A Preliminary Report on the Value of Oral Prophylaxis

Oral Hygiene: The Basis of Preventive Dentistry

This Important Phase of Dentistry is discussed by

Paul H. Belding, D.D.S, L.J. Belding, M.D., and Elaine F. Daily, D.H., in

“A PRELIMINARY REPORT ON THE VALUE OF ORAL PROPHYLAXIS”

 

                During the days of Williams, Miller and Black, it was generally accepted that pyorrhea and caries were bacterial diseases and that the greatest assistance which the individual could give towards the maintenance of his oral health, was the scientific application of the principle of mouth hygiene. Many years ago Black1 stated that: “Caries will not begin on well-cleaned surfaces. If there is any one fact regarding decay of the teeth that is well fixed by careful clinical observation, it is this one.”

Cleansing the Oral Cavity

As to the efficacy of the toothbrush in causing the disappearance of pathogenic organisms from infected mouths, he states: “These can be very effectually removed within a few days so that we will be unable to find pus microorganisms in the mouths of these persons in plant after plant.”2

He realized the relationship between soft tissue disease and oral hygiene and stated that by properly brushing the teeth it is possible “to keep off calculus and keep the gums in condition.”3 Miller was equally enthusiastic concerning the role of the tooth brush in the care of both the hard and soft structures. More recently Charters and many others have stressed the value of oral hygiene.

The ante-nutritional status of the value of oral hygiene is well stated by Merritt:4 “Much has been said and written about the value of oral prophylaxis in the prevention and control of dental caries; and there can be no doubt that it has an important place in this field; but it also plays a highly important part in the prevention of periodontal disease, because of this large part which bacteria play in the etiology of all periodontal disease.

“Anything which contributes to the multiplication of bacteria in the mouth, as for example, oral sepsis, is a potent factor in predisposing the periodontal tissues to disease. Conversely, anything which promotes cleanliness of the mouth is a valuable aid in the prevention and treatment of such disease. In the light of present knowledge, it is probably not an exaggeration to say that keeping the mouth physiologically clean would do more than any other measure to prevent the development of gingivitis, Vincent’s infection and periodontoclasia.”

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Volume II September, 1936

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With the rise of the nutritional school came a revival of the humoralistic theories and it again became popular to believe that pyorrhea was a constitutional disease and that caries began on the inside of the tooth and that both were due to malnutrition. In view of the tremendous amount of data which was presented to both the public and the profession it is not strange that these theories should have gained a rather general acceptance. It naturally followed that the control of these diseases clinically by the application of dietary measures would be undertaken.

Without attempting to minimize the importance of further research work into dental nutritional problems it is apparent that the pendulum has swung too far and that the clinical attempts to prevent and cure caries and pyorrhea by dietary measures alone have failed and that with present knowledge further attempts to do so will seriously injure the profession.

Mouth Cleanliness Not Stressed Enough

Prior to the rise of the modern school of dietary investigators, it was generally held that brushing the teeth was a definite therapeutic or prophylactic procedure and that it was definitely related to health, both oral and general. With the spread of the nutritional faith it became mandatory for its converts, from the standpoint of logic, to discard the belief that mouth cleanliness was related to health, either local or general.

They adopted the view that brushing the teeth was an end in itself and that it served no other function than that of (cosmetically) improving the appearance of the teeth. Their opinion as to the purpose of the toothbrush can be gleaned from the writings of the Dean of American Nutritionists, E.V> McCollum, M.D., Ph.D., Sc.D., who considers toothbrushing in the same category as he does the Saturday night bath and approves of it for the same reason that he does body cleanliness. He further believes that the establishment of an effective program of preventive dentistry must be based upon a dietary reformation of the nation. In that he fails to mention the use of the toothbrush in carrying out this program we are forced to conclude that he considers it to be without value in preventive dentistry.

Some years ago we would have believed it impossible that such opinions could have ever become accepted but it is apparent that they have and so universally that the supremacy of the toothbrush is being seriously challenged. Unfortunately this somewhat premature presentation of these imperfectly worked out theories to the public has caused many individuals to lose their interest in oral hygiene due to the delusions that caries and pyorrhea can be prevented and cured by dietary means alone.

Diet Enthusiasm Hurts Oral Hygiene

A considerable number of the profession have hit the sawdust trail of dietary salvation and the literature is filled with their successes in treating caries and pyorrhea by nutritional methods. Unfortunately, due to the promulgation of these theories, interest in oral hygiene has not only waned but the use of the toothbrush is being attacked.

Osborne5 states that, “Instead of preventing pyorrhea, not a few surgeons declare that the toothbrush promotes the disease.” Some become so fanatical in their preachings against prophylaxis that they would lead us to believe that professional attention is likewise without merit.

Herbert Ely Williams6, the sage from Red Bank, New Jersey, unwittingly presents the most damning indictment against modern teachings by contending that, “Advising unnecessary prophylaxis semi-annually in compliance with custom is distinctly unfair to our patients. Better by far to apply an unnecessary prophylaxis fee to restorative work of a permanent character, which will reflect the dentist’s ability and convince the patient that something has been accomplished of greater lasting than cleaning unneeded.”

Hanke so relegates oral hygiene to the background that it is apparent from reading his book that he considers its value to be negligible. We have near our community a physician, who has gained no little reputation as an orator and scientist who has been so taken in by the dietary theories that he publicly advocates the eradication of the toothbrush because it does more harm than good.

The benefits to be derived from scientific application of oral hygiene at one time was so thoroughly accepted that it was almost axiomatic among the profession and it seems rather futile to attempt to again prove that which was so thoroughly established in years gone by. However, we feel that there is a need for this study and therefore, to those who read this article and who have never lost faith in oral hygiene, we ask their indulgence for we feel that in spite of the obviousness of its value, there are many practitioners who have ceased to have faith in its virtues.

Clinical Study Instituted

For many years we have been convinced of the importance of oral hygiene in the maintenance of oral health and believed that it was the most effective weapon at our command for the preservation of the gingivae. Sometime ago we determined to institute a clinical study of its effectiveness in the maintenance of normal gingival tone and its therapeutic effect on gingival disease. No study was made of its relationship to caries; first, because of technical difficulties and secondly, we felt the prime preventive factor in caries was the practice of prophylactic odontotomy and that oral hygiene must always have a secondary importance to it and follow upon it.

In 1935, through the interest of our local school  board and the Reverend Father Sheehy, both the public and parochial school children of this community were placed at our disposal. For the purpose of our study it was determined to use one of these schools as a control and to devote our efforts to the other school. The latter is designated as school A and the other as school B. at the beginning of our study we determined the incidence of gingivitis in the two schools and found that in school A it was 88% and in school B 75%. The lower incidence in school B could be attributed to the fact that the children were younger (only grade students).

In order to secure the interest and cooperation of the students as well as to include many poor children in the study, we agreed to furnish all the tooth paste they used.** The children were instructed to purchase a good toothbrush and under the direction of one of us (E.D.), they were taught the proper mechanics and technique of toothbrushing. Once a month every month was examined and those who were not making satisfactory progress were given individual instruction. Absolutely no professional preventive treatments were given the children and any improvement noted can be attributed to the individual practice of oral hygiene.

At the start of the test period in 1935, in school A, there were 98 children under observation. The incidence of gingivitis was found to be 88.77%. At the end of the school year, due to sickness, graduation and etc., only 58 remained for examination. The other forty were, therefore, deleted from the study. The incidence of gingivitis was not appreciably changed; the percentage in the original group and the remaining 58 was almost identical showing that the deletions were at random. The data is presented in the following chart.

SCHOOL A 1935

98 children

Type One (mild) . . . . . . . . . . . . . . . .. . . . . . . .. . . . . . . .       49

Type Two (moderate) . . . . . . . .. . . . . . . .. . . . . . . .. . .        22

Type Three (severe) . . . . . . . .. . . . . . . .. . . . . . . .. . . .        16

Normal . . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .        11

88.77% diseased

SCHOOL A 1935

58 children

Type One . . .. . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . . . .         33

Type Two . . .. . . . . . . . . . . .. . . . . . . .. . . . . . . .. . . . . .          10

Type Three . . .. . . . . . . . . . . .. . . . . . . .. . . . . . . .. . . . .         8

Normal . . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .        7

87.93% diseased

 

At the end of the school year the children were re-checked to determine the incidence of gingivitis. Cooperation was never 100%. Many children were lax and some refused to cooperate at all, however, the results taken altogether were pleasing. The results are shown by the following chart.

School A 58 Children 1

9

3

5

1

9

3

6

Type one (mild) 33 13
Type two (moderate) 10 9
Type three (severe) 8 4
Normal 7 32
Incidence of gingivitis 88 45

 

We have found it possible to effect a fifty percent reduction in the incidence of gingivitis by indoctrinating the individual with the principles of oral hygiene only. No professional services (directed to the gingivae) were given and in so far as we know the diet remained unchanged.

During the test period the incidence of incidence of gingivitis in school B remained constant showing that no outside factors influenced the incidence of gingivitis in this community.

Recently one of us (L.J.B.) has had the opportunity of examining a large group of children who were, at an early age, indoctrinated into the practices of oral hygiene and who have in addition been periodically examined by practitioners who were not afraid to practice prophylactic odontotomy. The results are striking. In mouth after mouth, in children 15-16 years of age, there is no evidence of any carious activity, and the gingivae are in perfect health. It appears in some cases that hygiene alone prevents the development of caries but in view of the almost inevitable decay, defects must be eradicated at an early age.

Until diet can clinically duplicate the observed results, we believe that hygienic dentistry, the toothbrush, professional attention, prophylactic odontotomy and etc., must constitute the basis for a rational clinical practice of dentistry.

There is True Value in Tooth Brushing

The results which can be achieved by proper brushing of the mouth are truly startling; the results depending first upon the cooperation of the individual and secondly his proper training in the mechanics of toothbrushing. It is not enough to supply the child with paste and brush, for the results in the uninstructed are invariably bad. Most cases must be individualized and personally instructed. To that end it is essential that the instruction be given by a trained hygienist.

We have found that instruction given by the ordinary teacher is invariably bad and that if the children do brush their teeth, it is not efficiently done. The instruction must be professional and the results checked periodically in the dental office and the individual admonished to brush the areas which show neglect. For we have found that gingivitis invariably occurs in those areas not kept clean. From our observations we are lead to believe that early gingivitis can be cured and that practically all cases can be prevented by scientifically practicing oral hygiene.

P. H. Belding, D.D.S.

Lieut. L. J. Belding, M.D. (MC) USN

Elaine F. Daily, D.H.

Waucoma, Iowa

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BIBLIOGRAPHY

1, 2, 3 Black—Pathology of the Hard Tissues of the Teeth, pp. 156-158.

4 Merritt—Journal A.D.A. July 1933. Age 1163.

5 Osborne—Mouth Infection. Page 114.

6 Herbert Ely Williams—Journal A.D.A. Sept. 1935. Page 1582.

**In choosing a tooth paste we selected one which we had determined was harmless if used over a period of years; one which was effective in cleansing and one which contained no antiseptics or other drugs for it was the purpose of this experiment to determine the effectiveness of a detergent and a toothbrush alone.

All tooth paste used in this experiment was furnished by the Pepsodent Company and we wish to take this opportunity to thank them for their interest in our work.