AMERICAN
ACADEMY
OF
PEDIATRICS
PROCEEDINGS
DENTISTRY
IN
CHILDREN
Summary
of
Round
Table
By Paul K. Losch, D.D.S., and Charles 1. Boyers, D.M.D.
Childrens Hospital, Boston
Summary prepared by Dr. Boyers.
Presented at the Annual Meeting, October, 1956.
ADDRESS: (P.K.L.) 300 Longwood Avenue, Boston 15, Massachusetts.
148
PEDIATRICS, January 1958
Pediatrics
VOLUME 21 JANUARY 1958 NUMBER 1
I
T SEEMS only proper to begin thisdis-cussion with a few words about dental decay. Certainly in view of the prevalence of this disease, it deserves recognition as one of the great health problems.
The study of dental caries as a disease process has received a striking amount of attention in the past few years, yet we are forced to go back to an early theory of the etiology of this disease in order to discuss it intelligently.
Many years ago a theory was proposed in which it was stated that bacteria, with their enzyme systems working on a substrate of
fermentable carbohydrate found primarily
in plaques upon the smooth surfaces of teeth, lead to the decalcification of the mineral portion of the tooth. The theory also stated that the organic material is then destroyed by proteolysis. Much of the work which has been done in the field of caries since the time of this proposal has borne out the soundness of the original theory. But certainly we cannot regard dental caries as such a simple and straightforward dis-ease. As a matter of fact, we know that
dental caries is an extremely complex dis-ease, and each new area of research merely
emphasizes this point. For instance, we know that dental caries cannot arise with-out bacteria being present. This has been demonstrated in the experiments with ani-mals raised in a germ-free environment in which it has been shown conclusively that no caries occurs. To further elucidate the picture, we also know from the experiments of Shaw and Kite that animals fed by stomach tube will not develop dental
de-cay. Thus we have at least two factors at
work: We must have bacteria and we must have a substrate in the form of fermentable carbohydrates upon which these bacteria may act.
The tooth itself is not a simple substance. The enamel, being the hardest tissue in the body, is highly mineralized while the den-tin is somewhat less mineralized. Therefore it is postulated that destruction of enamel
is a result of decalcification from the action
AMERICAN ACADEMY OF PEDIATRICS PROCEEDINGS
seem, then, that if we realize bacteria are necessary, we should be able to isolate the responsible organisms and thereby gain some measure of control of dental caries. The bacterium most commonly associated with the disease is Lactobacillus acidophi-lus. As a matter of fact, the presence or ab-sence of this bacterium has given rise to a test for caries susceptibility which bears some validity, but this is undoubtedly not the only organism involved.
One factor which constantly appears, clinically, in the study of caries as a
dis-ease process, is the susceptibility or resist-ance of teeth to the decay process. This seems logical if we consider the tooth as a living structure which, by radioactive iso-tope experimentation, it has been proven to be.
But much work remains to be done to elucidate the reasons for the existence of resistance or susceptibility. Certainly, hemed-ity may play some part, and certainly minor defects in the tooth substance itself, which may be too small to be detected clinically and which may take the broader form of enamel hypoplasia, must have some bearing on this problem. But so far, clinically, we
are not able to do more than appreciate the existence of resistance and susceptibility.
Further investigation is needed in several areas in regard to the initiation of the
de-cay process. For instance, the role of saliva -both in quality and quantity-has received a lot of investigation, but its role is not clear. It has been observed clinically, how-ever, that a reduction in fermentable carbo-hydrates contained in the diet is one way of controlling the disease, and that reduc-tion of acid formation in one way or an-other, without a change of diet, may also be beneficial.
Another factor which merits considera-tion in the clinical control of dental caries is the fact that the number of times the caries process is initiated during the day
may be a vital factor. For instance, if the ingestion of sweets is limited to three times a day, that means the caries process is
mi-tiated only three times a day. But if sweets
are ingested more often than three times a day, then the initial process in the
pro-duction of caries is in a constant state of refueling.
Now to go on from a consideration of the initiation of carious lesions to a word about the progress of lesions. This disease can be initiated at any age, and indeed many children of 2 years of age have teeth which are already being destroyed. Clinic-ally, dental caries is a disease of the tooth’s
environment. In other words, it is a process which begins after the eruption of the tooth into the mouth. Thereafter, different
portions of the tooth have different
suscep-tibilities to the process. For instance, the occlusal, or chewing, surfaces of teeth are the most easily and the first attacked of all tooth surfaces. Next come the interproximal areas, or areas between adjacent teeth, and the most resistant part of the tooth is the smooth surface, or what is sometimes re-ferred to by the layman as the gum-line location. The occlusal, or chewing, surfaces of the teeth are rough and are formed into deep fissures and grooves which may be imperfect in their formation and also serve as food traps. These factors undoubtedly have something to do with the early appear-ance of decay on this type of surface. How-ever, the surfaces between the teeth present a different problem. Here they are smooth surfaces, but because the teeth touch to-gethem these are also areas of food deposi-tion. On the smooth surfaces of the teeth, we see the formation of what dentists call “plaques.” These plaques are prime spots for the initiation of carious lesions because they are made up chiefly of bacteria and fungi which are associated with food and debris left in the mouth and thus act as areas of high acid concentration.
reasonable, then, that if we could eliminate
one or the other of these, we would con-trol the disease; this is, to some extent, true. Most of the clinical methods for control which have been proposed have been aimed at one step or another in the process as outlined. Antibiotics have been tried as a means of controlling the bacterial popula-tion of the mouth. These have not been as effective as hoped. Ammoniated dentrifices were proposed as a means of blocking the enzyme systems which are active in the decay process. These have not proved to be as effective as hoped for, either. Clinically, the method of prevention of decay which
is perhaps the oldest and still one of the best is the reduction in intake of ferment-able carbohydrates. The acidogenic bac-teria which act on these carbohydrates act very quickly and therefore it is necessary to eliminate the carbohydrates from the environment of the mouth immediately in order to gain control through this method. For years, dentists have strongly advised brushing of teeth and this is the reasoning behind such advice. Obviously, on a purely practical level, it is impossible to eliminate fermentable carbohydrates from the diet, and of course we would not advise any such attempt. However, the number of times a day carbohydrates enter the mouth and the promptness with which they are removed from the mouth after their inges-tion may play a very important role. This
is why we, as dentists, recommend the
me-duction and elimination, if possible, of all
excess sweets, and brushing the teeth or at least rinsing the mouth immediately after each meal. If a child can be trained to limit his eating to meal times and to brush his teeth thoroughly, or at least rinse his mouth
thoroughly, immediately after each meal,
then we have some hope for control of the caries process. This method works clinically, and is a method which parents will accept if it is explained to them properly. By dim-ination of all excess sweets, we mean
chew-ing gum,
carbonated
beverages,
ice cream, cake and cookies, and all of the things which children love. However, we make the stipulation that these things are to becon-sumed only at mealtime and only if
brush-ing the teeth is done immediately after-ward.
This brings us to a consideration of what
advice the pediatrician should give to par-ents. We believe the pediatrician should advise the parent to take the child to a
dentist as soon as all of the primary teeth
have erupted into the mouth. This occurs usually around the age of 2% years. The
dentist will examine the child’s teeth and mouth thoroughly. He will be looking not
only for dental decay, but also for any
mal-formations or deviations from the normal.
He will probably clean the child’s teeth
at the first visit and perhaps take
roentgeno-grams of the teeth. Roentgenograms in this
age group are valuable, not only because they may show beginning camious lesions of
the teeth, but also because they may show
the presence of supernumerary teeth or the
absence of permanent tooth buds. It goes without saying that a slow, patient intro-duction to dentistry is the dentist’s job in
this situation.
The pediatrician should be in a position to advise as to the type of tooth brush to be used by the child, and tooth brushing
should have begun before the first visit to
a dentist. We advise that tooth brushing
should begin as soon as the child becomes
interested in the process. If he watches his parents brush their teeth and starts as soon
as his co-ordination will permit, he may
then acquire a habit pattern which will
carry over into his later formative years.
We do not believe in recommending
specific methods for brushing the teeth. The
child’s early co-ordination may not be up to doing the job in a prescribed manner.
Rather, we like to advise that the child be taught to scrub the teeth, and whether he
brushes in circles or rectangular patterns
makes little difference as long as he spends
the time actually scrubbing. We do con-sfder it important to introduce a child to
tooth brushing very early and to encourage him so that it will become a part of his personal hygiene which he himself does not want to give up.
AMERICAN ACADEMY OF PEDIATRICS PROCEEDINGS 151
of tooth paste should I use?” Most tooth pastes consist primarily of a soap and a flavoring agent, and most tooth pastes will do a satisfactory job of cleaning the teeth. However, considerable doubt has arisen in all minds during the last few years with the introduction of various additives in tooth paste. The most recent one is the addition of stannous fluoride to tooth paste on the basis that incorporation of fluorine into the tooth substance by this daily
appli-cation would be efficacious in reducing the anticipated decay rate. From the works published so far, this seems to be the most hopeful of all of the tooth pastes aimed at reducing decay.
Once again we refer back to the
physiol-ogy of the tooth to note that the enamel,
although long considered an inactive and
rather inert substance, actually can
under-go chemical change by the uptake of
fluom-inc when applied topically. The topical ap-plication of sodium fluoride to tooth sum-faces and the addition of fluoride com-pounds to drinking water have drawn a great deal of attention recently. Topical application of sodium fluoride is often cam-ned out as part of a school-health program and is to be encouraged. It has not been available to all children because it is a rather time-consuming and fairly expensive process when performed in the dentist’s
office. However, the use of fluorides as a public health measure is to be applauded, and the addition of fluoride compound to the communal water supply seems by far the best solution yet obtained.
In order to be beneficial, the fluorine must be available during the formative
period of the tooth. Thus, since the crowns of the permanent teeth start to form about the time of birth and are completed about 9 years of age, with the exception of the third molars, this is the period when fluorine in water supplies is beneficial. It is known that fluorine can pass the placental barrier and, therefore, if the mother consumed fluoridated water during pregnancy, the primary teeth of the fetus should be bene-fited. However, the benefit has not been as effective in primary teeth as in permanent
teeth, and it is concluded that insufficient amounts of fluorine reach the fetus. At least for practical purposes, we shall consider that fluorine should be present in the water
supply from the time of birth until about
9 years of age.
Many communities have adopted the
pro-gram of water fluoridation and are enjoying
its benefits now. Other communities have
considered the question and rejected it for their own reasons. In our opinion it is a measure which is worthy of adoption and which should be considered carefully on its own scieitific merits whenever it is
dis-cussed. Certainly, no public health measure
has been more fully documented as to its safety and benefit before its adoption. The
long-term studies which have been carried
out in this country reassure us of the safety of the measure and the technical aspects of the problem have been well worked
out. The recommended amount of fluorine to be added to water, that is, one part per million, will cause litttle if any mottling of the enamel. Of course, with additions of greater amounts, mottled enamel can and will appear. It may be recalled that the
presence of mottled enamel in areas of the country where teeth were highly resistant to caries was the clue to the discovery of fluorine as the beneficial agent involved. We would strongly advise the adoption of the fluoridation of water supplies as a good public health measure for any community.
Since fluorine is not available to every-one in drinking water, the question has arisen of whether it could be ingested as a food additive. We have prescribed sodium fluoride to be added to the child’s food, but in so doing several precautions must be observed. First, it must be ascertained that the local water supply is practically
fluoride-free. Secondly, it must be pre-scribed and dispensed in such a manner as to prevent intoxication. The dosage pre-scribed is, and this must be emphasized, empirical. It is based on the data gathered
by McClure and calculated from the
fluor-DENTISTRY IN CHILDREN
inc. This data is quoted in Shaw’s book Fluoridation as a Public Health Measure and appears in the section written by Dr.
Sognnaes in which he states that, by using this data as a guide, the object should be to supplement the usual fluoride ingestion with approximately 0.5 mg of fluorine per day in the 1- to 3-year age group; 0.7 mgI
day in the 4- to 6-year age group; 0.9
mg/day in the 7- to 9-year group; and 1.1
mg/day in the children 10 to 12 years of
age. Since most of the children for whom we have prescribed this drug are in the younger age groups, our prescription calls for 0.5 mg of fluorine per day. The pmescrip-tion is written for sodium fluoride in a concentration of 2 mg/mi, and 30 ml are dispensed. It must be dispensed in a plastic
dropper bottle and the dropper must be calibrated to dispense 20 drops per ml. The prescription must read that not more than 10 drops daily are to be taken. It must also carry a warning that it is not to be refilled except at intervals of 6 weeks from the date of the original prescription. By using these methods of control, we feel that we are dispensing this drug in as safe a manner
as is possible. The mother is instructed to add the directed amount, that is 10 drops am 0.5 ml of sodium fluoride solution (0.5 m of fluorine), to the food of the child eac day. It can be added to juices, or to vitamiii preparations, or given in the milk. Ther has been some question as to whether or not an insoluble calcium fluoride compound would result from mixing the solution with milk but this, according to Sognnaes, does not appear to be an important factor.
We have prescribed fluorine in this man-ncr on a purely experimental basis and with selected mothers and pediatricians whom we felt would follow the directions implicitly. If it can be a well-controlled program, it should be beneficial. However, we do not have enough cases at hand to make a systematic statistical survey of the results, nor will we have, and, therefore, this means of dispensing the chemical is suggested only as one of several available methods.
Now let us suppose that all of the pro-posed methods for control of dental decay do not completely eliminate the disease, and the child does develop cavities. What
must happen then? Of course the dentist is
responsible for the care of this child’s teeth, but the pediatrician also must take some responsibility in urging that the parents seek and obtain care for their child. If a tooth is decayed, the dentist will try to
restore the tooth on the basis that all teeth must be saved if possible.
You have heard the old saying, “Why bother about them, they are only baby teeth and they will fall out anyway.” This
is not only old-fashioned thinking but is
also dangerous to the child’s dental and
general health. If the decay has not pro-gressed too deeply into the tooth, then per-haps it can be restored with one of the
many filling materials which are available.
If, however, the decay has already pene-trated so deeply that the pulp of the tooth
is infected, then more drastic steps must be
taken. Some infected teeth can be treated and saved. Others should be extracted, and this is a question for the dentist’s judgment.
If a c1ild must face the extraction of a tooth lorg before its normal time of loss, what are the consequences? One way of thinking ibout the problem is to consider that nature has provided primary or
decidu-ous teeth to reserve places within the dental arch for the permanent teeth which will erupt at a later date. However, if the
pmi-mary teeth are lost early, then the spaces
may also be lost because the natural
ten-dency of the primary molars is to drive forward when they have nothing against which to abut. This will result in what we call loss of space for the permanent tooth. This is a problem which arises primarily in the molar region. Loss of space may occur in the anterior parts of the arch but is not
as common as in the molar regions. With
the use of space maintainers after premature
AMERICAN ACADEMY OF PEDIATRICS
PROCEEDINGS
153they can be very simple and rather inexpen-sive appliances which can be quickly made and placed in the child’s mouth. It is true that not every premature loss of a primary molar calls for the immediate insertion of a space maintainer, but if such a space main-tamer is not to be inserted, then the space must be watched very closely, and at the first sign of closure of the space, some
preven-tive step must be taken.
The placement of space maintainers is not necessarily a job for an orthodontist or a
pedodontist, but should be within the realm
of the general dentist. With this in mind, it might be well for pediatricians to call attention to the advisability of placement of such appliances in their patients if the premature loss of a tooth due to caries is noticed.
Premature loss of deciduous teeth is cer-tainly not the only reason for crowding and malocclusion of teeth. Another factor which is commonly incriminated is that of thumb sucking and related habits. For years, there has been a controversy as to how much
damage the thumb actually could do to the dental arches, and also as to how con-cerned we should be to correct or stop the
thumb-sucking habit. Many dentists have
believed that thumb sucking and other habits could, and should, be stopped early to prevent dental malformations. This view has often met with opposition from the psychiatrist and child psychologist. Dire warnings of the eventual damage have been heard from both sides and, as in so many cases, we are now standing on rather neu-tral ground. This position has been taken because of a lack of basic knowledge of the problem. Certainly, this is a fertile field for study, one which should involve not only an orthodontist and a psychiatrist but also a social worker and other allied per-sons in a comprehensive investigation of the problem over a long period of years, in order to assay the relative importance of various aspects.
We are certain, however, that if thumb
sucking continues beyond the usual infancy period, it can-and in some cases
does-produce malocclusion. It may also aggra-vate and enhance other factors which may be at work in a child to produce rnalocclu-sion. It goes without saying that, all other conditions being ideal, the child can only fulfill his genetic potential in the develop-ment of his occlusion. Thurnbsucking and allied habits may only be external factors
in aggravating a condition which would have occurred otherwise.
The lack of sound, factual data on which to base our opinions has led to adoption of the attitude which admits that the thumb can do serious damage if the habit is per-sistent over a long period, but that, except in extreme cases, treatment is not under-taken until the time of eruption of the per-manent anterior teeth. Such deformity as might have been caused by the thumb up to this time may then be partially self-correct-ing, and orthodontic help can be instituted to continue the correction. This attitude seems to have met with the approval of people in the psychiatric field and has allayed their fears that we would seriously disturb the child by interrupting what might be considered a necessary habit.
The question of when orthodontic treat-ment should be started is one that is not easily answered. Perhaps the one condition requiring early treatment which should be called to the attention of pediatricians is that of a so-called crossbite. Normally, all of the upper teeth encase all of the lower teeth. Occasionally the upper teeth take a position too far lingual to the lower
counter-parts and, indeed, the lower teeth may be completely outside the upper teeth. Such a condition is called a crossbite and calls for early correction. A simple procedure to be followed during a routine examination by the pediatrician is to have the child swal-low and hold his teeth together. If, in this position, all of the upper teeth do not en-case the lower teeth, then this case mer-its referral to an orthodontist for further study.
orthodont-ist and the techniques which he employs. Theme are some who believe that early com-mection may lead to guidance of the per-manent teeth into more favorable positions and thereby make the entire procedure of correction easier. There are others who hold that early correction results in too long an extension of the time of treatment and prefer, therefore, to delay treatment until
certain teeth have erupted. Both schools of
thought have certain features to mecom-mend them, and they should be discussed with the orthodontist.
Another subject of importance which should be mentioned is that of injuries to teeth. The pediatrician is usually consulted
first in such cases. Young children are es-pecially prone to dental injuries when they are first beginning to walk and sometimes these injuries can be quite severe. In chil-dren of this age group, injuries tend to displace the teeth so that they may be en-timely covered by gingiva or to luxate them completely rather than to break the teeth. If a tooth is driven into the investing tissue so completely that it is covered by gingiva, the usual practice is to wait patiently for the me-eruption of the tooth. Many times such a tooth will me-erupt and assume a fairly normal position. However, after such an injury, the tooth may be completely non-vital due to the shearing action on the blood
vessels and nerves at the apex of the moot at the time of the blow. The blow may be so slight as to produce only a slight hemom-rhage into the pulp chamber which will appear as a pink spot on the surface of the tooth. More severe injury will result in
massive hemorrhage within the pulp cham-ber and the retention of blood elements which may later discolor the tooth by penetration of the dentinal tubules. Such a tooth will appear greyish black. Complete loss of the tooth by a blow or fall usually poses no particular problem, but roentgeno-grams of the area should be taken to make certain that no root tip has been left be-hind. In older children, especially those with protrusion of the anterior permanent teeth, injuries tend to break off these teeth rather than displace them. In the case of a broken tooth, a pediatrician can perform a great service for both the patient and the
dentist by urging immediate treatment. The
dentist’s first aim in treating such a tooth will be to preserve the tooth as a
function-ing part of the dental arch, and if possible,
to retain it in its vital form. Delay in
treat-ment may necessitate a devitalization pro-cedure which might have been avoided had the child been seen earlier. A matter of
only a few hours can make a complete
