Chapter 14
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?
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.
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.
+----------------------------------------------------------------------+ | 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.
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.
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.