase o f health education and should be handled with care» A t present most periodontists agree that a proper toothbrushing technic is an effective, simple and relatively inexpen sive asset in maintaining oral cleanliness and preventing periodontal disease. T h e excursions o f fibrous foods and the co n stant manipulations o f the tongue, cheeks and lips provide a natural cleansing action to the teeth. Toothbrushing sup plements this natural cleansing action w hich becom es less effective with softer and m ore adhesive foods.26 V arious methods o f toothbrushing have been proposed, with each proponent claim ing some superiority or special bene fit for a particular m ethod. H ine27 states that the most effective toothbrushing m ethod depends on the adaptation o f one or m ore technics to the patient’s needs, after those needs have been assessed by the dentist. T h e stiffness o f bristles is another phase o f toothbrushing about w hich there has been m uch discussion and difference of opinion. As yet there are no official bristle stiffness standards. H ine28 recom m ends m edium bristles since they are stiff enough to clean adequately and massage satisfactorily, yet will not lacerate delicate gingival tissues. As yet no scientific evidence is avail able proving that massage is an effective aid in the prevention or treatment of chronic periodontal diseases.29,30 Clinical studies suggest, however, that the effects o f functional stimulation on the circula tion in the periodontal tissues are benefi cial and must be considered primary
assets in the restoration and maintenance o f periodontal health.31,32 D iet and nutrition are im portant fa c tors w hich must be considered in a dis cussion o f the prevention o f periodontal disease. It is now generally agreed32,33 that the physical character o f the diet does exert some influence on the perio dontium , and that the mastication o f hard, coarse foods stimulates the support ing tissues. M ost dental nutrition studies have been conducted on experimental animals so that the findings must be qualified in re lating them to humans. Som e o f these animal nutrition experiments were spec tacular and pointed out the possibilities o f malnutritionally inducing periodontal disease. V itam in A deficiency, for in stance, renders animals m ore susceptible to bacterial invasion.34,35 W idening o f the periodontal mem brane space and de generation o f the principal periodontal fibers have been observed38 in rats fed a vitamin A deficiency diet. P ronounced alveolar bone loss in men has been demonstrated in instances of vitamin B2 deficiency.37 Gingivitis and glossitis accom pany nicotinic acid defi ciency.38'40 G lickm an indicates41 that acute vitamin C -deficiency alters the re-
26. M iller, S. C . Textbook of periodontia, ed. 3. Phila delphia, Blakiston C o ., 1950. 27. Hine, M. K. Use of the toothbrush in the treat ment of periodontitis. J .A .D .A . 41:158 Aug. 1950. 28. Hine, M. K. Variation in toothbrush textures. J.A .D .A . 46:536 May 1953. 29. Loeb, V irg il, Gingival massage. J . Periodont. 19:70 A p ril 1948. 30. Lyons, H arry. Gingival massage. J . Periodont. 19:71 A p ril 1948. 31. Beube, F. E. Gingival massage. J . Periodont. 19:66 Ja n . 1948. 32. Glickm an, I. C lin ical periodontology. Philadel phia, W . B. Saunders Co ., 1953. 33. Pelzer, R. H . Study of the local oral effect of diet on the periodontal tissues and gingival capillary struc ture. J.A .D .A . 27:13 Ja n . 1940. 34. G o ldblatt, H ., and Benischek, M. Vitamin A de ficiency and m etaplasia. J . Exper. Med. 46:699 Nov. 1927. 35. Green, H . N ., and Meflanby, E. Vitamin A as antiinfective agent. Brit. M .J. 2:691, 1928. 36. Boyle, P. E., and Bessey, O . A . Effect of acute vitamin A deficiency on the molar teeth and paradontal tissues, with a comment on deformed incisor teeth in this deficiency. J .D . Res. 20:236 June 1941. 37.' Ross, J . A . Some observations on dental chanqes in possible riboflavin deficiency. Brit. J . Radiol. 17:247 Aug. 1944.
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sponse o f periodontal tissues so that gin gival inflam m ation accentuates the d e structive effect on the periodontal mem brane and alveolar bone. Edem a, hem orrhage and pronounced collagen degeneration in the periodontal m em brane result from acute vitamin C de ficiency.42 T h e effect on the periodontal tissues o f a diet deficient in vitamin D alone and in com bination with dietary calcium and phosphorus have been studied in experimental animals. T h e changes observed have included osteo porosis, distortion o f the growth pattern o f alveolar bone, reduction in the width o f the periodontal mem brane, gingivitis and extensive periodontal destruction with tooth exfoliation.43'45 Protein d e ficiency produces degeneration o f the gingival connective tissue and periodontal m em brane, and also osteoporosis and re tardation in cem entum deposition.46 O ther changes have been demonstrated from deficiencies in am ino acids, minerals and calories. T h e necessary nutriments must be sup plied in order to satisfy the chem ical re quirements o f the periodontal tissues. T h e prevention o f periodontal disease is, to some extent, dependent on nutri tionally adequate diets to maintain high oral tissue resistance. T h e con cept that periodontal disease begins in hum an beings with nutritional insufficiencies has not been substantiated. N or has it been demonstrated that, in the presence o f adequate nutrition, there is either an increase in effectiveness, o r a dim inution in the duration, o f treatment. Deterioration o f the periodontium may accom pany certain systemic diseases in which nutritional deficiencies are etiologic factors; however, it must be kept in m ind that a m ultiplicity o f factors makes o b scure a specific cause and effect relation ship. A ll these little known facts should be disseminated to the public so that every advantage may be taken o f whatever fa cilities exist in the com m unity fo r the
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prevention and control o f periodontal disease. SU M M AR Y
1. Dentistry is one o f the public health disciplines w hich is beneficial to the entire comm unity. 2. Instruction in oral hygiene, the pre vention and treatment o f periodontal dis turbances, and the produ ction o f scien tific inform ation are three specific ob jec tives o f dental public health. 3. Early diagnosis o f periodontal dis ease enables early treatment to be instituted, thus preventing tooth loss. 4. E pidem iologic surveys indicate that periodontal disease is ubiquitous. W ide variations in m ethods o f diagnostic tech nics render com parisons difficult and frequently impossible. 5. Reliable indexes o f periodontal a c tivity are vitally needed. 6. Factual inform ation is a pre requisite to the organization o f acceptable com m unity programs. 7. Periodontists must be trained to educate both the individual patient and the public about oral health facts, and all
38. Jeghers, H . M edical progress; nutrition: appear ance of tongue as index of nutritional deficiency. New England J . Med. 227:221 A ug . 6, 1942. 39. King. J . D. Vincent's disease treated with nicotinic a c id . Lancet 2:32 Ju ly 13, 1940. 40. W eisberger, D. Lesions of the oral mucosa treated with specific vitam ins. A m . J . Orthodont. & Oral Surg. 27:125 March 1941. 41. Glickm an, I. Acute vitamin C deficiency and the periodontal disease: The periodontal tissues of the guinea pig in acute vitam in C deficiency. J .D . Res. 27:201 A p ril 1948. 42. Boyle, P. E.; Bessey, O tto, and W olbach, S. B. Experimental production of the diffuse alveolar bone atrophy type of periodontal disease by diets deficient in ascorbic ac id . J .A .D .A . 24:1768 Nov. 1937. 43. Becks, H ., and W eber, M . Influence of diet on the bone system with special reference to the alveolar process ana labyrinthine capsule. J .A .D .A . 18:197 Feb. 1931. 44. Weinmann, J . P., and Schour, I. Experimental studies in calcificatio n : effect of a rachitogenic diet on dental tissues of white rat. A m . J . Path. 21:821 Sept. 1945. 45. Agnew R. G . A pplication of periodontal physi ology to orthodontic practice. Internat. J . Orthodont. 19:584, 1933. 46. Chawla, T. N ., and G lickm an, I. Protein depri vation and the periodontal structures of the albino rat. O ral Surg., O ral Med. & O ral Path. 4:578 May 1951.
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health workers should participate ac tively in dental health programs. 8. Programs o f prevention can be aided if public health education is sup ported by increased availability o f perio dontal care. 9. H igh oral tissue resistance is essen tial and may be produ ced through fu n c tional and m echanical stimulation. N u tritionally adequate diets should supply
the necessities fo r periodontal health and should supply a m odicum o f m echanical stimulation. 10. W hile additional inform ation from researchers is awaited, the existing body o f knowledge must be utilized to prevent, control and treat periodontal disturb ances, and to educate the public regard ing measures w hich it can take to reduce the incidence o f the disease.
A dental survey of an urban, employed group Bissell B. P a lm er * D .D .S ., N ew Y ork, and B. D uane M o e n ,f M .A ., Chicago
F or many years students in the field o f dental econom ics have encountered a “ dead end” whenever they required data on the prevalence o f dental diseases am ong members o f em ployed groups. T here has been a corresponding dearth o f inform ation regarding the costs o f treat ing and correcting dental defects on the basis o f the various fee scales. T h e im por tance o f this lack o f inform ation is em phasized by the fact that any planning to provide dental care for large groups o f em ployed persons must be tied in with in form ed estimates o f the probable claims rates and costs o f services. M any studies have been m ade o f the frequency o f dental diseases in children. Also, several studies have been m ade o f the dental conditions o f special groups o f adults, such as members o f the A rm ed Forces or patients at dental clinics. These special groups generally have not been rep resentative o f employed groups because the examinees were too young, too old, m en or w om en only, sick or indigent. T h e
data secured from these various studies, although o f value, have not supplied the inform ation so urgently required in re lation to the dental needs o f large groups o f em ployed persons. S E L E C T IO N
OF A N E M P L O Y E D GROUP
A fter a study o f the various previous in vestigations, it was decided that only through a dental survey o f a large em ployed group could the needed data be collected. It was decided that the em ployees o f a large urban department store w ould be reasonably typical o f em ployed
This study was made possible by a grant from the Group Health Dental Insurance, Inc. and Martin E.Segal and Company. Dr. Palmer conceived, organized, directed and se cured financing for the survey and transferred the data to work sheets. Mr._ Moen prepared the final tables and wrote the analysis of the survey statistics. *President Group Health Dental Insurance, Inc., and lecturer, School of Public Health and Adm inistrative Medicine, Colum bia University. fD Irector, Bureau of Economic Research and Statistics, Am erican Dental Association.
C lifton O. D u m m ett, D .D .S ., M .S .D ., M .P .H ., U. S. A ir F orce
a m ajor concern in present-day dentistry, and as one o f the health problem s in need o f support by the public health profes sion.
Public health is defined1 as the science and art o f preventing disease, prolonging life and prom oting physical and mental efficiency through organized comm unity effort. K nutson2 observes that this defini tion, despite its comprehensiveness, is not sufficiently practical. T h e specific o b je c tives3 o f public health as they affect den tistry encompass the prevention, early diagnosis and treatment o f dental caries, malocclusion, oral clefts and other anomalies, cancer and traumatic injuries o f the teeth and maxilla. In addition there are instructions in acceptable oral hygiene, the prevention and treatment of gingival and periodontal diseases, the production o f scientifically accurate in form ation, the m otivation o f proper oral health habits and attitudes on the part of the public, and the developm ent o f lec tures for dental public health programs. Periodontics is that specialty o f dental science w hich is concerned with the study, prevention and treatment o f dis eases o f the supporting tissues o f the teeth. In origin or in effect, periodontal diseases may include those local or sys temic disturbances o f the supporting tissues which may be m orphologic, in fec tious, traumatic or degenerative. A fter 35 years o f age patients lose more teeth as a result o f periodontal disease than from any other single dental dis ease.4,5 Affections o f the periodontium must therefore be reckoned with, both as
P U B L IC H E A L T H A S P E C T S OF P E R IO D O N T A L D IS E A S E
A n inspection of the teeth and their sup porting tissues and an evaluation o f other oral and systemic conditions are essentials in the examination o f patients fo r perio dontal disease. These examinations con stitute the basis o f diagnosis and should enable the periodontist to determine the distinctive nature o f periodontal diseases. A thorough examination is a prerequisite fo r effective treatment. Indispensable requirements fo r perio dontal diagnosis include an over-all ap-
Presented before the Section on Periodontics, ninetyseventh annual session, Am erican Dental Association, A tla n tic City, N. J., O ctober I, 1956. The opinions expressed herein are solely those o f the author and do not necessarily reflect policies o f the U. S. A ir Force M edical Service. Major, Dental Corps, U. S. A ir Force, 5005th U. S. A ir Force Hospital, A . P. O . 942, Seattle, Wash. 1. Winslow, C. E. A . U nfilled fields of p ublic health. M od. Med. 2:183 March 1920. 2. Pelton, W . J., and Wisan, J. M . Dentistry In public health, ed. 2. Philadelphia, W . B. Saunders Co., 1955. 3. Proposed re po rt on educational qualifications of pub lic health dentists. Am .J. Pub. Health 42:188 Feb. 1952. 4. Allen, E. F. Statistical study o f the prim ary causes o f extractions. J.D. Res. 23:453 Dec. 1944. 5. Brekhus, P. J. Dental disease and its relation to the loss of human teeth. J.A .D .A . 16:2237 Dec. 1929. 49
50 • TH E JO U RNAL O F TH E A M ER IC A N DENTAL A SSO C IA TIO N
praisal o f the patient, a consideration o f the principal com plaint, examination of the oral cavity, local and systemic case histories, history o f dietary intake and nutritional status, roentgenographic ex amination, study casts and the numerous laboratory aids utilized in the diagnosis o f oral and systemic diseases.6 T h e cor rectness o f the diagnosis is in proportion to the completeness o f these specific steps. It is in the area o f early diagnosis o f periodontal disease that there is an im portant relationship o f periodontics to public health. T h e incipient signs o f periodontal diseases can be detected by careful systematic oral examination, and dentists should not be satisfied until such examinations have uncovered the etiologic factors. T h e early diagnosis o f gingival and periodontal disease— a specific o b je c tive o f dental pu blic health— enables treatment to be instituted as soon as pos sible. T h e diagnosis o f varying types o f perio dontal diseases is dependent on an ac ceptable classification. Several classifica tions o f periodontal conditions have been proposed. T h e most generally accepted ones today are based on O rban ’s w ork7 which classifies periodontal diseases on the basis o f inflammatory, degenerative, atrophic, hypertrophic, traumatic and neoplastic entities. Such a classification is necessary to investigate the epidem i ology o f periodontal disease. Frost8 defines epidem iology as the science w hich considers the occurrence, distribution and types o f diseases o f m an kind in distinct epochs o f time at varying points on the earth’s surface. E pidem i ology presents the relations o f these dis eases to inherent characteristics o f the individual and to the external conditions which surround him and w hich determine his manner o f life. Ever since the examination o f ancient skulls showed that periodontal diseases are probably as old as man, there has been m uch interest in gathering data about the types o f periodontal disease,
the persons most affected and the regions in w hich varying conditions occurred. These studies of early m an indicate that some form o f periodontal disease has ex isted in practically every part o f the world. Surveys o f contem porary m an re veal a greater prevalence o f the m ore severe form s o f periodontal disturbances in some countries than in others. For exam ple, the natives o f W est A frica have been fou n d to have a higher incidence of periodontal disease than those o f East Africa. Generalized gingival hyperplasia affects practically 100 per cent o f the Australian aborigines.9 In Europe, south ern and Dinaric races are affected m ore severely with periodontal disease than those living in Finland and L aplan d.10 In Bombay, India, the disease is m ore prevalent and severe, with as high as 93 per cent o f children (11 to 16 years old ) being affected.11 Akhter reports12 that 95 per cent o f Punjab school children 10 to 16 years old showed signs o f perio dontal disease, chiefly hypertrophic gin givitis. Considerable evidence from A us tralasia indicates that the prevalence of periodontal disease increases with age.9 M any o f these epidem iologic studies record opinions and observations that are primarily subjective, and are frequently based only on visual inspection o f the gingiva. M oreover, a w ide variation in methods o f diagnostic technics and ap proaches to surveys has rendered co l lected data difficult o f confirm ation, un-
6. Thoma, K. H., and Robinson, H. B. G . O ral and dental diagnosis, ed. 4. Philadelphia, W . B. Saunders Co., 1955. 7. O rban, B. Classification and nomenclature o f perio dontal diseases. J. Periodont. 13:88 July 1942. 8. Frost, Wade Ham pton. Papers; a contribution to epidem iological method. Edited by K. F. Maxcy. New York, Commonwealth Fund, 1941. 9. Cunningham, W . M . Prevalence o f periodontal dis ease. 2. In Australasia. Internat. D.J. 5:200 June 1955. 10. Loos, S. Prevalence of periodontal disease: 3. Europe. Internat. D.J. 5:319 Sept. 1955. 1!. Mehta, F. S.; Sanjana, M . K., and Shroff, B. C. Prevalence o f periodontal disease. 5. Epidem iology in Indian child population in relation to their socio-eco nomic status. Internat. D.J. 6:31 March 1956. 12. Akhter, H. Incidence o f periodontal diseases in the Punjab. Pakistan D. Rev. 5:109 July 1955.
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reliable in com parison and, therefore, limited in value. T h e epidem iologic studies o f K ing, Schour, Massler and M arshall-Day evalu ated gingival diseases in children. K in g’s13 objective differentiation o f forms o f gingivitis was expressed quantitatively. M arshall-Day and Shourie assessed14 the severity o f gingivitis on the basis o f changes in gingival surface margins and papillae. F or their evaluations, Schour and Massler15 used the P M A index, a quantitative clinical measurement in which the location o f gingival inflam m a tion provides an estimate o f the degree of gingivitis in individual instances. A ll o f these investigators fou n d that inflam matory gingival conditions occurred in m ore than 90 per cent o f the persons examined. In a m ore recent study on the incidence o f gingivitis in Brisbane school children (age 3 to 12 years), K ru ger16 utilized the P M A index and fou n d that the per centage o f children with gingivitis ranged from 49 per cent (3 year age grou p) to 90.5 per cent (9 year age g ro u p ). T here was a definite correlation between dental caries attack and the incidence and severity o f gingivitis. Studies o f the more advanced stages o f periodontal disease frequently have uti lized roentgenographic estimations o f bone loss or evaluations o f the occurrence o f the disease without regard to degree o f severity. In using the amount o f bone loss as a determinant o f the advancement o f periodontal disease, M arshall-Day17 found that the prevalence o f periodontal diseases with roentgenographic evidence o f bone loss around on e or m ore teeth ranged from 4 per cent (age 13 to 15) to 100 per cent (age 6 5 ). A bove 35 years o f age, the prevalence o f bone loss was practically universal. In addition, tooth mortality increased from 6 per cent (age 19 to 20) to 60 per cent (age 6 0 ). Stahl, Wisan and M iller,18 after taking into account the alveolar resorptive changes which accom pany aging, re
ported a greater severity o f bone loss in Veterans Administration patients suffer ing from diseases in w hich general cellu lar metabolism was affected, than in p a tients admitted for local ills. M ehta, Grainger and W illiam s19 ex amined 670 Canadian civil servants (302 men and 368 w om en) aged 15 to 24 and fou n d that periodontitis simplex was the most com m on form o f the disease, affect ing 79.4 per cent o f the men and 79.6 per cent o f the wom en. Periodontitis com plex was diagnosed fo r 16.3 per cent o f the men and 9.4 per cent o f the wom en. T h e pockets per person and per tooth were significantly higher in men after age 35. O ral hygiene retrogressed with age and was poorer in m en than in women. A study by Belting, Massler and Schour20 forecasts that 50 per cent o f all males will have some clinical or roent genographic evidence o f periodontal dis ease by the time they are 45 years old. An alternative possibility w ould be the loss o f all teeth from periodontal disease. A promising quantitative m ethod o f scoring periodontal disease fo r field population studies recently has been d e vised by Russell,21 w ho accepted only positive signs as an indication o f disease, thus limiting reporting to late stages of the disease. T h e supporting tissues are
13. King, J. D. Vincent's disease treated with nicotinic acid. Lancet 2:32 July 13, 1940. 14. M arshall-Dayt C. D., and Shourie, K. L. H yper tro p h ic g in g ivitis in Indian children and adolescents. Indian J. M. Research 35 (4): 261, 1947. 15. Schour, Isaac, and Massler, Maury. Prevalence of g in g ivitis in young adults. J. D. Res. 27:733 Dec. 1948. 16. Kruger, B. J. Incidence of g in g ivitis among a sample of Brisbane school and pre-school children. Aus tra l. J. Den. 59:237 Aug. 1955. 17. Marshall-Day, C. D. The epidem iology of p erio dontal disease. J. Periodont. 22:13 Jan. 1951. 18. Stahl, S. S.; Wisan, J. M., and M ille r, S. C. In fluence of systemic diseases on alveolar bone. J.A .D .A. 45:277 Sept. 1952. 19. Mehta, M . M .; G rainger, R. M., and W illiam s, C. H. M. Periodontal disease among adults. J. Canad. D.A. 21:617 Nov. 1955. 20. Belting, C. M .; Massler, M., and Schour, I. Prev alence and incidence o f alveolar bone disease in men. J.A .D .A . 47:190 Aug. 1953. 21. Russell, A . L. System of classification and scoring fo r prevalence surveys of periodontal disease. J.D. Res. 35:350 June 1956.
52 • TH E JO U R N A L O F T H E A M ER IC A N DENTAL A SSO C IA TIO N
estimated individually fo r each tooth in a m outh and are scored accordin g to a progressive scale w hich weighs soft tissue inflammation lightly and bone involve ment heavily. T h e score for an individual patient is the arithmetic average o f scores for all teeth and reflects the status o f that patient’s periodontal tissues. T here is no reference to type or etiology o f perio dontal disease. Russell’s m ethod o f scor ing permits quantitative comparisons within hum an populations. In essence, existing epidem iologic in form ation shows that periodontal disease is widely prevalent, is probably influenced by systemic disease, is likely to occu r in creasingly with advancing age in both sexes and affects m en earlier in life than wom en. T here is a need fo r indexes o f perio dontal activity to procure statistically re liable inform ation fo r an accurate por trayal o f the m agnitude and charac teristics o f the periodontal problem . T h e present need can be attributed to the absence o f standardized systems o f exam i nation and diagnosis, and a lack o f uni form ity in survey methods w hich makes comparisons difficult if not impossible. P U B L IC H E A L T H A S P E C T S OF P E R IO D O N T A L T R E A T M E N T
A correct diagnosis is a prerequisite to effective treatment. T o avoid conflict or duplication o f therapeutic procedures, some form o f blueprint o f treatment plan ning is necessary. T h e blueprint may con tain several variations o f a specific plan or different plans o f treatment fo r a specific patient. T h e factors w hich influence treatment planning are many and m ay include the anticipated cooperation o f the patient, the circumstances under w hich therapy is instituted, the ability o f the operator, the psychologically negative attitude o f the patient and the patient’ s econom ic status. Should periodontal therapy include re storative or prosthodontic adjunctive
treatment, the increased costs may be com e a hindrance to periodontal care. Alternative measures, therefore, must be kept in mind. From the public health viewpoint, it is essential to know the factors which in fluence the acceptance or rejection o f in dividual periodontal therapy, since in a larger sense these factors will influence the planning o f treatment programs on a com m unity-wide basis. Few com m unity periodontal care programs exist because the problem o f periodontal disease has been eclipsed by the im portance im puted to dental caries and the attention given that disorder by both private and public health dentists. O n e o f the requirements for an effective com m unity periodontal program is extensive com m unity partici pation in fact finding. Inform ation must be collected, analyzed and interpreted. O nly after this has been accom plished can the com m unity plan an intelligent preventive and remedial program. Various periodontal treatment plans have been proposed, all o f which in clu d e : (1 ) the elimination o f doubtful teeth ; (2 ) the im plem entation o f periodontal treatment; (3 ) the removal o f irritating agents; (4 ) the correction o f injurious habits; (5 ) the adjustment o f occlusion; (6 ) instruction in oral hygiene; (7 ) ac com plishm ent o f associated rehabilitative technics, and (8 ) the initiation of sys tem ic therapeusis. M ost o f these processes must be carried out on an individual basis. O n a com m unity-wide basis, however, the correc tion o f injurious habits and the im prove m ent o f standards o f oral hygiene can be accom plished through public health edu cation technics. P U B L IC H E A L T H A S P E C T S O F P R E V E N T IO N
A program o f prevention o f periodontal disease can be effective only if it is based on a knowledge o f the factors causing the disease and also on an understanding of
DUMMETT
its epidem iologic characteristics. M any o f the local factors that contribute to periodontal disease are so well known that, on a com m unity scale, prevention o f the disorder can be prom oted through the application o f recognized dental health measures. M any o f the systemic factors w hich aggravate or produce periodontal disease are still little known or understood. In these instances, prevention must await future disclosures by the researcher. T here is every reason to believe that eventually rational systemic therapy will supplement present-day local therapeutic measures. Some difference in emphasis m ay be m ade between preventing the occurrence o f periodontal diseases in those persons w ho have never experienced the con d i tion and in preventing a recurrence of the condition in patients w h o have been treated successfully. Patients in the latter category should be cautioned to maintain constant vigilance, since it is necessary for such persons to observe a m ore strict m outh hygiene regime than it is fo r per sons w h o have never experienced the disorder. In a recent study, M arshall-Day, Stephens and Quigley2^ fou n d that only 9 per cent o f 1,279 Boston men and wom en (age 13 to 65) were aware o f the presence o f periodontal disease, and only 7 per cent received treatment fo r the co n dition, despite the fact that the incidence o f gingival disease ranged from 80 per cent at age 13 to 95 per cent at age 65. T h e author estimates that as high as 40 per cent o f the periodontal patients under his care over the past 18 months have never received any instruction from a dentist in proper oral health care. Education appears, therefore, to be o f m ajor im portance. Periodontists as well as other dentists must educate b oth the private patient and the public in matters o f oral hygiene and preventive dentistry. M u ch progress is being m ade in this field. In most dental schools, students are m ade
VO LUM E 54, JA N U A R Y 1957 • 53
familiar with the aims and objectives o f preventive dentistry and dental public health and with the social aspects and responsibilities o f the dental profession. Schools emphasize the responsibility of the dental practitioner to the com m unity; this is well, as dentistry will continue to progress in direct proportion to the a c ceptance o f these ideas. O ther members o f the health profes sions also need to be m ade aware o f the im portance pf periodontal preventive and corrective treatment, and to participate actively in dental com m unity health p ro grams. Despite the pessimism displayed in some quarters o f the profession regarding the value o f dental health education, it has been demonstrated that prescribed instruction in dental hygiene does p ro duce beneficial results. T h e Baltimore toothbrushing study23 showed a measur able salutary effect on tooth cleanliness in upper elementary grade children in that city. A public health program fo r the pre vention o f periodontal disease can suc ceed if the health education aspect o f the project is supported by increased availability o f periodontal care.24 A re cent report25 on trends in public health dentistry by the dental health section o f the Am erican Public Health Association states: T he new concern of dental research has been with prevalence and relative risk— the epidemiology— and the evolution of survey methods which will permit the comparison of different populations, studied with different examiners. Already differences in risk be tween and within the populations are bein
22. Marshali-Day, C. D., Stephens, R. G., and Ç>uîgley, L. F., Jr. Periodontal disease: prevalence and incidence. J. Periodont. 26:185 Juiy 1955. 23. McCauley, H. B.; Davis, L. B., and Frazier, T. M. Effect on oral cleanliness produced by dental health in struction and brushing the teeth in the class room: The 1953-54 Baltimore toothbrushing study. J. School Health 25:250 Nov. 1955. 24. Dummett, C. O . Public health aspects of perio dontics. J.D. Med. 10:28 Jan. 1955. 25. Trends in p ublic health dentistry. Am . J. Pub. Health 46:353 March 1956.
54 • TH E JO U R N A L O F TH E A M ER IC A N DENTAL A SSO C IA TIO N
to specific causative factofs, mass preventive methods may be indicated.
Periodontics, especially, has been the victim o f a profusion o f misleading state ments and misconceptions. Periodontal health inform ation must be subjected to critical scrutiny. O nly the inform ation that is accurate and scientifically proved should be utilized. T h e presentation of such inform ation to the public is an im portant phase o f health education and should be handled with care» A t present most periodontists agree that a proper toothbrushing technic is an effective, simple and relatively inexpen sive asset in maintaining oral cleanliness and preventing periodontal disease. T h e excursions o f fibrous foods and the co n stant manipulations o f the tongue, cheeks and lips provide a natural cleansing action to the teeth. Toothbrushing sup plements this natural cleansing action w hich becom es less effective with softer and m ore adhesive foods.26 V arious methods o f toothbrushing have been proposed, with each proponent claim ing some superiority or special bene fit for a particular m ethod. H ine27 states that the most effective toothbrushing m ethod depends on the adaptation o f one or m ore technics to the patient’s needs, after those needs have been assessed by the dentist. T h e stiffness o f bristles is another phase o f toothbrushing about w hich there has been m uch discussion and difference of opinion. As yet there are no official bristle stiffness standards. H ine28 recom m ends m edium bristles since they are stiff enough to clean adequately and massage satisfactorily, yet will not lacerate delicate gingival tissues. As yet no scientific evidence is avail able proving that massage is an effective aid in the prevention or treatment of chronic periodontal diseases.29,30 Clinical studies suggest, however, that the effects o f functional stimulation on the circula tion in the periodontal tissues are benefi cial and must be considered primary
assets in the restoration and maintenance o f periodontal health.31,32 D iet and nutrition are im portant fa c tors w hich must be considered in a dis cussion o f the prevention o f periodontal disease. It is now generally agreed32,33 that the physical character o f the diet does exert some influence on the perio dontium , and that the mastication o f hard, coarse foods stimulates the support ing tissues. M ost dental nutrition studies have been conducted on experimental animals so that the findings must be qualified in re lating them to humans. Som e o f these animal nutrition experiments were spec tacular and pointed out the possibilities o f malnutritionally inducing periodontal disease. V itam in A deficiency, for in stance, renders animals m ore susceptible to bacterial invasion.34,35 W idening o f the periodontal mem brane space and de generation o f the principal periodontal fibers have been observed38 in rats fed a vitamin A deficiency diet. P ronounced alveolar bone loss in men has been demonstrated in instances of vitamin B2 deficiency.37 Gingivitis and glossitis accom pany nicotinic acid defi ciency.38'40 G lickm an indicates41 that acute vitamin C -deficiency alters the re-
26. M iller, S. C . Textbook of periodontia, ed. 3. Phila delphia, Blakiston C o ., 1950. 27. Hine, M. K. Use of the toothbrush in the treat ment of periodontitis. J .A .D .A . 41:158 Aug. 1950. 28. Hine, M. K. Variation in toothbrush textures. J.A .D .A . 46:536 May 1953. 29. Loeb, V irg il, Gingival massage. J . Periodont. 19:70 A p ril 1948. 30. Lyons, H arry. Gingival massage. J . Periodont. 19:71 A p ril 1948. 31. Beube, F. E. Gingival massage. J . Periodont. 19:66 Ja n . 1948. 32. Glickm an, I. C lin ical periodontology. Philadel phia, W . B. Saunders Co ., 1953. 33. Pelzer, R. H . Study of the local oral effect of diet on the periodontal tissues and gingival capillary struc ture. J.A .D .A . 27:13 Ja n . 1940. 34. G o ldblatt, H ., and Benischek, M. Vitamin A de ficiency and m etaplasia. J . Exper. Med. 46:699 Nov. 1927. 35. Green, H . N ., and Meflanby, E. Vitamin A as antiinfective agent. Brit. M .J. 2:691, 1928. 36. Boyle, P. E., and Bessey, O . A . Effect of acute vitamin A deficiency on the molar teeth and paradontal tissues, with a comment on deformed incisor teeth in this deficiency. J .D . Res. 20:236 June 1941. 37.' Ross, J . A . Some observations on dental chanqes in possible riboflavin deficiency. Brit. J . Radiol. 17:247 Aug. 1944.
DUMMETT .
sponse o f periodontal tissues so that gin gival inflam m ation accentuates the d e structive effect on the periodontal mem brane and alveolar bone. Edem a, hem orrhage and pronounced collagen degeneration in the periodontal m em brane result from acute vitamin C de ficiency.42 T h e effect on the periodontal tissues o f a diet deficient in vitamin D alone and in com bination with dietary calcium and phosphorus have been studied in experimental animals. T h e changes observed have included osteo porosis, distortion o f the growth pattern o f alveolar bone, reduction in the width o f the periodontal mem brane, gingivitis and extensive periodontal destruction with tooth exfoliation.43'45 Protein d e ficiency produces degeneration o f the gingival connective tissue and periodontal m em brane, and also osteoporosis and re tardation in cem entum deposition.46 O ther changes have been demonstrated from deficiencies in am ino acids, minerals and calories. T h e necessary nutriments must be sup plied in order to satisfy the chem ical re quirements o f the periodontal tissues. T h e prevention o f periodontal disease is, to some extent, dependent on nutri tionally adequate diets to maintain high oral tissue resistance. T h e con cept that periodontal disease begins in hum an beings with nutritional insufficiencies has not been substantiated. N or has it been demonstrated that, in the presence o f adequate nutrition, there is either an increase in effectiveness, o r a dim inution in the duration, o f treatment. Deterioration o f the periodontium may accom pany certain systemic diseases in which nutritional deficiencies are etiologic factors; however, it must be kept in m ind that a m ultiplicity o f factors makes o b scure a specific cause and effect relation ship. A ll these little known facts should be disseminated to the public so that every advantage may be taken o f whatever fa cilities exist in the com m unity fo r the
. V O LU M E 54, JA N U A R Y 1957 • 55
prevention and control o f periodontal disease. SU M M AR Y
1. Dentistry is one o f the public health disciplines w hich is beneficial to the entire comm unity. 2. Instruction in oral hygiene, the pre vention and treatment o f periodontal dis turbances, and the produ ction o f scien tific inform ation are three specific ob jec tives o f dental public health. 3. Early diagnosis o f periodontal dis ease enables early treatment to be instituted, thus preventing tooth loss. 4. E pidem iologic surveys indicate that periodontal disease is ubiquitous. W ide variations in m ethods o f diagnostic tech nics render com parisons difficult and frequently impossible. 5. Reliable indexes o f periodontal a c tivity are vitally needed. 6. Factual inform ation is a pre requisite to the organization o f acceptable com m unity programs. 7. Periodontists must be trained to educate both the individual patient and the public about oral health facts, and all
38. Jeghers, H . M edical progress; nutrition: appear ance of tongue as index of nutritional deficiency. New England J . Med. 227:221 A ug . 6, 1942. 39. King. J . D. Vincent's disease treated with nicotinic a c id . Lancet 2:32 Ju ly 13, 1940. 40. W eisberger, D. Lesions of the oral mucosa treated with specific vitam ins. A m . J . Orthodont. & Oral Surg. 27:125 March 1941. 41. Glickm an, I. Acute vitamin C deficiency and the periodontal disease: The periodontal tissues of the guinea pig in acute vitam in C deficiency. J .D . Res. 27:201 A p ril 1948. 42. Boyle, P. E.; Bessey, O tto, and W olbach, S. B. Experimental production of the diffuse alveolar bone atrophy type of periodontal disease by diets deficient in ascorbic ac id . J .A .D .A . 24:1768 Nov. 1937. 43. Becks, H ., and W eber, M . Influence of diet on the bone system with special reference to the alveolar process ana labyrinthine capsule. J .A .D .A . 18:197 Feb. 1931. 44. Weinmann, J . P., and Schour, I. Experimental studies in calcificatio n : effect of a rachitogenic diet on dental tissues of white rat. A m . J . Path. 21:821 Sept. 1945. 45. Agnew R. G . A pplication of periodontal physi ology to orthodontic practice. Internat. J . Orthodont. 19:584, 1933. 46. Chawla, T. N ., and G lickm an, I. Protein depri vation and the periodontal structures of the albino rat. O ral Surg., O ral Med. & O ral Path. 4:578 May 1951.
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health workers should participate ac tively in dental health programs. 8. Programs o f prevention can be aided if public health education is sup ported by increased availability o f perio dontal care. 9. H igh oral tissue resistance is essen tial and may be produ ced through fu n c tional and m echanical stimulation. N u tritionally adequate diets should supply
the necessities fo r periodontal health and should supply a m odicum o f m echanical stimulation. 10. W hile additional inform ation from researchers is awaited, the existing body o f knowledge must be utilized to prevent, control and treat periodontal disturb ances, and to educate the public regard ing measures w hich it can take to reduce the incidence o f the disease.
A dental survey of an urban, employed group Bissell B. P a lm er * D .D .S ., N ew Y ork, and B. D uane M o e n ,f M .A ., Chicago
F or many years students in the field o f dental econom ics have encountered a “ dead end” whenever they required data on the prevalence o f dental diseases am ong members o f em ployed groups. T here has been a corresponding dearth o f inform ation regarding the costs o f treat ing and correcting dental defects on the basis o f the various fee scales. T h e im por tance o f this lack o f inform ation is em phasized by the fact that any planning to provide dental care for large groups o f em ployed persons must be tied in with in form ed estimates o f the probable claims rates and costs o f services. M any studies have been m ade o f the frequency o f dental diseases in children. Also, several studies have been m ade o f the dental conditions o f special groups o f adults, such as members o f the A rm ed Forces or patients at dental clinics. These special groups generally have not been rep resentative o f employed groups because the examinees were too young, too old, m en or w om en only, sick or indigent. T h e
data secured from these various studies, although o f value, have not supplied the inform ation so urgently required in re lation to the dental needs o f large groups o f em ployed persons. S E L E C T IO N
OF A N E M P L O Y E D GROUP
A fter a study o f the various previous in vestigations, it was decided that only through a dental survey o f a large em ployed group could the needed data be collected. It was decided that the em ployees o f a large urban department store w ould be reasonably typical o f em ployed
This study was made possible by a grant from the Group Health Dental Insurance, Inc. and Martin E.Segal and Company. Dr. Palmer conceived, organized, directed and se cured financing for the survey and transferred the data to work sheets. Mr._ Moen prepared the final tables and wrote the analysis of the survey statistics. *President Group Health Dental Insurance, Inc., and lecturer, School of Public Health and Adm inistrative Medicine, Colum bia University. fD Irector, Bureau of Economic Research and Statistics, Am erican Dental Association.