TEETH, DIET AND HEALTH TEETH, DIET AND HEALTH BY KURT H. THOMA, D.M.D. Assistant Professor of Oral Pathology, Harvard University Dental School ILLUSTRATED THE CENTURY COT New York and London 1923 Copyright, 1923, by The Century Co. PREFACE Does the public know that the most important dental diseases, some of which undermine the health of virtually all civilized people, are, to a large extent, preventable? Evidently not, be- cause the large number of dentists who are fight- ing the progress of ever-increasing dental diseases and repairing the ever-decaying teeth are unable to cope with the problem. To bring about a change in prevailing condi- tions it is necessary to have an understanding of the causes, symptoms, and effects of the various dental diseases and of their constant menace to the general health. Preventive dentistry has made great advances, and methods have been developed to check dental diseases to a great extent. Patients who cooper- ate with the dentist’s efforts by proper care at home can demonstrate the truth of the slogan, “A clean tooth never decays.” The habits of diet in different communities are largely based on custom, rather than on scientific V VI PREFACE knowledge of the needs of the body. The modern diet has a destructive influence on the teeth, with far-reaching consequences, which are not yet fully understood by the general public. The recent discoveries of certain constituents, called vita- mines, of natural foods and their relation to the proper development and quality of the teeth of the growing child are topics which should become the common knowledge of every father and mother throughout the world, and of all who have to do with the education and care of children. The application of this knowledge involves no cost and, therefore, is within the reach of every one. That there is a definite demand for instruction along these lines was represented to me by readers of my previous works, who suggested that a non- technical book, dealing with dental diseases and emphasizing the importance of diet, would do a public service. To meet this demand, I present this book, writ- ten in popular language, with the hope that it may bring before the public matters of vital con- cern. Kurt H. Thoma CONTENTS CHAPTER PAGE I Value of the Teeth in Health and Dis- ease 3 II Seven Thousand Years of Dental Disease 11 III Development of the Teeth and Face . . 26 IV Abnormal Development of the Face and Irregularities of the Teeth .... 41 V Dental Caries and Its Evil Consequences 59 VI Pyorrhea Alveolaris 78 VII Relation of the Teeth to General Health 90 VIII Substitutes for Lost Teeth 122 IX Pain: Its Meaning, Cause, Control, and Treatment 130 X Examination of the Mouth to Prevent Serious Disease 142 XI Mouth Hygiene 150 XII Nutrition and Its Relation to the For- mation and Maintenance of Dental Structures 165 XIII Diet as Applied to the Teeth .... 182 XIV Suggestions for the Diet of Young and Old 203 XV A Plea for the Future 214 Index , 217 LIST OF ILLUSTRATIONS FIGURE FACING PAGE 1 A Chichiri boy 4 2 Lower jaw of an Egyptian mummy .... 13 3 Same specimen 13 4 Specimen showing the teeth of an upper jaw from a pre-dynastic Egyptian skull ... 17 5 Same specimen seen from the side showing bone destruction 17 6 Jaws of a dolphin 32 7 Skull of a tiger 32 8 Skull of a babirussa hog 32 9 X-ray picture of the teeth of a girl about eleven years old 36 10 X-ray picture of the teeth of a child twelve years old 36 11 Lower aspect of a dog’s skull 40 12-16 Case of mouth breathing caused by irregu- lar teeth 45 17 A boy with protruding lower jaw . . . .48 18 Same boy after treatment 48 19 Models of teeth in a case of protruding lower jaw 48 20 Specimen with outer bone plate removed to show the inside of a lower jaw . . . . 56 ILLUSTRATIONS riGUEH FACING PAGE 21 Similar specimen 56 22 Photomicrograph of a stained section through a tooth which had given pain before extraction 65 23 Specimen showing an abscess cavity . . . .76 24 Specimen showing two broken-down roots . . 76 25 Front teeth affected by pyorrhea .... 84 26 Specimen showing condition of bone in an ad- vanced case of pyorrhea 84 27 Specimen showing the relation of the teeth to the maxillary sinus 104 28 Tooth-brushes for cleaning of bridges . . . 149 29-32 How to brush your teeth 152 33-36 How to brush your teeth 156 37-40 The use of silk floss 160 41 Photomicrograph of a thin section through a tooth developing inside the jaw .... 177 42 Specimen showing defects in the enamel of the incisors 180 43 Progress of calcification of permanent teeth . 180 44 Photograph showing the effect of vitamine diet on the growth of rats 189 TEETH, DIET, AND HEALTH Teeth, Diet, and Health CHAPTER I VALUE OF THE TEETH IN HEALTH AND DISEASE “And teeth of pearl, and bps that vie with coral.” Symmetrical, sound, and healthy teeth beautify the face. It is of no consequence whether they are pearly white, or of a slightly bluish or green- ish hue; the color depends principally on the com- plexion of the individual. In the brunette types the teeth are dark; in the blond they are light. The important part is that they be well kept and well preserved, indicating wholesomeness, culti- vation, and refinement. No matter with what fine qualities a person may be endowed, there are frequent occasions when he is judged entirely by first impressions. Broken-down teeth, in irregu- lar position, such as are frequently caused by pyorrhea, and the loss of teeth which are not replaced by artificial dentures, destroy the facial harmony. Lines appear in the face, the lower eyelids droop, the cheeks and corners of the mouth 3 4 TEETH, DIET, AND HEALTH sag, producing an expression of dejection and lack of spirit. Such dental infirmities may be- come a serious hindrance to our progress in life and react to our disadvantage in all social rela- tions. The sweetheart, wife, friend; the business or professional man and the employee—no one can afford to neglect his teeth. They are an im- portant asset to life’s success! Recognizing that the teeth play an important part in their appearance, some savage tribes are willing to submit to great suffering to mutilate the teeth, with the idea of beautifying themselves. In French Indo-China, for example, it is the cus- tom to dye the teeth black, because there is an intense dislike for the possession of white teeth, like those of dogs. Certain African tribes file their teeth triangular to simulate ferociousness, while others use angular patterns, or notch the sides of the incisors, as a distinctive mark (Fig- ure 1). J. J. Mann, in “Round the World in a Motor Car,” makes the following statement about the Hindus: “Natives, clad in rags, or a rag— dirty beyond description, brush their teeth every day and never twice with the same tooth-brush. Their religion teaches them to cut a twig from a special tree, which has an astringent sap, and to FIG. 1. A CHICHIRI BOY This type of tooth chipping is common to many tribes Courtesy of Professor Frederick Starr, from his book on “Congo Natives,” Chicago, 1912 TEETH IN HEALTH AND DISEASE 5 use one of these with plenty of water every day. As the operation takes place on the sidewalk, or where the sidewalk ought to be, you can see them daily as you pass, engaged in this interesting occupation. Their teeth are as white as ivory.’’ The fact that the Hindu is proud of a good set of teeth and takes his religious teachings to heart is further illustrated by Mann, who says, ‘ ‘ If you want to insult him, you must say his mouth is dirty, and that will fill his cup with bitterness to the brim.” The Teeth in Emotional Expression The psychoanalyst is able to form an opinion of the mental attitude of a speaker from an in- telligent study of his facial expressions. In business and social life we all form opinions, not necessarily intelligent, from our daily personal contacts. Certain gestures and movements of the muscles of the face give the initiated a great deal of information. If a person is well disposed and friendly to- ward us, he generally presents the appearance which we associate with smiling and laughter. In this emotion the lower lip is somewhat raised, exposing the upper front teeth. Who can resist 6 TEETH, DIET, AND HEALTH the smile made radiant by a row of beautiful teeth, even though the face is otherwise unpre- possessing; and what one of us has not been charmed by the spontaneous laughter of a child, who, with head thrown back, discloses its pearly array? Not only in the pleasant emotions do the teeth play their part in facial expressions, but also in rage when the lips are retracted and the comers are raised and drawn back, revealing the cuspids (canine teeth). This may be a habit inherited from primeval semi-human ancestors, who fought with tooth and nail. It is still the common ex- pression of the angry or defensive animal. Its various modifications warn us of a hostile, an- tagonistic, and unfriendly attitude. Sneering, the indication of contempt, is usually accompanied by a drawing back of the corners of the mouth and a lifting of the outer part of the upper lip. This, however, occurs on only one side of the face. A sardonic smile is ef- fected in the same way. The orator, the public speaker, and the singer find the teeth of great importance in their pro- fessions. A wide dental arch and well formed vault are great factors in voice production. Without teeth, precise and clear enunciation TEETH IN HEALTH AND DISEASE 7 would be impossible, and with the loss of certain teeth articulation is greatly impaired. Mastication The most important of the dental functions, however, is that of mastication, which is the first step in digestion. Unless the food is properly prepared in the mouth it is not only seldom used to the greatest advantage but causes disturbances in the digestive tract. The use of the teeth in- cludes the cutting action brought into play when biting off a piece of food, as well as the grinding movements of the back teeth (bicuspids and molars). It permits mixture with the saliva and prepares the food for gastric digestion. Value of Healthy and Diseased Teeth The healthy or diseased condition of the teeth has, so far, not been taken into consideration. While the possession and preservation of good teeth should be a constant source of joy, the im- portance of their functions, which have just been described, should not be allowed to influence us when the teeth are diseased. The fact that there is no pain or discomfort does not imply freedom from disease. Often the unsuspecting individual is not aware of the menace existing in his jaws 8 TEETH, DIET, AND HEALTH and the danger of their infection undermining his general health and causing the gravest chronic diseases. Such conditions are much more com- mon than is generally supposed. It is a rare occurrence nowadays to find any one who has not fallen a prey to one or another of their various manifestations. Indeed, the majority of middle-aged people find their dental apparatus sadly depleted. Notwithstanding the fact that our parents may have seen to it that we had proper dental care and attention, and in the face of the efforts of the family dentist and the time and expense involved, many teeth have become infected. It is, therefore, easy to understand why so many people sum up their dental expe- rience in the statement that teeth are an affliction from their eruption to their extraction. Healthy, normal teeth are a priceless posses- sion, but those which, through pulp removal, have lost their blood-supply become objects of sus- picion. If, in addition, infection has occurred at the apex of the root, they become a questionable blessing, while in cases where this infection has become also a focus of ill health—a source of disease in other parts of the body—the tooth be- comes a menace and its possession a curse. TEETH IN HEALTH AND DISEASE 9 Diseased Teeth a Continual Expense and a Sign of Neglect Neglected and diseased teeth are not only the cause of continual discomfort, ill health, and ex- pense but are a humiliating exhibit of bodily neg- lect. Any one who is careless of a matter so intimately connected with his own interests is very liable to give the impression of negligence in other matters. The beholder cannot fail to associate unhealthy-looking teeth with a general carelessness in the conduct of business and social affairs. The preservation of the teeth, as we have seen, is intimately connected with those ambitions dearest to us all—health and success. It is the duty of all parents to acquaint themselves with the results of neglect of the teeth and the means which influence the development of normal jaws and strong, healthy teeth. The prevention of dis- eases of the teeth not only decreases the dentist’s bill but reduces the family living expenses and, in consequence, is as great a boon to the poor as to the rich. How this can be accomplished is taken up in the chapters on prevention and diet. Here it is sufficient to point out that it is the 10 TEETH, DIET, AND HEALTH privilege and obligation of every father and mother to use their influence in applying the simpler principles of preventive medicine and dentistry for the benefit of their children. CHAPTER II SEVEN" THOUSAND YEARS OF DENTAL DISEASE “Records that defy the tooth of time.” The conviction that most dental diseases are preventable was reached by the writer during his investigations in anthropology. Examination of the teeth and jaws of ancient skeletons, together with a knowledge of the dental diseases of antiq- uity and a study of the conditions existing among isolated races to-day, give important information as to the possible causes of dental diseases, especially when considered in relation to their habits of living and diet. The Ancient Egyptians From papyri dating back as far as fifteen hun- dred years before Christ, and from the writings of the Greek historian Herodotus (born 484 b. c.), we can learn much of the life and customs of the ancient Egyptians. Herodotus journeyed to the shores of the Nile to learn the sacred mysteries and sciences of this nation of advanced learning and comparatively high civilization. He found 11 12 TEETH, DIET, AND HEALTH that surgery and medicine were divided into dis- tinct professions and that each of these branches had developed specialists in certain lines. These specialists were required to study the precepts laid down from the experience of their prede- cessors before being allowed to practise. There were surgico-physicians who treated diseases of the eyes, the ears, the digestive tract, and the teeth. Dentistry had, therefore, already been de- veloped into a specialty. In general it was be- lieved that most ills were referable to the diges- tive process, and the treatment usually consisted of small doses of medicine and other simple means of relieving the system. Great stress was laid upon the prevention of illness by abstinence and attention to regimen and diet. Unfortunately, we have no records of the remedies and surgical proceeding used for dental diseases. Specimen Showing Egyptian Dental Surgery While examining, in the Peabody Museum of Harvard University, a group of Egyptian mum- mies, which had been unearthed in Giza by Pro- fessor S. A. Eeisner from a tomb of the Old Empire period (approximately 2500-2200 b. c.), the writer had the good fortune to discover evi- dence of a surgical operation which had been per- FIG. 2. LOWER JAW OF AX EGYPTIAN MUMMY FROM THE OLD EMPIRE PERIOD, SHOWING EVIDENCE OF AN OPERATION DISCOVERED BY THE WRITER Observe how all the teeth are worn down on the grinding surfaces. On the first molar the pulp (A) became exposed Specimen photographed through courtesy of Professor Frederick Ward Putnam and Dr. E. A. Hooton, Peabody Museum, Harvard University FIG. 3. SAME SPECIMEN The two holes (B and C) in the side of the jaw below the first molar indicate a surgical procedure practiced by the ancient Egyptians for the purpose of establishing an outlet for the pus THOUSANDS OF YEARS OF DISEASE 13 formed. Attention was first attracted by a very small circular hole in the masticating surface of the first molar in one of the jaws. The surface of the tooth had apparently been worn down to such an extent that the pulp was exposed to in- fection (Figure 2). This condition was common among the early Egyptians, as will be seen later, and it generally resulted in what is now called an alveolar abscess—an infection in the center of the bone around the root of a tooth. That such an infection had occurred in this case was proved by means of an X-ray picture, which showed that around the roots of the tooth there was a dark area, such as we know to be associated with loss of bone because of an abscess. The in- teresting feature of this specimen, however, was two holes in the side of the jaw. These are shown in Figure 3. Closer examination revealed the fact that one of these holes led between the two roots of the molar, the other between the molar and bicuspid. Their regularity of outline and identical size in- dicated that they were artificially produced to permit drainage of pus from the abscess inside the bone. When I showed the specimen to Dr. Hooton of the Peabody Museum he investigated on his own account. The right side of the jaw 14 TEETH, DIET, AND HEALTH being fractured in such a way as to expose the infected area, he found by taking it apart that the two holes led through sound tissue into the abscess cavity. This confirmed my own con- clusions, that oral surgical procedures were prac- tised nearly three thousand years ago. Egyptian Teeth Show Signs of Wear Further examination of these mummies brought out some very interesting facts. The specimens were from the predynastic period and the Old and Middle empires, ranging from 4800-2000 b. c. The most apparent condition was the tremendous wear (attrition) on the masticating surfaces of all the teeth. Unworn cusps were but rarely found; the masticating surfaces were worn so smooth that often the dentine was exposed; and facets, such as we find in the front teeth of horses, were visible. The temporary teeth of the chil- dren showed the same results of wear. The Diet of the Ancient Egyptians “What did the ancient Egyptians live on?” was my first thought, when I realized that all their teeth showed evidence of this same attri- tion. Sir J. Gardner Wilkinson, in his writings, THOUSANDS OF YEARS OF DISEASE 15 states that the early Egyptians were very moder- ate eaters. While they took pride in serving a profusion of food for the entertainment of guests, their diet, in private life, was very simple. It consisted mainly of vegetables, fruits, and escu- lent roots, some of which were eaten in the crude state and others were roasted or boiled. Lentils, milk, cheese, and much fruit appear to have been the important articles of the laborer’s diet. Meat was consumed by the more well-to-do classes, but was plainly cooked. Herodotus writes that the builders of the pyramids lived mainly on onions, garlic, and lentils. The rich ate pastries, sweet- ened with figs, dates, and honey, but sugar and sugar-cane are not mentioned and apparently were unknown. This simplicity of diet began to give way about 1600 b. c., and in later periods the Egyptians became somewhat addicted to excesses, although never to the extent of the Roman indul- gences. Bread was an important food in ancient Egypt and was used by both the rich and the poor. For those who could afford it the bread was made of wheat and corn, while the poor used barley and sorghum flour. Adolf Erman, in “Life in Egypt,” says that bread was largely consumed in all periods of Egyptian history. In the Middle 16 TEETH, DIET, AND HEALTH and New empires they had great mortars in which corn was pounded with pestles. Finer flour was made by rubbing grain between two stones, and this, after being kneaded into dough, was baked in flat round cakes. The coarse food eaten by the ancient Egyptians might at first be thought to have caused the wear on their teeth. It will be found, however, if the condition is studied more carefully, that the method employed to prepare the grain and corn allowed a certain amount of grit to get mixed with the flour, and this is supposed to have been the main cause of the condition. Some Other Dental Diseases Pyorrhea was not present, and real dental caries was seen in only two teeth of the many jaws in the Peabody collection. It is curious that a race so free from this disease of modem civiliza- tion should nevertheless have fallen prey to the same evil consequences that to-day follow tooth decay. This occurred in the following manner: The teeth kept wearing down until finally the pulp became exposed. An infection of the pulp then set in, similar to that which we get from dental caries. In this stage the tooth frequently began to decay from the inside and crumble down FIG. 4. SPECIMEN FROM SAME COLLECTION AS FIGS. 2 AND 3, SHOWING THE TEETH OF AN UPPER JAW FROM A PRE-DYNASTIC EGYPTIAN SKULL .Note the facets on the masticating surfaces of the teeth. The exposed pulp (A) caused infection FIG. 5. SAME SPECIMEN SEEN FROM THE SIDE, SHOWING BONE DESTRUCTION B indicates the abscess cavity which had formed in the bone at the root of the tooth THOUSANDS OF YEARS OF DISEASE 17 almost even with the gum, a condition which leads to the mistaken idea that it was due to dental caries. From the pulp the infection spread through the opening at the root-end into the sur- rounding bone, causing tooth abscesses similar to those which are found to-day on so-called “dead” or pulpless teeth. That these bone infec- tions of dental origin were very frequent is quite evident, as they are found in almost every speci- men. The one in Figure 4 shows an open pulp chamber in an upper first molar. This was due to wearing down of the masticating surface. The opening is marked A and can be seen easily in the picture. In Figure 5, a side view of the same speci- men, the abscess cavity (B) is visible around the root of the tooth. In connection with these dental infections it is interesting to note that “rheuma- tism” was also quite common. The Ancient Greeks and Romans Hippocrates, who was one of the most accurate observers of his time (born 460 b. c.), gives in his writings some idea of the status of the teeth of the ancient Greeks. A lineal descendant of iEscalapius and famous for the axiom, “Diseases must be combated in their origin,’’ he describes diseases of the teeth and their treatment, both 18 TEETH, DIET, AND HEALTH manual operations and dentifrices. Two types of necrosis are distinguished by him, dislocated jaws seem to have been common, and a disease associated with flattening of the ridge of the jaw and sloughing of the gums is without doubt our modern pyorrhea. Both dental caries and pyorrhea were rampant among the Romans of the Christian era. In the records of Celsus, a celebrated physician of Rome, born 30 b. c., we find that he advised extraction of teeth and filling with gold, while for loose teeth (pyorrhea) he prescribed scraping, fixing with gold wire, and scarifying the gums. “The sad workings of a superior civilization, is the cause of the decadence of our health, ’ ’ com- plained Celsus, and it is small wonder that dis- eases of the teeth were extremely common in a people so given to feasting. While up to 188 b. c. their food was prepared with great simplicity, new methods of cooking began to be introduced in the year the Roman army returned from Asia Minor. In the two centuries which followed, cooking gradually became more and more elabo- rate; every establishment of any standing em- ployed a number of cooks, each of whom special- Roman Feasts THOUSANDS OF YEARS OF DISEASE 19 ized in some phase of food preparation—pastry- cooks, meat-cooks, etc. Banquets in the time of Nero, who reigned from 54 to 68 b. c., were ex- tremely sumptuous. It is said that the emperor would sometimes sit down to a table at noon and not leave till midnight, a profusion of delicacies being served throughout the whole period. Some- times the cookery took a whimsical turn, as, for example, when a pig would be served roasted on one side and boiled on the other. Aristotle, who followed Hippocrates, was the first to state that he thought decay of the teeth was occasioned by particles of sweet things re- maining between the teeth. The Greeks and Romans indulged freely in sweet fruits, and their pastry receipts called for the liberal use of honey, preserved dates, etc. Sugar was first mentioned by Theophrastus (born 372 b. c.), a Greek phi- losopher, who wrote several books on the history of plants. It was not until 1471 that a process for refining sugar was discovered by a Venetian. Modern Tribes and Isolated Nations African negroes, American Indians, the Maori of New Zealand, the Eskimos, and some of the natives of the South Sea islands are either living in parts of the world not easily accessible to com- 20 TEETH, DIET, AND HEALTH merce or remain untouched by civilization. Their habits are simple, they live under natural condi- tions, and their diet is restricted to the local supply of food. The Eskimos eat flesh, fat fish, birds, and a number of plants, such as reindeer- moss and berries of various kinds. In the wilds of Africa and New Zealand meat is not always procurable but is indulged in when at hand. The staple foods consist of native fruits and grains, which vary widely according to the local- ity, millet, maize, and manioc being used. The roots of plants, such as sweet potatoes, sweet roots of the ti-tree, the rarauh or fern root, and berries are eaten in quantity. The preparation of the food is, as a rule, ex- tremely crude. The teeth are depended upon a great deal for a final preparation and therefore are given considerable exercise. After meals, fresh water is taken freely, a habit which in some cases has become a tribal custom. Decay of the teeth is very rare among these people. Dr. Stanley Colyer, in his African researches into the cause of dental caries, states that the Barotzi and other tribes living near or upon the Lakes Mweru and Bangweulu are remarkably free from caries, while in the Transkeian terri- tories, where sugar has been introduced and is THOUSANDS OF YEARS OF DISEASE 21 eaten in considerable quantity, both raw and in food, and where it is given to children to pacify them at night, dental caries is extremely common. The Moors, a people of very ancient civiliza- tion, place great value on a good set of teeth, as is evidenced by the fact that slave dealers al- ways examine the teeth and gums before pur- chasing ; but, notwithstanding this, their teeth are poor. Professor Pickerell writes, “They partake freely of various kinds of confectionery and it is, therefore, not surprising that the native doctors are acquainted with and use three different kinds of instruments for extracting teeth.” In Asia Minor, especially in Persia, dental dis- eases are also extremely prevalent. The food is heavy and difficult to digest, and the sedentary life, especially of the women, is the cause of many maladies. Honey and sugar are used in great quantities. Between meals, sweets of native fab- rication and bad quality are eaten continually by the women and children. As for drinks, coffee, tea, orangeades, and lemonades with plenty of sugar are used. The Peasant Classes of Europe The immigrants at any of our port stations coming from the agricultural sections of Italy, 22 TEETH, DIET, AND HEALTH Greece, and the Balkan states, from Germany and Poland, have strong, healthy teeth, caries being the exception rather than the rule. It will be found that their diet consists mainly of coarse food, plenty of vegetables, and fruit. They are accustomed to preparing their grain at home or in a local mill. The only bread made is dark, and even this is never eaten when fresh. White flour and, above all, refined sugar are luxuries. Sweets and desserts are reserved for the Sun- day meal, or are indulged in only on very special occasions. Many state that they have never cleaned their teeth, but, after all, coarse food is the best cleanser, and with proper diet no partic- ular care of the teeth is necessary. The Effect of Modern Civilization In centers of civilization the demand for new and agreeable sensations has created the Epi- curean tastes which crave highly concentrated food. Refined sugar to-day is used in abundance for cooking and is added in ever-increasing amounts at the table. The eating of sweetmeats and candies, good and bad, between meals, for the sake of the flavor, is one of the most pernicious habifs, and is prevalent among poor and rich alike, and in the country as well as in the cities. THOUSANDS OF YEARS OF DISEASE 23 Other foods, for the sake of appearance, are sub- jected to elaborate chemical and mechanical ma- nipulation, or are spoiled by the modern process of cooking. Dental Conditions in the United States The Mayo Clinic examination of fifteen hun- dred patients showed that 87 per cent, had in- fected teeth and 80 per cent, suffered from pyorrhea. This gives some idea of the prevalence of dental disease among adults in this country. The poor condition of the teeth of the average child is shown by reports from examinations made by Dr. Fones in the schools of Bridgeport, Connecticut. He states that 98 per cent, of the children examined during a period of five years had irregular teeth, and that 1946 pupils of the fifth grades, examined in 1915, had 2906 cavities in the temporary teeth and 10,726 in the perma- nent teeth. This is an average of five and one- half cavities in the mouth of each child. A dental examination of the Marion school in Cleveland, Ohio, made in 1919, showed that of 846 children only three were found whose teeth were in perfect condition. One was a colored boy eleven years old, another a Slav girl of ten years who had been in America about six months and the third was 24 TEETH, DIET, AND HEALTH an American-born child, twelve years old, of Russian parentage. These statistics are start- ling, but they are typical. The same lamentable conditions seem to exist also in Great Britain. The British Dental Association reports that 86 per cent, of the English and Scotch school-boys and -girls are afflicted with decayed teeth. In New Zealand the percentage is 95; in Hamburg, Germany, 96.4. The development of good, sound teeth affects more than the individual’s health; it affects the efficiency and welfare of our nation. Poor, dis- eased teeth made thousands of men unfit to join the army during the war. One out of every five of the first draft in Massachusetts was rejected on account of deficient teeth. Diseased teeth rob industry. A large company in Ohio states that the establishment of a dental clinic in their plant saved them 21,031 hours in six months. The fi- nancial loss to the country as a whole, because of the never-ending relief and repair work, is so enormous that even an approximate estimate is impossible. Summary This historical review brings out the fact that the ravages of dental disease increase in direct THOUSANDS OF YEARS OF DISEASE 25 proportion to the advance of civilization. This fact was recognized nineteen hundred years ago by Celsus, who thought that in ancient times the health was well preserved on account of good habits, but that intemperance and idleness, two vices which appeared first in Greece and later in Rome, brought with them a multitude of evils. Without doubt, the methods of living in our own age have an important bearing on the health of our teeth. Modern diet lacks, as we shall see later, vitamines and calcium salts. Important constituents of our food are destroyed by fabri- cation, refining, and intensive cooking. Yet these elements are essential, not only to good teeth, but to good health in general. The most impor- tant factors, therefore, must be those concerning regimen and diet. After the reader has been made familiar in the following chapters with the causes, nature, and consequences of the different dental infections, this subject will be taken up again, because it is the key to prevention, and prevention alone is the door through which we can enter into immunity from dental disease. CHAPTER III DEVELOPMENT? OF THE TEETH AND FACE “There is no cut like cutting teeth.” The variations in the form and size of the teeth in different animals and in individuals of the same species are an interesting study. The reason for the development of these variations is an example of the wonderful work of nature. Philosophers and scientists for centuries have found material for thought and discussion in the study of variations in animals and the changes that have taken place in their organs. Aristotle thought these changes could be explained by the law of economy of growth. Lamarck, a French zoologist, believed there were two agencies at work: first, adaptation by means of use and habit, and, second, heredity transmitting the changes to the offspring. Darwin also believed that use and disuse of organs was a very important factor in organic development, but he discovered a third principle, which he took to be the chief agent in the transformations of evolution, namely, natural selection, or the survival of the fittest in the 26 DEVELOPMENT OF TEETH AND FACE 27 struggle for existence. Under changed conditions the animal which has best adapted itself to the new conditions has the best chance to survive. A wild boar, with well developed cuspids protrud- ing from its mouth, can readily kill its foe, while with underdeveloped teeth it would succumb in the battle. Evolution of the Teeth When animals were forced to change their habi- tations, some had to live upon different food, which demanded more powerful jaws and stronger, specialized teeth. Changes were produced in their shape, size, form, and number. From corn- like projections they developed into the primitive cone-shaped tooth still seen in some fish and rep- tiles. Animals with this type of teeth usually had extremely long jaws and a great many teeth. They served merely to take hold of the food, which was swallowed virtually without mastica- tion (Figure 6). In a later period, when some had to live upon food which required more power- ful jaws and stronger teeth of special shape, a remarkable change took place. The jaws became shorter, giving greater strength to the bite. The shortening of the jaws necessitated a reduction in the number of the teeth, which was accom- 28 TEETH, DIET, AND HEALTH plished in two ways: first, by eruption of the teeth in two sets, and, second, by fusing the simple teeth into more complicated forms. In this fashion teeth with two, three, and four roots and as many cusps were formed, which in time arranged themselves in the jaw so that they inter- locked in a manner most efficient for mastication. As time went on, the teeth became altered to per- form a variety of functions. Animals formed special food habits and developed carnivorous, insectivorous, and herbivorous types of dentation even as long ago as the giant saurians lived. The front teeth (incisors) are formed for cut- ting action. They are used to tear meat from bones, to browse on grasses; and in rodents these teeth grow continually as they are worn from gnawing. The canines (cuspids) serve the great- est variety of purposes and therefore show the most interesting forms. Beasts of prey have the strongest and most prominent cuspids—fang teeth, which sufficiently describes their use (Fig- ure 7). In other animals they have become for- midable weapons, as in the wild boar, the ele- phant, and the walrus. The babirussa hog, an animal native to the Malay archipelago, has curved tusks, by which it is said to hang from branches when resting or escaping from an enemy (Fig- DEVELOPMENT OF TEETH AND FACE 29 ure 8). In animals that crack nuts or break bones, the cuspids serve as a guide for the jaws so that they will not slide past each other. They would be a hindrance to the lateral motion, neces- sary for proper mastication in herbivorous ani- mals. Therefore, their cuspids are either under- developed or entirely missing. The back teeth (bicuspids and molars), are the teeth that grind the food, and their form differs according to the diet of the animal. In the car- nivora we have teeth with sharp edges, which cut like scissors, as meat does not require grind- ing and the teeth are used only to cut and tear (Figure 7). The herbivorous animals have the most complicated teeth, with crests and ridges for most efficient mastication, since there is very little nutrition in grasses. The omnivorous and fruit-eating animals and man have broad-cusped molars, because mastication of the vegetable, fruit, and cereal foods is necessary before digestion. How the Modern Human Face Developed Go back with me to the earliest time of man, the time before the use of fire, when the human being lived under the same conditions as the an- thropoid apes, when his only occupation was to hunt for food and defend himself against the 30 attacks of enemies; and you will understand the changes brought about during thousands of years. Physical strength was the greatest asset of pre- historic man, and the kind of food upon which he lived required massive jaws, with large, strong teeth, which resulted in a prominent mouth and face. His brain case was small and flat, as it is still, in a modified degree, in the African negro. When he began to use his wits and develop more and more his mental faculties, a wonderful change took place. The brain case became larger, and, through his acquired ability to obtain and masti- cate food with much less expenditure of strength, his face and mouth became less prominent. If you compare those cave-dwelling times, when man was a creature with hardly any thought except for food and protection, with our twentieth-century life, its gigantic demands upon the brain, and its diet prepared by modern cooking, you will under- stand why, with civilization, has come a develop- ment of the cranium at the expense of those parts which were so vital to our ancestors in obtain- ing food. The inherited modification in the size of the jaw has been brought about by the decrease in its use, generation after generation, because of eat- ing softer food. The same influence has also TEETH, DIET, AND HEALTH DEVELOPMENT OF TEETH AND FACE 31 caused changes in the appearance of the nose and other features. Of the first set of teeth, variously called decidu- ous, temporary, or milk teeth, the first to appear are the central incisors, the lower ones coming first, as a rule. The normal time for their erup- tion is between the sixth and eighth months. As the infant is usually nursed up to this age, it naturally needs no teeth during that period. Sometimes mothers worry if the teeth are late in beginning to erupt. This, however, is of no con- sequence. The second, or lateral incisors, erupt between the seventh and ninth months. Next come the first molars between the fourteenth and fifteenth months, then the cuspids between the seventeenth and eighteenth months, and finally the second molars between the eighteenth and twenty-fourth months, at which time all the twenty deciduous teeth have erupted. The Deciduous Teeth Breast vs. Bottle Feeding Deformities of the face are asserted, by some authorities to be due to bottle feeding, because little work is required to draw the milk from the bottle, and the motion is that of applying suction. 32 TEETH, DIET, AND HEALTH A bottle-fed infant, therefore, does not develop certain muscles, while the breast-fed child, who has to put considerable effort into his feeding, exercises a great deal the muscles of the mouth and tongue. Breast feeding includes kneading and munching movements, which stimulate the growth of the jaws. The fact that the food from the bottle comes so easily may even at this early age develop a habit of swallowing without mastica- tion. The baby’s mouth should be cleaned after every feeding with cotton dipped in a solution of boric acid. Disturbances caused by the eruption of the de- ciduous teeth can be avoided to a great extent, and the parents who apprehend this period can do a great deal to avoid such trouble by giving babies stale, hard bread-crusts, on which they love to gnaw and nibble. The front teeth are not so bad, but the cuspids and molars are more liable to cause trouble. When a tooth is ready to erupt the gum immediately over the erupting tooth appears white. It takes from two days to a week for a tooth to erupt. Pain may be due to pres- sure against the gum by the tooth in its effort to break through. This can easily be relieved by an incision, for which a dentist or physician should FIG. 6. JAWS OF A DOLPHIN Showing primitive mouth with many teeth of the same shape. Only part of the head is shown. FIG. 7. SKULL OF A TIGER Showing back teeth flat for scissors action, canines strong and prominent FIG. 8. SKUI.L CF A BABIRUSSA 1ICG Both the upper and lower cuspids have developed into tusks of enormous size DEVELOPMENT OF TEETH AND FACE 33 be called. Pain may also be associated with an inflammation caused by food or infection pene- trating underneath the gum lying over a partly erupted tooth. The gum then has a very red and inflamed appearance. When the teeth begin to erupt it is especially important to wash the mouth thoroughly after every meal with a swab of cotton saturated with a solution of boric acid. This solution should be freely applied to inflamed gums over partly erupted teeth. As soon as the teeth are erupted they should be brushed daily with a small, soft tooth-brush. The editor of “The Lancet/’ an English medical journal, writes, “The firm belief among the laity of all classes that the baby must be more or less ill whenever he is cutting a tooth has led, even among the best-intentioned mothers, to an enormous amount of neglect of the first symptoms of illness in infants, and that is the way thousands of infant lives are sacrificed to the fetish of teething.’’ If a child shows signs of illness, though you may think, comes from the teeth, consult a child specialist, and in most instances you will find that the child’s teething trouble is in reality a stomach or intestinal dis- turbance, or perhaps only a common cold. 34 TEETH, DIET, AND HEALTH The Child Two to Six Years Old The greatest progress in growth and develop- ment of the body is made during the period when the child is from two to six years old. At the age of two, when all the deciduous teeth have erupted, the child’s diet should contain not only plenty of mineral salts, which are needed for bone and tooth development (see chapter on diet), but should also include hard foods, which require a great deal of mastication. A set of healthy teeth is necessary for good digestion and to get all the nourishment out of the food, as well as for the local effect of mastication—stimulation of growth and development of the jaws and teeth. The child’s teeth during this period should be well taken care of; they should be brushed after every meal, and food which pro- motes decay (see chapter on caries) should be kept away. If cavities form despite the best ef- forts of the parents, they should be attended to while small by a dentist. If the child does not masticate properly the reason should be found at once. It may be due to formation of the habit of bolting the food (bottle-fed babies should be especially watched), to the fact that the child has received nothing but soft foods DEVELOPMENT OF TEETH AND FACE 35 which did not require chewing, or because he has been allowed to wash the food down, umnasti- cated, by drinking with each bite. Most children like to get the mouth as full as possible. This is said to be due to the fact that the taste-buds are much more active in a child’s mouth and are best satisfied when the mouth contains a great deal of food. The lips are also supplied with taste-buds, and this may be one of the reasons why children are fond of smearing food over the outside of the mouth. If a great deal of food accumulates in a child’s mouth without being swallowed, a large bolus forms, which finally cannot be got rid of. Parents should be warned against allowing the child to wash his food down with water, or else it will be done again and again. Teach children to take a small mouthful, to masticate it well and swallow it before taking more. If a child is made to eat hard food, the jaws develop properly and spaces appear between all the teeth at the age of five. This should not dis- turb parents, because it is a normal condition and is a sign that the permanent teeth will have a chance to erupt normally. This spacing provides room for the permanent teeth which at this time are already partly formed in the jaws, and the 36 TEETH, DIET, AND HEALTH crowns of which are much wider than those of the deciduous teeth. The mistake of supposing that the first perma- nent molar is a deciduous tooth is often made by parents. The first permanent molars erupt without a deciduous tooth being shed, and, be- cause they are far back in the mouth, they are not easily observed. It is a great pity that par- ents do not understand the importance of the first permanent molars, which are the corner- stones, so to speak, of the second dentition. Very often they are allowed to decay. The first or six-year molars, so-called because they norm- ally erupt when the child is six years old, should be carefully watched for. They are sometimes poorly calcified, and we find fissure defects, which invite decay just as soon as they have penetrated through the gum. It is important, therefore, to prevent decay by treatment of such defects as soon as these teeth erupt. Eruption of the First Permanent Molar The Permanent Teeth Animals shed their deciduous teeth while eat- ing; they are broken out when biting into hard food. In man the process is not always so simple, FIG. 9. X-RAY PICTURE OF THE TEETH OF A GIRL ABOUT ELEVEN YEARS OLI) The first deciduous molar has been lost. The first bicuspid (A) is about to erupt. The roots of the second deciduous molar (B) are becoming absorbed, and the second bicuspid (C) is developing below. The first permanent molar (D) is in its place and has already been filled. The second permanent molar (E) is still in the jaw, the roots are not completed, and the third molar, or wisdom-tooth (F) is only partly formed, only the cusps being calcified FIG. 10. X-RAY PICTURE OF THE TEETH OF A CHILD TWELVE YEARS OLD Early loss of the second temporary molar closed up the space. The molar (A) moved forward so that there is not enough room for the second bicuspid (B) to erupt DEVELOPMENT OF TEETH AND FACE 37 and the deciduous teeth are sometimes retained too long. This, as well as their premature loss, causes irregularities in the permanent set. The permanent teeth develop in the jaws while the deciduous teeth are still functioning. At the age of six years, the crowns of most of the perma- nent teeth are completed, but the roots are not entirely formed. As they develop and require more and more room, the roots of the deciduous teeth become absorbed until the surrounding bone no longer holds them, and they become loose (Figure 9). If the process is normal and enough hard food is taken, the deciduous teeth will be broken out during mastication, as in animals. If they are not lost and replaced at the right time, as indicated in the table on page 39, after allow- ing a reasonable time for individual variation, a dentist should be consulted. By means of X-ray pictures it is possible to determine conditions. When no permanent teeth have cut through the gum they are generally to be found developing in the jaw. If conditions are disclosed which would prevent the normal erup- tion of the teeth, steps should be taken toward correction. An X-ray of such a case is shown in Figure 10. The little patient, a girl twelve years old, had lost her deciduous molars several years 38 TEETH, DIET, AND HEALTH before. They decayed, abscessed, and had to be extracted. The molar A moved forward, closed the space, and prevented the second bicuspid (B) from coming through. Eruption of the Permanent Teeth When the deciduous teeth are lost, the perma- nent ones should take up the vacated space at once. An unoccupied space caused by the loss of a deciduous tooth before the permanent one is ready to erupt is generally partly closed up, because the back teeth have a tendency to move forward, with the result that when the perma- nent tootlh finally makes its appearance it is forced to the outside or the inside of the dental arch. The time of eruption of the permanent teeth is found in the table on the following page. The twenty deciduous teeth are replaced by the perma- nent incisors, cuspids, and bicuspids. It should be noted that the incisors erupt first, the bicuspids next, and the cuspids last. The three perma- nent molars, which do not succeed any temporary ones, take their place in the back of the jaw as it increases in length. The eruption of the first permanent molar takes place at the age of six, as already described. The second molar erupts DEVELOPMENT OF TEETH AND FACE 39 Time Time Time Tooth calcification begins calcification is completed of eruption tooth shed ►"3 ' Central incisor 4th fetal 17th—18th post- 6th-8th post- 7th year B month natal month natal month lateral incisors 4th fetal 14th-16th post- 1st—9th post- 8th year P month natal month natal month a Cuspids 5th fetal 24th post- 17th-18th post- 12th year H month natal month natal month CD © 1st molars 5th fetal 18th-20th post- 14th—15th post- 10th year S' month natal month natal month 2d molars 5th—6th fetal 20th-22d post- 18th-24th post- llth-12th year month natal month natal month Tooth © Central incisor 1st year lOth-llth year 7th—8th year B Lateral incisor 1st year 10th— 11th year 7th-8th year P Cuspids 3d year 12th-13th year 12th-13th year 1st bicuspid 4th year llth-12th year 10th—11th year 2d bicuspid 5th year llth-12th year 11th—12th year H3 1st molar 8th fetal month 9th-16th year 6th-7th year © 2d molar 5th year 17th-18th year 12th—14th year 3d molar 9th year 18th-20th year 17th-20th year The lower teeth generally precede those in the upper jaw by shortintervals. Chronology or Human Dentition 40 TEETH, DIET, AND HEALTH when the child is twelve years old and is called the twelfth-year molar. The third molars, popu- larly called “wisdom-teeth,’9 are the last to erupt, and when they are all present the second dentition is completed. This usually occurs be- tween the ages of eighteen and twenty, when the mouth contains thirty-two teeth. FIG. 11. LOWER ASPECT OF A DOG’S SKULL On the left side in the picture, the teeth were extracted to eliminate performance of their function. The effect of this on the growing dog was unilateral development of the entire skull. From the horizontal line A-l, drawn across the base of the skull, a vertical line, A-2, was drawn. Normally this line would lie in the median line of the skull. The picture shows how the entire jaw and the nose have grown toward the left, on account of the retarded develop- ment of that side Courtesy of Dr. Lawrence Baker, Harvard University Dental School CHAPTER IV ABNORMAL DEVELOPMENT OF THE FACE AND IRREGULARITIES OF THE TEETH “As the teeth are, so is the bite.” Apollo of Belvedere was the ideal of the Greeks, and his beautiful face is still held to be a fine example of harmony and proportion. Artists have ever sought to establish basic principles, by means of which deviations from a standard might be detected. To-day, however, and especially in our country, where many types exist, the facial proportions are influenced by the different phys- ical, mental, and moral habits of a large number of races. The question, therefore, is principally one of balance and symmetry, and it has been found that any departure from the full comple- ment of the teeth or their normal position will cause discord in the proportions of the mouth and other features. Experiments were made by Dr. Lawrence Baker of the Harvard Dental School on guinea- pigs and dogs, to determine how important a 41 42 TEETH, DIET, AND HEALTH role mastication plays in the growth of the face and jaws. He selected young animals and extracted or ground the teeth short on one side so that mastica- tion was possible only on the other. The result was very remarkable. There was a decided dif- ference in the development of the two sides of the jaws. The side where the teeth were left and where mastication was normal developed much more than the unused side. Not only were the jaws affected, but the entire head, including the cheek-bone and nose, presented an unilateral development, the whole face being twisted to one side (Figure 11). Children sometimes form a habit of masticat- ing on only one side, with the result that the two sides of the face develop unequally, just as in the guinea-pigs and dogs. One cheek then be- comes larger than the other, with unusual folds and a difference in the length of the lips. The real underlying cause is generally some painful condition of a tooth, which makes the child favor it by masticating on the opposite side. The early loss of a number of teeth on one side may have the same effect. Another cause of unequal de- velopment of the face was found in the instance of a child who had never had a deciduous nor ABNORMAL DEVELOPMENT OF FACE 43 permanent lateral incisor in the right side of the upper jaw. His lips were shorter on this side, and the corner was drawn up a little. Idiotic, Criminal, and Insane Types Abnormal proportions of the face and head are often a great handicap. Many investigators as- sert that there exist idiotic, criminal, and insane types of faces. Talbot, in his book, “Develop- mental Pathology,” states, however, that his study of facial deformities precludes this state- ment. The facial characteristics associated with idiocy, criminality, and insanity may be found in people varying in mentality from the lowest idiot to the most intellectual scholar. An open mouth, with the teeth of a narrow, pro- truding upper jaw projecting from under the lip, and with a receding chin, gives an appearance of weakness to the face. The narrow, V-shaped upper jaw with a high vault may cause a narrow nose, and the child is likely to have a dull, listless expression. Adenoids and other unhealthy conditions of the nose are very liable to occur in children with narrow jaws and a high, narrow palate, which is associated with contracted nasal passages. These conditions can be prevented and overcome by 44 TEETH, DIET, AND HEALTH mastication of hard food, which influences the formation of a wide dental arch and will produce a wide space in the anterior part of the nasal cavity, since the roof of the mouth is also the floor of the nose. The pull of certain of the muscles of mastication (pterygoid muscles) also exerts an influence on the back part of the nose (the nasopharynx), and their vigorous use tends to widen this space. The augmented circulation brought about by the muscular activity of masti- cation has a beneficial influence on the oral as well as the nasal tissues. This fact should be remembered by the speaker and the singer. A well preserved set of teeth and their energetic employment for mastication will preserve the health of these organs, so important in such pro- fessions. Mouth-Breathing Observe a child with a narrow jaw and face, and you will find that he opens his mouth just as soon as he runs. The constricted nasal passages cannot accommo- date the passing of a sufficient amount of air to supply the blood with the additional oxygen re- quired by the increased physical activity. He has to breathe through the mouth, allowing the Fig. 12 shows the typical appearance of a mouth breather. Note the pro- truding teetli Fig. 13. Profile of the same boy before treatment Fig. 14. Profile after treatment. The mouth is now closed, and the tip- per lip has been brought hack Fig. 15. Condition of the upper teeth of a mouth breather Fig. 16. Upper teeth after treat- ment, in normal position. Note the difference in width of the mouth. FIG. 14 FIGS. 12 TO 16. A CASE OF MOUTH BREATHING CAUSED BY IRREGULAR TEETH Courtesy of the Orthodontia Department, Harvard University Dental School FIG. 13 FIG. 16 FIG. 15 FIG. 12 45 ABNORMAL DEVELOPMENT OF FACE air to enter the lungs unfiltered, unmoistened, and cold. This, however, is not the entire damage done. If the mouth is constantly open the muscu- lar balance of the mouth is overthrown. Norm- ally the teeth receive as much pressure from the outside (the muscles of the cheek) as from the inside (the muscles of the tongue). With the mouth open the tongue exerts no pressure, which allows the cheeks to make the bad condition worse, the upper jaw becoming still narrower and the nose more compressed. If your child is a mouth-breather, first of all have him examined by a good nose and throat specialist. He is likely to find adenoids. Do not think, however, that removal of the adenoids will solve the problem. They may form again unless the jaws and face are widened by regulation of the teeth. Breathing-exercises will be found to be of great benefit. Have the child stand in front of an open window, breathing slowly through the nose, with the arms and shoulders extended back. The lungs should be filled completely, after which the air should be quickly expelled. This exercise should be repeated twenty times at least three times a day. In a typical case of mouth-breathing the patient was a boy who was treated in the orthodontia TEETH, DIET, AND HEALTH 46 clinic of the Harvard University Dental School. Figure 12 shows his normal appearance before treatment. The mouth is open, and the central incisors protrude, which is typical of the mouth- breather. In Figure 13 we see a profile view, also before treatment. This shows how the upper lip protrudes and the chin recedes. The condi- tion of the teeth of a mouth-breather is shown in Figure 15. The jaw is extremely narrow and compressed from side to side, so much so that the teeth have not room enough and are in very irregular position, both in the front and back of the mouth. Figure 16 shows how the teeth can be improved, the arches widened, and the teeth brought into their normal relations. The im- provement in the face is shown in Figure 14. In this photograph of the same boy after treat- ment, we see that he is now able to close his mouth without effort, and that his profile is very much better. Protruding Lower Jaw and Depressed Upper Lip A protruding lower jaw is generally due to an irregular position of the teeth, but it may be due to heredity. This peculiarity of face forma- tion sometimes is transmitted for generations. A notable example is that of the Hapsburg family. ABNORMAL DEVELOPMENT OF FACE 47 The unnatural prominence of the chin and lower lip is usually associated with a flat upper lip and depressed nose. Another hoy, which is also a case from the orthodontic clinic of the Harvard University Dental School, shows this type. The profile of the boy before treatment, which is typi- cal, is shown in Fig. 17. Note the protruding lower jaw and sunken upper lip. The condition of the teeth in a case of this type is shown in Fig- ure 19. The lower jaw not only protrudes too far forward but also extends beyond the upper jaw on each side. Deformed jaws may be due to pernicious habits. Of these the most important are thumb-suck- ing, which, through pressure on the upper teeth, results in protrusion of the upper jaw. Some- times other fingers, or the lips, are sucked, which affects the teeth in the lower jaw, wfiiile wrist- sucking produces a deformity known as an open bite, the front teeth being apart when the back teeth are together. The use of pacifiers will also result in similar conditions. The tissues of the child’s jaws are very tender in the early part of his life and respond surprisingly well to con- tinual pressure. Pernicious habits should be corrected at the very beginning and in an unobtrusive way. In- 48 TEETH, DIET, AND HEALTH stead of correcting the child and scolding him when he sucks his thumb, remove it gently from his mouth and get him interested at once in something else. Only in very stubborn cases is it necessary to use aluminum mittens, or to pin the night-dress sleeves to the sides, so that the hands cannot be raised. Short jaws, allowing insufficient room for the permanent teeth, are one of the principal causes of irregularities. They can be corrected by giv- ing the child, as soon as possible, hard food which needs to be thoroughly masticated. Mastication is among the most important factors in stimulat- ing development of the jaws by increasing the blood-supply and furnishing additional nutrition to the bones and teeth. Deviations from the normal in the arrange- ment or position of the teeth or the formation of the dental arches is designated by the term “malocclusion.” Irregular teeth are due prin- cipally to underdeveloped jaws, but they may also be caused by premature loss or too long retention of deciduous teeth and by extraction of perma- nent ones, which allows tipping and drifting of the teeth on each side of the space. In the Bridgeport, Connecticut, schools Dr. Fones found that out of 6768 children in the first fig. 17. A hoy with protruding lower jaw. Ob- serve the profile, the shape of the nose and position of the upper lip. fig. 18. The same hoy after treatment. The chin has been brought back into normal relation and the lips and nose show marked improvement pig. 19. Models of the teeth in a ease of protruding lower jaw. All the teeth in the lower jaw protrude, and the back teeth on each side extend beyond the upper ones All of the above figures are used by courtesy of the Orthodontia Department, Harvard University Dental School ABNORMAL DEVELOPMENT OF FACE 49 and second grades 98 per cent, suffered from malocclusion. As irregular teeth are very hard to keep clean, they decay much more easily than those in proper position. In pyorrhea, as we shall see later, the abnormal strain caused by the improper locking together of irregular teeth is an important contributory factor. Many people believe that it is not necessary to take care of the deciduous teeth, since they are lost later anyway. This is a great mistake. The first set of teeth is of great importance. This should be stated with particular emphasis, because neglect of the deciduous teeth has seri- ous consequences. If any of the deciduous teeth are lost prematurely it will cause trouble with the eruption of the permanent set. Prevention of Malocclusion Exercises are recommended by Dr. Alfred Bogers, one of America’s leading orthodontists, to prevent as well as to correct certain abnor- malities. He states that splendid results can be obtained by simple exercises if the child’s co- operation can be secured. Nature provides a normal condition to start with. Malocclusion of the deciduous teeth is rare, and any tendency toward an abnormal condition can easily be coun- 50 TEETH, DIET, AND HEALTH teracted if discovered early. One of the most important means of prevention is stimulation of bone growth and tooth development through mas- tication of hard food, and if the deciduous teeth are well taken care of there is no reason why the permanent ones should not erupt normally. The psychological attitude of children is of great importance. The child who has been fright- ened is suspicious and difficult to handle. Par- ents should, therefore, be very careful not to make any of those mistakes which spoil the dentist’s most conscientious efforts. If little Johnny sucks his thumb, do not tell him that unless he stops he will be taken to the dentist, who will put wires on his teeth. Such comments make a deep im- pression on the child’s mind and, when he needs treatment later, will make him an unwilling and remonstrative patient. It is just as bad if the parents express in little Marie’s presence their pity that she has to undergo such lengthy treat- ment and promise her that it will not hurt and that she must be brave. Such suggestions, with their implication of pain, are hard to counter- act. They are breeders of fear. Negative sug- gestions are as bad as undesirable positive ones. The child’s cooperation should be secured by stimulating his interest in the expected result of ABNORMAL DEVELOPMENT OF FACE 51 the treatment. If the little patient can be made to look forward to having beautiful, straight teeth, he will be glad to have the work done and will do his share to help as much as possible. Keep away the thought of pain entirely. If injurious suggestions have not taken root, the dentist has an opportunity to secure the child’s confidence, which makes the treatment easier for all concerned. There is no pain and very little discomfort if the teeth are regulated slowly and skilfully. The younger the child when the treatment is begun, the better will be the result. If any ab- normal condition is discovered, an orthodontist, or a dentist who understands the principles of orthodontic treatment (regulation of the teeth), should be consulted at once. Between the ages of five and eight the best results are obtained, because the treatment causes stimulation of bone growth, not only of the bone, so that the perma- nent teeth may find room enough to erupt in their proper places, but also of the jaws, the nose, and the entire face. When regulation of the teeth is begun late, between the ages of twelve and eighteen, that is, after the permanent teeth have erupted, a har- monious result cannot always be obtained, the 52 TEETH, DIET, AND HEALTH treatment having little effect on the facial de- velopment. The result often is that the teeth are too prominent for the size of the face, mak- ing the child appear to be “all teeth.” There are, however, other ways to overcome such a condition. Some time ago I saw a girl about fourteen years old with very pretty features but very irregular teeth. After careful study it was found that she had inherited extremely large, broad teeth, for which there was not sufficient room in her mouth. Instead of trying to gain room for the teeth by widening the dental arches out of all proportion, space was produced by ex- tracting four bicuspids, one on each side in both the upper and lower jaws. After the teeth were straightened the result was very pleasing. Such treatment, however, is not advisable except in extreme cases and should only be resorted to after careful consideration and expert advice; but it is one of several ways of correcting a condition that has not received attention during the time when a harmonious result could most easily have been obtained. Unerupted and Impacted Teeth Civilization is declared by certain investigators to be the cause of the jaws’ becoming shorter, ABNORMAL DEVELOPMENT OF FACE 53 and the tendency toward reduction of the denti- tion, in size as well as in number of the teeth, is laid to the same influence. Some teeth, espe- cially the lateral incisors and third molars, have become very much smaller. In some individuals they are even absent entirely, and it is the belief of certain scientists that in a few thousand years the human dentition will be reduced from thirty- two to twenty-four teeth. At present we are sup- posed to be going through a period of transition, during which the shortening of the jaws does not allow room enough for the present size and num- ber of the teeth. The interesting observation that occasionally we find some one with more than thirty-two teeth, can be explained in a similar manner. The de- velopment of a fourth molar, a third or even a fourth bicuspid, or a third incisor is supposed to be a retrogression to a lower type, there being four molars, four premolars, and three incisors in the mammalian dentition. If you suffer from an impacted tooth that has not sufficient room in your jaw you may wish yourself born a few thousand years hence, when the wisdom-teeth have disappeared. You deserve sympathy, but do not forget that the same influ- ences which tend to reduce the number of the 54 TEETH, DIET, AND HEALTH teeth will also continue further to decrease the length of the jaws. The trouble we are having now with the third molar would in all probabil- ity then be transferred to the second molar. When the third molar is ready to erupt, if there is no room for it, it is often forced into various positions and finally becomes locked, or impacted, by the second molar or the bone. The exact loca- tion of the tooth can be determined by means of an X-ray picture. In some instances impacted teeth remain en- tirely buried in the jaw, no matter how long you wait (Figure 20, A); others come partly through the gum, but the impaction makes it impossible for the tooth to come through entirely (Figure 21, B). In this partly erupted state they very easily become infected. Pain and locking of the jaws often accompanies the infection. In severe cases the muscles be- come so tight that the mouth cannot be opened enough to allow mastication of food. The re- moval of the offending tooth becomes necessary, and a dental or oral surgeon should be consulted without delay. In a typical case, the patient found it difficult to swallow, and the throat was so sore that he consulted a throat specialist. He was unable to ABNORMAL DEVELOPMENT OF FACE 55 open his mouth wide enough for an examination, but said that he had had trouble several times with a partly erupted wisdom-tooth. The phy- sician referred him to the writer for an X-ray examination, which showed evidence of infection around a partly erupted third molar. Removal of the tooth cured the condition. On account of its being the last tooth to erupt, the third molar is the one which most frequently gives trouble in this respect. Of the other teeth the cuspids are the most frequent offenders, be- cause they erupt later than the two adjoining teeth. An impacted bicuspid is shown in Figure 10. Pain and Pressure from Impacted Teeth Intense, sharp, throbbing, or dull pain may be caused by impacted teeth, but sometimes there is only a sensation of obscure, indefinite pressure These symptoms may be referred to any part of the head and are caused either by the tooth press- ing against the obstruction or the roots against the nerve-trunk in the lower jaw. Unable to continue his studies at school, a young man about nineteen years old was sent to the writer for examination. He complained of head- aches in the region of the forehead and an in- 56 TEETH, DIET, AND HEALTH definite sensation of pressure in the back of his head. At times these symptoms disappeared entirely, only to be followed again by a period of suffering. X-ray examination showed unerupted, impacted wisdom-teeth on both sides of the lower jaw, the roots being in close contact with the nerve of the jaw. After I removed these teeth for him, he was entirely relieved. Irritability, sulkiness, ill temper, and delin- quency may be the result of constant dental irrita- tion from irregular eruption of the teeth. There is a great difference between a child who is per- fectly comfortable and a boy or girl who is kept continually uncomfortable by slight irritants of a physical nature. While in some cases there is no disturbance apparent, there are others where far-reaching effects may be produced by an un- erupted tooth, disturbing the general psycho- logical balance and affecting the child’s future career and happiness in life. Ear Pain and Neuralgia As sound travels along a wire, pain travels along the nerves. On account of connections be- tween the nerves leading to the teeth, ear, and other parts of the face, paip, like the sound in telephoning, may originate in one place and be FIG. 20. SPECIMEN WITH OUTER BONE PLATE REMOVED TO SHOW THE INSIDE OF A LOWER JAW A, unerupted wisdom-tooth, impacted in horizontal position FIG. 21. SIMILAR SPECIMEN' The wisdom-tooth (B) is partly erupted. It is in a mesio- oblique position and is prevented from entire eruption by the second molar ABNORMAL DEVELOPMENT OF FACE 57 transmitted to another. This explains why an abnormal condition of a tooth frequently causes a neuralgia in the ear, eye, nose, and other parts of the head. The origin of the pain is sometimes very difficult to find and requires most careful study. The X-ray is again an inestimable help. A case in point is that of a man who consulted me as to the cause of a ringing and pain in the left ear. Examination of the mouth showed the upper third molar missing. An X-ray picture re- vealed the tooth impacted. The symptoms ceased with its removal. Dr. Henry S. Upson of Cleveland, and Dr. Henry A. Cotton of Trenton, New Jersey, both distinguished neurologists, state that nerve ir- ritation from impacted teeth may become the cause of very serious mental diseases, such as insomnia, melancholy, neurasthenia, epileptoid attacks, and mania. A well known doctor said, in discussing a paper on this subject, “I should not permit a friend of mine to be placed in an asylum for the insane or the mentally deficient without having his teeth thoroughly gone over.” Impacted teeth must be removed sooner or later. One should not wait until there is some disturbance, which might occur at an inconvenient time, but should avoid the possibility of future 58 TEETH, DIET, AND HEALTH trouble by choosing an early date for their re- moval. The influence of civilization and the develop- ment of the intellect has, as we have seen, a de- plorable influence on the physical make-up of the body of man, causing a deficiency in physique, a degeneration of important organs, and a disturb- ance of normal development. This tendency must, therefore, be corrected by proper living and by supplying artificially, by exercises and preventive measures, favorable influences, which will result in the restoration of normal development and functioning of the body. It is necessary, therefore, to stimulate the growth of the jaws, the development of which is retarded in most children. This is the best way to create space for all the teeth and can be ac- complished by a diet which requires mastication and which will be discussed more fully in another chapter. CHAPTER V DENTAL CABIES AND ITS EVIL CONSEQUENCES “A decayed tooth injures its companions.” Dental caries, or tooth-decay, as it is commonly called, is only the beginning of a long chain of diseases, which may culminate in serious involve- ment of the general health. There is no disorder afflicting the human race that is more common, and its wide distribution has already been de- scribed in Chapter II. From 85 to 95 per cent, of civilized people and even some household pets suffer from the disease. Savages, upon whom we look down from our pedestal of modern culture, would turn away in disgust from people with mouths as unclean as those of many of the inhabitants of our cities. People of an intelligent race should make an earnest effort toward prevention of a disease so rampant and with so many serious consequences. The indifference of the general public should be replaced by a feeling of pride in the possession of a beautiful set of teeth. To bring up children 59 60 TEETH, DIET, AND HEALTH with healthy, normal teeth lies within the power of all, as we shall see later. “My teeth are so soft they just crumble away,” is an expression often heard, and there is a great deal of truth in it. Hard and well formed teeth resist decay, while poor and defective tooth- substance easily falls prey to the attacks of dis- ease. The quality of the hard tooth tissues de- pends upon the process of calcification, which in the deciduous teeth begins nineteen weeks before birth, and in the permanent teeth (the first perma- nent molar is the first to calcify) ten weeks be- fore birth. The calcification of the crowns, which is the only part of the tooth exposed to caries, is complete in the deciduous set six months after birth and in the permanent set between the sixth and ninth years, except for the third molar, the crown of which is not finished until the twelfth year. It is, therefore, evident that in the first set of teeth the quality depends mainly upon the mother’s supplying during pregnancy, as well as while nursing, the material necessary for strong teeth. The food that the expectant mother eats supplies, through her blood circulation, nutrition for the growth and development of the child. The mother’s milk should contain all the ingredi- ents needed. Vitamines and organic mineral DENTAL CARIES AND ITS EVILS 61 salts are of greatest importance for the develop- ment of bone and teeth, and can only be supplied during this period of life if the mother’s diet contains an abundant supply. All the permanent teeth, with the exception of the first permanent molar, begin to calcify after the child is one year old. At this age the child’s diet, therefore, must contain all the vitamines and mineral salts in abundance. Unfortunately, our modern food is extremely deficient in these im- portant tooth-builders, for reasons which will be explained later in the chapter on diet. On this account teeth are frequently of poor quality to begin with, and poorly calcified teeth are very susceptible to dental caries. Strong, hard teeth do not necessarily remain so. The lime salts which are used in the formation of the teeth may become absorbed if there is a de- ficiency of lime salts in the body. This deficiency may be due to a diet particularly poor in lime salts. In regard to these salts it is interesting to observe that they are abundantly contained in those parts of our food which are usually wasted, such as the hulls of grains, fruit-skins, potato- peelings, and so on. Some of the lime salts are removed from food in the process of refinkig. Refined sugar, for example, is liable to do very 62 TEETH, DIET, AND HEALTH great harm, for when taken into the system it attracts the free lime salts, which then have to be supplied in excessive quantity to prevent a decalcification of the bone and teeth. A third and comparatively recently discovered factor is the function of the vitamines. It has been shown that lime and other salts cannot be used by the body, no matter in what form they are supplied, unless a vital agent or force is also present, such as the vitamines, of which we know three types. Our modern diet, however, is very deficient in these important substances, which will be dealt with more fully in the last chapter on diet. All this proves that our diet is not adequate, and it is evident that the teeth have a very poor chance of remaining in a condition in which they can successfully resist disease. If we realize that during the process of growth more lime salts are needed than in adult life, we can also easily understand why children are so much more sus- ceptible to dental caries than adults. What a Tooth is Composed of To understand how a cavity forms we must first learn the construction of a tooth (Figure 22). The part which is visible in the mouth is called the crown. It is covered with enamel (E), a very DENTAL CARIES AND ITS EVILS 63 hard substance, which is devoid of sensation. This serves as a protection against outside influ- ences. The root or roots of the tooth, which are connected by means of a membrane (peridental membrane), are covered with a layer of cementum (C). This is not visible under normal conditions, but wThen the gum recedes it becomes exposed and is often the cause of painful sensations. The bulk and inner part of the tooth consists of dentine (D), which is very porous, with many fine canals running through it and conveying sensations to the pulp. The pulp is contained in the hollow part which runs through the center of the root (P). Immediate Cause of Dental Caries Colonies of bacteria, called plaques, form on unclean tooth surfaces, especially in protected places and in imperfectly formed pits and fissures. These bacteria depend for nourishment on food, particularly on easily fermentable carbohydrates, of which the most important are sweets. These bacterial colonies are protected by a gelatine- like membrane from the neutralizing effect of the saliva, and underneath this membrane sugar and other carbohydrates ferment. Lactic acid is pro- duced and comes into direct contact with the tooth, 64 TEETH, DIET, AND HEALTH dissolving its inorganic enamel. This is the first step in the formation of a cavity. Influence of Refined Sugar Sugar and all other sweets furnish food for the bacteria, which produce decay. The worst time to eat sweetmeats is between meals, and the abomi- nable practice of some parents of giving their children candy as a bribe to induce them to go to sleep is a perfect method of inviting dental caries. The greatest harm, however, is done by the sugar when it is taken up by the body and begins its attraction of mineral salts, as described above. Free sugar is not a natural food, and the idea that children, or adults, for that matter, crave sugar because it is needed by the body is not based on sound reasoning. Contrary to prevail- ing opinion, sugar is not a food necessary to the development or nourishment of the body. Under certain conditions it forms an easily absorbed emergency food, which is valuable after exhaustive exercise, but in normal life all the sugar needed by the growing child or the adult is formed from starchy foods in the process of digestion. A so- called craving for sugar is, in fact, a desire to indulge in the pleasure of its flavor, which in time leads to the formation of a habit that is most dif- FIG. 22. PHOTOMICROGRAPH OF A STAINED SECTION THROUGH A TOOTH WHICH HAD GIVEN PAIN BEFORE EXTRACTION E, enamel; D, dentine; C, cementum; B, cavity; P, dental pulp, A, abscess in dental pulp, due to bacteria that entered from the decayed area, B; N, nerves of the pulp pressed to one side by the abscess DENTAL CARIES AND ITS EVILS 65 ficult to break, especially in children. A child who has never been permitted to indulge in sweets will eat cereal without sugar with as hearty an appetite as the one who covers his plate of oat- meal with it. It should be repeated that free sugar is not a natural food. Nature does not supply any food in such concentrated form, but man manufactures it from sugar-cane, sugar- beets, or the sap of the sugar-maple. Primitive man’s only supply of sugar was honey, and honey is made by the bee for the bee. However, if one’s children have already been brought up with the sugar habit, one can at least replace the refined sugar used in most candies and cooking with brown or unrefined sugar, maple-syrup, honey, or sweet fruit, such as figs, dates, and raisins. Eecently the writer went to see a little boy at his home. The writer was offered chocolates, and so was the boy. He accepted with great pleasure and said he was very fond of them. When asked how many pieces of candy he had had during the day he answered, “Only six.” Apparently his mother did not consider that too much. Now, this boy was only four years old, he was thin and ap- peared under-weight, and when the writer looked at his teeth he saw a most pitiable condition. The writer mentally compared him with his own 66 TEETH, DIET, AND HEALTH boy of the age of five, who has never eaten candy and whose teeth are without blemish. Effect of Caries on the Teeth At first the process of decay is very slow, be- cause the enamel, which covers the entire crown of the tooth, is extremely resistant. When the inner part, the dentine, is reached, tooth-decay progresses more rapidly, the dentine containing much organic matter, which furnishes food for the bacteria. It frequently happens, therefore, that a large cavity forms inside the tooth, when there is but a very small opening in the enamel. Because of the crushing in of the enamel of a large part of the tooth, which has become under- mined, the cavity finally becomes noticeable (Fig- ure 22, B). In some people dental caries has done so much harm that the greatest skill of the dentist is re- quired to make the mouth presentable where the destruction has occurred. It is difficult to recognize caries in its early stages, and when we become aware of the condi- tion we find to our regret that the harm done is considerable. A whitish, milky appearance of the enamel is a sign that it has been undermined, and if the cavity is deep a certain amount of pain DENTAL CARIES AND ITS EVILS 67 may be caused by sugar, sweets, salt, fruit, acids, and irritating food of any kind. Examination and Treatment for Dental Caries It is of the greatest importance that cavities be discovered at their beginning and treated at once. As it is impossible for the individual to deter- mine early cavity formation in his own mouth, frequent examinations are necessary. The best results are obtained when the patient has his teeth cleaned at regular intervals (see chapter on hygiene), thus giving the dentist an opportunity to find new cavities. Cavities, however, are sometimes not discovered by means of instru- mental exploration, especially if they occur in ob- scure places, such as under the gum, or beneath a crown or filling. The writer advises frequent X-ray examination. Some of his patients have their teeth X-rayed once a year, and often it is possible to find, in this way, hidden decay which would have led in a short time to serious conse- quences. The coming generation need not fall prey to the ravages of dental caries if the parents are will- ing to do their share. With a diet favorable for bone and tooth formations, strong, hard teeth can be developed. With prophylactic care, both 68 TEETH, DIET, AND HEALTH at home and at regular intervals at the dentist’s, such teeth will not decay unless sweets and sugar are used in excess. A child does not crave sweets if it is brought up properly, but habits are formed early and are not easily corrected. If one has decided to save his child from the consequences of candy and other sweets, he must not let polite- ness stand in his way, and it is best to have an early understanding with his relatives and friends. If they insist upon feeding the child be- tween meals, let them choose some food which does not give rise to such evils. In the United States the consumption of sugar for each person is one hundred pounds a year. That is more than half the weight of an average adult. In Italy thirteen pounds per capita is used, which is about a teaspoonful a day, including that used in cooking. If sweets are indulged in by the adult they should be taken during the meal. He should never eat candy the very last thing at a meal, but should take some cleans- ing food, such as fruit, or rinse the mouth out immediately with water. Most people eat candy between meals, or just before going to bed. This is the surest way of furnishing a continual food supply for the bacteria, which causes tooth-decay to work night and day. DENTAL CARIES AND ITS EVILS 69 Involvement of the Dental Pulp Wrongly but popularly called the nerve of the tooth, the dental pulp is contained in the pulp- canal, already described. It is made up of soft tissue containing blood-vessels to supply nutri- tion and nerves to transmit sensation (Figure 22). Unless timely care is taken of a decayed tooth, bacteria, which abound in the cavity, will reach the pulp and cause infection. This is generally associated with pain, the kind that is at first aggravated by cold. Later it is intensified to extreme suffering when anything hot touches the tooth, while a cold application will result in relief. Under certain conditions the infection may pro- ceed painlessly, even to the point where the en- tire pulp is destroyed. The condition is then spoken of by the laymen asa“ dead nerve. ’ ’ Fre- quently the pain is referred to some other part, when it is called a neuralgic pain and can be traced only by the most painstaking examination. A patient who came to me at one time com- plained of a pain which she had in the upper jaw. Careful examination of all the upper teeth on that side revealed nothing unusual. X-rays of the lower jaw, however, disclosed a large cavity in a molar, under the gum and beneath a filling. 70 TEETH, DIET, AND HEALTH Further investigation showed an infection of the pulp, and when this pulp was removed the pain referred to the upper jaw ceased. Many people have pain in the ears, because of an infected tooth-pulp, which, however, gives no local trouble. In other cases the pain may be referred to different parts of the face, but always on the same side as the tooth. One young man who consulted the writer complained of very tender swellings under the jaw and in the neck. These proved to be lymph-glands. The teeth, so far as he knew, were all right. When making an X-ray examination, a cavity was found under a large silver filling in a lower molar. This cavity extended into the pulp-chamber. The pulp in that tooth must, therefore, have been infected, a conclusion which was borne out by the fact that the X-ray showed the infection to have already progressed through the ends of the roots and into the bone. When opened, an extremely putrescent pulp was disclosed. After proper treatment the glands become normal, and all the tenderness dis- appeared. A diseased pulp must be removed. This de- prives the tooth of its main blood-supply. As the tooth also receives nutrition from the outside, this would not be so serious were it not for the DENTAL CARIES AND ITS EVILS 71 fact that it is difficult to remove the infection from the root-canal. Sooner or later, either be- fore, during, or after the root-canal treatment, the tissue around the root apex may become in- volved. Early attention to the decayed tooth, before the pulp has become infected, is, there- fore, in the interest of the patient, since only under the most favorable conditions can we ex- pect satisfactory results from root-canal treat- ment. Infection of the Bone If, for any reason, the treatment of the pnlp is not undertaken, or is improperly executed, in- fection will spread through the opening at the end of the root into the tooth membrane and the bone. This will lead to the formation of an alve- olar abscess, of which there are different types. Most people do not know, that, besides the acute abscess with swelling and pain, there is also an- other kind which forms and exists without giving any apparent trouble. Alarming symptoms accompany the acute alve- olar abscess, on account of which the treatment is very seldom neglected. It begins just as soon as the infection penetrates through the opening at the root end. An inflammation of the tooth 72 TEETH, DIET, AND HEALTH membrane sets in, and soon pus forms and de- stroys the surrounding bone. This pus after a few days burrows a hole to the surface, where it accumulates underneath the gum. Finally an outlet, or sinus, forms, either in the mouth or on the outside of the face. At first the tooth is, as patients frequently ex- press it, “too long.” It is forced out of the socket, and every time the teeth are closed to- gether it comes in contact first and causes pain. Later, pressure is exerted by the accumulated pus, and the pain becomes constant and is of a deep and throbbing character. The face begins to swell. If the tooth is in the upper jaw, the eye may become partly closed, and if in the lower the swelling often extends down the neck to a con- siderable extent. Just before the abscess breaks, the swelling on the gum has a whitish appear- ance, which is referred to as the pointing of the abscess. As soon as it has broken and when most of the pus has been discharged, the pain ceases. Fever, with the temperature rising to as much as 104°F., preceded by chills, is not uncommon. Headache, flushing of the face, constipation, and highly colored urine are usually observed. In serious cases there may be delirium at night, and, DENTAL CARIES AND ITS EVILS 73 if the pus absorption is extensive, septicemia or blood-poisoning may result. Relief of the pain and inflammation is the patient’s first desire, but a speedy recovery with- out complications can only be effected by the prompt removal of the cause of the condition. This is generally diagnosed with the help of the X-ray, and the patient should, therefore, at once secure the services of a competent dental surgeon. It is a mistake to wait until the abscess quiets down. Often the acute symptoms will subside without any treatment, or with the incomplete removal of the cause. The disappearance of the swelling and pain does not necessarily mean that total healing has taken place. On the contrary, pus discharge may continue in such cases through the sinus and may become a serious disturbance to the general health of the body (see Chapter VII). Should the reader happen to have a sinus in his own mouth, he can easily prove for himself that pus is discharged by pressing it with his finger. The Blind Abscess or Dental Granuloma The dental granuloma has received the popular name “blind abscess,” not because it cannot see, 74 TEETH, DIET, AND HEALTH but because one cannot see it and because it causes so little local disturbance. In most cases its existence is entirely unknown and can be dis- covered only by means of an X-ray examination. It is generally caused by infection from a tooth from which the pulp has been removed and may have existed before the root-canal was treated or afterward. Instead of dissolving a large amount of tissue into pus, an abscess sac, or granuloma, is formed. This sac replaces a certain amount of bone, and it is the defect in the bone that shows as a dark area in the X-ray picture. The skull pictured in Figure 23 shows an upper bicuspid with a gold crown (C) on a tooth from which the pulp had been removed. In the bone over the root of the tooth, a hole is seen (H), which has been formed by the granuloma that formerly filled the space. When the bone is covered by gum, this hole cannot be seen. So slow is the formation of a blind abscess that symptoms are rarely experienced. If an open bone cavity has formed, as in Figure 23, the patient sometimes feels a tenderness when pres- sure is applied on the gum over the root of the tooth. This, however, cannot be depended upon, as it does not occur unless the outer wall of the DENTAL CARIES AND ITS EVILS 75 bone has become perforated, a condition very rarely found in the lower jaw. General symp- toms, however, are often caused by absorption of pus for which there is no outlet and which, there- fore, is taken up by the circulation. This results in general and special diseases, of which more will be said in Chapter VII. The end of the root is in contact with the in- fection and easily becomes saturated with the products of the inflammation. The cementum that covers it is porous and becomes infested with bacteria. This is an unwholesome condition, of which Nature attempts to rid herself. This is evidenced by the process of absorption, which can be seen at the surface of the root end, and for which there is no treatment of any kind except surgical removal. The dead tooth has to be eliminated before healing of the abscess can take place. The irritating influence of the infection causes also new formation of cementum near the abscess at the side of the root, where it is healthy. This enlargement near the end of the root makes ex- traction of the tooth extremely difficult. Condition of the Root of the Tooth 76 TEETH, DIET, AND HEALTH Serious Diseases May Result from Caries and Alveolar Abscesses Neglect or improper treatment may have seri- ous consequences. A condition may start from a simple cavity, pass through the various stages described, and end in extensive disease of the jaws. Any abscess, acute or blind, is in reality an infection of the jaw-bone. Fortunately it is generally limited, but under certain conditions it may develop into infection involving a large part of the bone, or causing lesions known as cysts. The following case demonstrates what serious trouble may result from a comparatively simple condition. A patient, twenty-six years old, told the following story: In December, 1915, she had had a toothache in the right side of the lower jaw and had consulted a dentist, who examined the tooth and said it needed “capping.’’ After the gold crown was put on, the pain became very much worse, but the patient was assured that it would get better in a few days. The condition, how- ever, grew worse, the face became swollen, the pain was intensified, and the neighboring teeth became tender. She finally became alarmed and consulted another dentist, who extracted the tooth from which the infection had started. From this fig. 23. Specimen showing an abscess cavity (H) in the bone of the upper jaw, around the root of the second bicuspid (C), which was a pulpless tooth carrying a gold crown fig. 24. Specimen showing two broken-down roots (R) in front of the lower second molar. H indicates the ab- scess cavity, due to an infection connected with these roots DENTAL CARIES AND ITS EVILS 77 she experienced only temporary relief, and when the symptoms again grew worse she went to a hospital. When first seen by the writer she com- plained of pain in the lower jaw and swelling of the face from the chin to the neck. She was un- able to open her mouth, and, while her upper teeth were firm, all those in the lower jaw were ex- tremely loose. An X-ray examination revealed that the entire jaw was infected, from one side to the other. The disease was a stubborn case of osteomyelitis, which could have been prevented had the tooth been extracted at the very begin- ning. As it was, it took ten months to restore the jaw to a normal condition. The reader can readily see that each of the conditions described in this chapter is a link in a progressive chain, and he can, therefore, realize the tremendous importance of early treatment in dental caries before serious harm is done. CHAPTER VI PYORRHEA AJLVEOLARIS “A loose tooth and a feeble friend are equally bad.’* Almost as common as dental caries, and one of the scourges of our time, pyorrhea effects the teeth of man as well as those of certain domesti- cated animals, such as dogs and cats, which live as pets under our roof. Other names for pyor- rhea are Rigg’s disease, receding gums, and pericementoclasia, the latter being the latest scientific term. It has been estimated that ninety out of every one hundred persons in the United States suffer from pyorrhea in one form or an- other. Dr. Theobold Smith, when experimenting on scurvy, in an endeavor to prove that the disease could be produced by faulty diet, was the first to produce pyorrhea artificially. He found that guinea-pigs fed on oats would in three weeks present all the symptoms of scurvy. The teeth loosened, and the gums became red and swollen, very much as we find them in pyorrhea. 78 PYORRHEA ALVEOLARIS 79 Dr. Percy Howe of Boston has made an elabo- rate study of the effect of diet on the teeth in ani- mals. He found that certain dental diseases are caused by lack of the substances in the food that are called vitamines. The absence from the diet of one or more of these vitamines, or, as they are more correctly designated by Dr. E. V. McCollum of Johns Hopkins University, Fat-Soluble A and Water-Soluble B and C, will cause so-called “defi- ciency diseases.” The foods which contain them most abundantly are certain fats, leafy vegetables, and fruit-juices. The characteristics of the vita- mines and the manner in which they are effected by the processes incident to food preparation will be taken up in the chapter on diet. Dr. Howe found that the animals fed on a scorbutic diet (a diet lacking one group of vitamines, and known to cause scurvy) suffered from pyorrhea. After three days the teeth became loose, and the gums were red and spongy and bled easily. The molars were elongated and in an abnormal position. In- fection set in in many of the cases, and other parts of the body showed disease. Some of the animals developed eye diseases and others swol- len joints. Some became so lame that they were unwilling to walk. It is interesting to observe that the few animals which received the same diet, 80 TEETH, DIET, AND HEALTH but with the addition of orange-juice, which con- tains an abundant supply of antiscorbutic vita- mines, had none of the symptoms described above. Constitutional or Underlying Causes According to the most recent researches, the constitutional or predisposing factor in pyorrhea is that of malnutrition. Errors in diet, and particularly faulty preparation of food resulting in insufficient content of vitamines and mineral salts, play a most important part. Unbalanced diet, faulty elimination, and toxic absorption from intestinal food decomposition resulting from chronic constipation are also important factors. A certain type of pyorrhea is found accompany- ing other debilitating diseases such as diabetes and mercurial poisoning. Local or Contributory Causes The local causes which aggravate the condition causing injury or infection consist principally of unhygienic conditions, such as soft deposits and stagnant food under the gum margin or between the teeth. In his African researches, Dr. Stanley Colyer of London found that along the Upper Zambesi the Barotzi and related tribes suffer a PYORRHEA ALVEOLARIS 81 great deal from pyorrhea, while others are virtu- ally free from the disease. On careful study of the diet it came to light that the Barotzi, Mweru, and Bangweulu natives use as their main food cassava, a root which is dried, crushed, and pre- pared until it becomes a stodgy, elastic, and rather sticky mass. The natives free from pyorrhea did not possess this food. From these findings Dr. Colyer makes the deduction that pyorrhea is caused by the sticky food remaining around the teeth and irritating the gums. He also believes that modern cooking produces foods of similar consistency which, being gelatinous and adhesive, have a harmful effect when lodged under the gum margin and between the teeth. This theory would also be supported by the fact cited in the first chapter, where it was shown that pyorrhea be- came rampant among the ancient Greeks and Romans simultaneously with the introduction of elaborate cooking and excessive feasting. Hot and freshly baked bread, cake, and similar foods form a whitish deposit around the teeth, which sticks to the gum margin and cannot be properly removed. Old, dry bread made of coarse flour will not adhere; as a matter of fact, it acts as a cleanser. Hard concretions on the teeth, such as salivary 82 TEETH, DIET, AND HEALTH calculus, commonly called tartar, also irritate the gum. In addition to this there is serumal calcu- lus, which, deposited underneath the gum and in pyorrhea pockets, forms a secondary source of irritation, contributing much to the chronicity of the disease. Injury of the gums by tooth- picks, injudicious use of the tooth-brush or dental floss, poor filling, inlays, and especially overhang- ing crowns and ill-fitting bridges are contributory factors. Uneven position of the teeth, uneven wear, faulty restoration, and many other factors caus- ing excess strain on certain teeth are also very liable to induce pyorrhea. Early recognition of the symptoms is of great- est importance, because in its early stages the disease can be easily cured. If the gums look bluish red and inflamed, if the small papillse be- tween the teeth become swollen, or if brushing or using dental floss starts bleeding, no time should be lost in consulting a dentist who treats pyorrhea. Later the tissues become infected (Figure 25), and the disease spreads beneath the gum and attacks the membrane and the alveolar process of the bone which holds the teeth in place. The bone dissolves, leaving a pocket into which the gum PYORRHEA ALVEOLARIS 83 collapses, giving the appearance known as re- ceded gums, exposing part of the root of the tooth. With loss of its bony support, the tooth becomes loosened, and the case must be considered well advanced when the teeth can be rocked with the fingers. All teeth are not affected to the same degree. Some are worse than others, on ac- count of the local contributory causes above men- tioned. The specimen reproduced in Figure 26 shows a case of advanced pyorrhea. Observe that the bone around the teeth has not been equally affected. On the upper incisor (A), the lower cuspid (B), and the first molar (C), the roots are almost entirely exposed. These three teeth were loose. There is considerable calcareous de- posit on the roots of the teeth. So-called “drifting” of the teeth is frequently associated with pyorrhea and generally is found in patients who have lost a number of teeth. The loss of the molars causes the lower front teeth to press against the upper ones during mastica- tion. This makes the upper incisors protrude, spaces appear between the teeth, and the patient’s appearance is liable to be impaired. More serious, however, is the constant flow of pus from 84 TEETH, DIET, AND HEALTH the pockets, which not only causes a malodorous breath but contaminates the food. Systemic Effects The discharge of pus from the pyorrhea pockets is a constant danger to the patient’s health. The infection may spread from the gums to the tonsils, and, by inhalation of moisture, globules laden with bacteria cause laryngitis, bronchitis, and catarrh. The swallowing of quantities of pus, mixed with food, results in digestive disorders. Hunter, the famous English physician, who first called attention to the harmful effects of “oral sepsis,” lays stress on the fact that pus from the teeth, when taken into the body with the food, is a cause of ulcers and other diseases of the stomach and intestines. One patient, whom the writer saw several years ago, had completely broken down with rheumatic fever. He had intermittent attacks of eye dis- ease and had lost a great deal of weight. Ex- amination of his mouth showed inflamed gums. All the teeth were loose, and there were pus pockets discharging freely. X-rays showed that the disease was far advanced and that abscesses had formed at the roots of various teeth. After careful study of the case it was found necessary FIG. 25. FRONT TEETH AFFECTED BY PYORRHEA Observe inflammation of the gums FIG. 26. SPECIMEN SHOWING CONDITION OF BONE IN AN ADVANCED CASE OF PYORKIIEA The bone is not equally affected. See text PYORRHEA ALVEOLARIS 85 to extract all the teeth, and this treatment resulted in almost immediate improvement and rapid gain in weight. Early treatment is the secret of a complete cure. If the reader has any suspicious symptoms, he should seek, without delay, the best profes- sional advice. A prominent dentist in the western part of the country, when giving a clinic at a dental convention to show the method which made his treatment of pyorrhea so successful, was re- proached with the statement that his cases did not present pyorrhea at all. He replied that this criticism was a proof that most dentists either did not recognize the early stages of pyorrhea or else paid no attention to it until the disease was virtually incurable. When the gums began to bleed and show signs of inflammation, that is the time to begin treatment. In a great many cases this condition of the gums is a symptom of some other disorder of the body, which should be inves- tigated and corrected. The diet of the patient must be carefully studied. Sometimes habits of eating excessive amounts of certain foods, such as meat, sweets, and white bread, have been so firmly established that the patient thinks they are nec- Treatment 86 TEETH, DIET, AND HEALTH essary for his welfare. Such food should be re- placed by cheese, buttermilk, raw or slightly cooked eggs, uncooked fruit, fresh vegetables, and other foods rich in vitamines, as advised in Chap- ter XIII. All local contributory causes, such as soft and hard deposits and mechanical irritations, must be removed, the patient’s mouth must be put into a hygienic condition, and all artificial work must be so adjusted that there is no cause for irritation and food retention. He must be in- structed in the care of the teeth and the home treatment of the gums. The brushing of the teeth as described in the chapter on prophylaxis also stimulates the gums. One should not be alarmed if he makes the gums bleed. Bleeding is a na- tural cleansing process, and after a few weeks the gums will become so firm that one cannot start bleeding by the use of the tooth-brush. Medi- cated mouth-washes and tooth-pastes are of great help if used in conjunction with dental treatment and on the advice of the dentist. A Case of Deficient Diet A young patient, discouraged because of in- flamed and bleeding gums, for which he had re- ceived treatment for more than a year without result, consulted the writer, to find out whether PYORRHEA ALVEOLARIS 87 it was possible to do anything more than scaling by the dentist and brushing the teeth and gums at home. His mouth was carefully examined, and it was found that the teeth were clean and well cared for. When questioned as to his diet, he said that he ate a great deal of meat at all meals, including breakfast; he was very fond of sugar and ate candy in large amounts all day. The writer advised him to change his diet, to eat very little meat, not more than twice a week, and to partake of vegetables freely, especially un- cooked vegetables. Candy and sugar he was to deny himself, except as used in the preparation of foods, and as a substitute fresh fruit, espe- cially oranges, were recommended. He followed these directions faithfully, and within two months his gums became normal. In well advanced cases, when a considerable amount of bone has been destroyed, the first step is to find out the exact nature of the condition. This is done by means of X-ray examination, which reveals teeth that are hopelessly involved and discloses irritating conditions under the gum, caused by poor artificial restorations and compli- cations such as abscesses. The treatment con- sists first of removal of all the teeth that are beyond saving. The fastening of loose teeth with TEETH, DIET, AND HEALTH 88 wires or splints is an unsatisfactory procedure from the point of view of cleanliness. Teeth that are so loose that they need support are a menace to the health and should be extracted. It is also important to know that better artificial substi- tutes can be made if the teeth are extracted before absorption of the bone around the teeth has gone so far as to destroy the entire alveolar process. Putting the evil moment off for a year or two of- ten means a mouth which cannot be fitted with a comfortable denture, and therefore trouble for the rest of the life. The treatment of the remain- ing teeth is exactly the same as described for the early stages: the lost teeth should be replaced as soon as possible, and the locking together of the teeth must be so adjusted that the lateral strain during mastication is equally distributed over all the teeth. Prevention If pyorrhea is to be avoided, a well regulated mode of living must be persevered in. Soft, starchy, and gelatinous foods, cake, and the like should never be taken between meals nor the last thing at night. They should be followed by food which acts as a cleanser, such as uncooked fruit and foods of a fibrous nature, which are tabulated PYORRHEA ALVEOLARIS 89 in Chapter XIII. Thorough mastication helps by increasing the circulation, which not only furthers the nutrition of the teeth and their investing tissues but also eliminates any waste products which may have accumulated. Cleanliness and hygiene of the mouth are the last but not the least important means of preventing pyorrhea. Many faults that originate from faulty diet can be cor- rected by carefully brushing the gums and teeth after every meal and thoroughly rinsing the mouth with a mouth-wash as described in the chapter on hygiene. CHAPTER VII RELATION OF THE TEETH TO GENERAL HEALTH “Infected teeth are ill tenants.” W. Hunter,1 a celebrated English physician, in an address on “The Role of Sepsis and Anti- sepsis in Medicine,” was the first to call atten- tion to the harm done by what he called “septic dentistry,” which he had observed was responsi- ble for serious ills in many cases. His criticism was at first bitterly resented by the dental pro- fession, but it lead to wholesome investigations which revealed that his statement contained a great deal of truth. Before that time the teeth were treated as though they had no relation to the rest of the body and could not affect the general welfare of the patient. Ten years ago the retention and preservation of the teeth was considered only from the point of view of inefficient mastication and its consequent evil of impaired digestion. The extraction of teeth was, therefore, advised only with great reluctance. The dentist had i London “Lancet,” January 14, 1911. 90 RELATION OF TEETH TO HEALTH 91 a guilty feeling when he had to admit that a tooth was beyond his power and skill to save, while his ability to retain, by some device or method, a miserably broken-down root soaked in pus, or a tooth ready to fall out by itself, was a sign of distinction and a token of ability. In the construction of crowns and bridges, the cosmetic and mechanical aspects claimed most of his attention; and the teeth used for support, regardless of their condition, gave him an opportunity of displaying his ingenuity. Thus extensive and expensive restorations were often placed on teeth which were hopelessly dis- eased and the cause of chronic infections in the jaws. There are many people who have septic conditions under crowns and bridges but are de- ceived by the usefulness of their dentures. Investigation Proved Hunter Right Research work undertaken by eminent bacteri- ologists, physicians, and dental pathologists, such as Billings, Rosenow, Hartzell, Grieves, and Gil- mer, has proved beyond a shadow of doubt that dental infections play an important part in many systemic diseases. The writer’s bacteriological and pathological investigations of the infections of the mouth and their relation to general dis- 92 TEETH, DIET, AND HEALTH eases have been published in a book entitled “Oral Abscesses,” to which those readers who want more technical knowledge may refer. The Mayo clinic, world-famous for its high standards and conscientious treatment, requires a thorough investigation of the mouth of every patient. They insist that all dental infections be eliminated and the mouth put in proper condition before any other treatment is undertaken. Dr. Charles Mayo once said that the great mass of people of this generation would not die from one of the great plagues, as they have in times past, but that ninety out of a hundred would probably die because of some simple infection, the result of a focal infection, the focus or original cause of which would give them no trouble. Other physicians who have a reputation for careful and systematic diagnoses include in every general examination of the body a careful in- vestigation of the condition of the mouth and teeth, and modern hospitals have added to their staff of consultants a dental diagnostician. Life insurance companies, realizing the dangers which may lie dormant in the mouth and ready to launch a vicious attack when the resistance is lowered, now insist upon an examination of the mouth, including X-rays of the teeth, before con- RELATION OF TEETH TO HEALTH 93 sidering an applicant as a fair risk. One way of increasing the possibility for life extension and insuring an old age free from suffering is the removal of dental infection. The efficiency experts in large industrial estab- lishments employ dentists to examine their em- ployee’s teeth and give them advice, while others go a step further and establish dental dispensaries in their factories in order to prevent illness and its consequent loss of time to the concern and to get the highest grade of service from their workers, who can only be expected to give such service when they are in perfect health. The Phenomenon of Focal Infection If one has an infection in one part of his body and it is transported from this place to another, the process is spoken of as focal infection. The original site of the disease is called the focus, and the material which is absorbed and which causes the secondary disease is made up of germs and their poisonous products called toxins. Diseases of the nose and throat, the air sinuses of the face, and the mouth and teeth are proba- bly the most important foci, but less frequent and less considered portals, such as the gall-bladder and genito-urinary tract, should not be overlooked. 94 TEETH, DIET, AND HEALTH Gastro-intestinal infection, food intoxications, and absorption in chronic constipation are other very important factors. All this illustrates the fact that a complete examination should be made in order to best serve the patient. This includes thorough investigation by different specialists who have been trained in their special branches of medicine and a study of the various findings before treatment is decided upon. Dental Diseases as the Cause of Focal Infection A diseased pulp in a carious tooth, an infection at the end of a root, involving the bone of the jaws (Figure 23 and 24), and severe cases of pyorrhea are the most frequent dental causes of focal infection. The causes, nature, and symp- toms of these afflictions have been described in previous chapters, but it may not be amiss to state here again the fact which puzzles so many patients; that is, that the absence of pain and swelling does not preclude the possibility of a focus of infection in the mouth. One may be harboring in his mouth millions of bacteria with- out knowing it (see chapter on examination). Good general health is no guarantee that one has no infection around his teeth, nor that he may forever remain immune to its danger. Every RELATION OF TEETH TO HEALTH 95 normal person lias a certain amount of so-called general resistance; the fluids and cells of the body bring about a reaction which checks infec- tion and destroys bacteria. Resistance, however, varies in different people and may he less at one time then at another in the same person, and when the resistance is decreased, germs may survive, settle in some part, and cause disease. Hunger, bad ventilation, lack of exercise, over- exertion, both physical and mental, exposure to cold, acute and chronic disease in other parts, and pregnancy are some of the factors which de- crease the general resistance and favor disease. It frequently happens that during pregnancy, when the forces of the body are occupied with special functions, an infected tooth, which has been quiet for years, develops an acute abscess. Such a case is illustrated by the experience of a patient who had X-rays taken of her teeth several months before consulting me. This ex- amination showed clearly evidence of infection on one of her teeth. Her dentist at that time had advised extraction, but because the condition was latent she refused to lose what she called “a perfectly good tooth.’’ When I saw her she was suffering excruciating pain from this same tooth, the gum around it was inflamed, and her 96 TEETH, DIET, AND HEALTH face was badly swollen. This condition could have been avoided if she had followed the advice given her by her dentist. Dental Treatment if General Health is Good So much harm has been done by dental infec- tions that some dentists believe every pulpless tooth is a menace. They believe that no one should retain such a tooth. Others, who have never happened to see a case of remarkable im- provement in general health after extraction of infected teeth, are ultra-conservative and still think that a tooth should be saved at any risk, so as not to impair mastication. In my opinion the solution lies somewhere between these two extremes. Although I have often been quoted as radical, I am not one of those who believe in ruthless extraction. There is no reason why pulpless teeth, if properly treated and filled, should not be retained, if the X-ray proves that they are not infected. In younger patients it is also justifiable to treat, by antiseptic measures, teeth with abscesses of very short duration, if the X-ray indicates that conditions are favorable for root-canal work. Teeth, however, which have been diseased for a long time and which the X-ray shows to be necrosed and absorbed should be re- RELATION OF TEETH TO HEALTH 97 moved. No one who has studied the tooth and bone pathology of old, pus-soaked teeth, or who has experienced the odor from one which has been removed, would ever hesitate, or have any doubt as to what should be done. In such cases I believe in radical measures. Nature itself shows its abhorrence of a tooth which has become an obnoxious foreign body. The absorption at the end of the root indicates a process of elimina- tion which should be hastened by extraction of the tooth. This is necessary from a purely dental point of view, or even for the sake of cleanliness. Patients are often bewildered by the opposing views and advice which they receive. Unfortu- nately, no hard and fast rules can be given. It is a matter of judgment and opinion, based upon careful analysis, into which must enter a thorough knowledge of pathology, and experience gained by observation of large numbers of such cases. The patient should seek the advice of a dental diagnostician who is qualified for this work. Dental Treatment if General Health is Affected In patients suffering from systemic disease, which is known to be caused by focal infection, the question arises whether the dental infection is the original cause or whether the two condi- 98 TEETH, DIET, AND HEALTH tions are not related to each other. Such a ques- tion must be answered individually. McCrudden writes that “in chronic disease, the hopeful therapeutic measure lies in improving the func- tional efficiency of the body and in improving the general health.”1 To further this achievement it is important to remove all infectious tissue, because the organs whose function it is to combat disease must be freed from any additional bur- den. The patient, therefore, will benefit by the elimination of dental disease, even though the condition in the mouth is not the direct cause of the trouble. This applies especially to heart- disease, the treatment of which requires that any- thing taxing the function of the heart be elimi- nated. In such cases conservative treatment of diseased teeth is not advisable because, in addi- tion to the reasons just stated, in patients with lowered resistance it is always doubtful whether the treatment of infection will be successful. I know of patients who were advised, without even an X-ray diagnosis, to have all their teeth re- moved, when further examination revealed a num- ber of vital teeth that were very useful in re- 1 F. H. McCrudden, “The Treatment of Chronic Diseases Is a Problem of Applied Physiology,” “Boston Medical and Surgical Journal,” Vol. CLXXV, No. 2. RELATION OF TEETH TO HEALTH 99 construction work. Such ruthless extraction is inexcusable. The patient’s interest naturally centers around the question of how much benefit he will derive from the removal of infected teeth, but this is difficult to forecast. Positive statements are sel- dom justifiable and sometimes lead to disappoint- ment, especially if made by an enthusiast who has no intimate knowledge of the medical aspect of the case. A patient who was suffering with pain in his foot once came to me for extraction of a number of teeth because he had heard that rheumatism could be cured by extracting teeth. I had a hard time to convince him that his teeth were all right. The specialist to whom I referred him reported that he had fallen arches. The fact that some people do not improve after a focus of infection has been eliminated may be explained by the presence of another focus exist- ing elsewhere, such as in the nasal sinuses or the gastro-intestinal tract. Another reason is that often the secondary disease is of long standing and is so firmly established, or the tissues so ex- tensively destroyed, that very little can be hoped for by removing the focus. It is not unlike the stoppage of a leak in the plumbing, which may have caused a wet spot on a ceiling. Even if the 100 TEETH, DIET, AND HEALTH spot dries, it leaves a mark, which requires further repair. It is necessary to resort to special treat- ment to eliminate the secondary disease; but in the patient, as well as in our example of the leak, one important thing has been accomplished: the cause of the trouble has been removed, and we are safe from it in the future. This also teaches the value of extracting infected teeth before any harm has been done in other parts of the body. How Dental Disease May Affect the Rest of the Body There is more than one road from bad teeth to ill health, and the rest of the chapter will be devoted to a description of the principal meth- ods by which dental infections may affect the rest of the body. Neglected mouths, with decayed and broken- down teeth containing decomposed food, red and congested gums, and pyorrhea pockets furnish great opportunities for the incubation and de- velopment of bacteria. It is no wonder that communicable diseases are rampant among chil- dren with unhygienic mouths. Neglect of par- ents to take care of their children’s mouths be- fore they start to school causes the greatest harm in this respect. Dr. A. C. Fones, who has intro- RELATION OF TEETH TO HEALTH 101 duced mouth hygiene into the schools of Bridge- port, Connecticut, gives some interesting statistics of three diseases common among school-children. The figures give the death rates per 100,000 population in 1914, before introducing mouth hygiene, and in 1918, after it had been established four years. 1914 1918 Diphtheria 36.6 18.7 Measles 20. 4.1 Scarlet fever 14.1 0.5 This is a reduction of these three diseases from 24.6 to 7.8 per 100,000 population. While the Government is endeavoring to en- force its pure-food laws, quantities of food are being spoiled in the mouths of the consumers. With this thought in mind it is interesting to re- call what tremendous efforts are made to examine cattle, certify milk, inspect meat and other food- stuffs, and furnish pure water, and the enormous amount of money spent for this purpose. New York City alone spends about one hundred thou- sand dollars annually for food inspection. All this is of no avail when the things we eat and 102 TEETH, DIET, AND HEALTH drink are mixed, before they reach the stomach, with decayed food and pus oozing from the gums and teeth. If one’s food seems to have lost its flavor so that one does not enjoy eating, it may be due to septic conditions in the mouth. The taste-buds cannot perform their duty if they are constantly filled with unhealthy secretions, such as pus, com- ing from pyorrhea pockets and fistulae, or with decomposed food decaying in broken-down teeth, so that whatever is eaten tastes like everything else. Deficient Teeth and Insufficient Mastication It is evident that mastication cannot be properly performed unless all the bicuspids and molars are present. Needless to say, the loss of teeth decreases the efficiency of mastication. There are, however, other conditions which lead to in- sufficient mastication. Malocclusion sometimes prevents proper motion of the jaws, and bridges, or other artificial appliances, if not properly con- structed, may be a hindrance instead of a help to mastication. In children, deep cavities or in- fected teeth cause a painful sensation when grind- ing food, with the result that the child bolts his food unmasticated. Insufficient mastication is RELATION OF TEETH TO HEALTH 103 frequently the cause of indigestion, since food not sufficiently broken up does not offer enough surface for the action of the digestive juices. Starchy food, especially, should be thoroughly masticated, as it depends upon mixture with a large quantity of alkaline saliva for favorable digestion. Dyspepsia is frequently caused by bolting the food. The Effects of Swallowed Pus on the Digestive System If one were asked to take half a spoonful of decayed food and pus with every meal would he expect to remain healthy! This is exactly what happens in children suffering from dental caries and gum-boils, because of broken down temporary teeth, and in the mouths of adults who have pyorrhea, sinuses from infected teeth, or ill- fitting crowns and bridges, which often cause most unsanitary conditions and are a source of gingival inflammation and ulceration. Many can withstand the ingestion of this pus for a long time, but the day of reckoning is sure to come. For a long time the acids of the stomach have been regarded as destructive to bacteria. Hun- ter, however, says that there is a limit to the power of the stomach to destroy micro-organisms TEETH, DIET, AND HEALTH 104 and that these powers become progressively weakened. Eventually disease of the stomach re- sults, and the infection may also be carried to still more remote parts of the intestinal canal. A patient consulted Dr. Hunter once for severe intermittent sickness and pain in the stomach, which had been causing trouble for eight months. There was loss of weight, increasing weakness, and other symptoms suggesting cancer. Morphia had to be used, and constant complaint was made of a bitter taste in the mouth, nausea, and loath- ing of all food. The tongue was coated with a dirty, moist fur. The patient wore false teeth, both in the upper and lower jaws. The plates were scrupulously clean and the gums beneath healthy. Of the four teeth present three were decayed, suppurating around the roots, with pus welling up on pressure. On examination Dr. Hunter found no sign of malignant disease in the stomach or abdomen, and he made a provisional diagnosis of gastritis (inflammation of the stom- ach), caused by continual swallowing of pus. He ordered the removal of the teeth. A week later the patient’s tongue was clean, and his sense of taste had returned for the first time in eight months. The condition of the stomach improved, but was not cured at once. The vomitus obtained FIG. 27. SPECIMEN SHOWING THE GELATION OF THE TEETH TO THE MAXILLARY SINUS The outer plate of bone has been removed to show the roots of the teeth extending into the sinus cavity (A). Observe that very little bone covers the ends of the roots RELATION OF TEETH TO HEALTH 105 two weeks later was still found to be loaded with bacteria. Treatment of the stomach was nec- essary in addition to removal of the dental cause, after which there was complete cessation of all pain and a steady recovery, with increase in weight, from that time onward. Dental Diseases as Related to Diseases of the Nose and Throat Dental diseases are frequently related to dis- eases of the nose and throat. We have already seen in a previous chapter that narrow dental arches may be the cause of insufficient lateral de- velopment of the nasal passages, which invites the formation of adenoids. Pus from the teeth, on the other hand, when discharging into the mouth, often causes infection of the crypts of the throat, the tonsils, and passages leading to the ears (Eustachian tubes). The air-chambers, called maxillary sinuses, in the cheek-bone on either side of the face, are in- timately related to the teeth, as illustrated in Figure 27. When an infection begins on the end of the root of a tooth it easily spreads to the mu- cous membrane lining the sinus cavity. This may result in an acute inflammation, with the following symptoms: fullness in the affected side of the 106 TEETH, DIET, AND HEALTH face, pain, and purulent discharge from the nose. More frequently, however, we get a chronic proc- ess of degeneration, which goes on without the patient’s knowledge, and the slight amount of pus is absorbed by the system. To illustrate the danger of an infected tooth and the spreading of the disease to the maxillary sinus, let me cite the case of a patient who came to me with the following history: About six months before, he had felt a pain in the right side of the upper jaw, and the first molar was tender when he bit anything hard. He bought some toothache drops in a drug-store, and after a few days was relieved. He was advised to con- sult a dentist, but as the pain did not return he thought it was not necessary. Two days before I saw him, however, he woke up with a dull pain and heavy sensation in the right side of the face, and the next morning he found a considerable amount of pus coming from the right nostril. Re- membering the trouble he had had with the tooth, he made an appointment for an examination. X-rays revealed an abscess area on the tooth, ex- tending into the maxillary sinus, and a picture taken of the entire face showed clearly that the neglected infection had involved the maxillary sinus. RELATION OF TEETH TO HEALTH 107 Every one who suffers from maxillary sinus disease should have an X-ray examination made of his teeth and, on the other hand, when infected teeth are found in the back part of the upper jaw, it is advisable to have the sinuses investi- gated by a competent nose and throat specialist and by the X-ray method. That a tooth which is only slightly abnormal from an X-ray point of view is a danger point from which infection may spread, causing serious disease of the maxillary sinus, is exemplified in my own experience. When my upper first bicuspid was prepared for a filling years ago, the pulp was accidentally exposed and had to be removed. The dentist treated and filled the root-canal to the best of his ability and according to the best methods then in use. About three years ago I had an X-ray taken of the tooth, which was found to be in close relation to the maxillary sinus. A slight area was discovered around the end of the root, so slight that I decided to retain the tooth, on the chance of its giving no trouble. One morning, however, I awoke with a throbbing sensation and a fullness in the side of the face where the tooth was. On leaning over, there was a slight discharge from the nose. I consulted a nose specialist and had an X-ray taken. My 108 TEETH, DIET, AND HEALTH suspicion that the tooth had infected the maxillary sinus was confirmed. On account of immediate recognition of the nature of the disease and prompt removal of the cause by extraction of the tooth, the sinus soon became normal again and has remained so ever since. If the reader has never had any trouble with the maxillary sinuses, he may not know where or what they are, but if he realizes that in more than 60 per cent, of the cases the underlying cause is an in- fected tooth he will appreciate the importance of taking no chances with infected teeth which ex- tend into the maxillary sinuses, especially when he considers the seriousness of the disease and the difficulties of treating and curing cases of long standing. How the Teeth Affect the Ears The nerves of the teeth, both in the upper and lower jaws, are connected with those of the ears, and it is not at all uncommon for pain from some dental cause to be referred to the ear. The patient then supposes that he is suffering from some aural disease, but examination of the ears shows them to be absolutely normal. After a careful dental examination we generally find a diseased pulp, an infection at the end of a root, RELATION OF TEETH TO HEALTH 109 or an impacted tooth, causing pressure (see Chapter IV, pain in the ears caused by impacted teeth). A patient suffering from earache or otalgia was referred to me by a friend who had had a similar experience. She had consulted an ear specialist, but he could not find any cause for her symptoms, the ear being entirely normal. I took X-rays of her teeth and discovered a lower second bicuspid on the affected side with an obscure cavity under the gum. There was evidence of infection at the end of the root, and apparently the pulp was diseased. The tooth, however, had never given the slightest trouble. After it was extracted the earache was entirely relieved. Micro-organisms from septic conditions in the mouth may travel to the back part of the nose and throat and pass through the Eustachian tubes to the ear. Besides this path, there are the blood and lymph channels through which bacteria may cause an infection of the middle ear. A patient who had suffered from repeated at- tacks of middle-ear infection, with a great deal of discharge from the ear and pain which would not subside, was advised by her physician to have her teeth examined. When she consulted me I made a complete X-ray examination of her teeth 110 TEETH, DIET, AND HEALTH and found in the upper jaw on the affected side evidence of extensive infection on a bicuspid and molar. The third molar was found to be im- pacted, and the gum around it was highly in- flamed, with a sinus discharging pus. I advised removal of all three teeth under local anesthesia, and after I had injected the nerves supplying these teeth the pain in the ear stopped at once. The treatment of the dental condition was fol- lowed by rapid improvement, and after a short time the patient was entirely relieved of her ear trouble. Involvement of the Lymph-Glands The lymph-glands which drain the teeth and tissues of the mouth are situated behind the chin, inside the angle of the jaw. When pus and bac- teria are absorbed by the lymphatic vessels they reach these glands, which are sometimes com- pared with filters. The net chain, of glands, which form a second line of defense, are located on the side of the neck. In the performance of their duty, the lymph- glands, which ordinarily are so small that they are not noticed, become enlarged. They may be either elastic, soft, and tender to the touch, or, in infections of longer standing, hard, large, and RELATION OF TEETH TO HEALTH 111 prominent. Enlarged lymph-glands are most common in children, but they frequently occur in adults. A student consulted me on account of a round, movable swelling underneath his jaw, which was tender. Examination showed that what appeared to be a swelling was in reality an enlarged lymph- gland. He complained of no pain from his teeth and when looking them over I could find nothing that seemed abnormal. X-ray pictures, however, showed evidence of disease on the roots of the lower second molar, apparently caused by an in- fection, which was transmitted through the pulp from decay under a filling. When I opened into the pulp I found it putrescent, and after proper treatment the lymph-glands became normal in a very short time. Absorption from Dental Infection Pus absorption in acute dental infection does not differ from the absorption of acute infections from other parts of the body. It is the cause of the so-called constitutional defects. These are evidenced by fever, quickening of the pulse and respiration, hot, dry skin, constipation, highly colored urine, and, later, sweating and, perhaps, delirium at night. In serious cases, when the ab- 112 TEETH, DIET, AND HEALTH sorbed bacteria grow in the blood, we get sep- ticemia, popularly called blood-poisoning. In chronic infection pus absorption takes place only on a small scale, and, therefore, there are no sudden and alarming symptoms. This causes a great many people to underestimate its dangers. The fact that in most instances there is no pain or swelling is the reason for the infection remaining unnoticed for years, sometimes until the general health is irreparably undermined. The Result of Absorption of I us and Bacteria The most common result of septic conditions in the mouth, such as pyorrhea, or infection at the roots of devitalized teeth, is a so-called chronic toxemia, which manifests itself by all kinds of vague symptoms caused by the action of the ab- sorbed bacteria, or the poisons they form, or both, on other tissues or organs in any part of the body. It is true that a perfectly healthy person may be able to eliminate the daily dose that is absorbed, as he may eliminate a certain amount of alcohol or nicotine, but at some time or other conditions may arise which bring about grave results. Disproportionate fatigue from slight exertion, a constant tired feeling, the inability to do an RELATION OF TEETH TO HEALTH 113 ordinary day’s work, both mentally and physi- cally, are common manifestations of chronic tox- emia. A frequent accompaniment of these symp- toms are dry, sallow, or grayish skin, loss of ap- petite, headaches and constipation, and often the patient loses weight and requires an abnormal amount of sleep. More rarely there is a rise of temperature in the afternoon or evening. Gen- erally the patient is not really sick and often thinks that a tonic or a rest and change of climate will give relief, only to find that the benefits from this treatment are but temporary. A cure can- not be effected without removal of the cause of the condition. A number of years ago, when we had just began to realize the importance of dental infection, a patient presented the following conditions: He was a middle-aged man who had always been in the best of health. Recently, however, he com- plained of a feeling of grogginess on rising and other symptoms which manifested themselves in benumbed mental activity. Smoking made him ill, whereas he had been able to smoke a great deal before. He also complained of chronic con- stipation. He had consulted two physicians, who could find nothing radically wrong with him, but an examination of the teeth revealed infection 114 TEETH, DIET, AND HEALTH of the bone around the roots of three teeth. I first attempted to treat these teeth through the root-canals, which when opened gave out a vile odor. The patient improved during the treat- ment, but a few weeks after the root-canals were filled the same symptoms returned. I then un- dertook more radical measures, and after all the diseased tissue was surgically removed the patient got permanent relief, his mind became again keen and alert, and his other symptoms disap- peared and have not returned in the six years that have elapsed since. Another patient, a young girl, came to see me about a tooth that had been treated for several weeks without success. She had no discomfort in her mouth, but complained of a constant tired feeling and intermittent fever of about eight months’ standing. After X-ray examination, which showed evidence of a large abscess at the end of the root, I advised extraction of the tooth. When this was done the patient improved rapidly, and her fever did not recur. Also complaining of a constant tired feeling and headaches that came on in the morning once or twice a week, a patient once consulted me, be- lieving that the condition was due to the teeth. X-ray examinations showed four pulpless teeth, RELATION OF TEETH TO HEALTH 115 three of which were without infection, but one showed a very small area at the end of the root. I advised a thorough physical examination before considering extraction of the teeth. She took my advice, and her physician found that she had some intestinal trouble which he thought caused her symptoms. When this condition was reme- died she became perfectly well. Tuberculosis Suspected Another patient, a man about eighty years old, who had formerly enjoyed good health, suddenly developed a temperature, running about ninety- nine degrees during the day and up to one hun- dred at night. It was accompanied by lassitude and lack of appetite. He was examined by a careful physician who could find no disease, but on account of the fever he thought there might be a slight tubercular process present. X-rays of the lungs, however, showed that this was not the case. He continued to suffer from this condi- tion for two months, when X-rays were made of his teeth. The pictures revealed three large abscesses. I did not give the patient too much hope of relief from his general symptoms, but advised extraction of the three teeth on principle. The result of this treatment, however, was very 116 TEETH, DIET, AND HEALTH gratifying. The temperature became normal within two days; the patient rapidly improved and has remained well ever since (two years). Septic anemia is a disease of the blood char- acterized by sallow complexion, loss of bodily and mental vigor, and loss of weight. A change in certain constituents of the blood takes place. Hunter classifies under this head all cases of anemia that are due to infection, the cause of which he says is generally found to be disease in the nasal cavity, the nasal sinuses, the teeth, or intestinal tract. He described several cases of this type. Here is a case from the writer’s prac- tice. The patient, a very active and prominent man from one of the Southern cities, gave a history of having been unusually well until about a year before, when he broke down after a severe at- tack of grippe, the symptoms being principally those of a nervous collapse. His physician sent him away for a rest, and after two months he was somewhat improved and returned to work. Soon, however, he was again obliged to give up his duties, and, after another medical examina- tion, he went to the mountains for a month. Here he became very anemic and had some other dis- quieting symptoms. When he consulted a phy- RELATION OF TEETH TO HEALTH 117 sician in Boston an X-ray examination of his jaws and teeth was advised. The pictures re- vealed a large cyst in the lower jaw, caused, as the plates showed, by a root that had been left after extraction of a tooth many years before. An operation for removal of the cyst was per- formed, and the root was removed at the same time. A large amount of pus was released. The patient improved rapidly and soon went back to work. Although he had a great many extra activities during the war, which began soon after- ward, he remained perfectly well and has been so ever since (six years). Mental Diseases Dr. Henry A. Cotton, medical director of the New Jersey State Hospital of Trenton, presented to the medical profession the results of his ex- tended study and observations, asserting that a certain precentage of nervous and mental dis- eases are the results of toxemia caused by chronic focal infection. From his work he deduced that the removal of infected teeth and tonsils and the clearing up of infection in the stomach, intestines, and other vital parts of the body had resulted in remarkable recoveries of insane patients. An article in the “Review of Reviews” for April, 118 TEETH, DIET, AND HEALTH 1922, written by the state commissioner of insti- tutions of New Jersey, describes the work at Trenton in an interesting manner. The insane asylum has been transformed into a hospital. All restraining apparatus has been elminated, and the place has been freed of those terrors, partly real and partly imaginary, that torment the minds of the insane. The patients are treated just as any other sick person is, and a careful, systematic survey, aided by well equipped clinical and X-ray laboratories, is made in every case. A number of cases were reported by Dr. Cotton in the “Journal of Dental Kesearch,” and all of these undoubtedly were relieved of the symptoms of insanity.” 1 The Rheumatic Group of Diseases There is no question that certain conditions often spoken of as ‘ ‘ rheumatic ’ * are due to focal infection and are frequently caused by dental dis- eases. Among these belong certain arthritic con- ditions, such as cause swelling and pain of the joints, neuritis in various parts of the body, and secondary infections of the eyes and ears. A patient suffering from a severe attack of lumbago was sent to me for examination of the i “Journal of Dental Research,” 1919, p. 209. RELATION OF TEETH TO HEALTH 119 teeth, with the idea of discovering any possible infection in the mouth which might account for her trouble. All other causes had been ruled out by her physician. The X-rays showed a large area on a lower molar, indicating an abscess at the end of the root. This was one of the chronic type, causing no pain or local disturbance of any kind. I extracted the tooth, and the patient reported that she was relieved promptly and that her back had been well ever since. Another case is that of a patient who had such pain in his back and shoulders that he was in- capacitated for work and had to give up his place as a chauffeur. A careful physical examination showed no cause for his trouble, and X-rays of his back revealed no changes in the bones. The condition was thought to be due to focal infection. When he was referred to me I took X-rays of his teeth, several of which showed evidence of infec- tion. As there was no other infection found in the body, the extraction of these teeth was decided upon. The result of this treatment was rapid improvement, so that he was soon able to go to work again. He is now driving a truck and has been free from the symptoms he had complained of. In a consultation with another patient, he stated 120 TEETH, DIET, AND HEALTH that five years before he had had a sudden attack of rheumatic swelling and pain in the knees. The shoulders were next involved, and in a short time all the joints were painful and inflamed. The patient had taken electric baths, but they had not given him any relief. At the time of my ex- amination he was in great pain from his joints and had to walk on crutches. He had no pain in his teeth or face, but an X-ray examination showed that one of his upper molars was diseased and had caused a chronic infection of the maxillary sinus. Extraction of the tooth and treatment of the sinus resulted in general improvement, and after seven weeks he was entirely rid of his rheumatic symptoms and could walk without as- sistance. Summary The movement that began about two decades ago to save every tooth at all costs, and the prac- tice of removing the pulps of teeth for the pur- pose of attaching bridges or improving their appearance by cutting them off and attaching porcelain crowns, are greatly to blame for the fact that so many people to-day suffer from chronic dental infection. Before that time, teeth were promptly removed on the slightest provoca- RELATION OF TEETH TO HEALTH 121 tion. This was a great safeguard against septic absorption from dental disease, but frequently teeth were extracted, not because they could not be filled, but because it was simpler to make an entire artificial set. The value of the teeth was greatly underestimated. To-day physicians and patients have begun to realize the importance of the teeth, both in health and disease. The cases enumerated in this chap- ter have been selected, not to give the impression that all ills come from diseased teeth and can be cured by ruthless extraction, but to emphasize the important relation of dental diseases to the general health, and for the purpose of arousing the layman to timely treatment. When the pa- tient’s general health has become involved it is generally too late for conservatism and preven- tive treatment, and the existing conditions usually demand extraction of the infected teeth, if only for the sake of hygiene. Preservation of the teeth starts at an earlier age. The lamentable fact that so many people have to lose some of their teeth before they reach middle life discloses the need for preventive dentistry and a better understand- ing of the benefits that may be derived from oral hygiene and proper diet. CHAPTER VIII SUBSTITUTES FOB LOST TEETH “A mouth without teeth is like a mill without a stone.” The loss of even one tooth will often cause a disturbance in the proper locking together of the teeth, breaking up the contact of the dental arch. Teeth which have lost their lateral support will tip, and if they have lost their opposing teeth in the other jaw they will gradually work out of the socket. The loss of teeth also frequently changes the facial expression. If there are large spaces in the dental arch the teeth may tilt, and if the sup- port of the back teeth becomes insufficient the jaws close, bringing the chin and nose in closer rela- tionship. This changes the proportions of the face and may cause abnormal folds or wrinkles about the mouth, giving an expression of age and dejection. The efficiency of mastication is decreased by the loss of teeth, but many people are not aware of this fact, and it is surprising how they some- times get along without missing their back teeth 122 SUBSTITUTES FOR LOST TEETH 123 and without properly masticating their food. The onset of digestive troubles may cause them to reflect. To avoid the ultimate loss of good teeth, pre- vent digestive disturbances, and ward off certain disfiguring changes in facial expression, all the spaces where teeth have been lost must be filled in as soon as possible, the only exceptions being the wisdom-teeth. There are different ways of replacing teeth, but the most important are fixed bridges, removable bridges, and plates. Each type has its advantages and disadvantages, and after studying the mouth the competent dentist will recommend the type which he thinks best suited. A great deal of confusion in this respect is caused by well intentioned friends, who give ad- vice from the depths of their own experience with- out knowing anything about the particular condi- tions in the mouth. A description of the ad- vantages, and disadvantages of the different types of substitutes should, therefore, give the reader a general idea of their most important character- istics; but he should remember that in each case a careful study is necessary, and a selection must be made with consideration not only to the de- sires of the patient but of the various conditions in the mouth. 124 TEETH, DIET, AND HEALTH Surveying the Mouth When several teeth have been lost and substi- tutes are to be planned, it is necessary to consider the mouth as a whole if harmonious results are to be obtained, even though all the work is not to be done at one time. For this purpose the dentist should make plaster models of the teeth and from these models study the case from every angle. A complete examination of the teeth is always ad- visable, to detect infected and diseased teeth, the extraction of which might entirely upset the plans for restoration. For example, let us consider the case of a patient who has lost two teeth on the left side of the lower jaw. On each side of the space is a good tooth to which a sanitary fixed bridge could be attached. All the teeth on the right side except the wisdom-tooth are present. Before be- ginning the bridge, X-ray examination of the teeth on the right side discloses the fact that two molars and one bicuspid are infected at the ends of the roots. The condition is such that extrac- tion is necessary. This will leave no teeth on the right side posterior to the first bicuspid. Con- sidering the case with these new facts in mind, a removable bridge or partial plate would be very much better suited to this particular case, since SUBSTITUTES FOR LOST TEETH 125 it would replace the teeth on both sides and is the only means of replacing those on the left side. The Fixed Bridge The fixed bridge is firmly cemented to the teeth on either side of the space from which the teeth are missing. It simulates the natural condition more closely than any other substitutes. Al- though a great deal may be said for removable dentures, the fixed bridge, if properly constructed, is still the most desirable means of replacing lost teeth. Fixed bridges, however, have been se- verely criticized on account of the unhygienic conditions frequently found under them. This, however, may be due to the fact that the patient does not take proper care of the appliance. The wearer of a fixed bridge should be instructed in the care and cleaning of it (see chapter on hygiene). Irritation of the gums and pus pockets are often due to poorly fitting gold crowns and poor methods of construction. Fixed bridges must be so made that no injury of the tissues occurs, and they must not interfere with the hygienic condition of the mouth and must be easy to clean by means of special brushes and dental floss. There are various ways of attaching them to the supporting teeth, the best being those which 126 TEETH, DIET, AND HEALTH require the least tooth destruction. The removal of the dental pulp for the sake of a better at- tachment is seldom justified, as it may cause loss of the tooth. Removable Bridges From the sanitary point of view, removable bridges are ideal since they can be taken out and cleaned and the teeth to which they are attached thoroughly brushed. There are several different methods of attaching them to the teeth, and with some of these it is not necessary to destroy any of the tooth substance. Experience has proved, however, that all attachments that cause friction on the anchoring teeth, no matter how well the denture is constructed, will in some mouths cause erosion. The fact that the bridge can be removed is sometimes a disadvantage. Patients often come into the dentist’s office complaining that the den- ture does not fit satisfactorily, and when the mat- ter is investigated it is generally found that instead of wearing it the patient leaves it most of the time reposing in a dressing-table drawer or a waistcoat pocket. The teeth change their relations if the bridge is not worn every day, and in a comparatively short time these changes pre- SUBSTITUTES FOR LOST TEETH 127 vent the denture from fitting properly. Gen- erally it is better to wear it at night also. Dentures The replacement of a large number of teeth necessitates the wearing of a plate. In the upper jaw full dentures, those supplying all the teeth, are often more satisfactory than partial ones, be- cause if two or three teeth remain and the plate is built around them the suction by means of which upper plates are held in the mouth is ren- dered less efficient. In the lower jaw, on the other hand, it is a great advantage to be able to save two or more teeth to give the plate support. People with pyorrhea who lose teeth are particu- larly hard to fit with artificial dentures because the disease destroys the alveolar bone which is the principal support of the plate. Most people do not know this and wait as long as possible before having the teeth extracted, with the result that the mouth is in such a condition that it can never be fitted with a comfortable denture. There are many different ways of constructing a plate. It may be made of rubber, of aluminum, or gold, and when a particularly artistic effect is desired, platinum may be used with hand-carved 128 TEETH, DIET, AND HEALTH teeth and porcelain gum. Gold, aluminum, and platinum, being less porous than rubber, are not so easily affected by the fluids of the mouth and are therefore less liable to irritate the tissues of the mouth. Dental Crutches Some people neglect their teeth and think that some day they will have them all extracted, be- lieving that this will save trouble and expense. They do not realize that the best possible sub- stitutes are never equal to their own teeth and that if they happen to have a poorly formed mouth no really comfortable denture can ever he made. Although a few patients say they pre- fer their artificial teeth to their own, as a rule the artificial denture is a compromise. With all the conditions favorable and the workmanship perfect, it has been estimated that the average person wearing a full upper and lower plate has only about 40 per cent, of his original biting and masticating ability. The success of artificial dentures depends in large measure on the mental attitude of the pa- tient, besides the shape and form of the mouth. Every case is different. Some people are fortu- nate enough to have mouths which would hold up SUBSTITUTES FOR LOST TEETH 129 the crudest plate, while others find the most up-to- date and carefully made dentures only partially satisfactory. When a denture is first inserted it seems so large that no room is left. This feeling disappears within a few days if the patient is willing to do his share by wearing the denture constantly. If sore spots appear on the gums, it means that the denture needs adjustment. As time goes on and the places where the teeth were extracted heal, a certain amount of shrink- age of the gums may ensue. This means that the plate must be relined or remade. The question of being able to eat with new dentures depends upon mechanically correct construction, but in all instances the patient must learn to masticate with them, and after some practice and perseverance their proper use will be acquired. CHAPTER IX PAIN : ITS MEANING, CAUSE, CONTROL, AND TREATMENT “He jests at pain who never felt a toothache.’’ Pain is a monitor which warns the conscious mind that there has been neglect and abuse which will undermine and impair the structure and func- tions of organs unless immediately attended to. It is primarily a protective device, giving in- formation as to conditions affecting the normal state of the body. In this capacity it is a friend, but when operative measures become necessary to correct abnormal conditions pain is a hindrance and it is necessary to take steps to control it. In disease, pain is to be regarded as a symptom, and the treatment for relief must be directed to- ward the cause of the disease. Closely related to the physical manifestations of pain is fear, an emotion which is deeply rooted and has strong reactions on the functions of the body. Fear can only be controlled by psychological influences. Race, age, sex, general health, and susceptibil- ity of certain individuals are factors which ex- 130 PAIN: ITS MEANING AND CAUSE 131 plain differences in the intensity of pain. The promotion of self-control, such as was practised by the ancient Spartans and the American In- dians, tends to minimize both the mental and physical aspects of pain, while such emotions as worry, fear, fright, and dread may cause an enormous exaggeration of the actual sensation. The intensity of pain also varies according to the part of the body affected, some parts being much more sensitive than others. In the mouth the nature of pain varies greatly. As has been already stated, pain from disease is a blessing in disguise. One should not try to cure a toothache by means of toothache drops or other palliative methods, but should see a dentist at once and get at the cause of the trouble. There are pains that are due to chemical action, such as the influence of sugar, salt, or acid food, and these indicate that there is a cavity somewhere in the tooth, although they may also be caused by exposure of the sensitive surface of the root when the gum shrinks from the tooth. When the pulp of the tooth becomes involved there is, first, pain from cold; later, hot things cause in- creased pain, which is relieved by cold; but when the pain is intensified by pressure, percussion, or other mechanical influences it is a sign that 132 TEETH, DIET, AND HEALTH the infection has spread beyond the tooth and that an acute abscess is beginning to form. Such toothaches may be sharp or dull, lancinating, con- tinuous, intermittent, localized, or diffuse. The character of the pain is often so typical that it helps the dentist to discover the seat of the trouble. Chronic infections, such as we have studied in Chapter V, generally develop without transmit- ting any danger-signals. This entire absence of pain is the reason extensive harm has been done when the condition is finally discovered. Referred Pain Pain in one tooth may be referred to another or even to other parts of the head, and it is then frequently spoken of as neuralgia. Pain in the forehead, the back of the head, the nose, the eye, and the ear may be due to any one of a large number of dental conditions. The discovery of the cause is often very difficult and requires not only a careful study of the history and symptoms but also X-rays of the teeth and entire face. One of many such cases that I have seen was that of a young woman who had been suffering from earache and what she called “face-ache” on the right side. She consulted an ear specialist, who PAIN: ITS MEANING AND CAUSE 133 examined her carefully but found her ears entirely normal. She was referred to me, although she thought at first that it could not possibly be due to her teeth, as she had had them examined very recently. I took X-rays and found a large cavity in a lower bicuspid, underneath an amalgam fill- ing, entirely hidden by the gum. The picture also showed evidence of infection at the root of the tooth, indicating that the decay had reached the pulp and caused a chronic infection. Extraction of the tooth promptly relieved all her symptoms. Operative Pain Operative pain is the pain one thinks of when dentists or dentistry is mentioned. “Will it hurt?” is the question most frequently asked in the dental chair, and “Does he hurt?” is the in- quiry made in confidence to a friend when the ability of a new dentist is being discussed. This, however, is a poor standard by which to judge a dentist, and in general one can suspect that the saving of pain may be at the expense of the quality of the work. On the other hand, a dentist is very often not to blame for poor work. It may be entirely the fault of the patient, who is not willing or able to submit to the discomfort neces- sary for proper performance of the operation. 134 TEETH, DIET, AND HEALTH The patient’s attitude is of great importance. Here comes Mrs. Touchy, who is five minutes late for her appointment because she has been shop- ping all morning. She is very much put out be- cause the attendant tells her that she will have to wait a few minutes, the dentist being engaged in finishing a delicate operation that happened to re- quire a little more time than he had expected. ‘ ‘ The idea! ’’ she says. ‘ ‘ My appointment was for twelve o’clock. It is now seven minutes past, and I don’t see why I cannot be seen promptly.” When she finally sits down in the dental chair, the head-rest is first too high, then too low, then a little too far back. She has a barette in her hair which presses into her scalp and makes her un- comfortable during the entire sitting, and she is sorry she did not go to her friend’s dentist, who has a very fine chair. The dentist has a painful operation to perform and advises the use of a local anesthetic, but the patient just hates the idea of it: “These dentists just enjoy sticking a needle into you when it is not at all necessary.” The dentist tries to make the best of it, but the tooth is hypersensitive, and the patient cannot see why he must constantly touch the place that hurts. The dentist in Skowhegan, where she used to live, had a very much better way of doing it. PAIN: ITS MEANING AND CAUSE 135 When the sitting is finally over the dentist and the patient are completely used up, and the result of the work is a compromise. Another patient, although highly sensitive, realizing what can be accomplished, arranges matters so that she is well and rested at the hour of the appointment. She allows plenty of time, so that she can sit down a few minutes before being asked into the dentist’s office. Her mind is in a calm and cooperative mood, and she tries her best to relax. She has perfect confidence and realizes that if the dentist tells her he must hurt a little he does it because it is necessary and not to satisfy his “professional craving to inflict pain.” Any dentist is happy to serve such a patient because it gives him the opportunity to apply his greatest skill. Operative Pain can be Controlled To-day we have efficient methods of controlling pain successfully. When a sensitive cavity needs to be excavated, or a tooth ground, when an aching pulp must be removed, a tooth extracted, or any surgical operation performed on the jaws, it can be done in a painless manner. Nitrous oxide and oxygen gases were first used for this purpose and are still employed with good effect. The patient 136 TEETH, DIET, AND HEALTH can be put into a semi-conscious or entirely un- conscious condition, so that he does not mind, or does not know anything about the pain. Perfec- tion of the method of injecting novocain, or pro- cain, as it is also called, has made local anesthesia the most popular method of eliminating pain from dental and oral surgical operations. The solu- tion can be injected directly into main-nerves, making it possible to operate on a large section of the mouth or to extract a number of adjoining teeth painlessly. It has the advantage, which is especially important in filling teeth and the like, that the patient is fully conscious and, therefore, can cooperate in every way. Furthermore, the anesthesia last more than an hour, which is suffi- cient time for the ordinary dental operation. No- vocain when administered by an expert, gives ex- cellent results, pain is entirely eliminated, and there are no after effects, such as soreness and sloughing. Failures in administration of this an- esthetic are generally due to not reaching the nerve, and not to the fact that the drug does not take effect on the patient. Patients sometimes think that pain after extraction is caused by the local anesthetic, while as a matter of fact it is entirely due to the operation, as will be seen in PAIN: ITS MEANING AND CAUSE 137 the next paragraph. The action of procain is solely local, unless accidentally injected into a blood-vessel. It can be used with safety in preg- nancy and nursing. Pain after Operations Injury to the bone and soft tissues incidental to the operation, such as a difficult extraction of an infected tooth, causes pain, which is felt just as soon as the effects of the anesthetic wears off. The same pain is felt with the return of consciousness after gas or ether unless the patient is under the influence of morphia. When pain seems likely to occur, the patient should be given a prescription for some palliative treatment, which differs ac- cording to the case. Ten grains of Empirin, or five grains each of aspirin and phenacetin, taken together, with half a glass of water, will in many cases help until the services of a dentist can be secured. Generally, however, drugs should not be taken except on professional advice, as some people react abnormally to them. Many patients do not realize that they should receive further treatment after the extraction of teeth and should visit the dentist until the wound has healed and all pain and discomfort have subsided. 138 TEETH, DIET, AND HEALTH Fear Fear is an emotion, a state of the mind, but is associated with bodily sensations, especially pain. Closely related to fear are other emotions, such as dread, which is a diminutive, and fright, an intensified condition. Fear in animals induces fight, or flight. Man has learned to suppress these actions, and the effect of energies, gen- erated but not actually transformed into ac- tivity, is still discernible but expressed as trem- bling, sweating, blanching, rapid respiration, and increased heart-beat. Dr. Crile, of Cleveland, Ohio, well known for his studies of surgical shock, compares these manifestations with the detrimen- tal action of a motor running at full speed in an automobile that is kept stationary. Fear exaggerates all of the bodily sensations. Timid persons alone in a house at night imagine all kinds of things if they hear the slightest sound, and in the same way fear gives rise to false ideas regarding the state of the body. It destroys the power of the mind to reflect and paralyzes judg- ment and reason. The person who, before an operation, has been told dreadful stories by some thoughtless friend is at least apprehensive if not actually frightened, and associations such as the PAIN: ITS MEANING AND CAUSE 139 sound of surgical instruments, the sight of blood, the thought of a surgical operation, or the neces- sity of having a tooth extracted induce in many people extreme effects amounting to prostration. Even the use of the dental engine produces a feeling that cannot be described but is familiar to most of us. Fear cannot be overcome by taking drugs. Its only antidotes are faith, confidence, and knowl- edge. If a person knows that his dentist uses the latest methods to eliminate suffering and has suf- ficient confidence in him, his fears will be de- creased to a minimum. Instead of telling every one how he dreads having a certain dental opera- tion performed, he should accept it as a matter of fact. The less he talks and thinks about it the better. When in the dentist’s chair, he should not let himself fix his mind on the operation. Pain is much better borne when the mind is calm and relaxed. It is the constant nervous tension which causes fatigue and weariness rather than the suffering of actual pain. Right Psychology Helps Children » Children should be brought up with a proper amount of self-control and taught the virtue of submitting heroically to a certain amount of 140 TEETH, DIET, AND HEALTH physical pain and punishment. Such training begins in the nursery and is achieved by suppress- ing too many expressions of sympathy for minor hurts and accidents. Wrong suggestions are often made carelessly or thoughtlessly and have an important influence on the child, ever alert to increase his knowledge of life. One should not discuss his own dental troubles when the children are about, and when one takes them to the dentist one must not instruct them to “be brave” and “not to be afraid,” or assure them that “they will not be hurt.” In the first place, it may be neces- sary for the dentist to do something that causes slight pain, and the confidence of a deceived child is not easy to regain. Secondly, just as soon as pain and fear are mentioned, a suggestion is made which fixes the mind of the child so that he can think of nothing else but pain and fear and be- comes extremely suspicious. On the child’s first visit to the dentist, it should be arranged that nothing be done but an examination and, perhaps a cleaning of the teeth. This gives the dentist a chance to make the acquaintance of his little patient and gain his confidence. The rest can be left to him. He has made a study of how to take care of children, and very often it is better if the mother does not stay with the child. Parents who PAIN: ITS MEANING AND CAUSE 141 pay attention to these little details do their children a great act of kindness, besides mak- ing it easy for themselves and every one else concerned. CHAPTER X EXAMINATION OF THE MOUTH TO PREVENT SERIOUS DISEASE “ Knowledge is the foe of disease.” The reader has learned from the previous chapters that dental diseases may start and pro- gress unnoticed, since pain often gives its warn- ing only when the opportunity for successful treat- ment has passed. Unsanitary conditions may exist in people’s mouths without their being aware of the fact, and when the day of reckoning comes it may be necessary to lose one or even all the teeth, which, in addition to physical and esthetic disadvantages, may involve a large outlay of money for reconstructive work. To get some idea of what is going on in his mouth, the reader should scrutinize his teeth care- fully, standing in front of a well illuminated mirror. He should examine his child’s teeth from time to time and observe the color of the gums, whether the teeth are clean and free from deposits, whether they are straight or crooked. Tooth-decay, however, cannot always be dis- 142 EXAMINATION TO PREVENT DISEASE 143 covered in this way, especially when the cavities are small. Spots of chalky character indicate that the enamel has been softened, while dark discolora- tion may be due to certain filling material or medication (silver nitrate). If a tooth turns pink or dark after an injury it indicates bleeding inside the tooth, after which it becomes dis- eased. These conditions need immediate atten- tion. On account of the importance of attending to cavities when they are just beginning, it is neces- sary to go to a dentist at regular intervals for examination. This visit may be made the occasion for a cleaning of the teeth. One should form the habit of having his mouth carefully ex- amined every five or six months. He should not put it off until he has a toothache, for then it may be too late to save the tooth. The Value of the X-Ray Unless it is evident that the teeth are per- fectly healthy, that there are no large fillings, crowns, or bridges and no inflammation of the gums, one should have an X-ray examination of his teeth. The dentist, if he is painstaking, may find every cavity in the month by means of an ex- 144 TEETH, DIET, AND HEALTH plorer and discover any unhealthy place on the gums by careful inspection, but no matter how long one has gone to him nor how well he knows every tooth in one’s mouth he has no means of finding out what is going on inside of the jaws and teeth except by the X-ray method. The X-ray picture will show the conditions under the surface; it will show whether a tooth has a root-canal filling and whether this filling is perfect or not. It is the only means of dis- closing infection at the root end of a tooth and pus pockets at its side. Leaky fillings, over-hang- ing gold crowns, and other imperfections can be discovered. To the expert dentist, who under- stands how to read the marks left by disease, treatment, and healing, a complete X-ray exami- nation, combined with clinical inspection, will tell the whole past history besides the present condi- tion of the mouth. If one has dead, or pulpless teeth, he should have them investigated by the X- ray method. He should not try to remember which of them have had the pulps removed. It is a mistake to have only a few of the teeth X-rayed. A careful diagnostician will insist on a systematic investigation, as it reflects on his judgment if any- thing is overlooked. EXAMINATION TO PREVENT DISEASE 145 The Value of Periodical X-Ray examination Because of the ease with which diseased condi- tions are overlooked, the writer has recently in- stituted an arrangement with some of his patients to have their teeth X-rayed every year, or at least every second year. The discovery of small cavities hidden under the gum, or just beginning under a filling or a bridge, fully justifies such a procedure and often prevents a great deal of trouble, suffering, and expense. A man made an appointment with me some time ago for extraction of a loose and painful tooth. He had lost a great many of his back teeth, which had been replaced years before by bridges. After extracting his tooth I tried to im- press upon him the importance of having the rest of his mouth X-rayed, to determine whether the teeth were all right under the crowns. He thought, however, that since he had had no pain or discomfort from these teeth it was not neces- sary. I advised him not to put it off too long. He returned two years later, sent back to me by a nose and throat specialist, whom he had con- sulted because of a discharge from the right side of his nose. It was found that the pus came from 146 TEETH, DIET, AND HEALTH the maxillary sinus, which had become infected by a tooth. X-rays of the teeth showed that the only molar on the right upper side had a large cavity under the crown, which had caused disease of the pulp, from which the infection had spread. When he found that the tooth, which anchored a long bridge, must be extracted and that the only re- placement that could be used was a plate, he was indeed very sorry that he had not taken my advice. Beware of Commercial X-Ray Laboratories Can any one explain why some people should prefer to patronize commercial X-ray labora- tories, operated by laymen, rather than dentists who have been properly trained in dental schools, or by graduate work and special studies, and who have been examined and licensed by the State to safeguard the people ? Any one can be trained to take X-ray pictures, but to interpret them cor- rectly it is necessary to have exact knowledge of the anatomy and pathology of the parts concerned. The man who makes a diagnosis of any value must be familiar with the problems of dentistry and must know how disease affects the radiability of the tissues. A man who works with the pick and shovel, although he may be an excellent excavator, would not be the one who would be asked for an EXAMINATION TO PREVENT DISEASE 147 opinion about the value of a mine, and it seems just as illogical to consult an electrician, no matter how good a one he may be, about the teeth. In my books on oral roentgenology I have lamented the fact that there was no law prohibiting the most incompetent from taking X-ray pictures and furnishing elaborate reports. Since that time such a law has been passed in Pennsylvania, making it illegal for laymen to make and interpret X-ray pictures. How an X-Ray Helps When One is Suffering When one has a pain from some diseased con- dition in the mouth it is not always easy for the dentist to make a correct diagnosis at once. An X-ray investigation will, however, almost always give information which may help to differentiate between conditions causing the same symptoms. Many mistakes in treatment can be avoided by the use of the X-ray, saving the patient a great deal of trouble and expense. I can recall many cases in which the patient had indefinite swelling and pain about the jaws, which were treated for weeks or months by means of root-canal medication, until the patient finally became discouraged. When an X-ray examination was made it invari- ably revealed the trouble, which generally was 148 TEETH, DIET, AND HEALTH some diseased condition in the jaw that required more radical measures for a cure. A patient, a boy sixteen years old, had observed a swelling under his upper lip for several months, two upper incisors being somewhat tender to touch. His dentist opened the root-canal of one of these teeth, removed the pulp, and treated the tooth. Whenever the root-canal dressing was re- moved, a yellowish fluid escaped. This treatment failed to help the condition, and the gum was lanced several times without result. When the boy was first brought to me for consultation an X-ray picture was taken, from which a diagnosis of cyst, containing an unerupted tooth, was made. Another patient had a discharge of pus from a sinus on the gum over the right upper central incisor. The tooth had been extracted and a bridge had been made to replace it, but still the pus discharged from the socket. An X-ray pic- ture revealed an infected cavity, partly connected with the socket of the extracted tooth, and the end of the adjoining lateral incisor root protruded into it. The discharge from the socket came from an infected cavity in the bone. All this shows the reader how important it is FIG. 28. TOOTH-BRUSHES FOR THE CLEANING OF BRIDGES EXAMINATION TO PREVENT DISEASE 149 to have the condition of the teeth investigated. He should not wait until he has pain, or until his general health is undermined by pus absorption. * ‘ To-morrow is the enemy of health. ’ ’ CHAPTER XI MOUTH HYGIENE “It is a clean tooth that never ached.” Until certain errors in man’s diet have been radically changed, and food is selected, manufac- tured, and prepared according to the needs of the body, instead of for the pleasure derived from its consumption, it will always be necessary to resort to artificial means to prevent the common diseases of the teeth from which civilized man suffers to- day. In 1914 Dr. Alfred C. Fones, pioneer in oral hygiene work, established in the public schools of Bridgeport a system of mouth hygiene by means of which he was able to decrease dental disease to a large degree. He demonstrated that it was better to prevent the teeth from decaying than to establish repair clinics, the work of which would be endless. Dental hygienists were placed in the different schools, and their number was increased until in 1919 twenty-six were appointed. These women, who received intensive training, both sci- entific and practical, in a special school for dental 150 MOUTH HYGIENE 151 hygienists, have under their care the mouths of nearly twenty thousand children. A firm believer that clean teeth will not decay, Dr. Fones began the first year with the first and second grades. A system consisting of four dis- tinct parts was carefully worked out. First, the hygienist would clean the teeth of every child in the school. Secondly, tooth-brush drills were established to teach a method of mouth brushing at home. Thirdly, class-room talks concerning food and cleanliness were given and stereopticon pictures shown; and, fourthly, the parents’ inter- est and cooperation were secured by means of special educational literature. The Results of Dr. Fones’s Work The result of this work gives an excellent foun- dation for hopes of what may be accomplished by prophylactic treatment. In 1921 the reduction in dental decay in thirty schools where the children were under treatment averaged 69.3 per cent. Only sixty-five children out of 1161 in the fifth grades had any cavities in their permanent teeth. The reduction in decay was also accompanied by a reduction of the percentage of retarded pupils from an average of forty to twenty, which means a considerable saving to the taxpayer. This is TEETH, DIET, AND HEALTH 152 a great accomplishment when one considers the many difficulties which stood in the way of proper execution of the plan. Much depends on the will- ingness of the children and parents to do their part at home, and a great deal more could be done if the dietary factor could be controlled. If such averages can be obtained in public schools, how much more can be accomplished at home! With proper mouth hygiene and pro- phylactic treatment, caries and pyorrhea can be reduced to a minimum. The best results are obtained by giving the teeth the right care every day, supplemented occasionally by a thorough treatment at the office of a dentist. The Care of the Mouth at Home The brushing of the mouth has a double pur- pose. First, it removes the soft deposits which gather around the gum margins, between the teeth, and in defective places, and, secondly, it increases the blood circulation in the gums and other oral tissues. Certain places, however, which cannot be reached with a tooth-brush, require the use of dental floss. A thorough rinsing of the mouth to remove all foreign material will complete the toilet of the mouth. There are many satisfactory brushes made, but FIGS. 29 TO 32. HOW TO BRUSH THE TEETH See text Courtesy of Dr. A. C. Fones, Bridgeport, Conn. MOUTH HYGIENE 153 the type illustrated in Figure 29 is preferable. It should be remembered that tooth-brushes do not last forever. No one would be willing to use a broom to sweep the floor when it was in the con- dition of many a tooth-brush I have seen. When the brush is old and ragged, the gums are easily injured. For best results use a different tooth- brush on different days, alternating between two brushes, so that each will have a chance to dry after it is used. Fresh air and sunlight will keep them clean and in good condition and prevent rotting of the bristles. Special tooth-brushes have been designed for cleaning bridges in the mouth. Those illustrated in Figure 28 are particularly well adapted to this purpose. Many dentists believe that a powder is better suited to thoroughly cleaning the tooth surfaces than a paste. It should, however, be free from grit, so as not to injure the enamel of the tooth. The simplest preparation consists of the finest grade of English precipitated chalk, or this chalk mixed with powdered Castile soap (one half pound of chalk to one- and three-fourths pounds of soap). The other ingredients of the powders on the market are mostly flavoring-material. There are many pastes sold which are just as efficient as the 154 TEETH, DIET, AND HEALTH powders and more pleasant to use. Your dentist can advise you in this respect and recommend special dentifrices and washes for diseased gums or pyorrhea. Dr. Fones’s Instructions By home care of the mouth it is possible to re- move all of the food debris from the teeth if the following details are carefully observed: First. The outside surfaces of the teeth and gums of both the upper and lower jaws. Second. The inside surfaces of the lower teeth and gums. Third. The inside surfaces of the upper teeth, the gums, and the roof of the mouth. Fourth. The chewing surfaces of the teeth and the posterior ends of the arches, upper and lower. A light, rapid stroke of the brush should be used at all times. Place the tooth-brush inside the left cheek and on the upper gums, and nearly close the teeth to- gether. Make the brush go backward and down- ward to the lower gums, then slightly forward and upward, until it has traveled a complete circle. This circular motion should be done rapidly, so that the gums will be stimulated and the teeth cleansed of food. Keep up this fast circular MOUTH HYGIENE 155 motion and brush all the teeth on the left side, as well as all of the front teeth. Do not brush the teeth and gums crosswise (Figures 29 and 31). Now brush the right side with the same circular motion, reversing the circle if found more con- venient. Brush long enough to thoroughly stimu- late the gums and cleanse the teeth, going back and forth over all the surfaces several times. (Figures 30 and 32). With the bristles of the brush pointing upward and the end of the thumb on the back of the handle, brush the roof of the mouth and the inside gums and surfaces of the teeth with a fast in-and- out stroke, reaching back on the gums as far as you can go. Go back and forth across the roof of the mouth with this in-and-out stroke at least four times (Figures 32 and 34). Hold the handle of the tooth-brush in the fist, with the thumb lying across the back of the handle, and brush the gums and teeth with an in- and-out stroke, using chiefly the tuft end of the brush. Reach back in the mouth on the gums be- low the last tooth on both sides and brush with a fast, light, in-and-out stroke. Tip the handle of the brush up in brushing the gums back of the lower front teeth, or use the tuft of the brush (Figures 33 and 36). 156 TEETH, DIET, AND HEALTH Lastly, brush the teeth with an in-and-out stroke on the chewing surfaces, as the food must be re- moved from the grooves or fissures of the molars. Four-fifths of the decay of teeth takes place on the surfaces between the teeth and on the chew- ing surfaces. There is but one way which is effective in removing the food from between the teeth, and that is with a piece of floss silk, pref- erably the wide kind. Use a section of floss about twelve inches long. Hold one end between the thumb and first finger of the left hand, and wrap the floss twice around the end of the first finger. Do the same with the thumb and first finger of the right hand. Now, by using com- binations of the ends of the thumbs and second fingers, the floss may be carried into the mouth and forced carefully between all the teeth. Eub it back and forth against the surfaces of each tooth to loosen and remove the food and to clean these surfaces. After a little practice one can floss all the surfaces between the teeth in a moment (Fig- ures 37-39). People who wear fixed bridges should be sup- plied with the blunt curved needles called bodkins, The Use of Floss Silk FIGS. 33 TO 36. HOW TO BRUSH THE TEETH See text Courtesy of Dr. A. C. Fones MOUTH HYGIENE 157 by means of which floss silk can easily be carried underneath a bridge for the purpose of cleaning the part in contact with the gum. Lime-Water There still remains on the surfaces of the teeth, particularly between them, a glue-like deposit known as mucin. This mucin must be removed, as it allows the bacteria to cling to these surfaces. Dr. Fones recommends, as the most effective sol- vent, lime water, which is used as a mouth-wash and is harmless. In fact, if but one thing could be used to prevent decay of the teeth, lime-water used three times daily would prove to be the most valuable. Secure from a paint-store five cents’ worth of coarse unslacked lime and crush it into a fine powder. The refined lime that the druggists sell does not seem to have the same solvent action. Place a half-cupful of the powdered lime in a quart bottle and fill nearly full with cold water. Thoroughly shake and then allow the undissolved lime to settle at the bottom of the bottle, which will require several hours (Figure 40). After the lime has settled, pour down the sink as much of the clear water as can be poured without losing 158 TEETH, DIET, AND HEALTH any of the lime. This water is poured off because it contains the washing of the lime and is not pure enough to be used. Again fill the bottle with cold water, shake well, and allow the solution to clear itself. After the lime has again collected at the bottom of the bottle, fill a twelve-ounce bottle with the clear solution of lime-water, being careful not to stir up the lime at the bottom. The twelve-ounce bottle is used as it is easier to handle at the wash- bowl. Refill the large bottle with cold water, shake well, and set it aside to use when the smaller bottle has been emptied. This process may be re- peated until all the original half-cupful of lime has been completely dissolved. After brushing and flossing the teeth, pour out a little of the lime-water into a glass and, taking it in the mouth, force it back and forth between the teeth with the tongue and cheeks until it foams. When it begins to foam, this shows that it has been in the mouth long enough to have had a beneficial action on the teeth. Now rinse out the mouth with clear water. If the lime-water is a little strong at first, dilute it about half and half. It should be used full strength, however, just as soon as the gums have MOUTH HYGIENE 159 become hard and healthy through the treatment by brushing method. With the use of lime-water the toilet of the mouth is complete. The actual time required for the care of the teeth amounts to fourteen minutes daily. Faithfulness in mouth cleanliness will not only prevent dental disease but will prove to be a valuable insurance for health. No one can save a person’s teeth but himself. If the teeth are sensitive, if they are set on edge when acid fruits are eaten, such as grapes, lemons, or grape-fruit, use milk of magnesia as a mouth- wash. In children’s mouths it will also prevent the green stain which comes on the teeth from an acid condition. The Rules of Dr. Fones 1. Brush the teeth four times a day: Before breakfast with clear water, after each meal with a tooth-paste or powder. The teeth must be clean and free from food before going to bed, as most of the decay takes place during sleep. 2. Brush two minutes each time, two minutes by the clock. It takes two minutes of brushing prop- erly to stimulate the gums and thoroughly cleanse the teeth. Be sure and brush the gums. 160 TEETH, DIET, AND HEALTH 3. Do not use pressure with the brush. A fast, light stroke is best. A brush should never be worn out by having its bristles flattened and spread out. Do not brush the teeth crosswise. 4. Never allow any one to use your brush. Disease germs may be easily carried from one mouth to another, readily causing sickness. 5. Candies, sugar, crackers, cake, pastries, bread, will all decay the teeth if allowed to remain on their surfaces. Prophylactic Treatment by the Dentist The care of the teeth at home must he supple mented by regular visits to the dentist for pro- phylactic treatment. Very few people, no matter how conscientious, can keep their teeth entirely clean and free from tartar; and a great many, although they may make a great effort, will never accomplish anything like a satisfactory result. The dentist should decide how long the patient can keep his teeth free from deposits, and then tell him how often to report for prophylactic treatment. Some people require such service once a month; others can go two months, and others still longer. The prophylactic treatment consists of the removal of all deposits from ex- posed surfaces of the teeth and from under the FIGS. 37 TO 40. TIIE USE OF SILK FLOSS See text Courtesy of Dr. A. C. Fones MOUTH HYGIENE 161 free margin of the gums, and of careful polishing of the teeth in order to remove stains, films, and bacterial plaques, which, as we have seen in the chapter on dental caries, all predispose to decay. The Dental Hygienist It was Dr. Fones who proved the great value of dental hygienists to help solve the problem of dental caries and pyorrhea through his energetic work with thousands of children in Bridgeport. We have far too few dentists to-day even to take care of the repair work, for which reason the busy practitioner often has no time for prophylactic work and preventive dentistry. It is, therefore, highly desirable to have trained assistants to help in this work, under the direction of a registered dentist. Training-schools have been established in several cities. Among these are the schools in Columbia University, at New York, the Forsyth Dental Infirmary, at Boston, the Rochester Dental Infirmary, in Rochester, New York, the Univer- sity of Maine, the University of California, and Colorado College. Academic courses of not less than a year are given in these places. They con- sist of dental and medical subjects as well as practical training, and after graduation it is nec- essary to pass an examination held by the state TEETH, DIET, AND HEALTH 162 board of dental examiners. Dental hygienists are sometimes called dental nurses, which is not cor- rect. They are in no sense nurses, because they do not care for “sick and infirm” teeth, but do exclusively work of a sanitary and preventive na- ture. In Massachusetts dental hygienists have been practising since 1917. The value of their services in private practice is undisputed, and for public health service there is a demand for dental hygienists which far exceeds the supply. Here is an excellent opening for young girls. Public dispensaries, public schools, Red Cross hospitals, industrial concerns, and department- stores all need dental hygienists to prevent dental diseases and to educate people in the benefits de- rived from such services. Care of the Mouth during Illness At no time is there a better chance for rapid decay and the beginning of diseases of the gums than during prolonged illness. The sick are gen- erally fed on liquid or soft foods, which eliminate the self-cleansing action of mastication of hard and fibrous food; and brushing is often neglected or impossible. The result is that the gums be- come covered with a white film of dead gum tis- sue, which normally would be rubbed off, there MOUTH HYGIENE 163 is a bad taste in the mouth, and an excellent chance for the growth of bacteria. The invalid’s mouth should be cleansed with a piece of sterile gauze, moistened in a saturated solution of boric acid, and wrapped around the index-finger, or an orange-wood stick. The gums and all the sur- faces of the teeth should be rubbed. If the pa- tient is able to sit up, a tooth-brush can be used. A high temperature is usually accompanied by a coated tongue, which should be cleaned with a tongue scraper. As soon as the patient is well enough to go out, a prophylactic treatment should be given so that all the bacterial plaques which have formed can be removed before serious harm is done to the teeth. There is nothing more disagreeable than to come in contact with a person whose breath is offensive. In unclean mouths the breath takes up the odor of decomposing food and gases formed from bacterial activity. The breath can- not be sweet unless the teeth are scrupulously clean and the tissues of the mouth healthy. Mouth hygiene is, therefore, an essential. Dental Care for Expectant Mothers Dental caries and acutely abscessed teeth are common occurrences during pregnancy. This 164 TEETH, DIET, AND HEALTH may be partly due to the additional requirements made upon the system, so that a latent infection can no longer be resisted, or to the lack of an adequate supply of mineral salts in the diet. Such a deficiency in diet may result in these salts being taken from the bones and teeth, predispos- ing the teeth to decay. The expectant mother should have a careful examination, including X-rays, made of her teeth. If infected teeth are found they should be ex- tracted, and the patient may rest assured that this treatment may be undertaken with perfect confidence. Cavities should be filled, but if a great deal of work is necessary temporary ce- ment fillings should be used to stop the decay, leaving the permanent fillings for a later date. That we may cease to be a race of dental cripples, all parents must be sufficiently impressed with the importance of the subject to make an earnest effort to protect their children from dental diseases by prophylactic measures, which should be begun as soon as the teeth appear in the baby’s mouth. CHAPTER XII NUTRITION AND ITS RELATION TO THE FORMATION AND MAINTENANCE OF DENTAL STRUCTURES “He who does not masticate well is the enemy of his own life.” In an endeavor to understand the functions of our own body, in which each organ is made up of innumerable cells, highly specialized for their particular work, let us consider an animal which is merely a single cell, and yet capable of carry- ing on all the processes of living, just as effectu- ally as the most complex organisms. The Amoeba This tiny animal is the simplest form of life and is to be found on water-plants, or on dead leaves at the bottom of stagnant pools. It is called the amoeba, and viewed under the micro- scope appears as an irregular mass of granular, jelly-like substance, which is called protoplasm. Careful observance will cause the student to realize that the mass is constantly changing its shape, by throwing forth projections (pseudo- 165 166 TEETH, DIET, AND HEALTH podia) of itself, into which the rest of the body protoplasm flows. This changing of shape is termed amoeboid movement, and is the animal’s method of locomotion. It is brought into opera- tion by stimuli from various substances, which cause the animal to move, with seeming intel- ligence, in the direction of food, or away from harmful influences. The amoeba takes food into its body at any point, by simply rolling over and encircling the desired substance. The waste prod- ucts are discharged with equal simplicity, by being brought together in one contractile vacuole and thrust from the body at any convenient point. These are its simple means of eating and elimi- nation. It also has the power of reproduction. In considering this single-celled animal, which breathes, takes up food, discharges waste prod- ucts, and reproduces,—in fact, performs all the activities of the more highly specialized animals, —we are brought to realize that all the processes of life reside, in some mysterious manner, in that living substance of which all cells are composed, the protoplasm. Complex Organisms It was the custom in earlier civilization for every man to perform all the duties incidental to NUTRITION AND ITS RELATIONS 167 his personal welfare. He was his own gardener, blacksmith, carpenter, hunter, and so on, and each labor was executed with a rudeness which necessarily accompanies the untrained hand. Un- der modern civilization it is the system for groups of men to confine their energies to a particular work, and the product of that work is better adapted for use than that which is accomplished by individual effort. An analogy can be drawn on the one hand between the single-celled animal and the early worker, and on the other between the more modern banding together of men and the grouping of cells in the human body for the performance of more highly specialized functions. Some of these groups of cells have developed by gradual evolution the power of contraction. They form the muscles of the body. Others have been changed so as to become suitable for the transmission of impressions to the brain, and these are the nerve-cells. Others produce bone and dental tissue. Because digestion is very complicated in man, it requires many groups of cells performing separate functions, and because all parts of the body depend upon the digestive system for their nourishment, it is necessary to have a simple but comprehensive idea of nutri- tion. 168 TEETH, DIET, AND HEALTH The Process of Digestion Food is digested in the so-called alimentary canal, around which all animal forms are con- structed. The human body, with its millions of cells, depends upon the flow of nourishment through the alimentary tract. The maintenance of the health, vigor, and youth of all material life depends primarily upon the right food and its proper digestion, prompt absorption of the nutri- ment, and quick and complete evacuation of the undigested residue from the intestines, to prevent absorption of poisons formed by bac- terial decomposition of meat and other protein foods. The digestive mechanism is put in readiness before the food is taken into the mouth. The pleasant sensations from the sight or smell of foods “make our mouth water,” which means that the salivary glands are stimulated, with a consequent flow of their secretion into the mouth. The function of the mouth is to prepare the food for digestion, which is facilitated in propor- tion to the amount of this preparation. Un- fortunately, however, this important work, which should be thoroughly performed by the organs in NUTRITION AND ITS RELATIONS 169 and intimately connected with the mouth, is gener- ally neglected. A result of this is not only im- paired digestion, but, as we have seen in previous chapters, underdeveloped jaws and many dis- eases of the teeth and surrounding tissues. Mastication of Vital Importance We sometimes read of the lost habit of chew- ing, when as a matter of fact the habit generally is not lost hut is never acquired. Children, even when they have their first teeth, are still kept on a liquid, or semi-liquid diet which requires little or no mastication. The habit of bolting is formed, and it is not easily overcome. A dislike for hard food is acquired because the muscles of mastication have not developed sufficient strength to perform their natural vigorous func- tion. The material should be pressed between the teeth and ground to a pulp by means of a lateral motion. To accomplish this it is necessary to possess a normal set of teeth. If a person has lost a number of his back teeth, his only ac- complishment will be to punch a few holes into the food. Besides crushing the food, mastication is also of great importance for a thorough mixing with TEETH, DIET, AND HEALTH 170 the saliva. I find that people do not realize this important factor, because patients often tell me, when I impress upon them the importance of replacing lost back teeth to restore masticating efficiency, that they get along quite well, as they eat hardly any meat. The idea seems to be prev- alent that it is meat that requires the greatest amount of mastication, while actually the reverse is true. The saliva which is poured out of the glands into the mouth must be abundantly and thoroughly mixed with the starchy foods, such as potatoes, bread, and cereals, because they depend for proper digestion upon a ferment contained in the saliva called “ptyalin.” After suffering a long time from severe indi- gestion, a friend of mine had come to believe that he had some serious gastro-intestinal disorder. He had lost many of his back teeth and formed the habit of swallowing his food improperly mas- ticated. His diet consisted, to a large extent, of carbohydrates, such as mashed potatoes and white bread. He did not realize that these foods, al- though soft, require mastication to mix them with the ferment contained in the saliva. His symp- toms disappeared entirely when he had substitutes for the lost teeth made and learned to eat with them. NUTRITION AND ITS RELATIONS 171 The Part the Stomach Plays in Digestion The stomach is a large receptacle in which food may remain until it has undergone certain changes. Again, sensations start the flow of cer- tain gastric secretions, and here it is the sense of taste that is the predominant one. When the food is in the stomach it is acted upon by weak hydrochloric acid, the ferment pepsin, which acts principally upon protein materials, such as meat. This chemical reaction is greatly aided by a me- chanical function, the rolling motion of the stomach. These powerful muscular contractions bring all the particles of food into contact with the gastric juice. When we consider that the stomach is made up of soft tissue and lined with a delicate coat, containing the important secretory cells, it is easy to understand the warning that one should not expect the stomach to do the mechanical work of the teeth and perform the chemical action of the saliva. When the food passes into the intestines it is acted upon by most powerful ferments secreted by the pancreas and the liver. The proteins, starches, sugars, and fats are now further re- duced to simple compounds, such as can be ab- sorbed and utilized by the body. 172 TEETH, DIET, AND HEALTH After the food is swallowed, the digestive proc- ess is involuntary and, assuming that the food is pure and wholesome, proceeds in a normal manner. Unpleasant feelings, however, such as vexation, worry, and anxiety, or great emotions such as anger, fear, and jealousy, will stop the flow of saliva, the gastric juices, and other impor- tant functions. The effect of the emotions on the body is a subject of great interest, and the reader who desires more information on this subject may be referred to Professor Cannon’s book, “Bodily Changes in Pain, Hunger, Fear, and Rage.” It is necessary, therefore, that the state of mind at meal-times be one of contentment and tranquillity and that the conversation be confined to pleasant topics, avoiding disagreements and quarrelsome arguments. The psychic secretion of the diges- tive glands is also promoted by serving the food in a dainty manner so that it is pleasing to the eye and savory to the nostrils, especially when, through illness, the appetite is fickle. Assimilation and Evacuation Assimilation or absorption of the nutrient fluids prepared by the process of digestion as de- scribed takes place along the walls of the in- testinal tract. The greater part of the elements NUTRITION AND ITS RELATIONS 173 to be used by the body is absorbed from the small intestine. When the part which is the undigested residue reaches the large intestine it is a semi- solid. By the time the content has reached the last part of the large intestine, most of the water and food elements have been absorbed from it, and it is ready to be evacuated. Unless evacuation takes place promptly and com- pletely, bacterial decomposition will take place. The reason for retarded evacuation may be an organic condition, or lack of training to encourage the habit of regular bowel movement at least once a day. Generally, however, the consequence of continued dietary mistakes is an important factor in chronic constipation. The use of too highly concentrated, purified, softened, and almost pre- digested foods is one of the greatest shortcomings of our diet. Milk, eggs, and sugar, white flour with the bran removed, and vegetables or fruit, with the cellulose destroyed by too much cooking, are examples. In such foods almost everything is absorbed, and there is not enough waste left to give sufficient bulk to the contents of the large intestine. Evacuation, therefore, takes place only after long intervals, and the residue clogs the walls of the intestinal tract. This long retention of the residue gives bacteria a chance to form 174 TEETH, DIET, AND HEALTH poisonous substances. Especially is this true if protein foods predominate. Absorption of poisons formed in the large in- testine is often the cause of serious injury to susceptible cells which make up parts or entire organs of the body. Symptoms of such a condi- tion are undue fatigue, headaches, and a poor complexion. Their irritating effect on the tis- sues of the alimentary canal is often clearly ex- pressed as a stubborn inflammation of the gums, a forerunner of pyorrhea alveolaris. Metabolism The nutrient fluid absorbed from the intestinal tract is carried by the blood-stream to all parts of the body and furnishes food for every cell, while the waste products of these cells are re- moved by the same carrier and finally disposed of by the function of special organs, such as the kidneys, the lungs, and the sweat-glands. Protein, mineral salts, and water are the build- ing-materials of the body, while carbohydrates, fats, and oils are essential to fuel or energy sup- ply. Oxygen is also necessary and is supplied through the lungs, where it is taken up by the blood. Long before the teeth come through the gum, NUTRITION AND ITS RELATIONS 175 large bands of cell workers have been busy with their molding and construction. If a thin sec- tion is cut through the center of a tooth develop- ing inside the jaw, it appears, when examined under a high-power microscopic lens, as shown in Figure 41. The so-called tooth-germ (A) is seen in a trench formed in the bone (B) and is covered by a thick layer of the gum (C). It is made up of two parts, an enamel organ and a dentine organ. The enamel organ (D) is com- posed of a large number of cells, from which highly specialized workers called ameloblasts have been developed. These are all lined up at the inner surface, like a battalion of engineers (E), while the remaining cells, left in the rear, aid in furnishing the necessary building-material. The dentine organ, which, is contained in the bell- shaped enamel organ, also forms an army of builders, called odontoblasts (Gr), which are lined up opposite the ameloblasts. Blood-vessels are seen in the center of the dentine organ (I), their branches extending as far as the odontoblasts, which they supply with the material needed for building the dentine (II) or inner part of the tooth. Against this a layer of enamel is formed in similar fashion (F). It should be observed that the construction of these two parts of the 176 TEETH, DIET, AND HEALTH tooth occurs in opposite directions. The dentine workers proceed from the outside inward. They remain at the inner dentine wall, the pulp-chamber of the tooth, and, although they gradually become inactive, they are ever ready to take up again their duty of protecting the pulp, upon the vitality of which depends the health of the tooth. They do this by the formation of a well of secondary dentine, which blocks the way of the invading bacteria and fortifies the place which has been weakened by the formation of a cavity. The enamel workers proceed from the inside out, and disappear after the tooth has erupted. Enamel, therefore, cannot be renewed if part of it be- comes destroyed after completion of the tooth. The Quality of the Building-Material While the soft enamel and dentine are laid down as a matrix, they are hardened by gradual deposit of calcium salts. A great deal depends upon an abundant supply and good quality of the material needed by these wonderful tooth workers. They must be furnished through the blood-stream with an abundance of mineral salts, and the supply must be kept up continually by selection of the proper food. A deficiency in mineral salts is the cause of soft teeth. If any FIG. 41. PHOTOMICROGRAPH OF A THIN SECTION THROUGH A TOOTH DEVELOPING INSIDE THE JAW A, tooth germ; B, bone; C, gum; D, enamel organ; E, ameloblastic cells; F. layer of enamel formed by ameloblasts; G, layer of odontoblastic cells; H, layer of dentine formed by odontoblasts; 1, center of dentine organ with blood-vessels, later forming the pulp of the tooth NUTRITION AND ITS RELATIONS 177 interruption in the calcification occurs, places which are only partly calcified will remain in the tooth. These are weak spots and cause the teeth on which they occur to decay very rapidly. The welfare and strength of the tooth constructors are also of great importance. If poisons circulate in the blood, taken up from some diseased condi- tion in another part of the body, the workers suffer, their energy is lessened, and in some in- stances they may become so debilitated that work is stopped entirely. This leaves visible defects in the teeth and is a common result of scarlet fever, measles, or whooping-cough contracted dur- ing the period when the crowns of the permanent teeth were being formed (see Figure 42). To emphasize the importance of a sufficient supply of mineral salts during the time when the teeth are forming, it may be well to impress upon the reader that, unlike the soft tissues of the body, the enamel of the tooth, when once built, cannot be changed to any great extent, and, as the enamel has the function of withstanding mechanical wear and protecting the more porous and organic struc- tures underneath, its hardness is of the greatest importance. The diet, therefore, must be se- lected with a view to supplying in sufficient quantity good building-material for the tooth. 178 TEETH, DIET, AND HEALTH The food which fulfils this demand is described in the chapter on diet. After the tooth is fully formed, it still needs nourishment. This it receives through the blood- vessels of the dental pulp and the membrane sur- rounding its root. The dentine of the tooth, as well as the cementum covering the root, contains very fine canals, through which fluids may pass, distributing nutrient elements. It is important, therefore, to preserve the vitality of the tooth by preserving the dental pulp. A certain amount of increase in the calcification of the tooth is possible by these channels, and some investi- gators believe that an improvement is also pos- sible in the case of the enamel, which, continually bathed in saliva, may take up calcium salts from this medium. It has been observed that people who are troubled with the formation of a great deal of hard deposit, or tartar, on their teeth generally have exceptionally hard enamel. Both conditions come from the saliva. The old saying that every child costs its mother a tooth contains a great deal of truth. If the diet of the expectant mother does not contain enough organic mineral salts, the needs of her own body and that of the developing child are not supplied, and lime is extracted from her bones NUTRITION AND ITS RELATIONS 179 and teeth to satisfy the demand. Lime is always needed by the body for various functions, but large amounts are required during the growing period of the child. Supply of Mineral Salts for the First Teeth It is the blood of the mother which furnishes the nutrition for the developing child. Although the teeth are not visible when the baby is born, and although the first tooth usually does not erupt until the child is six to eight months old, they nevertheless begin to calcify five months before birth, and at the time of birth the deciduous teeth are all present inside the young jaw. Their crowns are almost completely calcified. Even the first permanent molars are developing and have lime salts deposited in their cusps. When the child is six months old the enamel is com- pletely formed on the entire first set of teeth. Proper calcification of the deciduous teeth, there- fore, depends entirely upon the maternal nutri- tion. Calcium salts must be supplied by the mother’s blood and later, when she nurses the baby, through her milk; therefore careful atten- tion should be paid to her diet. A case reported by the Department of Pre- ventive Dentistry of the Royal College of Dental 180 TEETH, DIET, AND HEALTH Surgeons is an illustration of the far-reaching effects of improper diet on the teeth of a child. The mother’s diet was confined entirely to bread, cakes, and jam, with from twelve to fifteen spoon- fuls of sugar a day in tea or coffee. She con- sumed very little protein and could not masticate her food. The child was twelve months old, breast fed. It vomited after every feeding, and the teeth when they erupted were almost bare of enamel, which demonstrates the importance of proper diet for the expectant mother. When the Permanent Teeth are Calcified The permanent teeth calcify while the decidu- ous ones are in use. At the age of nine the crowns of all the teeth are finished, except that of the third molar, which takes about three years more (Figure 43). It is important, therefore, that the child should receive a diet rich in calcium salts and vitamines during this period of life. To some extent nature, ever economical, utilizes the mineral salts of the roots of the first teeth, which become absorbed as the permanent ones develop and get ready to take their places. Another im- portant factor that must not be overlooked is the exercise of the mouth and muscles of the jaws when the child nurses at the breast. This ex- FIG. 42. SPECIMEN SHOWING DEFECTS IN THE ENAMEL OF THE INCISORS These defects are caused by interruption in the work- ing of the cells producing the teeth, especially well shown in the upper central and lateral incisors, marked A, B, C. See text. FIG. 43. PROGRESS OF CALCIFICATION OF PERMANENT TEETH The lines show how far the teeth have developed within the jaw at given ages NUTRITION AND ITS RELATIONS 181 ercise brings an ample flow of blood to the month, carrying with it the building-material for the de- ciduous teeth, and stimulating proper develop- ment of the jaws and face. After the child has teeth, the same result may be obtained by giving it hard food for the principal part of the meals, so that the jaws have to do natural, honest hard work, which the children enjoy if they have been rightly started. What to eat to afford the teeth exercise and supply all the ingredients of a diet favorable for the development of hard, healthy teeth and the maintenance of that condition will be taken up in the following chapter. CHAPTER XIII DIET AS APPLIED TO THE TEETH “Gourmands dig their graves with their teeth.” The bees have, for thousands of years, aroused the admiration and interest of man. They have been cultured since the time of the ancient Egyptians, and inscriptions on tombs show that they were highly reverenced. They have been cited by statesmen as having a model social sys- tem, with government by a single ruler, the queen. Poets, philosophers, and scientists, among whom may be mentioned Vergil, Aristotle, and Pliny of the Greek and Roman period and Reaumur and Maeterlinck of more recent times have eulogized the bees as unique among insects and have spent years of their lives in studying them. They have sung their praises and set forth their good qualities before mankind as an example worthy of emulation. One of the mar- velous instances in the life of the bees is their method of feeding their young. There are three kinds of bees in a colony: the queen, the workers, and the drones. The drones are the males. The 182 DIET AS APPLIED TO TEETH 183 queen is the true female of the hive. She is fully developed and resembles the worker except for her larger size. Capable of laying five thou- sand eggs a day, she can increase the number of workers and drones in her tribe enormously, but she jealously guards her sovereignty and permits no contemporary ruler in her domain. Under certain conditions, however, because of loss of the queen if she goes away with a swarm, or when old age comes upon her and her functions fail, or if she dies, a new queen must be reared. The workers, which are undeveloped females, make up the principal part of the population, do all the work in the hive, rear and nurse the young, and gather the nectar and pollen in the fields. The bees can raise a new queen at will from the same egg that might have become a worker by means of a special diet which is fed to the larva when it hatches from the egg. The larvae of the working bees for three days are given a milky food prepared from honey and pollen, partly di- gested. Afterward they receive pollen and honey undigested until the sixth day, when their cell is sealed. If a queen bee is to be developed, the larva is fed on the very finest and most perfectly digested and concentrated food, called “royal jelly. ’ ’ She receives this during the entire period 184 TEETH, DIET, AND HEALTH of her larval state (five and a half days), and her cell, before it is closed, is half filled with the precious mixture. The discovery that the bees can produce from a female egg either a working bee of comparatively small size, or a queen bee, fully developed and larger, by different feeding, shows what an important part food plays in de- velopment of the young and what great results might be achieved if we should but study and apply the hidden truths of diet. Knowledge to Improve Our Bodies Very few people know what to eat; a large number eat too much, others eat too rich food, and a great percentage of people eat food which should not he used at all. Hardly any of us realize that certain shortcomings and weaknesses in the physical make-up of our race could be overcome by simple changes in the routine of our lives. Food, air, water, sleep, and exercise are the physical essentials which develop a healthy body and keep it in good condition. A great amount of suffering is caused by disregarding the laws of nature governing the principles of these fac- tors, and this applies especially to food. It is DIET AS APPLIED TO TEETH 185 said that Napoleon remarked that “an army moves on its stomach.” Indeed, all the impor- tant activities in life that depend on health and energy are dependent upon proper nourishment of the body. If the reader is sufficiently interested in the welfare of his body, he would do well to study his diet. Virtually all of us eat according to the desires of our palates, instead of the needs of our bodies and the requirements of our occupations. One should get some expert advice on the matter. It is better to consult a specialist when one is well, for an ounce of prevention is worth a pound of cure. Food is classified into protein, carbohydrates, fats, and mineral salts and should contain in sufficient amounts certain substances called vita- mines, which are absolutely necessary to good health. Proteins The proteins are nitrogen-containing substances which constitute the greater part of our bodies. Protein food is used to build and repair tissue and to replace the waste in the body cells. In times of great muscular exertion and when doing 186 TEETH, DIET, AND HEALTH heavy manual labor one requires a much greater amount of protein than when leading a sedentary life. It is supplied from both animal and vege- table foods (see table). Fats The fats are used to produce heat and energy and are stored in the body as reserve food, which is utilized in case of deficiency. A good example of storing fat is the hump of the camel. The hibernating animals, the woodchuck, bear, and others, exemplify the storing of fats at one season for use during another. Fats, or oils, are also found both in animal and vegetable foods (see table). If the diet contains too much fuel for the daily requirement one accumulates a store of fat and fastens on the body a useless burden, which interferes with the proper functioning of the body. It also incloses the body like the walls of a fireless cooker and prevents radiation of heat. This retention of heat in the body lowers the fuel requirement so much that no matter how little the fat person eats it is usually more than is needed and continually accumulates as fat. In winter and in cold climates more fats should be consumed for heating the body. DIET AS APPLIED TO TEETH 187 Carbohydrates The carbohydrate foods, of which the principal ones are starch, cellulose, and sugar, yield heat and energy. Starch is one of the most important foods. It is transformed during the digestive process into sugar, which is absorbed and utilized by the body. It is contained in certain vege- tables, but not in the leaves of vegetables, nor in fruit and animal foods. Cellulose Cellulose and woody fibers are not assimilated in the body. Although not classified among the principal food elements, they are nevertheless of great importance, helping digestion in a me- chanical way and giving proper consistency to the contents of the bowels. They are found only in the vegetable world and in the husks of grains and are not contained at all in high-grade wheat flour. Sugars The principal sugar supply should come from the starchy food, which, as we have seen, is con- verted into sugar during the process of digestion. TEETH, DIET, AND HEALTH 188 The body makes its own sugar, and in addition obtains sugar from natural sources, such as sweet fruits, which supply levulose and grape- sugar. Commercial sugar is not only unnecessary for the well-being of the body, but, being re- fined, that is, deprived of its mineral salts, under- mines the health and plays an important factor in the causation and predisposition to diseases of the teeth. The so-called craving for sugar is nothing but the desire to indulge in a habit that pleases the palate. For emergency food, sugar is the most easily absorbed of all. It is not a body-builder but merely supplies fuel and, taken between meals, destroys the appetite. Children who are allowed to eat sweets whenever they like show the effects, not only on their teeth, but on the entire development of the body. Whether the quality of the candy is good or bad does not mat- ter ; in fact, the very purity of sugar is its greatest fault. If one insists on eating sugar, or if he has to sweeten his food to make it palatable, he should use natural sugar. The genuine brown sugar contains its original supply of mineral salts, and molasses often contains an excessive amount. Then, there are such sweets as maple-syrup and honey, “the drink of the gods.” These natural fig. 44. These two rats, exactly the same size at weaning-time, were fed on rations of exactly the same character except that the one shown on the left in the picture was given 5 per cent of sun- flower-seed oil, the other (on the right) was given 1| per cent of butter fat. Butter fat contains Vitaniine A, which is not found in vegetable-oil. Observe the difference in growth Courtesy ol Dr. E. V. McCollum, of Johns Hopkins University DIET AS APPLIED TO TEETH 189 foods contain all their mineral salts and can be used in cooking to make the most delicious des- serts. Children who have never had sugar with their food, except as it is used in cooking, do not miss it. Their meals taste just as good to them. On no account should one tolerate the pitying re- marks of friends who condole with “the poor child deprived of sweets.’’ He is to be congratu- lated on having parents intelligent enough to insist upon adherence to a diet which will make him a robust man. No greater gift than health can be made to any child, and when this is the ideal the momentary pleasure that comes from indulging in candy sinks into insignificance. Mineral Salts Mineral salts are as important a part of our diet as protein food. Without either, life would be impossible. Bone, and especially teeth, re- quire large amounts of mineral salts during their developmental stage, but mineral salts are con- tinually used by the young, as well as the adult, for the performance of functions most important in maintaining life. The food, therefore, must contain such mineral matter as calcium, phos- phorus, potassium, sodium, chlorine, and iron in 190 TEETH, DIET, AND HEALTH various combinations. During pregnancy and lactation there is an additional demand for mineral salts, and they must be abundantly sup- plied during these periods in the mother’s life. Popular Food Is Deficient White bread, meat, and sugar, the most popular foods in America, are decidedly poor in calcium content. It would be impossible to eat enough of these to supply an adequate amount of lime salts to the body. Lack of mineral salts in the diet stunts the growth of the young. Without them, poisonous acids, which are formed as a re- sult of fatigue, fail to become neutralized, and the user of such impoverished foods shows signs of chronic fatigue, nervous irritability, and de- pression. “Give your friend a whole peach; peel it for your enemy.” There is a great deal of truth in this old saying, because the mineral salts, so important for the reasons just described, are con- tained largely in the skins of fruits and in the outer coating of grains and vegetables. For this same reason, potatoes should be cooked without paring. To prevent loss of the soluble mineral salts when cooking vegetables, as little water as possible should be used, and in most instances the DIET AS APPLIED TO TEETH 191 water should afterward be used in making soups and sauces. Mineral matter is not evenly bal- anced in many foods. Some are rich in one and poor in another. Milk is very rich in calcium salts, while eggs contain an abundance of calcium, potassium phosphates, and iron. Meat is rich in potassium phosphates, but poor in calcium, while potatoes and other vegetables have a high potas- sium content. Refined sugars, white patent flours, and polished rice are deficient in mineral salts. The parent should see to it that the growing child eats plenty of food rich in these impor- tant substances, which are absolutely necessary for the formation of bones and teeth. In the following table the more commonly used foods are classified under the heading of the nutri- tional element which is their chief constituent: PROTEINS Fats Carbohydrates Mineral Starch Cellulose Sugar Salts Meats Meat Sago Whole grains Molasses Milk Fowl Lard Tapioca Wheat Maple-syrup Eggs Fish Marrow Corn flour Oats Honey Meat Eggs Cream Rice Bran Dates Potatoes Milk Butter Maize Green vegetables Figs Fruits Cheese Peas Beans Lentils Nuts Grains, 10 per cent. Eggs Nuts Olives Cotton-seed oil Barley Oats Wheat Potatoes Peas Beans Fresh fruits Vegetables 192 TEETH, DIET, AND HEALTH Vitamines Although no one has ever seen vitamines, they are most important constituents of our diet. Without them we cannot live and be well. The only way one can tell whether they are present or absent in a food is by feeding animals and observing the result. Certain diseases known as deficiency diseases are caused if one or more of them are missing. A noted physiologist, Professor Hopkins of Cambridge, made experiments which proved that no animal can live on pure protein, fat, and carbohydrate food even when the necessary min- eral salts are carefully supplied. The vitamines, just as the mineral salts, are most abundant in the outer layer and the germ of grains and in vegetables and fruit. They are also contained in milk, eggs, butter, and meat. There are three groups of vitamines, the Fat- Soluble A, the Water-Soluble B, and the Water- Soluble C. The function of each of these is known and will be described. Vitamine A Vitamine A is called fat-soluble because it oc- curs in the animal food dissolved in fat. It is DIET AS APPLIED TO TEETH 193 fairly resistant to heat and is important to pro- mote growth. The principal foods which supply it abundantly and which can be used as pro- tective foods are cod-liver oil, the yolks of eggs, milk, butter, and most animal fats except lard. Dr. E. V. McCollum, who has written an excellent book entitled, “The Newer Knowledge of Nutri- tion,” experimented to show the influence of Vitamine A on the growth of rats (Figure 44). He took two rats, which at weaning-time were exactly alike. Both were fed on rations of exactly the same character, except that the one shown on the left in the picture was given 5 per cent, of sunflower-seed oil, while the other (on the right) was given 1 y2 per cent, of butter-fat. Butter-fat contains Vitamine A, which is not found in vege- table oil. Observe the difference in growth. Dr. Mellanby, an English scientist, found that puppies fed on food lacking this vitamine devel- oped rickets within six weeks. Those that were given the same food with the addition of a little butter or cod-liver oil, did not have the disease. Rickets is a disease affecting also the human race and is characterized by impaired nutrition with an unusually low quantity of calcium salts in the bones. Since this was written Dr. McCollum has stated 194 TEETH, DIET, AND HEALTH in a paper read before the Massachusetts Dental Society that his latest research work disclosed a fourth vitamine which is contained in abun- dance in cod-liver oil, also to a less degree in butter fats and to a far less degree in cocoanut oil. Vitamine A is absent in the last. By tak- ing cod-liver oil and subjecting it to heat and oxidation he could destroy Vitamine A and ex- periment with the fourth vitamine. He found that this has to do with calcification and that cal- cium salts could not be utilized for the formation of teeth and bone unless it was supplied in suf- ficient quantity. Vitamine B Vitamine B is called the antinenritic vitamine, because the lack of it causes certain nerve dis- turbances. It is resistant to heat and, accord- ing to McCollum, is not destroyed in canned vege- tables. The use of soda in cooking has a destruc tive action. It is found to some extent in all natural food, but is especially abundant in the seeds of plants, leafy vegetables, the germs of grains, and their peripheral layers, which are peeled off with the outer lining and form the bran. In whole wheat and rye flour, the bran is DIET AS APPLIED TO TEETH 195 not removed and contains this vitamine, while in white flour and polished rice it is lacking. Eijkman, a Dutch physician, found that rice accidentally fed to his hens caused polyneuritis, a disease of which one of the symptoms is paral- ysis. The hens had been given cooked polished rice some days before the outbreak of the dis- ease. Eijkman then made experiments and found that polished rice always produced polyneuritis in birds and that unpolished rice, or merely the addition of its outer coating, which is discarded in milling, immediately brought relief. Mendel made experiments with dogs and found that the lack of Vitamine B caused failure of appetite, decreased food consumption, and finally gave rise to polyneuritic symptoms, which would promptly disappear if extracts containing the Vitamine B were given. Vitamine C The Vitamine C, called the antiscorbutic vita- mine because it cures the disease known as scurvy, is easily destroyed by heat, particularly heat of long duration. This is an important fact, when we consider that a good many people eat only cooked food and that generally it is the cus- tom to cook food longer than necessary. By de- 196 TEETH, DIET, AND HEALTH veloping scurvy in guinea-pigs and then giving dif- ferent foods for relief it can be determined which foods contain this antiscorbutic factor. In this way it was found that orange-juice and other fruit juices are protective foods. The Vitamine C, however, is also contained in vegetables, espec- ially the leafy varieties, such as lettuce and cab- bage. Professor Theobald Smith was one of the first who demonstrated that scurvy could be produced in guinea-pigs by special diet, but Holst was the first to attribute the result to deficiency of the Vitamine C. The principal symptoms from a scorbutic diet are loss of weight, soreness of the joints, and characteristic changes in the jaws and teeth. Dr. Percy Howe, of the Forsyth Dental Infirm- ary at Boston, has conducted interesting experi- ments to study the effects of vitamine-deficient foods on the condition of the teeth. He states that animals fed in this manner develop extensive dental defects. The teeth become elongated, ir- regular, and very loose. The gums become red and spongy, and extensive absorption of the sup- porting bone takes place. These conditions more How the teeth are Affected DIET AS APPLIED TO TEETH 197 closely resemble pyorrhea than any such condi- tion that has been previously artificially produced in animals. The dental conditions which are produced by scurvy in man are illustrated by the suffering of the members of the crew of Stefansson, the Arctic explorer, who contracted scurvy in 1916. Besides general symptoms of weakness and dizziness, with a tendency toward laziness, depression, and ir- ritability, they complained of loosening of the teeth and recession of the gums, with a dull ache in the gums and roots of the teeth. The teeth became so loose that they could easily be removed with the fingers, and the gums were of a cheesy consistency. Vitamines That Come in Bottles ‘ * Can you explain that curious twist in human nature,” writes the editor of the “Physical Cul- ture” magazine, “that makes so many people buy their health in bottles?” Instead of correcting the dietary errors which cause constipation, they prefer to eat pills, and now, when the importance of vitamines has become more generally known, they try to buy vitamines in the drug-stores in pill-boxes and medicine-bottles. It is very much better to eat fresh natural food, 198 TEETH, DIET, AND HEALTH in which vitamines are abundant, the so-called protective foods, which have been mentioned above. Milk, eggs, whole grains, and a liberal amount of fresh vegetables and fruit, according to the season, will furnish all the vitamines re- quired by the body. Although canning and cook- ing do not destroy all the vitamines, it should be remembered that uncooked fruits and vegetables are to be preferred and should be eaten every day. These, besides containing vitamines, also contain an appreciable amount of mineral salts to build bones and teeth, and sufficient cellulose or fibrous material to prevent constipation, which so often results from the use of foods in con- centrated form, and is so frequently the cause of sallow skin, headaches, pyorrhea, and nervous irritability. Slightly Deficient Diet Dangerous Dr. Clarence J. Grieves of Baltimore, who has made extensive experiments in this direction, found that serious results may occur, not only from diets entirely lacking one or more vitamines, but even when the vitamine content is only rel- atively defective, and that the disturbance from such diets appears to be out of all proportion to the cause. DIET AS APPLIED TO TEETH 199 A student in the Harvard Dental School wrote the following interesting facts in a thesis on the influence of diet on the development of the teeth: “My sister, one brother and I were all born and brought up in India, until I was eight years old, I being the youngest of the three. The food there was wholesome, and before our births my mother had this same kind of food. When I was eight years of age the family moved to Canada, where my youngest brother was born and brought up for six years. The food there was less whole- some and more fancy and sweet. My mother was always particular about the cleanliness of our teeth and mouths. Later my family returned to India, but alas! the damage was done. My little brother suffered from extensive decay and dental ailments, while the other three of us are free from any dental sufferings.” This instance seems to indicate that diet plays an important part in pre- ventive dentistry. The following table compiled by the British Medical Research Committee to show the vitamine content of a variety of foods is taken from a book by Dr. Benjamin Harrow entitled, ‘ ‘ Vitamines. ’, The plus signs indicate the comparative abund- ance of the vitamines in the foods given: 200 TEETH, DIET, AND HEALTH Classes of food- stuffs Fat-Soluble A, or antirachitic factor Water-Sol- uble B, or antineuri- tic ( anti-beri- beri) factor Anti-scor- butio-factor Fats and oils Butter + + + 0 Cream 0 Cod-liver oil + + + 0 Mutton fat + + Beef-fat or suet + + Peanut oil 4- Lard 0 Olive-oil 0 Cotton-seed oil 0 Cocoanut-oil 0 Cocoa-butter 0 Linseed-oil 0 Fish-oil 4—h Hardened fats, animal or vegetable ori- gin 0 Margarine pre- Value in propor- pared from tion to amount of animal fat animal fat con- tained Margarine from vegetable fats or lard 0 Nut-butters 4- Meat, fish, etc. Lean meat (beef, mutton, etc.) 4“ -1- 4- Liver 4-4- 4-4- 4- Kidneys 4-4- 4- Heart 4- + 4- Brain 4- + 4- Sweetbreads 4- 4~ 4* Fish, white 0 very slight, Fish, fat, sal- if any mon, herring, yy etc. 4-4- Fish roe 4- 4- Tinned meats V very slight, 0 DIET AS APPLIED TO TEETH 201 Classes of food stuffs Fat-Soluble A, or antirachitic factor Water-Sol- uble B, or antineurir tic ( anti-beri berij factor Antiscor- butic factor Milk, cheese, etc. Milk, cow’s, whole, raw 4-4- 4- 4- “ skim, raw 0 4- 4- “ dried, whole less than + -+- / X less than 4- “ whole, boiled undetermined ti “ condensed sweetened 4- + ii Cheese, whole milk “ skim Eggs Fresh 4- 0 + + + + 4- ? 0 Dried 4-4- —1—1—1— ? 0 Cereals, pulses, etc. Wheat, maize, rice, whole grain 4- 4" 0 Wheat, germ 4-4- 4-4-4- 0 Bran 0 4- 4- 0 White wheaten flour, pure corn flour, pol- ished rice, etc. 0 0 0 Custard pow- ders, egg sub- stitutes, pre- pared from cereal prod- ucts 0 0 0 Linseed, millet 4-4- 4- + 0 Pea flour, kilned 0 0 Soy beans, hari- cot beans 4- 4-4- 0 Germinated pul- ses or cereals + 4- + 4-4- 202 TEETH. DIET, AND HEALTH Classes of food stuffs Fat-Soluble A, or antirachitic factor Water-Sol- uble B, or antineuri- tic ( anti-beri beri) factor Antiscor- butic factor Vegetables and fruits Cabbage, fresh + + 4- 4-4-4- " cooked 4- M dried 4- 4- very slight “ canned a a Swede, raw, ex- pressed juice 4-4- + Lettuce 4-4- 4- Spinach, dried 4-4- 4- Carrots, fresh, raw, 4- 4- + ** dried very slight Beetroot, raw, expressed juice less than -|- Potatoes, raw 4- 4” “ cooked + Beans, fresh, scarlet runner, raw + + Onions, cooked -(- at least Lemon-juice, fresh + + + “ “ pre- served + + Lime-juice, fresh + + “ “ pre- served very slight Orange-juice, fresh 4—1—h Raspberries ++ Apples 4- Bananas 4- 4" very slight, Tomatoes, canned — Nuts 4- 4-4- Miscellaneous Yeast, dried -j—1—4 “ extract T 4- + + 0 Meat extract 0 0 0 Malt extract in some specimens CHAPTER XIV SUGGESTIONS FOB THE DIET OF YOUNG AND OLD “Oh! that man should put an enemy into his mouth/’ Calcification of the teeth begins, as we have seen, five months before birth, and to insure strong jaws and sound teeth it is necessary that the mother’s blood, which has to furnish all the material for the development of the child’s body, should contain the necessary substances for the formation of the teeth. It is true that certain substances such as calcium salts and vitamines may be taken from the stores of her own body. This, however, can take place only to a limited extent and at a sacrifice of her own health. It is important, therefore, that the mother’s diet should contain all the essentials for her own welfare and the normal development of the child. This means food rich in mineral salts and containing the vitamines necessary to the child’s growth. The one food best adapted for the first six to tAvelve months is the mother’s milk, and there is 203 204 TEETH, DIET, AND HEALTH no artificial device which will furnish the same exercise to the baby’s nose, mouth, and throat as nursing at the breast. The breast-fed baby must work hard for his food, and the parts which perform this work receive their benefit in an in- creased blood-stream and more abundant nourish- ment. It is evident that the quality of the mother’s milk is influenced by her diet and that the supply of calcium salts and vitamines should be continued, as there is a great demand for these substances at this period of the child’s life. If the mother’s milk is poor, artificial feeding will bring very much better results, if carried out under the advice of a competent children’s specialist. It is generally agreed that the diet of the nurs- ing mother should include a plentiful supply of milk and eggs and whatever vegetables and fruits are obtainable. In this connection it should be remembered that Vitamine C is only abundant in milk in spring and early summer, when the cows receive plenty of green foods. During the rest of the year the nursing mother must receive this vitamine from other foods (see table). When the first teeth appear, that is, about the ninth month, there is a demand for something DIET OF YOUNG AND OLD 205 more than liquid food. The baby should be given a little toast, or bread-crusts, which will also help the teething. If the child is weaned, a large part of his diet will still consist of cow’s milk, modi- fied and supplemented in one way or another; but it should be remembered that the Vitamine C is destroyed by heat, and if pasteurized or sterilized milk is used orange-juice must be given. When the baby is twelve months old, soft cooked eggs and spinach should be added to the bill of fare. Between the ages of eighteen and twenty-four months, the child completes the first dentition and is now fully equipped to masticate his food properly, and mastication should be induced by giving him the proper food. Children very easily acquire a taste for soft food and refuse anything which requires special effort to chew, but if they are properly started they enjoy hard food. Soft fibrous food is, therefore, introduced, such as baked potato, baked apple, stewed prunes, green vegetables, peas, and carrots, as well as tender roast beef and lamb chops, finely ground. The Period When the Permanent Teeth are Calcified Although the first permanent molar begins to calcify before birth, the most important time for 206 TEETH, DIET, AND HEALTH the formation of the enamel of the permanent set of teeth as a whole is between the ages of two and ten. It should also be remembered that the enamel is formed from the inside out, and the enamel which is exposed to the influence of the mouth is the last to calcify. The illustration in Figure 43 gives an idea of the progress of calcification of the permanent teeth, according to age. It is important, therefore, that the child should receive, during the period of tooth forma- tion, a large amount of the foods necessary to the formation of sound tooth tissues. This means foods rich in mineral salts and vitamines. The child is gradually given harder and harder food, for its beneficial effects on the growth of the jaws and nourishment of the teeth. Milk, although not a natural food after the child is equipped with teeth to eat, is neverthe- less a most desirable addition to the diet of the growing child, because it supplements whatever is deficient in the other foods. Its mineral con- tents are of great importance, as is also the fact that it supplies all three vitamines. One should remember, however, that the Vitamine C is only abundant in the milk of cows if they receive plenty of green food, and that in pasteurized, DIET OF YOUNG AND OLD 207 sterilized, or cooked milk, these same vitamines are to a large extent destroyed. It is necessary, therefore, to nse with such milk orange-juice or fresh vegetables, which are rich in Vitamine C. Milk should be taken preferably at the close of the meal and not as a fluid in which to soak bread, crackers, and other hard food, so as to render chewing unnecessary. Bread is, next to milk, perhaps the most popu- lar food. That which is made of white patent flour is generally the best liked. It is, however, deficient in vitamines and mineral salts and should be avoided if bread forms a large part of the diet. Whole wheat and rye bread and whole corn bread are recommended instead, as they con- tain all the ingredients of the cereal. If one cannot obtain genuine whole wheat flour, one can, for a few dollars, buy a small grinding machine and make his own flour. Many people do not realize that corn, like wheat, has an outer skin which contains the valuable substances for growth and maintenance of life, and that this is lost dur- ing the process of refining. Animals fed on such corn-meal will not grow; poultry fed on it ex- clusively will die within two months. Why should one give food made of deficient flour to his chil- 208 TEETH, DIET, AND HEALTH dren, and why should he eat it himself ? What is true of flour is true of breakfast-foods prepared from cereals. One should be sure that the va- rious preparations that he uses are made from the entire grain and that the vitamines are not destroyed in the process of refining. This pertains to all breakfast-foods, whether made of oats, wheat, buckwheat, rice, barley, or corn. For Breakfast When the child is two years old and can be trusted to use the teeth, hard breakfast food is to be preferred and should be gradually intro- duced. It should be given, without sugar, but with thin cream or milk. Use whole wheat meal or undegerminated corn-meal porridge, or scotch oat-meal (not the long, soft-cooked oat-meal pap), or any of the patented breakfast-foods, so long as they are made from the honest, whole grain. The addition of nuts, and of dried fruits such as dates and figs, is very beneficial, and makes the food so palatable that even children who are ac- customed to eating their cereal with sugar will not miss it. The choice of fruit can after the age of four be enlarged to ripe raspberries, straw- berries, blackberries, oranges, ripe cantaloupes, DIET OF YOUNG AND OLD 209 stewed dates or figs, and raw or cooked apples with the skin. Dried or toasted whole grain bread, or, for a change, some muffins made of the same flours, are given until the appetite is satisfied. Pre- served fruits, honey, or pure maple-syrup in moderation may be given with bread. It is nourishing and at the same time tickles the child’s palate. Milk is given according to age. For Dinner At noon soup made of beef-juice, lamb, or chicken broth, with two or three vegetables, or with thoroughly cooked, unpolished rice may be given. Soups made of stewed vegetables are also good. Meat or soft cooked (coddled) eggs, with plenty of fresh vegetables, potatoes steamed or baked and served in the skin (mashed potatoes are generally bolted), green peas, stewed carrots, beets, beans, or any of the leafy vegetables, and, in winter, dried peas and beans, unpolished rice, dried lentils, apple sauce, or any other fruit may be added. A slice of whole wheat bread with butter, a muffin, or a piece of toast may be added if necessary. Swedish bread, or oat cake, gives excellent exercise to the jaws and teeth. For dessert, uncooked fruit is the best, when the child 210 TEETH, DIET, AND HEALTH is more than four, and almost any kind that is entirely ripe will do, but be sure to serve it in the skin. Apples, dates, and figs can be used in winter when berries and other fruits are no longer available. The Supper The supper should be light; a breakfast-food such as has already been described, with milk and whole grain bread or toast, should be the founda- tion. An occasional change or an addition from the dinner menu may be made. Between Meals Children should be trained to eat a sufficient amount of food at meal-times and should not be allowed to eat between meals. The constant use of sweets is the cause of poor appetite and results in sickly, pale complexions and undernourished bodies. Sweet fruits, raw or cooked, should also be withheld until the hearty food is eaten. Water, however, should be freely given between meals. Many children have to be encouraged to drink water. During meals, however, only a lit- tle water should be allowed, and care must be taken that children do not use it to wash down their food. DIET OF YOUNG AND OLD 211 The Food of the Adult The food problem is a very perplexing one. A large number of our minor ills and a good many more serious ones are due to our criminal ways of eating. Proper eating is an important func- tion, and what one should eat and why, is a knowl- edge every one should possess. Here we are only interested in the relation of diet to the teeth. What has been said in regard to choosing food to promote the development of strong, normal teeth in the child holds good for the maintenance of healthy teeth in the adult. Hard food will fur- nish the required exercise to keep the tissues surrounding the teeth in good condition. Soft, soggy foods have a tendency to lodge be- tween the teeth in places where they are irregular, and underneath inflamed gum margins and im- perfect restorations, causing dental caries and pyorrhea alveolaris. Foods of this character should be avoided as much as possible. Under this group belong sugar, in its various forms, sweet biscuits, puddings, bread made from white flour, all new bread and that without a crust, bread soaked in milk, and preserved fruit. The cooking of certain foods, especially if overdone, also causes changes which make the food still 212 TEETH, DIET, AND HEALTH more adhesive. Stanley Colyer writes in “The Dental Record” that starch grains may be trans- formed into mucilage, and animal foods into solu- ble gelatine. These substances, he says, will not readily be removed by saliva, and its prolonged contact leads to damage to the dental tissues. One should always use cleansing foods as much as possible. When this is not possible, he should at least see that the meal is ended with food of the cleansing kind. Dr. Sim Wallace, in a lecture at the London Hospital, gives the following foods as examples of the cleansing kinds: fibrous foods, such as fish, meat, bacon, poultry, fruit, pickles, savories, uncooked vegetables, lettuce, cress, radishes, and celery. Cooked vegetables, he says, are also cleansing, but in a less degree. He recommends using stale bread only with the crust, toasted bread, and twice baked bread. To this it should be added that our staple bread should be made of the entire wheat or other flour which has been milled without the removal of its outer layer. Such bread is coarser because it contains more fibrous material, and therefore its cleansing action on the teeth and its beneficial effect on the bowels occur. The fresh fruits make ideal dishes to end a meal. Those requiring mastication are to be preferred, such as apples, pears, and berries. DIET OF YOUNG AND OLD 213 Rules for Eating One should form the habit of eating properly. The following short rules may be found helpful: When you sit down to your meal, be at peace with yourself and all who are with you. See that you have plenty of time and do not feel hurried. Eat hard foods, masticate them well, and get all the taste you can out of them. Do not soak your food in milk, nor lubricate it with butter, nor wash it down with water. Nature provides us with saliva for this purpose. Food should be of the right temperature. We drink and eat many things that are too hot. The child will refuse food that is too hot, and, if he is forced to take it, it will hurt the delicate mem- branes and cause suffering. The evils of over-eating become evident in adult life. Be moderate in your eating and stop when your appetite says, “Enough!” Finish your meal with cleansing food, especially when you will not have an opportunity to brush your teeth at once. Eat no food except at regular meal-times, but drink plenty of water, especially in summer. CHAPTER XV A PLEA FOR THE FUTURE “Help develop sound teeth in the coming generation.” To be happy it is necessary to be physically fit, and the readers of this book must now realize that nothing contributes more to the development and maintenance of health than right living and especially right eating. Clean and healthy mouths are only found in people in good physical condition. It is the healthy, happy, rosy-cheeked child who possesses beautiful and useful teeth. A mouth full of decayed teeth, harboring millions of bacteria, exposed pulps which cause pain every time hard food is crushed, and sinuses discharg- ing pus which mixes with the food, cannot pos- sibly be associated with good health, and causes, as we have seen, a great deal of suffering. The reader has observed that a mouth full of neglected teeth predisposes to indigestion and that poisons draining into the system from unsuspected abscessed teeth may sap the strength and vitality of the body and prevent the attainment of a full share of success, whatever it may be, business, 214 A PLEA FOR THE FUTURE 215 social, or personal. With such handicaps one may look forward to years of infirmity and a burden- some old age. If the reader realizes the importance of being well, he should have teeth X-rayed, his mouth put into healthy condition, and lost teeth replaced by substitutes, so that he can masticate his food properly. This will improve the digestion and the general health. If he has become a dental cripple through neg- lect, either from carelessness or lack of knowl- edge, faulty diet or lack of hygiene, it is his duty to protect his child from the same mistake. Every child has the right to be protected from prevent- able diseases and to be started oft in life with a healthy body and sound teeth. How this can be accomplished is now clear to readers of this book, and the time is not far dis- tant when so important a topic will become a feature in the education of every child. The ap- plication of such knowledge will greatly reduce the prevalence of dental diseases, and the writer will be more than content if this book succeeds in conveying the message of how to develop sound teeth in the coming generation. INDEX Abscesses, acute alveolar, 71 alveolar, 71 blind, 73 Absorption, from dental in- fection, 111 of pus, 112 of pus from teeth (Case of), 113 Adenoids, 43 dental, 105 narrow jaws, 45 Adult, food of, 211 Ameloblasts, 175 Amoeba, 165 Amori of New Zealand, 19 Anemia, due to dental infection, 116 Hunter on, 116 septic, 116 Anesthesia, local for pain, 136 Anthropology, study of 11 Ape, anthropoid, 29 Appetite, 172 loss of, 113 Apples, 209 Apprehension, 138 Aristotle, 19-26 Arthritis, arthritic condition and dental infection, 118 Asia Minor, diet of, 21 Aspirin, 137 Assimilation, 172 Baby, diet of, 205 Baker, Dr. Lawrence, 41 Bangweulu, 81 Barotzi, 81 Tribe of, 20 Bees, diet of, 182 Berries, 208 Between meals, 210 Blood Poisoning, 73 Bodkins, 156 Bolting food, 169 Bone, infection of, 71 Bran, 194 Bread, 207 fresh, 211 Swedish, 209 Breakfast foods, 208 suggestions, 208 Breast feeding, 204 Breath, breathing exercises, 45 malorodous, 84 offensive, 163 Bridges, fixed, 125 instruction and care*of, 125- 156 removable, 123, 126 Bridgeport, Connecticut Schools, 150-151 Eritish Medical Research Com- mittee, 199 Bronchitis, Pyorrhea, 84 Building Material, quality of teeth, 176 Calcification of teeth, 176, 203 217 218 INDEX permanent teeth, 180 temporary teeth, 180 Calculous, salivary, 82 serumal, 82 Cannon, Professor, 172 anger, anxiety, fear, jealousy, vex- ation, worry, 172 Carbohydrates, 187 Care of the mouth at home, 152 Caries, dental, 59 difficult to recognize, 66 effect on teeth, 66 examination, 67 immediate cause, 63 influence of sugar on, 64 (Case on), 65 treatment, 67 X-ray examination, 67 Cassava root, 81 Catarrh, Pyorrhea, 84 Cell, evolution of, 167 Cellulose, 187 Celsus, 18 Cementum, 63 Chewing, lost habit of, 169 necessary for developing, 34 Child, bolting food, 34 diet of, 205 hard food, 35 psychological attitude, 50 two to six years of age, 34 Chronology of human denti- tion, 39 Civilization, influence on de- velopment, 58 modern affect of, 22 Cod L'ver Oil, 193 Colyer, Dr. Stanley, 20, 81, 212 Complexion, sallow, 116 Condition, summary of dental, 25 Constipation, 113, 173 inflamed gums, 174 symptoms of, 174 Cooking of food, 211 effects of, 173 Corn, 207 Cotton, Dr. Henry A., 117 on impacted teeth, 57 Cows, influence of food on milk of, 204 Crile, Dr. 138 Crutches, dental, 128 Darwin, 26 Dates, 209 Deciduous teeth, care of, 49 Delinquency, due to teeth, 56 Dental care of expectant moth- er, 163 Dentine, 63, 175 secondary, 176 Dentist, prophylactic treat- ment, 160 Deposits on teeth, 80, 82 Development and mastication* 44 Diet, 182 deficient (Case of), 86 improper for tooth develop- ment (Case of), 179 influence on development of teeth (Case on), 199 in pyorrhea, 79-80-85-88 modern and dental caries, 9 of ancient Egyptians, 12 of the baby, 205 of the bees, 182 of the child, 205 of the nursing mother, 204 INDEX 219 slightly deficient, 198 suggestions, 203 Digestion and emotions, 172 and loss of teeth, 123 process of, 168 the stomach’s part 171 Dinner suggestions for chil- dren, 209 Diseases, mental, 117 resulting from dental infec- tion, 76 7000 years of dental, 11 Disorders, digestive due to in- fection, 104 Dyspepsia, mastication, 103 Ear ache, (Case of) 132 condition due to teeth, (Case of) 57 from teeth, (Case of) 109 Ear, affected by dental condi- tion, 108 infection, middle (Case of), 109 pain in, 56, 132 pain in caused by teeth, 69 Eating, rules for, 213 Effects, systemic in pyorrhea, 84 Eggs, calcium content, 191 Egyptians, ancient, 12 attrition of teeth in Egypt, 14 dental surgery among, 12 diet of, 14 pyorrhea, 16 teeth show wear, 14 Emotion and digestion, Profes- sor Canon on, 172 Empirin, 137 Enamel, 62, 175 Epileptoid attacks, 57 Erman, Adolf, on dental dis- eases, 15 Eruption, of first permanent molar, 36 of permanent teeth, 38 of teeth, disturbances, 32 of teeth, table of, 39 Esquimoes, 19 Evacuation, 172 Evolution of cell, 167 Examination, of dental caries, 67 of diseased teeth, 9 of expectant mothers, 164 of the mouth, 142 X-ray, 145 Exercises, breathing, 45 Expense of diseased teeth, 9 Expression, changed by loss of teeth, 122 facial, 5 Eye, disease (Case on), 84 pain in, 132 Eyes, ears and dental disease, 118 Face, ache (Case of), 132 development of, 26, 41 idiotic types, 43 modern development of, 29 proportions of, 41 sinus on, 72 swelling of, 72 unequally developed, 42 Faith, confidence, 139 Fatigue, 112 Fats, 186 Fear, 130, 138 Feasts, Roman, 18 220 INDEX Feeding, affect of bottle feed- ing, 31 artificial, 204 breast vs bottle, 31 Figs, 209 Floss, dental, use of, 156 Food, bolting, 103 cleansing, 212 contaminated, 84 cooked, effect of, 81 cooking, 195, 211 fibrous, 212 hard, 205 hard for children, 35 of the adult, 211 popular, 190 protective, 198 soft, 205 soggy, 211 temperature of, 213 vitamine deficient, 196 Fones, Dr. A. S., 23, 150 malocclusion, 48 rules for burshing teeth, 159 statement of dental coditions by, 23 Fright, 131, 138 Fruit, 209 General health, its relation to teeth, 90 Granuloma, dental, 73 Great Britain, dental condition in, 24 Green stain on teeth, 159 Grieves, Dr. C. J., 198 Gums, bleeding, 86 inflamed, 82 receding, 83 sinus on, 72 Habits, malocclusion resulting from, 47 pernicious, 47 Hamburg, dental conditions in, 24 Hands, poly-neuritis in, 195 Harrow, Dr. Benjamin, 199 Headache, 72, 113, 115 from dental infection (Case of), 114 Herodotus, 12 Hindu, 4 Hindu-China, 4 Howe, Dr. Percy, 196 Human dentition, chronology of, 39 Hunter, Wiliam, on anemia, 116 on oral sepsis, 90 Hygiene of the mouth, 150 Hygienist, 150, 161 training schools for, 161 Hypocrates, 17 Illness, care of the mouth in, 162 111 temper, due to teeth, 56 Indians, American, 19 Industrial establishments dental infection, 93 Infection, dental, arthritis, 118 causing absorption, 111 digestive diseases, 104 diseases resulting from (Case of) 76 eyes and ears, 118 industrial establishments, 93 in pregnancy, 95 in pure food laws, 101 neuritis, 118 INDEX 221 nose and throat, 105 rhuematic diseases, 118 treatment for, 96 good general health, 96 poor general health, 97 Infection, focal phenomenon, 93 Insomia, 57 Instruction for care of the mouth, 154 Irregularities of teeth, 41 Irritability, due to teeth, 18 Jaws, narrow, 43 short, 47 undeveloped, 48 Knees, rhuematic swelling in, (Case of) 120 Lamarck, 26 Laryngitis-pyorrhea, 84 Life Insurance Companies dental infection, 92 Lime water, how to make it, 157 its use, 158 Liver, pancreas, function of, 171 Loss of teeth, expression changed, 122 Lower jaw, protruding, 46 (Case of), 47 Lumbago, from dental infec- tion, (Case of) 118 Lymph Glands and infected teeth, 110 swollen (Case of), 111 Malocclusion, 48 pernicious habits, 47 prevention of, 49 Man, earliest time of, 29 Mania, 57 Mann, J. J. 4 Marion School, dental condi- tion in, 23 Mastication, development of the jaws, 44 function of teeth, 7 indigestion, 170 insufficient in deficient teeth, 102 liquid diet, 169 of vital importance, 169 Mayo Clinic, dental infection, 23, 92 McCullan, E. V., 193 Measels, effect on teeth, 177 Meat, calcium content, 191 Melancholy, 57 Mellanby, Dr., 193 Mental diseases, 117 Mental vigor, loss of, 116 Metabolism, 174 Milk, 206 calcium content, 191 of magnesia, 159 pasteurized, 205 Mineral salts, 189 supply for permanent teeth, 180 tooth development, 176 Molar, first permanent, erup- tion of, 36 third, impacted, 54 Moors, 21 Mother, expectant, examina- tion of, 164 milk, 203 nursing, diet of, 204 Mouth, breathing, 44-45 care of it at home, 152 222 INDEX care of in illness, 162 examination of, 142 hygiene, 150 instruction for care of, 154 open, 43 poor for plate, 128 Mucin, on teeth, 157 Mweru, 81 Neck, swelling of, (Case of) 72 Neglect, (Case of) 145 Negroes, African, 19 Nero, diet during time of, 19 Nerve of tooth, (see pulp) Neuralgia, (Case of) 56, 69, 132 Neuresthemia, 57 Neuritis and dental disease, 118 Nervous tension, 139 New Zealand, dental conditions in, 24 Nitrous oxide and oxygen for pain, 135 Nutrition and structures of tooth, 165 Nose and throat disease, due to dental infection, 105 Nose, constricted, 44 pain in, 132 Novocain, 136 Nursing, breast, 180 Nutrition, dental structures, 165 Odontoblasts, 175 Operation, pain after, 137 Orator, importance of teeth, 6 Otalgia, 109 Pacifiers, use of, 47 Pain, after operation, 137 cause, 130 character of, 131 control of, 130, 135 ear, 56, 132 eye, 132 from cold, 69 from heat, 69 from impacted teeth, 55 from pulp disease, 69 from sweet food, 69 in back, (Case of), 119 neuralgic, (Case of), 69 nitrous oxide and oxygen for, 135 nose, 132 operative, 133 palliative treatment for, 137 protective device, 130 referred, (Case of) 132 throbbing, 72 tooth eruption, 32 treatment, 130 upon exerting pressure on tooth, 72 Pancreas liver, function of, 171 Paring of fruit, 190-194 Patient, nervous, (Case of), 134 Peasant classes of Europe, 21 Pericementoclasia, 78 Permanent teeth, absence of, 37 eruption of, 38 Persia, diet in, 21 Phenacetin, 137 Phenomenon of focal infection, 93 Pickerell, Professor, 21 Plaques, bacterial, removal of, 161 INDEX 223 Plates, 127 and pyorrhea, 127 gold, 127 mental attitude toward, 128 platinum, 127 poor mouth, 128 rubber, 127 Plea for the future, 214 Polished rice, 195 Poly-neuritis in hens, 195 Pregnancy, dental care in, 163 dental infection, 95 mineral salts needed, 190 Pressure of impact teeth, 55 Prevention of malocclusion, 49 of pyorrhea, 88 Procain, 137 Protein, 174, 186 Protrusion of lower jaw, 46 Psychology—children, 139 Ptyalin, 170 Pulp, dental involvement of, 69 of the tooth, 63 removal of, 70, 120, 126 Pulp disease (Case of), 69 Pure food laws—dental infec- tion, 101 Pus, absorption, 112 continuous discharge, 73 swallowed, its effect, 103 Pupils, pus pockets, 84 retarded in school, 151 Pyorrhea alveolaris, 78 in animals, 78 constipation, 80 constitutional causes, 80 diet deficient (Case of), 84, 86 effect of diet, 79, 80, 85, 88 in African tribes, 80 in Egypt, 16 local causes, 80 plates, 127 prevention, 88 symptoms, 82 systemic effects, 84 treatment, 85 X-ray examination, 87 Race of dental cripples, 164 Radiographic examination, 145 Regulation of teeth, time to begin, 51 Restoration, dental (Case of), 124 Rheumatic disease—dental in- fection (Case of), 118 Rheumatic fever (Case of), 84 Rigg’s disease, 78 Reisner, S. A., 12 Rickets, 193 Roentgen examinations, 145 Rogers, Dr. Alfred, prevention of malocclusion, 49 Romans, dental diseases of, 17 Root, absorption of, 75 condition of, 75 Rules, for brushing by Dr. Fones, 159 for eating, 213 Rye, 194 Saliva, function of, 213 Salivary gland, function of, 168 Salts, mineral, 189 Scarlet fever, effect on teeth, 177 Scurvy, 78, 195 224 INDEX Self control, 131, 139 Silk floss, 156 Sinus, Maxillary, infection of (Case of), 105-107 Sinus, on face, 72 on gum, 72 Sinus disease, maxillary, tooth extraction in, 108 X-ray examination in, 106 Skin, gray, 113 sallow, 113 Smith, Professor Theobald, 196 Smoking, Toxemia, 113 Soda, used in cooking, 194 South Sea Islanders, 19 Soup, 209 Spaces, between teeth, 35 Speaker, public, importance of teeth, 6 Spots, white and milky on teeth, 66 Starch, sugar, 187 Substitutes for lost teeth, 122 Sugar, consumption of, 68 commercial, 188 craving for, 188 dental caries, 61-64 effect of, 22 natural, 187 starch, 187 Sulkiness, due to teeth, 56 Stefansson, Arctic explorer, 197 Stomach’s part, digestion, 171 Stomach, disease of due to teeth (Case of), 104 Structures of tooth and nu- trition, 165 Supper suggestions for chil- dren, 210 Surgery, dental among the Egyptians, 12 Survey of the mouth, 124 Sweets, 210 Swelling, on face, 72 on neck, 72 Tables, Nutritional elements, 191 Tooth eruption, 39 Vitamine content of food, 200-202 Talbot, 43 Tartar, 82 Teeth, artificial gold, platinum, rub- ber, 127 building material, 176 calcification of, 176 cleaning regularly, 67 color of, 3 customs of savage tribes, 4 deciduous, 31 deciduous calcification of, 179 deciduous, root absorption, 180 deficient, causing insufficient mastification, 102 development of, 26 diseased, 7-9 discolored, 143 drifting, 83 effect of caries, 66 emotional expression, 5 eruption disturbances, 32 eruption, table of, 39 evolution of, 27 facial harmony, 3 hardness of, 61 healthy, value of, 7 ill temper due to, 56 INDEX 225 impacted (Case of), 55 infection of, 54 irregular, 41-48 iritability due to, 56 loose, 83 loss of, and digestion, 123 milky spots, 66 mucin on, 157 mutilated, 4 of carniverous animals, 29 of habiverous animals, 29 of omniverous animals, 29 permanent, 36 development of, 37 deciduous calcification of, 179 regulation of, time to begin, 51 sensitive, 159 set on edge, 159 shedding of, 36 soft, 60 spaces between, 35 special functions, 28 stains, removal of, 161 substitutes for, 122 sulkiness due to, 56 supernumerary, 53 unerupted, 52 use in animals, 27 value in health and disease, 3 Teething, 32 disturbances, eruptions, 32 Tension, nervous, 139 Theophrastus, 19 Time to begin regulation of teeth, 51 Tired feeling, 112 Tonsils, 105 Toothache drops, 131 Tooth, blood supply, 71 brush and care of, 152-153 brush, special for bridges, 153 decay, 59 development of, 175 mineral salts, 176 diseased, causing fever, 72 extraction of in sinus dis- ease, 107 maxillary sinus infection, 106 nourishment of, 178 paste, 153 pick, injurious, 82 powder, 153 saving at all costs, 120 too long, 72 what it is composed of, 62 Toxemia, 112 and smoking, 113 Training schools for hygien- ists, 161 Treatment, dental caries, 67 infection, 96-97-98-99 Tribes, teeth, customs of, 4 Tuberculosis isuspected (Case of), 115 United States, dental condi- tion in, 23 Upon, Dr. Henry S. on im- pacted teeth, 57 Vegetables, cooking of, 190 Views opposing dental infec- tion, 97 Vitamines, A, 192 B, 194 C, 195 antineuritic, 194 226 INDEX antiscorbutic, 195 dental caries, 62 fat soluble, 192 how to detect, 192 in bottles, 197 Wallace, Dr. Sim, 212 Water, 210 Weight, loss of, 113 White bread, wheat, sugar, 190 Whole wheat, 194 Whooping cough, 177 Wilkinson, Sir, J. Gardner, 14 Worry, 131 X-ray, examination (Case of) 145 alvoolar abscess, 73 dental caries, 67 developing teeth, 37 expectant mothers, 164 periodical, 145 pyorrhea, 87 sinus disease, 107 to make correct diagnosis, 148 value of, 143 laboratories, commercial, 146 wrong diagnosis without, 148