The Dental Status and Prophylaxis

The Dental Status and Prophylaxis (Part I)
New York City
The widespread ravishes of the structures within and around the teeth continues unabated.
It is a condition often discussed because the problem persists. Because it persists, it will continue to stir us to consider it in our efforts to eradicate it. Therefore repetition is in order, for each new discussion often contributes some new nuance which helps toward the goal. If a consideration does not offer a new scientific finding or a correlation, it is at least important as to its emphasis of the subject.
Considerable advancement has been made in dentistry, of course, yet will all due respect to remarkable attainments, we are far from the end.
With an endeavor to see the situation more clearly and broadly for the purpose in hand, let us review in a large general way the dental status from many of its angles.
First, let us consider lay participation. A very small percentage of laymen have been made sufficiently interested to receive the best dental care available. Another small percentage receive some of the attention they require. This is due to the facts that good dentistry is just a passing fancy with some of these people, that financial ability limits some, and that fear of pain discourages others. There are many more who think and seek dentistry only in the emergency of severe pain. If they are conscious of dental values these individuals often intimate their needs and their attentions of receiving treatment. But usually they let it pass until the next dental pain drives them to receive alleviation. There are many who are not at all conscious of dental conditions and of course do nothing about their mouths. Much ignorance and indifferences prevails.
It follows then, if all people were informed as to the needs of dentistry, and thus made conscious of it, they would desire and seek it. It would do much to overcome the deterrent of fear and even eliminate to some extent the financial inabilities (from practical experiences this handicap does not really always exist –it is the handicap of will). However, too much hope must not be expected from education, for people have many other parts of the body that require equal attention. The aggregate attentions if fully satisfied would be much more than practically possible.
What is more, a healthy person is one who is not conscious of self and thus the proclivity is away from physical attention when the defects are not disturbing. Furthermore people have so many other cares and occupations in order to exist and progress. They enjoy indulging in concentrated soft foods and leisured living despite the disintegrating effect upon their physique.
I do not mean to discredit the educational work of many agencies, for it is splendidly helpful, but we must realize its limitations and how much good we can derive from it.
In summary, little of dental needs existing are treated; factors of fear and finances deter, education is limited in effect, the sharing of dental health care with other health cares, the many social and economical interests eclipsing dentistry, all exist to make the lay phase of dentistry fraught with immense obstacles.
Prevention is Not Practiced
As to the professional aspect, practicing dentists on the whole have developed a more or less blase immunity to the hopes and promises of eradicating dental disease. This attitude has been the result of a historic background of disappointing panaceas and an unchanged basic state of dental defects. New ideas and new suggestions are received with a matured view, without undue enthusiasm, one thing practitioners have learned. There is present the demand for the mitigation of dental defects after they have occurred. The treatment of such conditions have infinite problems. Dentists have become mainly interested in solving these technical problems. This immediate phase of dentistry is quite a thing to contend with, and quite a strain as we all know.
Dental work being mainly amputative and artificially restorative, has been comparatively crude and imperfect to the natural structures and function.
Correction of a carious area is not curative in its true sense of restoring similar lost tissue in its original physique and physiology. Restorative materials at their best are not as strong as the original structures. Expansion and contraction of inserted materials are still problems. Proper restoration of cusp formations which have good reasons for their existence are often not made at all or are poorly or irrationally constructed.
Bridgework strains the supporting teeth. The removable types with clasps cervical gingiva. Wearing of the ridge and settling of the saddle inclines to pull supporting teeth out of their position at times. Fixed and movable types place strains upon abutment teeth beyond the amount they were created to withstand, with possible consequent injury. Pontics do not function nearly as well as natural teeth. The margins formed by artificial attachments and tooth structure in many restorations are constant sources of decay and destruction, especially where patients neglect to care for the work.
The extraction of teeth create spaces, and when not replaced cause a breakdown of the dental structures by derangement.
Devitalized teeth present doubts as to results in a noticeable percentage of cases in spite of untiring efforts of leading operators. The pulp, being the vital part of the tooth, is when removed a great loss to the usefulness of the tooth. I mention this just as a reminder of prevention value to be considered later.
Restorative Work is Limited
The limitations of the full denture is well known. The basic surface of a full denture that rests upon tissue is no more than the aggregate surface around all the three roots of a single upper molar. This does not include the comparative retentive value of Sharpy’s fibres, the bends of the roots and the depth of the roots in the bone. Just this one comparison gives an idea of the vast difference between the natural creation and the limitations of artificial simulation. How much better is the conservation of original structures!
The value of dental work, however, is not disputed. The great efforts and achievements of the profession day and bygone days are recognized. So are the benefits of professional services to dilapidated moths. The point nevertheless is, that artificial work is comparatively elementary. The proof lies in the continual endeavors at improvement.
Professional Problems Are Increasing
The more dentistry improves, newer problems appear. The work becomes more involved, dental structures reveal their greater intricacies, the multifarious mechanisms. Instead of the work approaching solution, ease of operation, it becomes farther from our ability to cope with the condition.
Thus, dental work remains mostly restorative, not curative –characteristically artificial, not natural –helped, not too efficient –replacing but endangering natural tissues –repairing, yet irreparable. The work is usually strenuous and nerve-wrecking to the operator when striving for good work; the results frequently do not attain the efforts extended. The procedures keep purchasing carious destruction and periodontexlasia but both diseases regain, and strongly so.
In seeking to combat the trouble of the source, we have learned to date but the etiology of these diseases have not been definitely oriented. Bacteriologically, no specific has definitely ascertained. Micro studies have not attained final explanation of causes. Systemic, nutritional and glandular influences are in a state of incomplete and undecided discussion as we shall see anon.
There prevails however, considerable and feverish investigations of dental conditions by many diligent and thinking workers. Much valuable information has been recorded. There are many phases that have been presented and have established their prestige in relation to dental problems, notwithstanding, there has not been attained a complement of the solution.
One of these phases, nutrition, has of recent years taken on a dominant position in preventing dental disease as is commonly known. It has become undisputedly established as one of the influencing factors upon the body’s well-being, including the teeth and jaws of course. What we are, depends upon what we consume. The realization of nutrition’s importance has inspired considerable research. Outstanding factors brought forth are the vitamin activators, the calcium-phosphorus level of the blood, the acid-base balance, calories, quantities, protein-carbohydrate-fat constituents.
As investigation proceeds, more and more facts are discovered which tend to complicate matter however, and cause them to become intricate. Individual investigators inspired by repeated proof of their particular phase, by the importance multiplied and emphasized by further studies, have a proclivity to exaggerate their phase, though sincere, to the exclusion of other phases.
Those interested in the other phases experience the same thing. The result is conflict and confusion. This is bound to occur in a new field –incomplete, unclassified and still incoherent. But it tends to prolong a good comprehension. Nevertheless it is doubtful it its intricacies will ever become completely unfolded, following the characteristic path of all great problems. Even if nutrition becomes controllable and formulative, it is also doubtful whether man-prepared nutritional formulas of accurate proportions can be attained. If so, will it be possible to induce people to follow the prescribed diet? Even if this should succeed, I anticipate the naturally made concoctions of food –the unadulterated vegetations and meats will be found the ideal formula ultimately. Man’s endeavors would seem then somewhat Iudicrous when it is discovered the preparations have always been easily accessable.
Deficiencies of Foods
However, the problem of nutrition is not limited to kinds and quantity of food. There is too the problem of derivation. The natural foods as we obtain them today are not entirely “natural.” Many fruits are treated with arsenical sprays, poisonous was coatings to obviate insect destruction of the vegetation. Unfortunately we receive considerable quantities of the food unarmed of its poison and few of us know about it so that we can remove these baneful accretions. We have discovered that fruit, picked unripe, is deficient in necessary values and even deleterious. Foods treated with concentrated activators seem questionable as to their value to some practitioners. We read much about what food to consume but what obnoxious influences of these other conditions. There are many other consumption factors to be considered.
Dr. M. E. Page observes “Land grown food is greatly different in mineral content than food grown in the sea. Minerals found in sea water were once to be found in the soil but centuries of rainfall have washed out those most soluble. The minerals in solution have taken a one-way trip to the sea, the water which came back to the land in the form of rain was distilled water ready again to repeat the leaching process.” He observes also that men having changed their environment find a different food available. Since it takes several generations to become adapted to the new diet, they suffer the deficiencies they were accustomed to –he refers to mineral deficiency. “Not only are we affected by our changed environmental conditions, but we still further complicated matters by the treatment we give our foods. We have learned to process them that they may look better, or that they may keep better, not knowing that in so doing we ruin the material for food.” To his reference of minerals being washed to sea, may I add that the erosion to the soil from which we derive our foods has been caused by the destruction of our forests, the roots of which had functioned to prevent this washing process. This begins to give us an idea how far this subject of food and dental destruction carries.
Assimilation is Important
The analysis of food is not final in itself. Once it is taken in the body, it depends for its effect upon how the system accepts it. Some of it may be no accepted at all and excreted. That part assimilated is treated by the body metabolism, and this metabolism is due partly to another factor equal in importance to diet, and that factor is the glandular action, both digestive and endocrine. Diet assumed constant, will vary depending upon the amount of HCl in stomach, the amount of bile, the quantity of pancreatin secreted, the rate of oxidation believed to be controlled by the thyroid gland and neurological influence upon the thyroid.
Another factor is the elimination of wastes. When delayed, it ferments and putresces, to be absorbed into the system through the intestinal walls and into the blood stream to penetrate the cells. This matter acts as an intoxicant, inflicting baleful effects upon tissues of which dental tissues are one. Thus another destructive effect to dental structures is announced. LePlay and Charrin have demonstrated the effects of intestinal toxicity. Bassler mentions the fact that too little attention is given or intestines as a source of dental affection, believing the latter is more a symptom of intestinal intoxication. The work of Kaushansky in this direction is most enlightening.
There are more systemic affections upon the dental condition. The effect of diabetes on dental tissues has been observed for some time. M. L. Rhein, H. Bloch, I. B. Williams, W. A. Price and others have observed that periodontal destruction often accompanies diabetes mellitus. I. M. Sheppard reports a high incidence of alveolar absorption in diabetic patients between the ages of 15 to 40, under observation in his studies.
Moreover, we know that syphilis exhibits in its earlier stages symptoms in the mouth, in the form of mucous patches. Recurrences of Vincent’s infection in the gums should make one suspect the presence of syphilis as many cases prove so on test. In the later stages of the disease, there subsequently occurs loss of teeth and destruction of periodontal tissues as well as bone generally in the oral cavity.
Then there are the affections of the nervous system on dental conditions. Dr. E. F. Briggs has accumulated many interesting facts and quotes Cicero as saying “The diseases of the mind are more numerous and more destructive than those of the body.” He quotes E. A. Strecker “It is not an overestimation to say that fully fifty per cent of the problems of the acute stages of an illness and seventy-five percent of the difficulties of convalescence have their primary origin not in the body but in the mind of the patient. The divorce of the mental from the physical is a grave source of error.” Dr. Briggs himself is of the opinion “it would seem that the psychic trauma experienced by all civilized peoples is unknown to the primitive Eskimo, and so far as I am able to learn this is true of all people n all latitudes form the Arctic to the South Seas who are now living, or have lived, in their primitive state and are free from dental caries.”
G. R. Heyn in reviewing literature on hyperthyroidism, states “Its close connection with psychic alterations is well known.” In the same article Dr. Briggs refers to the Medical Bureau of Lourdes, the Shrine of St. Anne, the clinic of Dr. Locke of Canada, the Thought Control Clinic in Boston as outstanding examples of healing by thought influence. The influence of psychology on healing suggests the prior influence of psychology on disease, and dental disease of course, is one of the disease.

Local Factors of Great Importance
Considerable investigations have been made in the local field in the endeavor to ascertain dental disease. There are many evidences to support the exclusive responsibility for some dental abnormalities of local factors.
One of the oldest embodies the views of Black, Miller and others, that is, the external surface decay of teeth. Food plaques, bacterial attack, the formation of acids, enamel erosion, dentin invaded by bacteria are all participants. This aspect has much in its favor for which reason it remains dominant, and receives always further research.
The defects formed by the development of two plates of enamel joining in a fissure, and when three plates join at a point leaving a pit, are susceptible to harboring food and subsequently decay. The treatment by odontotomy, contributed by Hyatt as a preventive is most commendable.
The saliva is believed to play an important part in dental health. McCollum believes that phosphorus in a certain percentage is necessary in the saliva for the best preventive efficiency while calcium must also be present sufficiently to obviate enamel corrosion. This calcium-phosphorus balance in the saliva is dependent upon the blood constituency.
Deviations of the teeth and jaws from their usual arrangements, shape and positions creating disharmony in function, is another important local factor causing dental defects. The irregular spaces between teeth invite and entrap food particles encouraging decay in the teeth and causing pockets in the parodontium. Resulting occlusal traumatism of irregular articulation causes fractures to enamel and transmits through the teeth destructive injuries to the investing issues.
The harmonious order of the mechanical arrangement of the dental organ induces a healthy condition free of troubles. Then correction of irregularities would prevent dental destruction. This is possible to a goodly extent before destruction is extreme and in young people whose bones are sufficiently pliable. But the orthodontists in their endeavors to correct irregularities have encountered many problems. The deeper their studies, the more difficult it is to hold to stock routines. Anthropometric considerations of the skull in relation to the jaws seem more and more to be individual problems, and the oral structures are closely related to the variations and complexities of the skull physique. Therefore it becomes increasingly difficult to establish some basis of treatment due to elaborating findings with advancing studies. The best approach would be to obviate malocclusions by early care of diet and by correcting faulty habits of children causing abnormal pressures on the jaws. The results are irregularities, by conserving the relationship of early dentition. Here again, it is prevention that achieves the best result. Proper occlusion should be conserved for it is so essential to prevent dental destruction.
Another factor influencing occlusion and malocclusion strongly, yet little known, is the tone of the muscles. Upon the amount and manner of their function depends to a good extent, the irregularities of jaws and teeth by the forces muscles exert up on the bony structures. Dr. J. B. Stein in a splendid paper writes “plastic tonus of the muscles which move the mandible, tongue, buccal parieties and the face is an etiological factor in occlusion of the dental arches and in their disocclusion because dental occlusion is a very significant part of facial expression.”
To be continued in the November issue of Nutrition and Dental Health