DENTAL SANITATION
"Have their teeth attended to first, and many of the eye defects will
disappear." This was an unexpected contribution to the debate upon free
eyeglasses for the school children of New York City. So little do most
of us realize the importance of sound, clean teeth, and the
interrelation of stomach and sense nerves, that even the school
principals thought the eye specialist was exaggerating when he declared
that bad teeth cause indigestion and indigestion causes eye strain.
"Bad" teeth mean to most people dirty teeth and offensive odors, loose,
crooked, or isolated teeth, or black stumps. Even among dentists a
great many, probably the majority, do not appreciate that "bad" teeth
mean indigestion, lowered vitality, plague spots for contaminating
sound teeth and for breeding disease germs. Until recently the only
rule about the teeth of new recruits in the United States army was:
"There must be two opposing molars on each side of the mouth. It
doesn't matter how rotten these molars may be." The surgeon general was
persuaded to change to "four opposing molars on each side"; still
nothing as to the condition of the two additional molars! In the German
army there is a regular morning inspection of teeth and toothbrushes.
Several German insurance companies give free dental treatment to policy
holders, not to bestow charity but to increase profits.
Neglecting "baby teeth" and adenoids may mean crooked second teeth that
will cause: (1) hundreds of dollars for straightening; (2) permanent
business handicap because crooked teeth are disagreeable to others,
because mastication is less perfect, and because a disfigured mouth
means dis-arranged nerves; or perhaps (3) large dental bills because it
is difficult to clean between cramped, crooked teeth.
Unfortunately the great majority of parents rarely think of their
children's teeth until too late to preserve them intact. Even among
families where the rule of brushing the teeth twice daily prevails,
regular dental examination is often not required. Doctors and dentists
themselves have not been trained to realize that the teeth are a most
dangerous source of infection when unclean. Does your dentist insist
upon removing tartar and food particles beyond your reach, upon
polishing and cleansing, or does he regard these as vanity touches, to
be omitted if you are in a hurry?
[Illustration: INDUSTRIAL HANDICAPS DISCOVERED AT SCHOOL]
Physicians send tuberculosis patients to hospitals or camps without
correcting the mouth conditions that make it impossible for the patient
to eat or swallow without infecting himself. Tonics are given to women
whose teeth are breeding and harboring disease germs that tear down
vitality. Nurses watch their suffering patients and do the heavier
tasks heroically, but are not trained to teach the simple truths about
dental hygiene. The far-reaching results of neglect of teeth will not
be understood until greater emphasis is placed on the bacteriology, the
economics, the sociology, and the æsthetics of clean, sound teeth.
Whether or not there is at present a tendency to exaggerate the
importance of sound teeth, there is no difference of opinion as to the
fact that the teeth harbor virulent germs, that the high temperature of
the mouth favors germ propagation, that the twenty to thirty square
inches of surface constantly open to bacterial infection offer an
extensive breeding ground, and that the formation of the teeth invites
the lodgment of germs and of particles of food injurious both to teeth
and to other organs.
By scraping the teeth with the finger nail and noticing the odor you
can convince yourself of the presence of decomposing organic matter not
healthful to be carried into the stomach. By applying a little iodine
and then washing it off with water, your teeth may show stains. These
stains are called gelatinous plaques, which are transparent and
invisible to the naked eye except when colored by iodine. These plaques
protect the germs, which ferment and create the acid which destroys
tooth structure. Their formation can be prevented by vigorous brushing
and by eating hard food.
The individual with decayed teeth, even with unclean teeth, is open to
infection of the lungs, tonsils, stomach, glands, ears, nose, and
adenoid tissues. Every time food is taken, and at every act of
swallowing, germs flow over the tonsils into the stomach. Mouth
breathers with teeth in this condition cannot get one breath of
uncontaminated air, for every breath becomes infected with poisonous
emanations from the teeth. Bad teeth are frequently the sole cause of
bad breath and dyspepsia, and can convey to the system tuberculosis of
the lungs, glands, stomach, or nose, and many other transmissible
diseases. They may also cause enlarged tonsils and ear trouble.
Apart from decomposing food and stagnant septic matter from saliva
injured by indigestion, and by sputum which collects in the healthy
mouth, there are in many infected mouths pus, exudations from the
irritated and inflamed gum margins, gaseous emanations from decaying
teeth, putrescent pulp tissue, tartar, and chemical poisons. Every
spray from such a mouth in coughing, sneezing, or even talking or
reading, is laden with microbes which vitiate the air to be breathed by
others. Indigestion from imperfect mastication and imperfect salivation
(themselves often due solely to bad teeth) is far less serious than
indigestion from germ infection. Germs taken into the stomach can so
change the composition of saliva (a natural disinfectant when healthy)
as to render it no longer able to kill germs. Indigestion may result in
excess of uric acid and toxic material, so that the individual becomes
subject to gout and rheumatism, which in turn frequently destroy the
bony support of the teeth and bring about Riggs's Disease. The last
named is a prevalent and disfiguring disease, whose symptom is receding
gums. The irritating toxins deposited on the teeth cause inflammation
of the tissues at the gum margins. The gums withdraw more and more from
sections of the teeth; the poisons get underneath and work back toward
the roots; the infection increases and hastens the loosening of the
teeth. I know of a man who had all of his teeth extracted at twenty-one
years of age, because he was told that this was the only treatment for
this disease, which was formerly thought to be incurable. Yet thorough
cleansing and removal of this matter from under the edges of the gums,
disinfection, a few visits to the dentist, will stop the recession but
cannot regain lost ground.
Among those who regularly use the toothbrush, instinct, comfort, or
display is the ruling motive, while a small percentage have evolved to
the anti-nuisance stage, where the æsthetic standard of their group
forbids any member to neglect his teeth. The anti-slum and pro-slum
motives for mouth cleanliness and dental sanitation have been awakened
in but one or two places. A significant pro-slum activity is the dental
clinic organized by forty volunteer dentists, acting for an industrial
school maintained by the New York Children's Aid Society.
[Illustration: NEW YORK CHILDREN'S AID SOCIETY'S DENTAL CLINIC
FOR SCHOOL CHILDREN]
Here 550 children have been examined, 447 teeth extracted, 284 teeth
filled, 200 teeth treated for diseased pulp (and only 24 sets cleaned),
40 dentists taking turns in giving time to this work. The equipment
cost but $239; cards and stationery, $72; incidentals, $33. The
principal attends the clinic, because in her presence no child is
willing to confess fear or unwillingness. To supplement this work, the
dentists have prepared for free distribution a leaflet which tells in
short, clear sentences how to care for the teeth.
[Illustration: (leaflet)]
+----------------------------------------------------------------------+
| A DENTAL CATECHISM =When should they be cleansed?= |
| |
| =What are the teeth for?= Immediately after the morning and |
| noonday meals and before going to |
| To masticate food; that is, bed. |
| grind it into fine particles, |
| mix it with saliva, and so =By what means should they be |
| begin its digestion; also to cleansed?= |
| aid in speaking and singing. |
| By a moderately stiff brush, |
| =How long should they last?= water, and floss silk. |
| |
| To the very end of life. =How should these be used?= |
| |
| =How do we lose them?= The brush should be first used in |
| a general way, high up on the |
| By decay, by loosening, and by gums length-wise of the jaws, to |
| accident. remove large particles and |
| stimulate the gums, then the |
| =What causes teeth to decay?= brush and the teeth should be |
| carefully rinsed with water. The |
| Particles of food decaying in brush should next be used with a |
| contact with them. rolling or circular motion, so |
| that the bristles will follow the |
| =Where does food lodge?= lines of all the grooves and |
| spaces in which the particles of |
| All along the edges of the gums, food have lodged, and so brush |
| in the spaces between the teeth, them out. Then again the mouth |
| and in the crevices of their should be rinsed with water. |
| grinding surfaces. |
| =Should the gums be brushed?= |
| =Can we prevent this loss?= |
| Yes, moderate friction helps to |
| Yes, to a large extent. keep them healthy. |
| |
| =How can we do it?= =How can the spaces between the |
| teeth be reached?= |
| By using the teeth properly and |
| by keeping them clean and the By dental floss silk passed |
| gums healthy. between the teeth, drawn |
| carefully back and forth till it |
| =What does using them properly reaches the gum, pressed firmly |
| mean?= against the side of each tooth in |
| turn and drawn out towards the |
| 1. Using sufficient hard or grinding end of the tooth, and |
| fibrous food to give the teeth this repeated several times in |
| and gums full exercise. each space. |
| |
| 2. Taking time enough to =Should tooth powder or paste be |
| masticate food thoroughly before used?= |
| swallowing. |
| Usually once a day. |
| =How often should teeth be |
| cleansed?= |
| |
| As often as they are used. |
+----------------------------------------------------------------------+
Such a leaflet should be given out at dispensaries, hospitals, dental
offices, schools, and from many Sunday schools and missions.[5]
The time for the schools to begin is when the child is first
registered. Examination and reëxamination must be accompanied by
explanation of the serious disadvantages of neglected teeth, and the
physical, social, and economic advantages of clean, sound teeth.
Instruction at school must be followed by education of parents. The
school or health authorities should examine the teeth of all children
before issuing work certificates. Finally, the dental, medical, and
nursing professions and the press must be enlisted in the school's
campaign for dental hygiene. The Dental Hygiene Council of
Massachusetts should be copied in all states.
A preliminary examination of teeth can be made by parent or teacher.
Crooked, loose, dirty, or black teeth or receding gums can be detected
by a layman's naked eye. In fact, children can be interested in finding
the most obvious defects in their own or their brothers' teeth. There
could be no better first lesson than to ask each pupil to look in a
hand mirror and to count each tooth obviously needing a cleaning or a
filling. The most urgent need can thus be ascertained without expert
aid. But because parent, teacher, or child cannot discover defects does
not prove that dental care is not imperative; hence the importance of
examination by a dentist or by a physician competent to discover dental
needs. If a private, public, or parochial school has no paid visiting
dentist, a zealous school officer can, at least in large towns,
persuade one or more dentists or physicians to make a few first tests
to confirm the teacher's findings, and to persuade the community that
regular examination and reëxamination are necessary and a saving of
pain, beauty, and money.
Reëxamination is necessary because decay _may_ start the day after a
dentist has pronounced a tooth sound. For most of us twice a year is
often enough. A reëxamination should be made upon the slightest
suspicion of decay, breaking, or loosening.
Educational use should be made by the teacher of the results of school
examination. Children cannot be made self-conscious and cleanly by
telling them that their teeth will ache three or five years from now.
They can be made to brush or wash their teeth every morning and every
night if they once realize that cavities can be caused only by _mouth
garbage_. All decay of human teeth starts from the outside through the
enamel that covers the soft bone of the tooth. This enamel can be
destroyed by accidentally cracking or breaking it, or by acids eating
into it. These acids come from (1) particles of food allowed to remain
in the teeth; (2) tartar, etc., that adheres to the teeth and can be
removed only by a dentist; (3) saliva brought up from an
ill-conditioned stomach. Even where the enamel is destroyed, absolute
cleanliness will prevent serious decay of the tooth. A perfectly clean
tooth will not decay. Generally speaking, unless particles of food or
removable acids remain on or between the teeth long enough to
decompose, teeth cannot decay. Decay always means, therefore,
uncleanliness. To unclean teeth is due in large part the offensive odor
of many schoolrooms.
Uncleanliness becomes noticeable to our neighbors sooner or later.
There is no offense we are so reluctant to commit as that of having
uncleanliness of our bodies disagreeable to those about us. Very young
children will make every effort in their power to live up to the
school's standard of cleanliness. The other side to this reason for
having clean teeth is vanity. Because all cleanliness is beautiful to
us, clean teeth are one attribute of beauty that all of us can possess.
Habits of cleanliness are easily fixed. In the most crowded, most
overworked section of large cities visitors from "uptown" are surprised
by the children's bright hair ribbons, clean aprons, clean faces, and
smoothly combed hair. It will be easy to add clean teeth to the list of
things necessary to personal and family standing. Armenian children
are taught to clean their teeth after eating, even if only an apple
between meals. They covet "beautiful teeth." American standards will
soon prevent these Armenians from cleaning their teeth in public, but
desire for beautiful teeth will stay, and will remind them to care for
their teeth in private. As coarse food gives way to sugars and soft
foods, stiff toothbrushes must supplement tongue and toothpicks.
[Illustration: AN ARMENIAN SCHOOL GIRL]
Strong as are the instinct and display motives in cleaning teeth, both
parents and children need to be reached through the commerce motive.
Instinct makes children afraid of the dentist, or content when the
tooth stops aching. Display may be satisfied with cleaning the front
teeth, as many boys comb only the front hair or as girls hide dirty
scalps under pompadours and pretty ribbons. Desire to save money may
give stronger reasons for not going to the dentist than instinct and
comfort can urge for going. But parents can be made to see, as can
children after they begin to picture themselves as wage earners, that a
dentist in time saves nine, and that no regular family investment will
earn more money than the price of prompt and regular dental care. A
problem in arithmetic would be convincing, if, by questions such as
those on page 98, we could compare the family cost of neglecting teeth
with the cost of toothbrushes, bicarbonate of soda, pulverized chalk or
tooth powder, early and repeated examination by a dentist, and
treatment when needed.
How many members in your family? What does a toothbrush cost?
How many teeth have they? How many do you need in one
year?
How many teeth have they lost?
How much does tooth powder
How many false teeth have they? cost?
How many teeth have been filled? How much is needed for one
year?
What is the total cost to date?
How much would two examinations
How many days have been lost a year by a dentist cost?
from work because of toothache?
How many teeth are now decayed?
What will it cost to have them
attended to?
The result will show that the money spent for one good "house cleaning"
of one child at fourteen or eighteen exceeds the cost of keeping clean
and in repair the teeth of the entire family. How effective and
economical is thorough cleaning is confessed by an eminent dentist, who
taught an assistant to clean his patients' teeth. "Do you know," he
said, "I had to stop it, so perceptibly did my work decrease." The
total time required to examine school children for teeth needing
attention is much less than the time now lost by absence from school or
wasted at school on account of toothache.
To remind school children regularly of dental hygiene is not more
important than for the school to remind parents repeatedly of the many
reasons for attending to their children's teeth. It is not enough,
however, to send one message to parents. Illustrated lectures, mothers'
meetings, demonstrations at hospitals and fresh-air homes are all very
serviceable, but listening is a poor substitute for understanding.
Schools should see that parents understand the æsthetics, the
economics, the humanity of dental hygiene. The best test of whether
the parent has understood is the child's tooth.
Dental examination of children applying for work certificates gives the
health and school authorities a means of enforcing their precepts. When
no child is allowed to go to work whose teeth cause malnutrition or
disgust, the news will spread, and both child and parent will see
clearly the grave need for dental care.
[Illustration: WON BY THE ECONOMIC ARGUMENT]
Finally, local papers can be interested. They will print almost
anything the teacher sends about the need for dental care. They like
particularly facts about the number of cavities found, the number of
children needing care, efforts made to procure care, and new facts
about diseases that can be caused by bad teeth or about diseases that
can injure teeth. Teachers can persuade dentists and physicians to
write stories. No newspaper will refuse to print such statements as
this: "A tuberculous patient in six weeks lost ground steadily. I
persuaded him to go to a dentist to clean the vestibule to his
digestive system, and to have a set of false teeth. He enjoys his
meals, and has gained twelve pounds in six weeks." Popular magazines
and newspapers mention teeth seldom, because those who best know the
interesting vital things are making money, not writing articles or
otherwise concerning themselves with dental education. It is said that
of forty thousand American dentists not over eleven thousand are
readers of dental journals, and probably not three hundred contribute
to professional literature. One dentist who is working for the
children's clinic described above, when asked by the board of education
to lecture to the people on the care of the teeth and to recommend
simple, readable books, told me that he knew no good books to suggest.
Five obstacles exist to practicing what is here preached:
1. The expensiveness of proper dentistry.
2. The untrustworthiness of cheap dental service and "painless"
dental parlors; the domination of the supply houses wishing to
sell instruments and other supplies.
3. The ethical objection to any kind of advertising or to work by
wholesale.
4. The lack of dispensaries.
5. The profit-making basis of dental education.
Additional reasons these for cleanliness that will make the dentist
serviceable for his knowledge rather than for his time and gold.
Good dentists really "come too high" for both the poor and the
comfortably situated. Families in New York City that have four or five
thousand dollars a year hesitate to go to a dentist whom they
thoroughly trust, because his time is worth more than they feel they
can afford to pay.
The "free-extraction" dental parlors undoubtedly are doing a vast
amount of harm. In every city are dental quacks that injure
wage-earning adults as much as soothing-sirup quacks injure babies.
Instead of teaching people to preserve their teeth, they extract, and
then, by dint of overpersuading by a pretty cashier hired for the
purpose, make a contract for a gold crown or a false set at an
exorbitant price. A reputable dentist has said that a dental parlor can
do more damage to the welfare of the race in a few months than a
well-intentioned man in the profession can repair in a lifetime. Its
question is not, What can I do for this patient? but What is there in
this mouth for me? Many "parlors" never expect to see the same person
twice, because they do not make him comfortable or gain his confidence;
they put a filling in on top of decayed matter or even diseased pulp;
put in plates and bridges that do not fit; charge more than the
examination at first leads one to expect; refuse to correct mistakes;
deny having ever seen the patient before. Yet true and severe as this
arraignment is, many of these parlors, with their liveried "runners
in," are doing an educational service not otherwise provided; it is
conceivable that in many cities they are doing less harm by their
malpractice than well-intentioned men in the profession by neglect of
public needs or by failure to organize facilities for meeting those
needs.
I realize that advertising is "unethical" among dentists as among
physicians. Humbug and imposition are supposed to go inevitably with
self-advertising by the methods used in selling shoes or automobiles.
Therefore such advertising is prohibited. But what seems to be
forgotten in this definition of ethics is that the need and the
opportunity for dental care must be advertised in some way, if we are
ever to control diseases and evils due to bad teeth. The rich that one
dentist can help are able to pay for his good taste, his neat
attendants, his automobile, his club dues, his vacations at fashionable
resorts, his hours without work, his standard of living. All of these
things advertise him, just as hospital appointments and social position
may and do advertise successful physicians. The patients of moderate
means that one dentist can treat cannot afford to pay for rent, time
disengaged, and indirect advertising. Either they must have free
treatment, must go without treatment, or must go to a dental parlor
where dental needs are organized so that a very large number will
contribute to rent and display. It is out of the question to have both
dentists and patients so distributed and prices so adjusted that
dentists can make a good living by charging what the patient can
afford, and at the same time admit of every patient being properly
treated when necessary. Judging from every other branch of work, the
solution of the problem lies partly in free care for those who can pay
nothing or very little, and partly in coöperative treatment through the
heretofore objectionable dental parlors. If instead of inveighing
against advertisers, honorable and capable dentists worked through
dental and medical societies to secure adequate public supervision of
dental practice, more progress would be made against dental
malpractice.
Dental clinics will quickly follow the publication of facts that
schools should gather. In some places these should be separate; but at
first the best thing is to make every hospital, every children's home,
every settlement a clinic, and every school an examining center. A
skilled dentist informs me: "The demand that will follow examination of
school children's teeth will make it profitable for young dentists to
adopt a coöperative scheme, where several young men hire a parlor in a
cheap district, and, under the supervision of some experienced dentist,
give good advice at reasonable rates. This is the best antidote to the
dental parlor which exploits the public so shamelessly." Bellevue
Hospital in New York is the first general hospital to establish regular
dental examination; others will undoubtedly soon follow.
Dental education for profit rather than for instruction and for health
has been the rule. Even where universities have put in dental courses,
they have demanded a net profit from tuition. Instead of protecting
society against men incapable of caring for teeth, the schools have
marketed certificates to as large numbers as slowly enlightened
self-interest would permit. Much progress has been made toward uniform
standards of admission and graduation, but dental colleges sadly need
the light and the inspiration of school facts about teeth.
Of fourteen dental journals in America, only one has the advancement of
dental science as its first reason for existence. Thirteen are trade
journals. Not one of these would print articles proving that the
supplies advertised by their backers were inimical to dental hygiene.
Many dental colleges still retain on their faculties agents or editors
in the pay of supply houses, Harvard's new dental school being a
notable exception. This trade motive tolerates and encourages the
disreputable practices of existing dental parlors. Largely because of
this prostitution of the dental profession, patients generally neglect
the repairing and cleansing of the teeth and the sterilizing of the
mouth from which germs are carried to all parts of the body. Dental
journalism for the sale of supplies cannot outlive the dentist's
reading of the school's index.
Many dentists will say that they must learn dentistry before they learn
the economics and sociology of clean teeth. Being a young profession,
it is natural that dentistry should first devote itself to learning its
own mechanics,--the tricks of the trade--how to fill teeth. But the
fact that it took the medical profession centuries to begin to feel
responsibility for community health is no reason why the social sense
of the dentist should be dormant for centuries or decades. We need
training and exercise to determine what kind of filling will be most
comfortable and most serviceable; whether the pulp of the teeth needs
treating or removing before the filling is inserted; whether it is
worth while to fill a deciduous or baby tooth. Sociology will never
take the place of dental technic. The few dentists who have studied the
social significance and social responsibility of their profession
declare, however, that careless workmanship and indifferent education
of patients continue chiefly because dentists themselves do not see the
community's interest in dental hygiene. The school can socialize or
humanize the dental profession if teachers themselves possess the
social sense and make known the facts about the need for dental care
among school children.
FOOTNOTES:
[5] _The Teeth and Their Care_, by Thaddeus P. Hyatt, D.D.S., is a
short, concise treatment of the principles of dental sanitation.