EFFECT OF DIET ON CARIES IN CHILDREN. p.erious energy through the phrenic will diminish and lead to movements of the vocal cord in which the excursions will be equal to, and not greater than, those of the vocal cord on the opposite or normal side? Another question also requires an answer : When the vocal cord is moving normally through nervous impulses conveyed to it through the phrenic, will the patient be able to phonate? This is the question asked by Sir Frederick Mott. The answer can hardly be decided by experiment on the monkey: operation on man will give the reply. This will be the decisive experiment. The conclusion, therefore, appears to be, that for the cure of recurrent laryngeal palsy and th8 attainment of normal moYement of the vocal cord in tranquil respiration, anastomosis with the vagus or the descendens noni must be rejected, and wme form of anastomosis should be carried out with the trunk or with one of the roots of the phrenic nerve. The Medical Research Council has defrayed the expenses cf this research, and given me every possible assistance at the National Research Institute.
THE EFFECT OF DIET ON THE DEVELOP3IE~T AND EXTENSION OF CARIES IN THE TEETH OF CHILDREN.* (Preliminary N ate.) BY
MAY
:\fELL~-\NBY,
AND
C. LEE PATTISON, M.B., B.S.LoxD., J. w. PROUD, L.D.S., SHEFFIELD.
INTRODUCTION.
IT has been found by May Mellanby 1 in her experimental work on puppies, first published in 1918, that the structure of the teeth and their arrangement in the jaws are controlled by the diet and environment to which the animals are subjected during the period of development of their teeth. Some dietetic factors tend to help, and others to hinder, the formation of well calcified, evenly arranged teeth. In the former group are to be found substances rich in a vitamin closely allied, both as regards distribution and properties, to vitamin A. This group of subatances includes cod-liver oil, animal fats (except lard), milk, and yolk of egg. Among those foods which lead to the development of badly fot·med teeth, cereals, and particularly oatmeal, occupy a prominent position. Thus the total influence of a mixed diet on the structure and the arrangement of the teeth in the jaws of puppies is the outcome of a battle between different dietetic influences. In addition to the influence of diet, May Mellanby 2 has also shown that exposure of the animal to either sunlight or other sources of ultra-violet radiation has, under some oonditions, an important influence on tooth formation. It is probable that the effect of these radiations is to make active the calcifying vitamin stored in the body. In fact, the interaction of the dietetic and environmental influences on tooth formation is certainly very close. . Two questions arise from the experimental work on the factors influencing the formation of puppies' teeth: first, Do the same factors control the formation of the teeth of human beings? and secondly, What relation ha Ye these facts to dental caries in man? With regard to the first question, it is not yet possible to state that the results are applicable to man, in spite of the fact that the experimental work was published some years ago. There seems, however, some justification for believing that they are. It may be said also that if the results of this experimental work can be extended to man, a partial answer to the second question is supplied, for if teeth perfectly formed and well arranged in the jaws can be produced in children by feeding them along the lines suggested by the animal experiments, then such teeth will be less liable to caries than if they were imperfectly formed. .Although such a relationship is obvious to some, yet the Jdea is not generally accepted by dental authorities, because of the supposed fact that children's teeth are in general " The expenses of this research were defrayed in part by a grant from the liledical Research Council and the Dental Board of the United J[lngdom, to whom our thanks are due.
r
THE BRITI!B
lfEDICJL J01JBNU.
well formed and yet very liable to become carious. May Mellanby, 3 however, found, when examining a large number of children's teeth under the microscope, that on the whole the more perfectly formed teeth, as evidenced by microscopical examination, were the least carious. There were,: however, exceptions to this rule, for out of 302 teeth examined microscopically 11 were carious and yet well formed, while 13 were free from caries although of defective structure. Closer examination revealed that when teeth were well formed and carious any secondary dentine present was usually poorly calcified; and, on the contrary, badly formed teeth free from caries, or in which caries had been arrested, generally had some well formed secondary dentine. It appeared, in fact, that although the formation of the original enamel and dentine was as a rule a good indication of the susceptibility of a. tooth to caries, the presence and structure of secondary dentine indicated a second line of defence dependent on resistance set up in the body and particularly in the tooth itself. These data, obtained by examination of deciduous teeth of children, were further correlated with some experimental results which showed in a few cases . that good secondary dentine was formed in puppies' teeth on a. " good " diet,, and imperfect secondary dentine when they were on ~ " defective " diet. Thus it appeared probable that in children also " good " diets might contribute to the arrest of decay. On the contrary, diets compatible with the formation of bad enamel and dentine might be expected tO offer less resistance to the initiation and spread of caries.It may be noted here that the resistance of the puppies to infective processes generally was found to be closely dependent on their diet--a " good " diet affording them great resistance, and a " defective " diet rendering them more susceptible. Reference must also be made to the claim 1\IcCollum, Simmonds, Kinney, and Grieves• and Howe• that " caries-like " lesions can be produced in rats and guinea-pigs by diets defective in certain respects.
of
OBJECT AXD CoNDITIONS OF INVESTIGATION.
It is evident that the previous experimental work sug~ gested most strongly that dental caries in human beings would be influenced by the small but specific differences in diet above mentioned. It appeared necessary, therefore, to investigate this matter, because corroboration of the animal results and their extension in man to the problem of caries would, if forthcoming, raise this subject from a position of academic interest to one of immediate human utility. The children under observatio=t were in an institution during the period of the investigation, and their diet and environment generally were under the close supervision of one of us (C. L. P.), by whom the improvement in the health of the children was carefully watched. Three groups of children were taken. One set (nine in number) were placed on diet (diet A) which included codliver oil, milk, and eggs, but no oatmeal. On the basis of the investigations referred to above, this diet, which has a potent effect in bringing about calcification, might be expected to increase the resistance of the body, and especially the teeth, to bacterial infection. The next group oon• sisted of ten patients1 who received a diet (diet B) similal' on the whole to diet A-the chief differences being that it included oatmeal, very little egg, and less milk thati diet A, and no cod-liver oil. The third group consisted of thirteen children chosen from patients on the ordinary hospital diet (diet C). They were selected so as to be comparable with the first two groups in age, duration of institutional treatment, etc. The diets eaten by the three groups are indicated below,· but naturally the quantities varied to some extent with the age of the child. It will be noticed that diet B, which contains more cerealt. including oatmeal, and less calcium and vitamin A, b otherwise not very different from the ordinary hospitai diet (diet C), which holds an intermediate position-so far as power to stimulate calcification in puppies is concerned -between diets Band A. ', The eHect of the three diets on the patients was very carefully watched, and as far as could be observed there was no difference in the improvement of the general health;
EF.FECT OF DIE'l' ON CARIES IN CHILDREN. 3. The average age of the patients at the beginning of the experiment was, in years: Group A, 7.5; Group B, 7.5; Group
TABLE !.-Daily Diet. Diet. 1\Iilk ...
Bread Fat ...
... ...
...
...
... ...
Sugar (including cooking) Oatmeal, groats or gruel Rice, tapioca, etc.
A.
B.
2 to 1~ pints 2 to! oz. 1 oz. (butter)
i to~ pint 5 oz. 1 oz. (margarine except towards end) 3oz. 2 to 4 oz.
1~
oz.
-
... ...
...
Fruit, etc ....
...
no,. 1~ oz . 2 oz . 2 oz. Made with milk 1 1 orange, or
Cod-liver oil
...
. 1 or 2 dr, 3 to 6 dr.
Meat (cooked) ... Potatoes ... ... Other vegetahleR Cocca }~gg
...
...
~tomato, or
0.
(Hospital Diet.)
H pints .4d lib.
1 oz. (margarine except towards end). H oz. and jam, etc. Occasionally.
~oz.
~oz.
Hoz. 4 oz. ! oz. Made with water Very little As in Diet A
2!oz. 4oz. ~oz.
Made with milk. Sometimes. As in Diet A.
c,
7.1. 4. The average period covered by the investigations was, in months: Group A, 7.5;· Grouf B, 7.5; Group C, 8. 5. The average amount o dental hypoplasia observed by the naked eye was practically the same in the three groups A, B, and C. 6. The average number of carious teeth in each child before commencing the diets was : Group A, 6.25; Group B, 6.125; Group C, 7.
TABLE H.-Summary of Investi,!Jation and Results.
c. A. B. --------------1-----Number of patients in each group Av~rage time between admission and first inspection (months) Average age at which diet started (years) Average period covered by the investigation (months) Average number of erupted teeth per child at first inspection Average number of carious teeth per child at first inspection
swede juice,
-
9
10
13
7.5 7.5 7.5 18.75 6.5
8.5 7.5 7.5
8.5 7.08
19.25 6.125;
8.0 21.0 7.0
Exttttsion o/ Caries. 2 to 3 dr.
in the three groups. The condition of the mouth and t~eth of each child was charted at the beginning of the dietary and also after some months, the period varying slightly m differei1t cases. The difficulties of correctly reeording all the findings are obvious, but we have tried to retain the same criteria throughout. Hypoplasia.-The general condition of the teeth as regards hypoplasia obvious to the naked eye was noted. A speeial standard (based on the observations mentioned above) was adopted, and as far as possible used, throughout the investigations. Cm·ies.-An attempt was made to record the position, extent, and deg1·ee of softness and hardness of each carious point in the individual teeth. After periods which varied in the three groups from an avera"G of seven and a half to eight months the teeth were ~gain examined and the results charted. The number of teeth in which new carious. areas had occurred since the first inspection and the number of teeth previously carious in which the caries had increased were noted. In addition, an attempt was made to record the a~ount of hardening or softening of the carious areas. Rad1ograms were taken at intervals, for it was ~hought possible that there might be some alterations in the structure and development of the bone surrounding the teeth, of a similar nature to that observed by May Mellanby in puppies. Histology.-In most cases at the beginning and also after some months of the dietary one or more carious teeth were extracted, mounted in balsam, and ground down so that a microscopic examination could be made. By this means the W:tailed structure of some o.f the teeth can be compared wtth that observed macroscopically. It wsp1tal dtet, before the first inspection of their teeth, was, m months : Group A, 7.5; Group B, 8.5; Group C, 8.5.
Average number of entpted teeth per child at last inspection Actual number of new teeth becoming carious between inspections Average number of new teeth per child becoming carious Number of teeth already carious in which caries increased Average number of teeth per child in which caries increased Total number of teeth showing new or increased caries Average number of teeth per child with new or increased caries Total number of carious teeth in which hardening has occurred Softening has occurred in
17.75 6.0
18.0
20.5
28.0
20.0
0.65
2.8
7.0 0.75
23.0
1.54
18.0
14.0
2.3 51.0 5.1 7.0
13.0
0
4.0
1.0
13.0
1.4
1.4 38.0 2.9
It will be noted that the average age of the child, the period· of investigation, and the dental condition before the first inspection were practically identical-in fact, the only obvious variation in the three groups was in the diet the children received. It is therefore this factor which is probably responsible for the differences observed in the dental changes. TABLE
III.-A~erage number of t<'eth per. child showing a spread of canes prevwusly present and new cartous areas, together with the main differences in the thl'ee diets.
Main Difference in Diet.
Diet.
-----;:-1 Abundant calcifying vitamin and calcium; small amount of carbohydrate, not including oatmeal
Average No. of Teeth per Child in which Caries has Spread.
I
1.4
Less calcifying vitamin and calcium; much carbohydrates, including oatmeal
I- - - - -
Intermediate amount of vitamin A, calcium, ~nd carbohydrates ; some oatmeal
I
5.1
2.9
In other words, the tendency for caries to spread was greatest in children receiving diet B, least in those receiving diet A, and intermediate in those receiving diet C. SUMMARY. It has been found that when children are fed on a diet which has been shown (by May Mellanby) in the case of puppies to result in the formation of well calcified teeth then the initiation and spread of caries takes place at ~ slower rate than in the case of similar children fed on diets not having such pote~t calcif):ing activity. The diet giving the best re~ults! be.stdes hav.mg th~ ordinary qualities of a_ nor~al dtet, 1s r~ch both m ~al~mm and the calcifying Vttamm, and contams comparattve,y little cereal none o{ which is in the form of oatmeal. ' REFERENCES.
'May Mellanby: Lancet, 1918; Dental Record 1920 · British Dental Journal, 1923, etc. ' • 2 The •ame: British Dental Journal, May, 1824. same: lbtd., January, 1923; P.-oc. Roy. Soc. !.led., vol. xvi, 19 • ~fcCollum, N. Simmonds, E. M. Kinney C J Grieves· Bull Johna lfo[Jkins Hospital. No. 382, 1922, p. 202. ' · · • · 5 Howe : Dental Cosmos, 1920, lxii.
;lhe
BRITISH MEDICAL JOURNAL LONDON SATURDAY JANUARY 13 1951
A FURTHER STUDY OF THE TEETH OF 5-YEAR-OLD CHILDREN IN RESIDENTIAL HOMES AND ·. D.(Y SCHOOLS BY
MAY MELLANBY AND
.
HELEN MELLANBT, M.D., Ph.D.
witlt the Assistance of J9AN JOYNER, B.Sc., and MARION KELLEY
!t
was brought home to one of us in 1929, when examinmg the teeth of some 5-year-old children in London County Council schools, that there was a great differen~e bet~e~n t~e condition of their teeth and those of children hvmg .m orphanages 'in the Midlands. Among the.L.C.C. pupds at this time there were only 4.7% *with canes-free or almost caries-free deciduous dentitions whereas it was obvious at a glance that the number of o~hanage children with caries-free teeth was much htgher. In 1943 the chance arose of making a limited ~u!Dber of sys~ematic inspections of the teeth of children hvmg under dtfferent conditions. It was decided, in the first place, to see whether any changes had occurred in !he teeth of L.C.C. pupils between 1929 and 1943. The ~provement was so great (the 4.7% of 1929 had mcreased to 24.2% in 1943) that similar inspections were made in 1945, 1947, and 1949 (MellanbyandCoumoulos 1944, 1946 ; Mellanby and Mellanby, 1948, 1950). ' I~ was not until 1945 that an opportunity arose of seemg whether there was any real connexion between living co~ditions and dental health in orphanage and L.C.C. chddren. . Concurrently, a similar inquiry was made am~ng pupds attending private (fee-paying) day schools ; hke the L.C.C. children, they lived with their own families. Meanwhile various workers had observed a tendency for children brought up in orphanages to suffer little from caries; while others, including Collett (1935) and S~hiotz (1939) in Norway; and Anderson et a~. (1934), .m Toronto, had published a few figures relatmg to m1xed age groups indicating that there was less caries among such children than among the general population. The threefold survey of 1945 (Coumoulos and Mellanby, 1947) showed that children living in homes had the worst dental structure, suggesting poor calcifying diets daring tooth development, and .yet had the least caries-less than the children of comparatively well-to-do families and much less than the L.C.C. group. It would have beeri instructive had we been able to parallel every survey in L.C.C. schools with similar inspections among residential homes and private-school children, but this was not possible. Early in 1950, however, the two groups in question were reinvestigated. This seemed especially urgent, since the present policy of boarding-out and adoption is removing nearly all · 5-year-olds from homes. In this paper we are using the term "home" or " residential home " to cover residential nurseries and schools a?ministered by the State or by voluntary bodies ; previOusly we called them institutions. These are maintained .*This figure of 4}% include,d, chil
for children deprived of a normal home life for a variety of reasons, such as the death, prolonged illness, or prison sente~ce of one or both parents, illegitimacy, or lack• of smtable housing facilities. Formerly such children were accommodated in orphanages or institutions of various types, including workhouse~. Clinical Material and Methods So far as possible the same homes and schools were included in the 1950 survey as previously, but others from near-by districts were added to increase the size of the sample. In all, 55 homes (mainly situated in L~ndon and the surrounding country, with a few in the Mtdlands) and 32 private and independent schools (in London and adjacent counties) were visited, the total numbers of children dentally inspected being 542 in the former and 560 in the latter group. In 1950, as in 1945, the average age of both groups of children was approximately 5t years. The st~mdards adopted for hypoplasia a~d caries in the clinical examination, and the methods used in calculating the results, were the same as those employed on many previous occasions. The degree of hypoplasia was estimated with a right-angled probe : and the rougher the labio-buccal surfaces the greater the degree of M-hypoplasia. For diagnosing caries an illuminated mirror and sharp rat-tailed dental explorer of standard size were used. The teeth were neither dried nor x-rayed, since, although these aids to detection would have resulted in more caries being seen, the findings would not have been comparable with those of past surveys ; moreover, the diagnosis of the presence and extent of caries by any known method often comes in for criticism. For this type of work the important thing is to have agreement on the standards to be adopted, followed by adherence to these standards on the part of the investigators, who must work in close collaboration. The method of presenting the findings, especially those relating to caries, is also open to criticism. We have considered the arguments for and against our system and the schemes adopted by some other workers, but for various reasons we prefer to retain our own. Most dental research workers concentrate mainly on the incidence of disease, including evidence of past decay, in recording the dental status of any given group of the population. They often ignore the structure of the teeth, apart from the grosser forms of defect, and its bearing on the liability to caries. We, however, feel strongly that both should be considered, and that, in accordance with the precepts of preventive medicine, the emphasis should be on the well-calcified and the caries4697
52
JAN. 13, 1951
TEETH OF 5-YEAR-OLD CHILDREN
free teeth rather than merely on the incidence of defect or disease. In giving the results of the surveys, therefore, we mention first the more ideal state which it is hoped more children will ultimately attain: In assessing the quality of the teeth, division was made into those which were externally smooth (no hypoplasia) and those with varying degrees of roughness of the labial or buccal surfaces. M-hypoplasia (King, 1940) was graded M-Hy 1 to M-Hy 3 , according to the ;ncreasing severity of the defects, while teeth with certain welldefin_ed types of surface irregularity were, as before, classified separately as gross or " textbook·, hypoplasia. The. numbers of teeth in the various categories of hypoplasia are expressed in the tables as percentages of the total number of teeth examined. Any teeth which were so carious or had such heavy deposits of tartar that the surface structure could not be gauged were omitted from this classification, and thus from the tables dealing \\ ith • structure. The average extent of surface texture defects of the M-type is represented by the average hypoplasia figure (A.H.F.) ; this, in conjunction with the percentages of hypoplastic teeth, is, we believe, useful in assessing the improvement or otherwise in the dental structure of wccessive samples of children-for example, 5-year-old L.C.C. pupils examined between 1943 and 1949. Caries is expressed both as incidence and as extent for each type of tooth, and for the sum of all types, in each group of children. The incidence of decay by itself, whether given as a percentage or as the D.M.F. (decayed, missing, and filled) figure, can be misleading,_ since a group of individuals with small cavities woUld appear in the table to have the same amount of caries as a group in which the cavities were large. For this reason the extent of caries in each decayed tooth is described as being of grade 1, 2, or 3, according to the estimated size of the cavity in relation to th.e 'size of the tooth. The average caries figure (A.C.F.), like the A.H.F., is some fraction of 3, and measures the estimated average extent of caries in the teeth. In our opinion the advantage of this method as against those involving tooth surfaces is its relative simplicity ; also the results so expressed are comparable with those previously given in this series of reports and those published by others using the same method (Deverall, 1936; Davies, 1939; King, 1940; Coumoulos, 1946; Stones et al., 1949). In all the surveys made since 1943 it has been possible to calculate from the published figures the D.M.F. values. For instance, the percentage of carious teeth. as expressed in Table IV and in earlier papers, is equivalent to the D.M.F. per lOO deciduous teeth, while the total number of carious teeth divided by the number of children and then multiplied by 100 gives the D.M.F. per 100 children. Since the deciduous incisors are in process of being shed between the ages of 5 and 6 years, the missing ones are considered, in all our surveys, to have been lost naturally, and are therefore omitted from the tables. On the other haQ.d, any absent canines and molars would almost certainly have been extracted for caries at this period ; they are therefore included in the caries totals (grade C 3 ). It will be seen from Table I that the majority of missing incisors in this age group are lower centrals, in which there is very seldom any decay, so that the total number of decayed teeth which might have been present in those counted as " shed ·• must be small. It is obviously more difficult to analyse caries figures for children of mixed age groups, espe-
TABLE
BIUTISH MEDICAL JOURNAL
I.-Percentages of Teeth Present at Time of Inspection
Type of Tooth
~~esidential Homes
Private Schools
1945
1950
1945
1950
Uppet: Centrals Laterals Canines 1st molars 2nd molars
94·0 97·8 99·8 99·5 99·8
93·3 98·6 99·9 99·4 99·4
93·5 99·2 100·0 98·2 99·5
94·9 98·7 100·0 98·1 99·2
Centrals Laterals Canines 1st molars 2nd molars
85·7 98·5 100·0 98·6 99·2
81·5 98·9 100·0 98·9 98·6
76·0 97·4 99-S 95·4 98·4
76·3 97·7 100·0 95·5 98·2
97·3
96·8
95·8
95·9
Lower:
All types
··I
cially those between 7 and 12 years, because the times of eruption and shedding vary widely. For the 5-year-old children the task is relatively simple. From Table I it is also seen that nearly all the teeth are still in situ, with the exception of the lower central incisors, which are normally shed relatively early.
Results Table II shows the percentages of children in the two groups who were caries-free and those who were nearly so, together with the numbers of D.M.F. teeth per 100 children. !f.--Children Caries-free or Almost So, a11d the D.M.F. Values Per lOO Children in. Residential Homes (R.H.) and Private Schools (P.S.)
TABLE
V
Group Investigated R.H. P.S ...
%Almost Caries-free
%Cariesfree+Those JlD.M.F. per 100 Almost Children Caries-free r.:;a;,.~:J;-
1945 1950 1945 1950
1945
1950
1945
1950
1945
1958
325 371
8·9 4·3
14·9 18·0
66·1 54·7
73·6 58·0
204 275
139 246
No. of Children Examined
%Cariesfree
57·2 58·7 5421 560 50·4 40·0
-
Although the figures for caries-free children are given here to conform with the reports of all the earlier surveys of the series, it has throughout been realized that where the differences between the various groups under review are not spectacular a better picture is gained by considering teeth rather than dentitions. Thus some 10% more private-school children had dental decay in 1950, yet the total percentage of caries-free teeth (C 0 ) was In other words, the actually greater than in 1945. disease was more widespread at the time of the later survey, but was of a milder form (see Tables II and IV). The findings relating to the teeth as opposed to the whole 4entitions of the children are given in Tables Ill to VI. In considering them, a comparison will first be made between the 1950 and the 1945 results for each of the two groups of children separately. Then the results for the residential homes and the private-school groups will be compared. Passing references to the finding> in L.C.C. schools in 1949 and 1945 will also be made, although 'the interval between examination was six months less for them than for the other groups.
Surface Structure of the Teeth Residential Homes in 1950 and 1945.-lt will be seen from Table Ill (column 4) that 42.0% of all the teeth were perfect or nearly perfect in structure--that is, hypoplasia-free-in 1950 as compared with 32.3% in 1945. This improvement was found in all types except the upper first molars, which remained the same as before, and the upper second molars, where the
JAN. 13, 1951
TEETH OF 5-YEAR-OLD CHILDREN ---
------·----------------------
percentage decreased. (It is realized that tartar deposits 1950 than previously, 1.7% of all teeth, as compared found on a proportion of upper molars, espec:ally with 4.8% in 1945, being affected by this form of second molars, may mask the actual surface texture, defect. thus making it difficult to assess the structure and therePrivate Schools in 1950 and 1945.--Among these fore any change. This applies to all our surveys.) There children the dental structure was substantially the same was very little M-hypoplasia of the most severe grade in 1950 as in the earlier survey. There were 52.3% of (M-Hy3 ) in any type of tooth in 1950, less than 1% of the total teeth free from hypoplasia as compared with all the teeth examined falling into this category, as 54.0% previously (Table Ill, column 4). Some, such as compared with the slightly higher figure of 1.7% in 1945. the upper incisors and canines, showed improvement in The A.H.F. had decreased for every type of tooth the five-year-period, while others, notably the mo~ars, except apparently the upper second molars, the total were not as good as formerly. having fallen from 0.92 to 0.76. Gross hypoplasia, As in the case of the residential homes, very few though relatively low in both series, was lower in _ teetli had re:tlly severe structural defects (M-Hy 3 ), the TABLE
(I) Type of Tooth
111.-Comparison of Tooth Structure in Residential Homes (R.H.) ~nd Private Schools (P.S.)
(l) Total No. of Teeth Examined (2) for Structure Group
1945 Upper: Central incisors Lateral incisors Canines
..
1st molars
..
2nd molars
..
Lower: Central incisors Lateral incisors
1st molars
.. ..
2nd molars
..
Totals
..
Canines
(4) Good Structure (Hy,)
1950
(S) Slightly Dofective Struc· tore (M-Hy1)
1945
1950
1945
%
%
%
(6) Defective Structure (M-Hy,)
1950
1945
%
%
R.H. P.S. R.H. P.S. R.H. P.S. R.H. P.S. R.H. P.S.
609 689 635 722 647 735 639 725 644 736
1,001 1,053 1,062 1,096 1,079 1,113 1,070 1,095 1,070 1,105
32·2 51·8 32·9 64·4 30·0 63·8 7·7 24·8 6·2 19·8
51·7 63·5 43·3 65·0 49·3 75-7 7·6 12·5 3·0 7·2
39·2 30·9 53·5 26·3 57·2 31·2 36·9 47·2 32·6 51·4
34·5 30·3 46·6 32·1 44·8 2H 49·0 60·0 36·5 49·8
20·5 14·2 8·3 6·5 9·1
R.H. P.S. R.H. P.S. R.H. P.S. R.H. P.S. R.H. P.S.
552 559 636 718 647 736 631 698 637 718
869 845 1,064 1,088 1,079 1,118 1,068 1,067 1,064 1,094
78·1 92·5 66·8 87·9 50·1 81-8 16·6 37·0_ 8·8 24·2
93·3 97·3 76·5 86·3 64·1 81·0 21·0 21·0 20·4 22-8
20·5 7-1 31·3 11·1 40·2 13·7 40·4 41·5 40·0 44·6
6·4 2·7 22·4 13-S 32·3 17·9 48·1 62·6 56·1 62·3
R.H. P.S.
6,277 7,036
10,426 10,674
32·3 54·0
42·0 52·3
39·5 31·0
38·3 36·1
(8) Gross Hypoplasia (G-Hy)
1945
1950
1945
1950
%
%
0/
%
/o
(9) A.H.F.* 1945
1950
2·8
0·2 0·0 0·2 0·0 0·0 0·0 0·8 0·1 5·1 "0·5
6·2 2·5 4·6 1-8 1·4 1·0 6·1 1·9 4·0 1-1
2·0 0·8 1·8 0·5 1·4 0·3 2·3 0·2 2·1 0·0
0·91 0·63 0·75 0·42 0·79 0·39 1·47 1·04 1·59 I'll
0·59 0·41 0·65 0·37 0·54 0·25 1·35 1-15 1·62 1·36
0·2 0·0 0·7 0·0 1·3 0·2 27·5 16·2 19·5 14·2
0·0 0·0 0·0 0·0 0·0 0·0 1·9 2·1 4·2 2·8
0·0 0·0 0·0 0·0 0·0 0·0 0·4 0·0 0·8 0·6
1·1 0·2 0·4 2·3 0·7 10·3 1-1 10·5 1·7
0·0 0·0 0·5 0·2 0·8 0·4 3·0 0·2 3·1 0·1
0·21 0·08 0·33 0·12 0·48 0·18 1·20 0·85 1·40 1·08
0·07 0·03 0·24 0·14 0·36 0·18 1·08 0·95 1·01 0·93
16·9 IH
1·7 1·2
0·8 0·1
4·8 1·3
1·7 0·3
0·92 0·60
0·76 0·59
46·6 23·2 51·7 24·9
11·6 5·4 8·1 2·4 4·4 0·7 40·3 27·2 53·3 42·4
1·6 0·6 0·5 0·6 0·5 0·3 2·7 2·9
0·4 0·2 0·8 0·4 2·2 1·6 30·7 18·1 36·4 26·7 20·9 12·1
3-3
I
1950
·%
(7) Very Defective Structure (M-Hy,)
S·4
H
•A.H.F. (average hypoplasia figure)= Total hypoplasia figure Total No. of teeth examined for structure (excluding those with G-hypoplasia or unclassified hypoplasia) A few of the teeth included in column 3 co:.ld not be classified into any of the grades shown in this table. Therefore the porcentages rlo not add up to 1110 in all instance•. • TABLE
1V.-Caries Incidence and Extent in Residential Homes (R.H.) and Private Schools (P.S.)
(2) (I) Typ> of To:>th Group
1945 Upper: Central incisors Lateral incisors. Canines
..
1st molan
..
2nd molars
..
Lower: Central incisor. Lateral
inci~ors
Canines
..
1st molars 2nd molars
.. ..
All typ:s
..
(4) No Caries (Co)
(3) Total No. of Teeth 1950
1945
%
(5) Slight Caries (C1)
(6) Moderate Caries (C,)
1950
1945
1950
1945
1950
%
0/
%
%
%
R.H. P.S. R.H. P.S. R.H . P.S. R.H . P.S. R.H. P.S.
611 694 636 736 650 742 650 742 650 742
1,011 1,063 1,069 1,105 1,084 1,120 1,084 1,120 1,084 1,120
89·7 88·8 95·0 94·2 97-1 95·8 86·3 79·8 74·6 72·4
90·3 90·6 96·4 96·7 99·2 97·8 93·5 84·5 88·1 76·3
/o 2·3 3·0 1·3 2·4 0·3 1·6 5·7 4·7 13·2 9·3
5·9 3-9 2·2 H 0·4 0·1 1·8 4·1 6·4 11-8
6·2 6·5 3·5 2·7 2·3 1·9. 5·5 9·7 10·2 14·2
0·3 2·0 H 8·8 4·6 10·4
R.H. P.S. R.H .. P.S. R.H . P.S. R.H . P.S. R.H. P.S.
557 564 640 723 650 742 650 742 650 742
883 855 1,072 1,094 1,084 1,120 1,084 1,120 1,084 1,120
98·9 98·9 99·2 99·4 98·9 97·3 83·5 69·9 7J·7 6H
99·7 99·5 99·4 99·6 99·1 98·8 86·2 71-4 77·9 61·1
0·4 0·5 0·5 0·1 0·3 0·3 4·2 4·5 10·2 11·5
0·1 0·0 0·3 0·1 0·6 0·3 5·2 7·5 IH 18·6
0·7 0·5 0·3 0·4 0·6 2·2 7·2 14·6 9·2 14·3
0·0 0·2 0·0 0·2 0·4 0·8 6·5 14·3 5·9 15·4
6,344 7,169
10,539 10,837
89·5 85·8
92·8 87·3
3-9 3-9
3·6 4·9
4·6 6·9
2·6 6·0
R.H. P.S.
I
• A.C.F. (average caries figure)=
3·3 4·9 1·3 1-6
(7) Severe Caries (CJ 1945
%
1950
%
(8) Total Carious Teeth (i.e. D.M.F. per 100 Teeth)
(9) A.C.F.*
1945
1945
1950
%
1950
%
O·S 0·7 0·1 0·5 0·2 0·2 1·4 2·7 0·9 1·5
10·3 11·2 5·0 5·8 2-9 4·2 13·7 20·1 25·4 27·6
9·7 9·4 3·6 3·3 0·8 2·2 6·5 15·5 11·9 23-8
0·20 0·21 0·09 0·10 0·06 0·07 0·24 0·42 0·40 0·50
0·14 0·16 0·05 0·06 0·01 0·05 0·13 0·30 0·18 0·37
0·0 0·0 0·0 0·0 0·2 0·2 5-l 1H 7·0 9·1
0·2 0·2 0·3 0I 0·0 0·1 2-1 6·8 H
H H 0·8 0·6 H 2·7 16·5 30·1 26·3 34·9
0·3 0·5 0·6 0·4 0·9 1·2 13-8 28·6 22-1 38·9
0·02 0·02 0·01 0·01 0·02 0·05 0·34 0·67 0·49 0·68
0·01 0·01 0·01 0·01 0·01 0·02 0·25 0·56 0·34 0·64
1·9 3-S
0·9 1·8
10·5
7·2 12·7
0·19 0·28
0·12 0·22
1·8 1·7 0·3 0·7 0·3 0·7 2·5
s-s
2·0 4-1
s-o
Total caries figure Total No. of teeth (includi='ng~e:;.,x"'t=racc::t:rio=ns=--)
14·~
54 JAN. 13, 1951
TEETH OF 5-YEAR·OLD CHILDREN
proportion being 0.1% of all the teeth examined, as compared with 1.2% in 1945. The only teeth coming within this grade in the more recent survey were the molars. There was very little variation in the A.H.F. for the different types, and the figures for all types together were the same. Gross hypoplasia was again very uncommon in either year, the total amount in 1950 being 0.3% of all teeth·examined-1% less than in 1945. Comparison of Homes and Private Schools.-lt will be seen from Table Ill that the children in the residential homes in 1950 still had worse dental structure than those in the private schools, 58.0% of all teeth as com~ared with 47.7% showing some degree of hypoplasia (A.H.F. 0.76 as against 0.59). Since, however, in the former group there had been an improvement during the past five years-that is, the percentage of hypoplastic teeth had fallen from 67.7 to 58.0, a 14% reduction-whereas in the latter group there had been none, the disparity was less. L.C.C. Schools.-Among the L.C.C. group examined in 1949, although the percentage of hypoplastic teeth had increased somewhat since 1945, being 68.0% as compared with 62.0%, the A.H.F.was much the same, 0.88 compared with 0.91. As regards dental structure, therefore, these observations indicate a general improvement among the residential homes population since 1945, but little change among private schoo!s or the L.C.C. group. The private-school children had on each occasion the best-formed teeth, while the positions of the other two groups were reversed at the time of the second inspection, the residential homes group having better calcified teeth than the L.C.C. group, though not reaching the standard of the privateschool children. TABLE
BluTISB MEDICAL JOURNAL
Caries of the Teeth Residential Homes in 1950 and 1945.-Table IV (column 4) shows that, in spite of the fact that a large percentage of the teeth were caries-free in 1945, there was an improvement during the five years between inspections, the respective figures being 89.5% and 92.8% of the total number examined. This improvement was reflected in each type of tooth, but especially in the molars, and in particular in the upper molars. With regard to disease incidence, there were very few carious teeth in these residential-home children in 1950, c,mly 7.2% of the total number being affected, as compared with the previous figure of 10.5%, which was in any case very low. In passing, it may be noted how small w::ts the proportion of carious teeth graded C" remembering that this category includes extractions. The extent of caries, as expressed by the A.C.F., fell iFl 1950 for every individual type of tooth, the figure for all types together being 0.12, as compared with 0.19 in 1945. Private Schools in 1950 and 1945.-The private-school children showed a slight improvement in the five-year interval. The total percentage of caries-free teeth rose from 85.8 to 87.3, and each type, with the exception of the lower second molars, showed improvement. The percentages of carious teeth at the two inspections were thus 14.2 in 1945 and 12.7 in 1950. The A.C.F. for each type of tooth in 1950 was the same. as or lower than before, so that the total A.C.F. showed a slight reduction (0.28 to 0.22). Comparison of Homes and Private Schools.-The figures given in Table IV indicate that, as in 1945, the teeth of the residential-home children examined in 1950 still had less disease than those of the private-
V.-lncidence of Caries in Teeth with Varying Grades of Structure
~--.
(3) J ncisors (I) Grade of
Structure
(2) Group
Total No. Examined 1945
Good(Hy,)
%
Ex~mined
Carious
1950
(5\ Molars
1950
1945
1950
1945
1950
1945
1950
1945
1950
1945
1950
1945
195()
0·9 1·4 5·7 8·7 14·7 (9-6] [25·0]
518 1,071 630 330 73 36 3 2
1,224 1,749 831 457 61 10 0 0
0·0 0·8 2·1 6·4 [13·7] [38·9) fO·O) (0·0]
0·3 0·6 1-4 3·5 [O·Oj (40·0)
250 758 956 1,330' 1,057 669 91 77
554 690 2,026 2,557 1,503 1,095 77 14
0·4 3·0 8·6 20·6 29·8 56·8 [58·2) [89·6)
8·1 17·0 13·3 22·6 12·7 34·7 [18·2) [42-9]
2.029 3,799 2,477 2,183 1,315 854 107 87
4,381 5,581 \991 3,855 1,775 1,188 81 14
0·3 Jo3 4·8 15·6 27·8 51·4 54·2 [86·2)
1·7 3·1 8·7 17·3 12·5 33·0 [18·5] [42·9]
24 12
24 8
[0·0] [0·0]
[0·0) (0·0)
112 5
19·8 [38·1]
12·5 [60·0)
301 88
180 29
23·3 (33·0)
13·3 [24·11
7,603 3,142 1,134 841 211 83 4 0
f38·5) 75-U)
I RH. P.S.
80 34
44 16
[38·8] [38·2)
-
[22·7] [25·0)
I
---NotP.-For some grados of structure the numbers of teeth were relatively small.
therefore given in brackets.
TABLE
(2) Group
-
197 42
The percentages based on these probably have little significance, and are • .
VI.-Extent of Caries in Teeth with Varying Grades of Structure
( 3) Incisors
Total No. Examined
(4) Canines
A.C.F.
I
Total No. Examined
(5) Molars
Total No. Examined
A.C.F.
1945
1950
1945
1950
1945
1950
1945
1950
1945
1950
RH. P.S. Slightly dofective R.H. (M-Hy,) .. P.S. Defective (M-Hy,) R.H. P.S. Very defective R.H. (M-Hy 1 ) P.S.
1,261 1,970 891 523 185 149 13 8
2,603 3,142 1,134 841 211 83 4 0
0·01 0·01 0·04 0·15 0·42 [0·69) [1·63]
0·01 0·02 0·08 0·16 0·23 [0·20) [0·25] 0·00
518 1,071 630 330 73 36 3 2
1,224 1,749 831 457 61 10 0 0
0·00 0·02 0·04 0·11 [0·25] [0·75) [0·00] [0·00]
0·004 0·01 0·02 0·07 [0·00] [0·90] 0·00 0·00
250 758 956 1,333 1,057 669 91 77
554 690 2,026 2,557 1,503 1,095 77 14
I P.S. R.H.
34
so
44 16
[0·81] [0·76]
[0·30] [0·501
24 12
24 8
[0·00] [0·00]
[0·00] (0·00]
197 42
112 5
Good (Hy,)
..
.. I
Gross (G-Hy) ..
%
Carious
0·5 0·8 2·7 8·8 21-6 [30·2)
1,261 1,970 891 523 185 149 13 8
Struuure
Total No. Examined
Ca~fous
1945
R.H. PS. Slightly defective R.H. (M·Hy,) P.S. Defective (M-Hy,) R.H. P.S. Very defective RH. (M-Hy,) P.S.
(I) Grade of
Total No Examined
%
Carious
(6) All Types "/
-~
..
Gross (G-Hy) ..
(4) Canines
Total No.
0·~6
Note.-For some grades of structure the numbers of teeth were relatively small. therefore given in brackets.
I
(6) All Types
Total No. Examined
A.C.F. 1950
1945
1950
0·004 0·11 0·04 0·24 0·12 0·21 0·36 0·36 0·51 0·20 1·11 0·59 [1·09] [0·31] [2·17] [0·93]
1945
2,029 3,799 2,477 2,183 1,315 854 107 87
4,381 5,581 3,991 3,855 1,775 1,188 81 14
301 88
180 29
0·39 [0·86]
I
0·18 i [1·20) /1
--
A.C.F. 1945
1950
0·004 0·02 0·04 0·02 0·07 0·13 0·27 0·28 0·49 0·19 1·00 0·57 1·01 t0·31] [2·07] 0·93] 0·47 [0·70]
0·18 (0·48]
The A.C.F. based on these probably have little significance and are
JAN.
13, 1951
TEETH OF 5-YEAR-OLD CHILDREN
school children, 7.2% in the former group compared with 12.7% in the latter being carious. Though in both cases there had been an improvement in the five years, this was proportionately greater in the former (a drop from 10.5% to 7.2% of carious teeth-a reduction of 32.0%-compared with a drop from 14.2% to 12.7% in the private-school group-a reduction of 10.5%), so that the gap between the groups had widened slightly. L.C.C. Schools.-In contrast to the slight improvement in the above-mentioned groups, the 1949 survey of L.C.C. school-children showed no improvement in the caries position as compared with 1945 .. The proportions of carious teeth in the two years were 26.5% in 1945 and 26.7% in 1949, while the corresponding average caries figures were 0.55 and 0.54. So far as caries is concerned, then, the children of the residential homes had fewer diseased teeth than those of ~e private schools and many fewer than those of the L.C.C. schools at both inspections. It must be emphasized again that the caries incidence and extent both in residential homes and in private schools are so low that improvements are inevitably small. Relation between Structure of Teeth and their Susceptibility to Caries in 1950 It was found in the latest survey, as in 1945 and all other surveys of this series, that within each of the groups· of children the better-formed teeth-that is, those with no hypoplasia-were less liable to caries than the M-hypoplastic ones, and that the more severe the defect the greater the liability to the disease (see Tables V and VI). This is true for individual types (incisors, canines, and molars) as well as for all teeth taken together. To demonstrate this point figures are given for three grades of structure in Table VII. TABLE ~~ ~ructure
Oood (Hy,) . . .. . ., Slightly defective (M-Hy,) . . Defective (M-Hy,) . . ..
VII
of Teeth Cariesfree (C,)
%of Teeth with Considerable Caries (C,+C,)
R.H.
P.S.
R.H.
P.S.
98·6 91·3 87·5
96·9 82·7 67·0
0·6 3-9 5·9
1·3 10·0 20·8
There were insufficient numbers oi"M-Hy,, teeth to give a statistical result for this group.
In all cases it will be seen that for a given grade of structure there was less caries among the children from residential homes than among those in the private schools. Further reference to this point is made in the discussion. Filling and Extraction of Carious Teetll Table VIII shows the considerable increase in treatment for both residential homes and private-school children over the past five years, especially as regards fillings. Much more treatment was recorded in both surveys among the private-schools group than among the children in the homes, approximately three times the TABLE
Vlll.-Percentages of Carious Teeth Extracted and Filled
GroUI'
R.H ... P.S . ..
No. Carious Teeth (Including Extractiorf§)
% Extractions
%Filled
1945
1950
1945
1950
1945
1950
664 1,019
754 1,378
2·9 6·3
5·6 7·3
4·7 18·5
11·8 29·7
I
%Total Treated 1945
1950
7·6 24·8
17·4 37·0
Note.-The few teeth treated With silver nitrate are omitted from this table.
number of fillings being present. It must be pointed out, however, that slightly over 50% of the carious cavities in the residential homes were very small (C, grading), while fewer (38%) of the private-school cavities were graded as cl. Staining of the Surface Enamel The superficial staining of deciduous teeth, which is often confined to the gingival margin and molar fissures, has been commented on _by several workers. In past surveys a note was made of this condition and it was found that those children with definite black or brown staining on few or many teeth had less caries than children with none, or children whose teeth showed definite green staining. In this most recent survey there was very little difference between the caries susceptibility TABLE
IX.-Amount of Caries in Relation to Superficial Staining of Teeth -
Type of Stain
Group
I
No. ofChildien
A.C.F.
1945
1950
1945
1950
R.H. P.S.
106 (32-6%) 294 (54·2%) 246 (66·3%) 458 (81-8%)
11·5 12·9
6·7 12·9
0·21 0·25
0·11 0·23
Black and
R.H. P.S.
109 (33·5%) 179 (33·0%) 25 (6·7%) 27 '(4-8%)
5·7 2·9
5·8 10·7
0·11 0·05
0·09 0·19
20 (3·7~~) 28 (5·0%)
20·2 22·5
14·4 18·7
0·39 0·46
0·22 0·33
brown
Green stain
R.H. P.S.
32 (9·8%) 64 (17-3~{;)
1950
I
No stain
stain
1945
%Carious Teeth
-··--
of mouths with black and brown stain and those with none (Table IX) ; but in this connexion it must be remembered that there is very little caries anywhere. Mouths with green stain appear more susceptible, but the numbers of children with this stain are small. Indeterminate varieties of colour were omitted from the calculations. An interesting point was the large proportion of residential-home children-about 33% at each inspection-who showed brown or black stains, as compared with less than 7% of private-school children. Arrest of the Carious Process There was an apparent decrease in arrested caries among both groups compared with 1945, but this may have been due p1rtly to the personal factor in examination. Arrest is a gradual process, and it is not always easy to agree on a specific standard and maintain it from year to year: The difference between the two groups, on the other hand, is real, the children in the residential homes showing more teeth with arrested caries, 13.5% of all the untreated carious teeth, compared with only 2.9% in the private-school group. So far as they go, therefore, these figures also indicate greater resistance to the carious process in the residentialhome children. Discussion The object of the 1950 survey among children in residential homes and private schools was twofold: (1) to find out if the differences observed in 1945 between the two groups were still evident ; and (2) to see whether there had been any change in dental status in either of the groups over five years. In both 1945 and 1950 the structure of the deciduous teeth of the residential-home children was not as good as that of the private-schools group, while their caries incidence was lower. Since 1945 there had been improvement in their dental structure (42.0% of the teeth were perfect in structure, compared with 32.3% in 1945-an improvement of nearly .one-quarter) and decrease in
56
JAN.
13, 1951
TEETH OF 5-YEAR-OLD CHILDREN
BRITISH
MEDicAL JouRNAL
caries (from 10.5% to 7.2% carious teeth), in spite of caries of the teeth of the private-schools group would the fact that at the time of the earlier survey the total tend to be weakened, and that of the homes group incidence and extent of the disease were already very strengthened. low. The private-schools group, on the other hand, In general these same relative conditions would, in which had comparatively good tooth structure in 1945, our opinion, be likely to obtain in respect of the children showed no improvement, while the decrease in caries examined in 1950 ; but whereas the pre-eruptive and in 1950 was very small (14.2% of the teeth were carious post-eruptive diets of the private-school children had m1945 and 12.7% in 1950). Thus the number of carious probably remained on much the same level in the interim teeth found in homes children was reduced by nearly (thus resulting in a rather similar dental condition), there one-third, that in private schools by only one-tenth. had been certain important modifications, especially in Whether the results given in this report are merely the pre-eruptive period, in the dietary of the homes periodic fluctuations cannot be stated. No examinations children. The uncertain quality of diets taken by expecof these two groups were made in 1947, which was the tant and nursing mothers and weaned infants in 1938-41 peak year for caries-free teeth in L.C.C. school-children ; (affecting the structure of the teeth of children seen in it is possible, although unlikely, in view of the .already 1945) had given place to the rationing of important small incidence of the disease, that the findings might foods, plus a system of special food priorities for these vulnerable groups, by 1943-6 (when the teeth of the have been still better then. What are the reasons for these differences ? A com- children examined in the later survey were developing parison between the two surveys does not suggest that and erupting). This priority scheme should have been the reduction in decay is due to any variation in the of especial benefit to the poorer mothers, the section sugar content of the diets or to the amount of dental of the population from which the majority of residential treatment given. The strict rationing of sweets and sugar homes children are derived. These priorities were availduring the war ensured little difference in this respect able on ration books, and would in many cases be takef\ throughout the post-eruptive period for the two groups as a matter of routine, especially as the milk could be examined in 1945, and those inspected in 1950 would obtained at a reduced price, or even free, and the codhave had, if anything, more sugar and sweets in their liver oil and vitamin tablets were issued free to all. In addition, more was being done than formerly diet. Again, there was more treatment in both the groups seen in 1950 than in 1945, but for both years through maternity and child-welfare services to disthe percentage of carious teeth treated was much greater seminate knowledge of better nutrition. Some of the in private-school children than it was in the homes · children entered the homes at the age of a few weeks or months, and in these cases there would be time for the children. There may be many contributory factors, but in dis- excellent infant and weaning diets given there to exert cussing the differences between the two groups examined their effect on calcification, especially of the deciduous in 1945 it was suggested on the basis of experimental molars. In such homes feeding had become even better and clinical investigations previously made (Mellanby, than in the early war period, owing to stricter planning 1923, 1934) that .. the calcifying properties of the respec- and supervision, thus increasing, if anything, the favourtive diets at different periods, both pre-eruptive and able post-eruptive influences of such diets. The work of Schiotz (1939) and Collett (1935), and a post-eruptive, are an important key to the situation." It was pointed out that, as a whole, the relatively well-to- small investigation by King (1946), suggested that the do mothers were more likely (from financial and other earlier in life the children were admitted to the orphanconsiderations) to follow medical advice, then becoming ages and the longer the period of residence, the less the commoner, to take plenty of milk and some source incidence of decay. There was evidence of this nature of vitamin D during pregnancy and lactation, than were in the data obtained in the 1945 survey, though it was the poorer mothers of the children who later entered not published; the results Qbtained in 1950 are now the homes.being analysed from this point of view. It also seemed likely that the mothers in better cirThe improved dental structure observed in the resicumstances would continue to give their children such dential-home children in 1950 can therefore largely be foods in the months immediately after weaning. Dur- attributed to the better nutritional status in the period ing both of these periods the deciduous dentition would of early tooth development as compared with the similar be developing and erupting. In the post-eruptive stage, period for the 1945 group. This would of itself tend to however, there would often be a change in the respec- result in a reduced caries incidence ; but in regard also tive positions of the children from this point of view. to the post-eruptive diet these children leading a comDietary discipline would tend to be relaxed in the case munal life would appear to benefit greatly. Not only of children living in their own homes, especially where are the diets in residential nurseries and homes well likes and dislikes of such things as eggs, milk, and cod- planned, but under the British rationing scheme there is, liver oil were concerned. In the communal life of the and has been since 1942 (Ministry of Food, 1947), acturesidential homes, on the other hand, fads and fancies ally more of the, important foods available per child would be much less in evidence and regular ·meals of in these homes than can be obtained for children living high nutritional and calcifying quality, including an with their families. Moreover, in the latter case any ample allowance of milk and a daily dose of cod-liver ~pecial allocation for the children may be all too often oil, were the routine, as was ascertained in the course pooled with the food for the rest of the household. of the survey. Furthermore, these children have far more say than Thus it seemed probable that the post-eruptive diet those in the homes in regard to what they will or will of the relatively well-to-do child might not be as good not eat, and in many instances they are able to spoil for the teeth as the pre-eruptive diet, whereas the later their appetite by eating food of low nutritional value diet of the residential-homes child would in all prob- between meals. ··ability be much better than that given during the period In our opinion, few families in Britain, whatever their of tooth development ; in this way the resistance to economic status, provide for their children diets which
JAN.
13, 1951
TEETH OF 5-YEAR-OLD CHILDREN
are as good in· their calcifying properties as those served in children's residential homes to-day, and in few is the intake of cod-liver oil and even milk likely to be nearly so regular or so long maintained. It seems to us, therefore, that the excellent diet given in these homes is responsible for their low caries incidence. The reduction noted since the previous survey five years ago is no doubt partially the result of improvement in dental structure, but it may have been enhanced by the even better diets provided for these children in recent years. It is a challenging thought that, on the whole, children brought up in orphanages and other public institutions have a better chance of remaining free from caries (at least up to the age of 5 years) than children of the same age brought up in private families.
Summary The new results given in this paper are compiled from the individual dental charts of a survey in 1950 of 542 children aged 5 years living in homes (orphanages and institutions) · and 560 children of the same age attending independent and private day schools, mainly in London and surrounding counties. These two groups of children are compared with similar groups examined in 1945 and with each other, as regards both dental structure (according to the standards originally set up by May Mellanby) and caries incidence and extent. Reference is also made to surveys among L.C.C. schoolchildren in 1945 and 1949. Among the children in the homes, tooth structure was found to have improved since 1945, there now being 42.0% of the teeth free from both gross and M-hypoplasia as compared with 32.3% previously. Concurrently there was also a reduction in caries incidence from 10.5% to 7.2%. The private-school group showed much the same average structure in 1950 as before, while the caries incidence had declined only slightly, 12.7% of all teeth being carious as compared with 14.2% previously. The average dental structure of the residential-home group still lagged behind that of the private-school children, b::~t the difference between the two groups was not as great as before. In spite of worse dental structure, the children in the residential homes had a lower caries incidence and extent. The relationship between dental structure and caries in both groups in 1945 and 1950 was such that the greater the degree of M-hypoplasia the greater was the liability of the teeth to caries, but for each grade of structure the residentialhome children had less decay than the others. This relation between structure of the teeth and liability to decay has been observed in all similar surveys where the same standards have been adopted. In each group of children there was an increase in the amount of dental treatment, both fillings and extractions. but particularly the former. At each inspection the percentage of fill!;d teeth among the private-school group greatly exceeded that among the residential-home children. .j\pproximately 33% of the children from residential homes showed black or brown staining on their teeth in both years, as compared with only 6.7% and 4.8% in the two groups of the private-school children. Suggestions are made to account for the differences found in both structure and caries incidence between residential homes and private schools, and for the change occurri•g between 1945 and 1950. We would like to put on record our grateful thanks to the many people who have so generously assisted us, and without whose help this survey would not have been possible. Particularly we acknowledge our indebtedness to the medical officers and governing bodies for permission to examine the 5-year-olds in children's homes, and· to the superintendents, matrons, and teachers who helped with the actual inspections. In the case of the private-school children we thank sincerely all the principals
and teachers who so willingly gave us time and assistance to further our researches. We also much appreciated the help given by Miss Irene Alien, of the Medical Research Council's Statistical Department. REFERENCES
Anderson, P. G., Williams, C. H. M., Halderson, H., Summerfeldt, C., and Agnew, R. G. (1934). J. Amer. dent. Ass., :zt, 1349. . Collett, A. (1935). Tidsskr. norske Laegeforen., No. 22. Coumoulos, H. (1946). Nature, Lond., 158, 559. - - and Mellanby, M. (1947). British Medical Journal, 1, 751. Davies, J. H. (1939). Brit. dent. J., 67, 66. Deverall, A. (1936). Spec. Rep. Ser. med. Res. Coun., Lond., No. 211. King, J. D.. (1940). Ibid., No. 241. - - (1946). Lancet, 1. 646. Mellanby, M. (1923). Brit. dent. J., 44, I. - - (1934). Spec. Rep. Ser. med. Res. Coun., Lond., No. 191. - - and Coumoulos, H. (1944). British Medical Journal, 1, 837. - - (1946). Ibid., 2, 565. - - and Mellanby, H. (1948). Ibid., 2, 409. Mellanby, H., and Mellanby, M. (1950). Ibid., 1, 1341. Ministry of Food (1947). Our Food To-day, No. 3. Schiotz, E. H. (1939). Brit. dent. J., 66, 57. Stones, H. H., Lawton, F. E., Bransby, E. R., and Hartley, H. 0. (1949). lbid.' 86, 263.
POSTERIOR GASTRO-ENTEROSTOMY IN PEPTIC ULCER: LONG-TERM RESULTS BY·
DOUGLAS H. CLARK, Ch.M., F.R.C.S.Ed.,
F.R.F.P.~.
(From the Peptic Ulcer Clinic, Western Infirmary, Glasgow)
Gastro-enterostomy in the treatment of peptic ulcer has been the subject of many reports, often conflicting and in recent years seldom favourable. Although to-day abandoned by many, there are still some wh9 champion its cause. In this country Sir James Walton (1950), on careful and complete follow-up of a large series of cases, has found a constant incidence of stomal ulcer of only 2%, but most other workers put the figure much higher, even as high as 40%. The results obtained by Heuer (1944) agree with the experience of the majority of recent writers. In his series of 159 cases followed for periods of 3 moitths to 10 years (85 followed from 5-10 years) 21.4% developed recurrent symptoms. In comp:uing the end-results of gastro-enterostomy and gastrectomy, Heuer found on both short-term and long-term follow-up that the outcome was 10% in favour of gastrectomy ; but, as he pointed out, this advantage is reduced by the lesser immediate mortality of gastro-enterostomy. To the debit side of the gastrectomy will have to be added a still undetermined but probably considerable percentage of unsatisfactory results in the form of " small-stomach " syndromes. It is also probably fair criticism of the more extensive procedure that when medical men, and especially surgeons, contemplate operation as a personal issue gastro-enterostomy is given more than fleeting consideration. With such thoughts in mind, it was felt that a further report on the results of gastro-enterostomy, stressing the long-term results, would be of interest.
Clinical Material The material in this review consists of 330 patients subjected to gastro-enterostomy for peptic ulceration during the 14 years between January 1, 1924, and December 31, 1937. All cases were under the care of one surgical unit in the Western Infirmary, Glasgow.
DIET AND DISEAsE.
'MARCH 20, 1926)
).
~ritisiJ
•tbital )ssodatian · Jt.dnrt 011'
DIET AND DISEASE, WITH SPECIAL REFERENCE TO' THE·Tli1ETH, LUNGS, AND PRE-NA1'AL FEEDING. • BY
-
EDWARD MELLANBY, M.D.CANTAB., F.}t.S.,
HO:&'OIURY PHYSICIAN, ROYAL J:liiFIR:U:ARY, SHEFFIELD; PROFESSOR 01' PHARMACOLOGY, UNIVER3ITY OF. SHEFFIELD.
(With SpeciaZ Plate.)
3 per cent. of defect observed in the deciduous teeth of children are cases of gross hypoplasia of the enamel, smaller abnormalities being passed as normal. It was -only when teeth were examined microscopically after being ground down to thin sections that the real structure of the teeth was appreciated and correlated with the naked-eye appearance of the enamel. When this was done it was at once evident that a large proportion of human deciduous teeth -were badly formed-not the 3 per cent. suggested, but something like 80 to 90 per cent.3b The following table sums up the results as to the structure of childr·en's temporary teeth after being ground down and examined microscopically. TABLE
EIGHTEEN months ago I delivered a British Medical Association Lecture at Bradfordla in which I discussed the subject I was actively ·i-nvestigating at the time-namely, the part played by modern dietary in the production . of disease as found in this country. I should not have chosen the same subject for this evening's discourse were it not that it is still being intensively investigated all over the world, with results that only emphasize its importance. Modern experimental work on animals, backed up by clinical observation, ha,s brought tp light the fact ·that the .(lietary of the people of this country is defective in two important respects: (1) that it includes too little of the substances which contain fat-soluble vitamins, and (2) that it contains relatively too much cereal. Each of these dietetic mistakes tends, among other things, to bring about a certain pathological defect ·of. structure and function in the body, so that their combined influence in this respect ·is very great and produces widespread disability ,la, b, c For instance, one of the fundamental effects of a fat-soluble vitamin is to stimulate calcification of bones and teeth, while, on the other hand, excess of cereal in the diet interferes with the calcification of these organs. It can be imagined, therefore, how potent must be. the destructive action on developing bones and teeth of a diet deficient in calcifying vitamin and containing an excess of cereal. The meagreness of the sunshine in this countr•y and its poor quality so far as ultra-violet radiations are concerned only serve to make matters worse; for, arising from the observations of Huldsch.insky2 on the effect of ultra-violet radiations on the calcification of bones of rachitic children, we now know that deficiency of antirachitic vitamin in the diet can be made up to some extent by exposure of the body to ultra-violet light, while I have shown elsewhere that excess of cereal in the diet, which interferes with bone calcification, can also be antagonized by exposure to these rays.l• To-night I propose to return once more to the same subject, and, by other ·illustrations of the action of these dietetic factors on the body, try to drive home, not only how widespread are the diseases for which these specific dietetic defects are responsible, but also show that it is only by feeding in such a way as to avoid these defects that success can be obtained in the control and elimination of much illness. . TEETH. I propose, first of all, to deal with the subject of the teeth, and to provide· some evidence obtained by May Mellanby3a-B which suggests strongly that much of the dental defect of this country is due to the dietetic mis:l;akes mentioned above. Incidentally the results also indicate the means for· combating this serious state of affairs. It will be clear that if the. fundamental cause of dental defect is due to the fact that ·the dietary of the people in this country is exceptionally low in calcifying properties, then the teeth ought to he badly formed. The test can be made at once. Befoi:e, howe.ver, dealing with the point, it may be welt to state that the ordinary accepted teaching by dental authorities. of the structure of, for instance, children's teeth in this country is that, on· the whole, they ar!l well formed, only something of the order of 2 to 3 per :Cent. being recognized as defective in structure. This, if true, would at once disprove the suggestion made above as .io .th~ .cause. of dental defect. But is it true P .The 2 to *Delivered to the Mid·Cheshire Division, November 12th, 1925.
I.-Relation between Structure and Caries in tl!e Teeth of Children.
Type of Tooth.
Number Ex&mined.
Incisors ... Canines ...
Good Structure.
Defective Structure. Caries.
Caries.
100
58
11
1
70
5
0
25
40
11
2
451
22
28
521
Molars
...
<166
2
Total
...
636
65
I
No Caries.
I
No Caries.
30
The different ratios of abnormal to normal teeth in th9 In the case of the molars, for instance, only 13 out of 466 teeth examined were well formed, while in the case of the incisors no less than 69 per cent. were of good structure. It will be also noticed that there was some correlation between the structure of the teeth and caries, for out of the 636 teeth examined 521 were of defective structure and carious, while 65 were of sound structure and non-carious. That is to say, 586 of these 636 teeth, or 92.14 per cent., were in agreement with the hypothesis that a sound tooth is less liable to caries and an imperfectly formed tooth more likely to be carious. Of the 636 teeth, 50, or 7.86 per cent., were in a condition oppose\l to this generalization. This subject has .been .discussed by May :Mellanby elsewhere,3d and it was pointed out that the exceptions could be explained by the fact, which can also be demonstrated experimentally, that even after eruption the reaction of the teeth to harmful stimuli can be varied by the same dietetic influ enees which control the formation of the teeth. Thus ~~ badly formed tooth can be. made to· resist more potently if the diet is made good, wh.ereas the resistance of a well formed tooth is lowered by a defective diet. The point I wish to make now, however, is that a very large percentage of human deciduous teeth are badly formed, and not the 2 or 3 per cent. as usually stated. In Figs. 1 and 2 can be seen ·cross-sections of two molars of children : Fig. 1 is a photograph of a perfectly formed molar tooth-a rarity nowadays in this country; the structure of the tooth in Fig. 2 is obviously very imperfect, and a small spot of caries is evident, yet this tooth was described by a dental surgeon as well formed judging by its external macroscopic appearance. It is clear that children's deciduous teeth in this country are not only very susceptible to caries, but that they aro very defective in structure. The question now arises, Can the structure of teeth be controlled experimentally by diet during development, and, if so, are the dietetic factors controlling the formation of teeth of the same nature in children as in experimental animals? It is tiow possible, according to the experimental work of May Mellanby, to produce any degree of perfection or imperfection in the structure of the teeth of dogs by means of the diet eaten during the development of the teeth. The most important variables of the diet that are altered to bring about these differences include (1) the .amount of fat-soluble vitamin,3a (2) the variation in the amount and type of cereal eaten,3c and (3) exposure of the ai1imal, or in some cases the food, to a .source of ultra violet radiation.3e The· more deficient the diet is in the calcifying vitamin, the more it . cons.ists ?f cereal, especially o~trheal, and the less the ammal 1s exposed ~!trious types is interesting.
[3403J
516
1\:IABCK 201 1.926]
DIET AND DISEASE.
tu. ultra-violet radiations, the worse formed will be the plasia, the carious points, their extent and degree of hard~ tPdh. On the· other hand, the more :the fat--soluble vitamin, ness, the missing teeth, etc., being noted. After seven and and the less the cereal eaten, and the greater the exposure a half to eight and a half months of the diets the condition uf tho animal to ultra-violet radiations, the better formeq of the teeth was again charted, and the followin& result. will be the teeth. These facts are demonstrated in the were obtained. illu~;trations (Figs. 3, 4, and 5), which are a few examples TABLE 11.-E.ffece of Dieu .A, B, and a on the Inieia,ion and Sprearl. ~;how: Hg the effect of these dietetic and environmental of Caries in Children. factc rs in dental structure. For instance, the difference between the teeth and jaws in Fig. 3 is simply due to the Avera.ge New No. of fact that the diet of A contained some cod-liver oil, which Carious Diet. Points of Children New M:a.in Dietetic Difference. Points per is a rich source of calcifying vitamin, the diet of B conCaries. in GrouP. Child. tained a corresponding quantity of butter with a smaller vitamin content, whereas the diet of C was very deficient A Abundant calcifying vitamin 1.4 13 9 in this vitamin, as linseed oil formed the fat content of and calcium B Poor in calcifying vitamin ; less 51 5.1 10 its diet. Except for these differences everything in the calcium, more cereal, espediet and environment of these three puppies, who were cially oa.tmeal . 0 In,ermediate between A and B 2.9 38 13 members of the same litter, was constant. The destructive effect of cereals on teeth formation, and t'specially that of oatmeal, is seen in Fig. 4. Except in the It will be noticed that there was nearly four times as ease of A, the diets of these animals, though deficient in much new caries per child on Diet B as in the Diet A fat-soluble vitamins, were constant in this respect, and the group. Sin~e all other oonditions of hygiene and :Jl!ode of variable tested was the cereal. It will be seen that when living were constant; it is probable that the differences in oatmeal was the cereal eaten (Fig. 4, B) the teeth were diet were respon~ible for the changes in the teeth of the Yet'Y badly formed. The abnormality was least when white children. If this be true, then the results observed experiffour was eaten (:!fig. 4, C), and rather worse when wheat 'imentally on the teeth of dogs can be applied to children. germ waS substituted for 10 per cent. of the white flour The numbers of children obseryed in this investigation (.l!'ig. 4, D). Even the potent actim~ of oatmeal, however, were small; a bigger investigation of a similar nature is was completely antagonized by 19 c:cm. of cod-liver·oil eaten necessary before the results can be regarded as definitely daily by the dog whose jaw is represented in Fig. 4, A. established. On. the other band, the amount of difference The· diets of the animals whose teeth are 1·epresented hi of developing caries in the various groups seems too pig Fig. 4, A and B, both contained oatmeal and were iden- to be explained by inaccuracies of observation and chan~e. tical in other respects except that 10 c.cm. of cod-liver oil To sum up, the experimental work d,emonstrating . the daily was eaten by A, and 10 c.cm. of olive oil by B. The conditions of diet which bring about the production of tooth illustrated in Fig. 4, A, is perfect in structure. perfect and. imperfect teeth in ~ogs, taken in conjunction Tl1e effect on the structure of the teeth of exposing an with the investigation on children outlined above, ~akes animal to a source of ultra-violet radiations can be seen it almost cer~ain. in Fig. 5 (A and B). Both of the animals whose jaws are (1) that the widespread development of caries in represented in Fig. 5 were brought up on identical diets children's teeth is primarily a problem of defecti'Ve deficient in the calcifying vitamin, and lived under the feeding which results in imperfect formation of theh· same conditions, the only difference being that one teeth; (Fig. 5, B) was exposed thrice weekly for twenty minutes (2) that the dietetic factors which result in good to the rays of a mercury vapour lamp. The improvement and bad formation of teeth also confer upon or take il1 the calcification of the te·eth produced thereby is away from the erupted teeth qf children the power of obvious. 1·esistance to the carious process; I have now shown you some evidence which indicates (3) that foods containing fat-soluble vitamins, such (1) that the deciduous teeth of children are for the most as milk, egg-yolk, butter, animal and fish fats, and ]>art badly ·formed, and (2) that the structure of dogs' especially cod-liver oil, bring about the formation of teeth can bo controlled at will by varying certain specific good teeth, while cereals, and especially oatmeal, in the factors of diet and environment. The question ~rises, How absence of calcifying vitamin1 bring about the formation do tlwse facts bear upon the widespread scourge of caries of defectively calcified teeth. in the teeth of children P One method of answering the IJUestion would be to feed children from birth along the lines which animt\1 experiments have indicated as resulting THE INFLUENCE OF THE MATERNAL DIET DURING PREGNANCY ON THE SUSCEPTIBILITY OF THE OFFSPRING TO DISEASE. in perfect tooth formation, determining the amount of caries in the temporary dentition, and after the shedding It would bo a generally accepted proposition that the of these teeth from the sixth year onwards grinding them feeding and nutritional condition of a mother during pregl'esent, so far a!! is known, caries has not appeared in the on this point would be difficult· to obtain, for the ability t<'eth of these children, but the oldest is now only 5-! years possessed by the maternal organism. of sacrificing her of ago, so the test is still in its early stages. tissues for the supply of the fundamental nutriment of .the In order to attack the point in a direct fashion with the developing foetus is certainly very great. There is, howidea of seeing whether the results obtained with animals ever, better evidence that the malnourished as opposed ~o oould have any bearing on the teeth of children after erup- the starved maternal organism transmits undesirable weaktion and after being fully formed, :the following preliminary ness and tendencies to pathological change to its offspring. investigation was made by May Mellanby, C .. Lee Pattison, In the case of rickets, for instance, the maternal factor and J. W. Proud.4 A number of children in an institution has appeared so important to sonie that heredity has even were placed on diets which, according to animal experiments, been advocated as the prime cause of this disease. This varied in their effect on calcification. Group A were given view has not, however, received much support. The cona diet which contained much milk and sqme cod-liver oil, genital influence which has been stressed by Kassovitz is less cereal (none of it oatmeal), in addition to other food- supported by such facts as the special tendency of prestuffs. The diet of Group B contained less milk, more mature babies and of twins to develop rickets. It is true, cct·eal (including oatmeal); while in the case of Group C as Schmorlli pointed out, that newborn infants do not show an intermediate diet from the point of view of calcifica- rachitic changes of bone, but it is not improbable that the tion, and one which was usually the standard diet of the osteoporotic condition as evident in the craniotabes seen institution,. was given~ The children were arranged in in infants soon after birth is a closely related state and groups so that the average age of each group was about may be due to malnourishment of the mother. the same. Before the diets were started the mouth of each Experimentally Korenchevsky and Carr't showed that, in ~:hild was carefully charted, the amonnt and type of hypothe case of rats, rachitic changes of the bones could be
MAR OH
20.• t"2~ '.# v.f
DIET AND DISEASE.
[ llBDIC.u.Jou !'IDI • . ...,
517
r·===========z~~~==============T=====================~~~~==~ produced more rapidly, and more certainly, if the _mother during pregnancy, as w~ll as the offspring, were fed on diets deficient in antirachitic vitamin and calcium. Hess and Weinstock5 h-ave also studied this problem and found that, although improving the diet of mothers during preg~ nancy and lactation mitigated tlie development of rickets n infants, it did not prevent it. In the experiments now to be described the mothers during pregnancy were certainly no.t insufficiently fed. F~om the point of view of energy-bearing dietetic con: stituents the diets were not greatly dissimilar. Even as regards many of the actual foods comprising the respective diets they were identical in kind and in amount eaten. On _the other hand, specific differences were introduced of such a na:ture that one bitch (A) received a diet which, from earh~r work, would be expected to result in good hea~th, while the second (B) received a diet which expenence had taught would lead to malnutrition. The diets were as follows : Bitch 4.
Bitch B.
Jlread (white 1lour), 150 to 200 grams. Cod-liver oil, 10 ~o 20 c. cm. Separated milk, 400 reduced to lOO c.cm. Me&t, loo gr&ms. Yeast, 15 grams.
Oatmeal, lOO to 150 grams. Olive oil, 10 to 20 c.cm. Separated milk, 400 reduced to lOO c.cm. 1\fe&t, 30 to lOO grams. Yeast, 15 grams.
These animals lived throughout the experimental period under identical conditions and became pregnant at approximately the same time, the father being the same n each case. The diets were started in February 1923 and continued throughout pregnancy, which ended o~ Jun~ 6th and 11th respectively, and during the period of !acta.; tion, which lasted until July 23rd and 28th, when the progeny in each case were removed from the mothers and lived separately. After weaning, the diets were so arranged that two puppies (one puppy from each litter) were given the same food. The following table illustrates the conditions of the experiments. All puppies received the same amount of lean meat! separated. milk, orange juice, salt, yeast, together with the special substances indicated in the table for each puppy. TABLE Ill.
I
No. of Puppy.
698}
Diet Vari&bles.
709
Oatmeal. linseed oil, and 0.5 gram calcium carbonate
699}
Oatmeal and linseed oil
706
Mother. Father.
Z-Ray ResuU.
A
R
Nearly normal.
B
R
Moderately bad rickets.
A
R
B
R
Slight rickets (Fig. 6, A). Very b&d rickets (Fig. 6, B).
A
R
Normal bones.
7041
B
R
Normal bones.
701} White 1lour and cod-liver oil 708
A
R
Normal bones.
B
R
Normal bones.
A
R
B
R
Slight rickets (Fig. 7, 1). Bad rickets (Fig.7,B).
700)
Oatmeal and cod-liver oil
703} Oatmeal and cod-liver oil, heated and oxygenated 707 72 hours
The only results that need be referred to here are those of the dogs on diets which would be expected to interfere most severely with bone calcification. 'l'hese are 698 and 709 (oatmeal, linseed oil, and calcium carbonate), 699 and 706 (oatmeal and linseed oil), and 703 and 707 (oatmeal and cod-liver oil, heated and oxygenated seventy-two hours). Since there is little or no calcifying vitamin in linseed oil, and that present in cod-liver oii is destroyed by seventytwo hours' heating and oxygenation, none of these diets contained the necessary amount of vitamin. The results obtained in the case of 699 and 706 (oatmeal and linseed oil) can be seen in Fig. 6 (A and B), where the radiographs after ten weeks of the diet are shown. It will be seen that 706 (defectively fed mother-,--Fig. 6, B) has advanced rickets in the radiograph, whereas the radiogr.aph 699 (well. fe~ mothe_r-Fig. 6, A) shows only sltgh~ nc~ets at th1s t1me. Smce the. only difference in the hfe-history of these two dogs is that the mother of
o!
o~e (706~ was defectively fed during pregnancy and ti~n, wh_Ile t~e J?-lother of 699 had a. good, strongly
lacta.calcifymg diet, It IS probable that this is responsible for the increased susceptibility of 706 to develop rickets aa compared with 699. A similar result was obtained with 703 and 707, where heated and oxygenated cod-liver oil was· the fat eaten by both. It will be obvious in Fig. 7, A and B, that 7Cfl (defectively fed mother-Fig. 7, B) has developed more severe rickets than 703 (well fed mother-Fig. 7, A), and the reason for this is probably the same as in the case of the preceding pair. Animals 698 and 709 (radiographs not shown) reacted_ in the same way: 709, having the defectively fed mother, developed much more severe rickets than 698 (well fed mother). It was a matter of interest· to know how long the influence of the defective diet of the mother would be evident in the offspring, and more information was obtained from other puppies in these litters in the following way. Animals 701 (well fed mother) and 708 (badly fed mother), after weaning, were given a good d_iet containing an abundance of antirachitic vitamin. This contiimed for four months, and by this time the puppies were in excellent condition and about 6 · months old. The diet of each was then changed to a defective one by the sub~titu tion of oatmeal for white flour jlnd olive oil for cod-liver oil. After six weeks of this defective diet it will be seen that the bones of 708 (defectively fed mother-Fig. 8, B) and of 701 (well fed mother-Fig. 8, A) were still practically normal. These animals were now 7! months old and well grown dogs. However, after three months more of these defective diets, when they were 10! months old, there was a great pifference between these two animals, which is obvious in the radiographs and photographs of these dogs (Fig. 8, C and D, and Fig. 9, E ai1d F). It will be seen that 708 (Fig. 8, D, and Fig. 9, F) is very rachitio in appearance as compared with 701 (Fig. 8, C, and Rig. 9, E). The rachitic chang~s in 708 (Fig. 8, D, and Fig. 9, F) are comparable to those of late rickets seen occasionally in adolescents. The greater resistance of 701 to the development of late rickets and the susceptibility of 708 to this disorder must have been due to the difference of the maternal feeding' during pregnancy and lactation; for, since weaning at the age of 6 weeks, the diets of each and all the other conditions of life have been identical. It seems clear, then, that the influence of a defective diet given during pregnancy and lactation is not only evident in the offspring during early life, but that, even after a prolonged period of perfect feeding, the tendency to the development of defect is still obvious in the case of dogs whose mothers have a bad diet. It is surprising that the defective diet effect should be so lasting, and that it should be so difficult to overcome by a _period of excellent treatment of the puppy.
Summary. If bitches are fed during pregnancy on diets which, in the case of puppies, will lead to rickets, then the offspring have a greater tendency to develop this disease. This tendency in the young is not removed by a period of good diet, but may become evident again at a later period of defective feeding. THE RELATION OF DIET TO SusCEPTIBILITY TO INFECTIONS OF THE RESPIRATORY TRACT.
Attention has been drawn by many recent workers on dietetics to the increased susceptibility of animals to infection as the result of diets which, while good as regards their protein, fat, carbohydrate, and energy content, are defective in quality. McCarrison,B for instance, has described the frequency of a catarrhal condition of the intestine, especially in the form of colitis, four~d in animals whose diet was deficient in vitamin B. In t.he course of my own work I commented on the readiness with which dogs succumb to distemper and the great intensity of mange when these diseases appear in animals whOISe diets are deficient in vitamin A.lb Drummond9 has described a lowering of resistance of adult rats to bacterial infection, ma!1ifesting itself sometimes in the form of an i lflammatory
518
DIET AND DISEASE.
MARCH 20, 1926]
condition of the lungs, when they were fed on diets defident in vitamin A. Cramer and KingsburylO have also called attention to the mortality of rats from bronchopneumonia when these animals are kept sufficiently long on diets free- from. vitamin A. They conside1· that the atrophy of mucus-secreting cells in the mucous membrane of the ·trachea and larynx, observed by Mori,ll and in the intestine, obsen·ed by themselves, allows the local bacterial infection of these tissues when the diet is deficient in vitamin A. These are a few of the instances in which attention has been called to this important problem. Any information on the question of the relation of diet to resistance to infection, especially as it concerns the respirah>ry tract, seems to me to be of sucli great tn•actical importance that I think it necessary to give my own experience on the subject. · At one period in the course of my experimental investigations on dogs, the work was greatly hampered by the development of an inflammatory condition of the lungs. Another condition of the lungs found post mortem in some of the dogs was that of local collapse, especially along the margins of the upper lobes of the lungs. This was often associated with patches of emphysema in other parts of the lungs. This condition, as a general rule, was not accompanied by congestion. It was usually found in dogs 'Yhich, on account of their diet, had become eithe1: very lethargic or had developed mnscular weakness or both. l-Iany of the experiments have been mariP with the object of elucidating the effect of diet on bone formation, so that the numher of animals developing bone defect has been large. This, no doubt, accounts for the fret1uency with which muscular weakness and the accompanying condition of local hmg collapse. or atelectasis occur in these dogs. Lately I hare examined microscopically many of the lungs seen to be abnormal at the post-mortem examination made at the end of each experiment, and found the inflammatory conditions in all cases represented varying degrees of bronchopneumonia. It then seemed worth while to analyse the results and see in what way, if any, the incidence of the bronchopneunionia was related to tl1e diet. I will briefly tabulate these results and then discuss them. TABLE
.
IV.-Lwru CouditiOiafound at Post-mortem Examination of a Series of 330 Dogs in Relation to Diet. Diets as regards Vitamin A Content.
Condition of Lungs.
Normal
Cod-liver Vegetable Butter Butter, Oil, Fat, Vitamin A Cod-liver + Vit&r Oil+ Vitamin A Vitamin A ntin A. Destroyed Deficient. by Heat. Vitamin A. Destroyed by Heat.
... ...
155
55
43
0
Bl'Onchopneumonia. Local collapse ...
23
...
221
Total ...
r-;9
----- ---- ---11
24
3
4
0
1
2.
0
G
24
4
17
I
lx,nes, strongly contracting musdes, and good general activity, that the diet should also be richer in ealcium. The ·reason for this is probably that bu.tter contains a much smaller amount of antirachitic vitamin than cod-liver oil, so that the butter effect on calcification is best seen when there is plenty of calcium.in the diet. In .the above table it will be seen that local collapse of lung tissue was found in nine cases in which butter was the fat eaten. -If the calcium of the diets in these particular eases had. been higher, the musculature of the animals would have been strqngC'r, the animals would have been more vigorous, and ~0 local collapse of lungs would have developed. Yet none of these animals eating butter, although some were abnormal in other ways, even as regards the· lungs, developed bronchopneumonia. Although, therefore, it is certain that there is an intimate relation between fat-soluble vitamin in the diet and calcium, especially as regards the &tructure and function of bones, teeth, and muscle, it seems possible to. deduce1 on the basis of the above statistics, that this vitamin alone confers an increased power of resistance to lung infection even under conditions when bone and muscle structure is defeetivC'. It is necessary, in discussing this question as to the relationship of diet and the resist~n!)(l c;:!f _j;he body to inflammatory conditions of the respiratory tract; to emphasize that, whatever truth there may be in the suggestion that fat-soluble vitamin aids in the defensive mechanism, it is only mie point 'of a more complicafed story. Whether thC're was aliy _'special organism which 'invaded the lungs of these dogs 1.s 1iot yet known, as, tip tO the present, the subject has not -been 'studied in detail. · There. ·a~e. certainly other points 'Of · crucial importance in · tlie ettology · of bronehoJincl.tinoiJi'a, ·but what these are, cannot bd stated definitely: In some cases,: at least, the bronchopneumonia. developed in 'aninials \\:hich not only· had 'the· diet defect deseribed above, but also had been taken out of their indoor kennels into the open air, wl1ere it was usually cold and windy and often wet, in order that their running pqwers should be determined. The opportunity, in fact, was presented to them of catching_a " chill." . Th_e dogs on the diets containing vitamin A were also placed under the same conditions, but their resistance was apparently sufficient to make the low temperature of the external conditions of no account. It is impossible to state that this cl1ange of environment, which lasted only a few minutes, was always a factor in the development of the inflammatory condition of the rt>spiratory tract, but it may have been a causative agent in many cases. Another condition which commonly develops in puppi('~ when feeding on diets containing excess of cereal and a deficiency of fat-soluble vitamin is diarrhoea. In animals which feed on such a diet for a long enough period diarrh'oea generally develops, but this may only happen after severe defed of bone formation is present. On the other hand, diarrhoea may appear soon after the diet begins and before there is obvious bone deformity. It has seemed, although not proved, that the better the puppies are fed during the pre-expPrimental period, the longer time will elapse before the defective diets are accompanied by diarrhoea. This statement is definitely true of rickets both as r~>gards the pre-natal and post-i1atal feeding ·of the mother, and it probably applies equally to the development of catarrhal conditions of the alimentary tract. It may also explain the variable susceptibility .of young animals to catarrhal and inflammatory conditions of the respiratory tr~aGt.
These results indicate a close relationship between the fatsoluble vitamin content of the diet and the susceptibility of the animal to develop an inflammatory condition of the lungs. All the cases of bronchopneumonia were found in dogs whose diets were deficient in fat-soluble vitamin, and no bronchopneumonia developed when the diet contained either butter or cod-liver oil. Except for the variable amount of fat-soluble vitamin, the diets of these animals THE POSSIBLE BEARING OF THE ABOVE RESULTS ON would formerly have been considered good-that is to say, THE " CATARRHAL" CHILD. they contained an abundance of protein, fat, carbohydrate, The observations described above, dealing with the and energy. In some cases the calcium intake was only effect of feeding the maternal organism during pregsufficient on the assumption that the diet contained a large nancy and lactation on the susceptibility of the young. to amount of calcifying vitamin. For instance, if diets of develop rickets, together with the results showing the this nature contained cod-liver oil as the fat entity, and altered resistance under similar dietetic conditions to therefore an abundance of calcifying vitamin, the calcium inflammation of the respiratory passage, have impressed intake was sufficiently high to result in perfectly formed upon me the possibility that the so-called " catarrhal " teeth and bones. In fact, it is to be doubted whether any cl1ild is probably a product of defective feeding of the ordinary diet can be so low in calcium content as to lead mother during pregnancy and lactation.. There is general to defective calcification of the body tissues if' cod-liver . agreement among clinical workers that there is some oil.is also ingested at the same time. On the other hand, ·common factor in the etiology of the diseases which result when butter is the source of fat-soluble vitamin in the diet l in the " catarrhal " child, the rachitic child, and the child. it is essential, in order to produce well formed teeth and with enlarged tonsils... So far as my own animal experi-
E. MELLANBY: DIET AND DISEASE.
MARCH 20, 1926 j
FIG. !.-Photomicrograph of ground section of a perfectly formed human deciduous molar. Rarely found . (May Mellanby.)
FIG. 2.-Photomicrograph of human deciduous molar: Note defect ia structure of dentine. A typical specime!l as ordinarily found in· this country. (May Mellanby.)
FIG. 3 (A, B, and C).-The eftect of the calcifying vitamin. The jaws of three pupJ.>ies of the same litter brought up on the same diets except that A contamed 10 c.cm. of linseed oil daily, B contained 10 grams of butter daily, and C contained 10 c.cm. of cod·liver oil daily. Note the perfect formation of the teeth of C and the imperfectly formed teeth m A. (May Mellanby.)
FIG. 5 (A and B).'-The eftect of ultra·violet radiations. Photograph!> of the lower jaws of. two puppies brought up on the same 'diet deficient in calcifying vitamin and living under the same conditione, Puppy A only was exposed thrice weekly 1or twenty minutes to the :radiation• ef a mercury vapour lamp. Note the better formed teetli 'of :A'tas comparetl with B.. (May Mellanby.)
·.
A
c
B
D
FIG. 4 (A, B, C, and D).-The eftect of difterent cereals. Photomicrograph• of ground sections of molar teeth of four puppies of the same litter. The diets of B, C, and D were deficient in antirachitic 'Vitamin and were identical except that B contained oatmeal as cereal, C contained white flour as cereal, and D contained white flour and wheat ' germ (10 . per cent.) as cereal. The diet of A was identical with that of B:.....that is, it contained oatmeal as cereal, but olive oil in Diet B was replaced by 10 c.cm. of cod·liver oil, which completely antagonized the bad eftect of the oatmeal. Note how defective is the dentine in B (oatmeal), also that wheat germ has made the teeth of D worse than C (white flour). (May Mellanby.)
E. MELLANBY: DIET AND DISEASE.
MARCH 20, 19:.6)
B
A FIG. 6 (A and B).-Radiographs of wrists of puppies (699 and 706) taken after ten weeks of the same experimental diet. A, durinll' pregnancy and lactation the mother of 699 had been well fed-that IS, received abundant antirachitic vitamin. B, durinjr presnancy and lactation the mother of 706 had been fed on defect• ve diet-that is, deficient in antirachitic vitamin.
FIG. 7 (A and B).-Radiographs of wrists of puppies (703 and 7111) taken after ten weeks of the same experimental diet. The mother of A (703) had been on a diet deficient in antirachitic vitamin during pregnancy and lactation, while the mother of B (7fYT) had had a diet good in this and other respects during the same period.
c
A
FIG. 8 (A, B, C, and D).- Radiographs of wr\sts of two puppies (701 a.nd 708). T~e moth~r of. 701 (~ an~ C) '!'as ~ell fed during pregnancy and lactation The mother of 708 (B and D) durmg pregnancy and lactatiOn had a d1et deficient ID ant•rach1tlc v1tamm, and containing, among
other things ·oatmeal. After weaning the diets of 701 and 708 were always identical; they were well fed from 6 weeks to 6 months old· they were then p~t on the same rickets·producing !iiet. . Radiographs A, (701). and B (708) after six weeks of the defective diet; Radiographs d (701) and D (708) aft.er eighteen weeks of the defective diet. See also F1g. 9, m text.
L. G
PARSO~S:
IHHADIATED CHOLESTEROL IN RICKETS.
FIG. I.-Radiogram taken on admission to hospital, September 19th, 1~25. The bones show very marked rachitic changes.
FIG. 2.-Radiogram taken November 11th, 1925, showing the result of treatment with irradiated cholesterol for a period of three weeks. A considerable degree of healing has occurred.
FIG. 3.-Radiogram taken January 6th, 1926. The tiones have completely healed.
FIG.
i.
FIG. 2.
FIG. 3.
VALUE OF IRRADIATED CHOLESTEROL IN RICKETS. ments at·e concerned, I have got no evidence that enlarged tonsils of the type seen so commonly in children are produced by dietetic defect, but this may be because dogs do not develop the condition at all, or because I do not keep them long enough on bad diets. Clinically, however, it would probably be agreed that chronic catarrh of the l"('Spiratory passages of children,_ tendency to bronchopneumonia, rickets, attacks of diarrhoea, and, later, enlarged tonsils, are intimately related. . The catarrhal condition in children may develop at any time, but often it appears in the first few weeks of life and before post-natal conditions in themselves could be accounted responsible for the absente of all resistance to this t~'pe of infection. It seems to me that such cases can probably be explained on the basis of defective feeding of the mother during pregnancy, and the defects are probably of the type indicated by some of the experimental work on animals described in this lecture-namely, a deficiency in the diet of foods containing fat-soluble Yitamin, such as milk, eggs, butter, cheese,. animal and fish fat, and a
[
Ta& Ba1nd
. II:&DIC.U.IOftlr.U.
618
children under 1 month of age, and, if the foregoing suggestions and experimental results are true, would result; in great improvement in the physique of children. It would increase the resistance of infants to those infections which produce catarrhal conditions of the respiratory and alimentary tracts and all the other sequelae so gonerally recognized as likely to follow. It would certainly result in a better grown and less rickety type of child, and would do something also to improve the structure of the teeth and thereby to reduce the appalling amount of caries in the teeth of children. It would probably also bring about; improvement in the general health of the pregnant womau,. and do away with some of the unfortunate expel"iences. to which she is liable. · REFERENCES. 1 E. Mellu.nby: (a) BRITISH MEDIC.. EXJ•tr. Path., 1924, 5, 300. " Mori : Jolms Hopkina Hosp. Bull., 1922, 33, 357.
'l'HE VALUE OF IRRADIATED CHOLESTEROL IN 'fHE TREATMENT OF RICKETS. BY
LEONARD G. PARSONS, M .D.Loxo., F.R.C.P., PHYSICIAN TO THE CHILDREN'S, GENERAL, AND INFANTS' HOSPITALS, BIRMINGHAM.
(lVith Special Plate.) THE
fact that many foods and vegetable oils "·ltich have
no antirachitic. value acquire that property after exposure FIG. 9.-Photograpbs of two puppies-E (701) and F (708)-after ~iuhteen weeks of defective diet. Animal 708 (badly fed mother) has d.r-·eloped severe " adult rickets " as compared with 701 (well fed mother). For radiogr-aphs and details as to diet see F1g. 8 in ~pecial plate.
relati\·e excess of cereals such as bread, oatmeal, and rice, and other foodstuffs deficient in vitamin A. The basis of this suggestion I have given above, and may be summarized a; follows: (1) It has been shown experimentally that these defects in the inaternal diet increase the tendency of the offspring to develop rickets. . · (2) The same defects in the diet seem, on the basis of the statistics supplied above, to increase the susceptibility of young animals to bronchopneumonia and inflammatory con· ditions of the respiratory tract, and, in general, to result in puppies of lowered vitality. (3) It is well known that the catan·hal child may develop this condition shortly after birth, and that it has a great tendency to become rachitic and to develop broncho· pneumonia.. . . . . (4) Puppies whJCh develop ru.:kets when feedmg on thes'.l experimental diets frequently develop a catarrhal condition of the alimentary tract sooner or later, the time seeming to depend partly upon the kind of feeding of the mother and the puppy in the pre-experimental days. Not only is there some expel"imental support for the suggestion, but experience shows that the dietetic defects de-scribed are those most commonly met with in human feeding. It is therefore probable that these defects of diet of women during pregnancy and lactation are responsible for some, ·and possibly much, of the illness and mortality of young infants. The new teachings of diet have been ap[)lied to some extent to the feeding of <·hildren, and this i> no doubt partly responsible for the decrease in infant mortality during recent years, at a time when overcrowding and some other hygienic defects are as bad as, or even worse than, ever ; but it is necessary to extend the teaching to the problem of maternal feeding. This would probably show its first effect by reducing the infaut mortality of
to ultra-violet rays is now common knowledge. Hcss anli Weinstock 1 have recently shown that the anti1·achitic factor is confined to the unsa.ponifiable fraction of these sub"stances, and that it resides largely in the cholesterol m· phytosterol which they contain. During the year 1925 there appeared, almost simultaneously, three paper5--{)ne by the British workers Rosenheim and Webster,• in which they produced evidence that irradiation of cholesterol conferred antirachitic powers upon it; the others by two groups of American worker5--{)ne by Hess, 'Veinstock, and Helman, 3 proving that irradiation of cholesterol and phytosterol re1,1dered these compounds antirachitic, and the other by Steenbock and Daniels,• showing that irradiated sterols possessed antirachitic properties. Usually about half the unsaponifiable material hom cod: liver oil consists of cholesterol, but Drummond and Coward• have shown that this sub~ance is not responsible for the physiological effects of the vitamins A and D. These re&ults have recently" been confirmed by Nelson and Steenbock.• The cholesterol obtained from cod-liver oil, however can be rendered antirachitic by irradiation. The f~regoing results were all obtained with laboratory animals, but Hess and Weinstock 7 state that inadiatcd vegetables and dried milks possess curative value in f.lte rickets of infants, and Cowell• has demonstrated the value of irradiated whole milk. Hess has given irradiated cholesterol to infants, but I do not know of any observations that have been published on the results obtained by its use in the treatment of infantile rickets.* I am indebted to Hess for the suggestion to use irradiated cholesterol clinically, and also for the method of irradiation. The cholesterol used was pure cholesterol prepared by the British Drug Houses, .Ltd. A thin layet~ of this was ·placed in a Petri dish and irradiated by a • Since this was w~itten a paper bv Hess and . \\'einstock has beell published (Lancet, 1926, i, 12), . in whlch they gi\·c . the results of the treatment of three cases of ricltets by irradiated cholesterol. In eucll case the inorganic pbosl_)borus of the blood was increased and the rad1~ gram showed slight beahn&. ~
BRITISH
MEDICAL WNDON
JOURNAL
SATURDAY OCTOBER 19 1946
TEETH OF 5-YEAR-OLD LONDON SCHOOL-CHILDREN (SECOND STUDY) A COMPARISON BETWEEN 1929, 1943, AND 1945 BY
MAY MELLANBY (Nutrition Building, National Institute for Medical Research. N.W.1) AND
HELEN COUMOULOS, Ph.Q.Camb., D.D.S.Athens (Girton College, Cambridge) Between May, 1943, and the end of January, 1944, the mouths of a large number of children aged 5 years and attending L.C.C. schools were examined and charted* and a preliminary report on this survey was made (Mellanby and Coumoulos, 1944). One of the objects of the work was to compare the condition of the deciduous teeth of these children with that of children of the same class and age group examined in 1929, when a survey on similar lines, but with a less elaborate system of charting, was made by one of us (M. M.). In order to make the two investigations as nearly comparable as possible the same schools were chosen in 1943 as in 1929, any which were no longer available being substituted by others of similar type in the same district. The number of children examined in these schools was 1,604. In addition, examinations of 266 children were made in a few schools in districts not visited in 1929, but these were not included in the main survey as they were not truly comparable. In the report on the 1929 survey published by the Board of Education (1931), figures were given only in relation to children and not to the individual types of teeth. For the sake of comparison, therefore, the 1943 results were given in the same form, and it was clearly shown that, as regards both structure of the teeth and caries, the general dental condition was much better than in 1929. A summary of the findings in the two surveys is given in the following quotation from the report: "It is clear that in the 14 years that have elapsed the picture of deciduous tooth structure has changed for the better. Even so, there are very few children with a full complement of perfectly calcified teeth; however, in 1943 18.1% had only slight M-hypoplasia compared with 7.8% in 1929, and there were fewer with much M-hypoplasia-33.3% as against 58.5% respectively. ... 22.4% of the children in 1943 were 'caries-free,' compared with 4.7% in 1929; and only 29.3% had much caries, as against 62.8% previously." Since very few of the children were free from caries in 1929 it was decided to include in the caries-free group any who had vnly one or two teeth which, according to the standards used, were probably carious to a very slight degree. Even so, as is seen from the figures quoted, only 4.7% of the 1,293 children examined came into the so-called caries-free group. (It should be noted here that the standards were much more severe than those adopted at that time in routine inspections by school dental surgeons, which are made for purposes of treatment.)
* For the sake of brevity this is referred to as the !943 survey.
The 1943 estimate of caries-free children as 22.4%, given in the report (Mellanby and Coumoulos, 1944), was assessed on the same basis as the 1929 figure for purposes of comparison, but in arriving at the assessment a distinction was made between those in whom no caries could be diagnosed by the methods employed and those in whom there were one or two teeth showing very slight caries. It is intended in the present paper to give the structure of, and the amount of caries in, the individual types of teeth as found in 1943 and to compare them with data obtained in an investigation made in 1945, the object of which was to ascertain whether the great improvement found in 1943 as compared with 1929 was maintained. Sample schools from each district visited in 1943 were taken for this purpose and the mouths of 691 5-year-old children were charted. The length of time that elapsed between the first of the 1943 and the last of the 1945 inspections was 26 months, and the average period between the inspections in the schools visited in both investigations was just over 20t months. Methods All children of the age of 5 years (i.e., up to but not including the sixth birthday) at school on the day of the examination came under survey. This is a useful age group for the study of deciduous teeth, since few have been naturally shed and all have been subject to post-eruptive influences for a considerable period-the anterior teeth for 4 to 5t years and the posterior for 3 to 4 years. The percentages of teeth present in the mouths at the time of inspection are shown in Table I. I.-Percentages of Teeth Present at Time of Inspection
TABLE
Type of Tooth Upper: Centrals Laterals
Canines
" "
"
1st rnolars 2nd molars Lower: Centrals " Laterals Canlnes "" lst molars 2nd molars All types
1943
1945
90·7 96·0 99·8 90·5 92·4
92·6 98·3 99·6 95·0 97·5
83·2 97·9 99·9 85·8 86·0
79·4 98·0 99·9 92·4 91·7
92·2
94·4
In an ordinary room, with the best light available, each child was subjected to as detailed an examination of the individual 4476
566
Ocr. 19, 1946
TEETH bF 5- YEAR-OLD LONDON SCHOOL-CHILDREN
teeth as was possible by direct inspection and with a mirror and probes, in order to obtain data which could be used as a basis for comparative surveys. Special probes were used throughout (S.S. White stainless ; No. 37 for hypoplasia, No. 12 for caries), and they were renewed from time to time. X-ray photographs were not taken, as the technical difficulties involved were too great; moreover, they are unnecessary in surveys of this nature, especially when made on such large numbers of children. Any caries undiagnosed by the methods used will be relatively the same in the different surveys. By means of symbols and notes the following conditions were recorded on a simple chart designed for this work and reproduced herewith : Chart Showing Condition of Teeth Ap. ...... .... ........... ........ ····-
N•m•.--.. --·-·-··· Addrus Mottllnc (1.2. l. 4. 5, 6) M-hypoplulo (1, :1, la G)
ti=t----· -- -
No._·--··· Date ............................... -
1·····....+
.... j........ j .......
---·'··-~--[·; ..; ·.:b~-~ :;·. . +..... ;] ..........: .......jl. . . . . .·. ·.··,.........
Carte•(l,l.J)
·.·If_......
Teecl\ pf'ltlnt Teeth prnenc Carift(l, :1. J)
...
M-hy,.,...ll (1,1.
J_. G)
HottllnJ (I, 2. ), 4, 5, 6)
::~i ~---- --·-- ~- - - -~ --~ ·--r-~ f--- --·--
-- --. --·- --- .. - ·-- -
+--
Occh•lon_ ________ ......... ___ ,.. ________ ,........... __ AtttttiOft, _________________ ,,,,,,. _________ _
Scaln. ·········------·..··-·-·--..--··------·······-· Other notet :
(l) Teeth present. (2) Structure of each Deciduous Tooth.- The standards used were evolved from the results of experiments on animals and investigations on children's teeth made by one of us (Mellanby, 1918-34). Individual teeth were taken to be of good structure when their surfaces were smooth, shiny, and white or creamywhite in colour. Variations from this standard other than gross hypoplasia are referred to as Mellanby- or M-hypoplasia, a term first used by King (1940) to distinguish these types from the gross hypoplasias (G-hypoplasia) which have long been recognized and whicn are not common in deciduous teeth. The M-type defects were originally described by one of us (Mellanby, 1923, 1927, 1934), who found them in over 80~6 of the thousands of deciduous teeth examined. Unless the teeth are dried and well illuminated, the defects are not often easily visible to the naked eye, especially when they occur in the molars, but they can be detected without much difficulty when the tooth surfaces are lightly rubbed with a probe. Degrees of roughness are not sharply defined, but merge into one another. With practice--and this must be emphasizedthey can, however, be judged by the "feel" of the probe, and the teeth ·can be grouped under the following headings: Hy" : Good structure. M-Hy,: Slightly defective. M-Hy,: Defective. M-Hy,: Very defective. G-Hy: All varieties of gross or " textbook " hypoplasia.
The incidence of mottled enamel was recorded on the charts ; but it will not be discussed here, as it is beyond the scope of this paper. Teeth showing signs of mottling were graded for M-hypoplasia and for G-hypoplasia in the same way as unmottled teeth. (3) Extent of Caries in Each Tooth.-The following categories were recorded : C,: No caries that could be diagnosed by our methods of examination. C, : Slight caries-i.e., very early and suspected fissure and approximal caries. C,: Moderate caries; cavities involving destruction of up to. roughly one-quarter of the tooth crown (including undermining caries).
BRITISH MEDICAL JOURNAL
C,: Advanced caries; destruction of more than one-quarter of the tooth crown (including undermining caries). In this category were also included roots of decayed teeth and all teeth which were assumed to have been extracted for caries-i.e., all missing deciduous teeth except incisors, which were considered to have been shed naturally. (4) Arrest of the Carious Process.-A carious cavity was regarded as arrested only when, by the feel of the probe, its surface was very hard, though not necessarily smooth and polished, as described in textbooks. A tooth. with such a cavity was graded for caries according to the size of the arrested area and included in that grade of caries. Early stages of arrest were not recorded in these investigations. (5) Treatment of Carious Teeth.-Silver nitrate applications and fillings were noted, and the cavities so treated were classified according to their size, in the same way as active or arrested caries, though some allowance was made for removal of noncarious tissue around a cavity in preparation for filling. · (6) Staining of the Teeth.-Records were made of the incidence, colour, extent, and contours of stains on the enamel surface or on a film adhering to it. (7) Other conditions, which will not be discussed in this paper, including the state of the mouth, accumulation of food, spacing of the teeth, occlusion, attrition, and gingivitis, were also noted.
Results Before considering the detailed results, it may be of interest to compare the findings as regards the percentages of children free or almost free from caries. Table 11 shows that in the three main surveys (those made in schools in the same districts) the improvement observed in 1943, and quoted above, was continued in 1945, and a comparison of the combined main and subsidiary surveys of 1943 with those of 1945 shows a similar improvement in the latter. The percentages of children with good dental structure also showed a progressive increase. TABLE
Year
11.-Percentages of Caries-free Children Tolal No. of Children Examined
1929 1943 11145
1,293 1,604 632
1943 1946
1,870 881
I
% Caries-free
II
% ~lmost
Tota
Caries-free
(Seep. 565)
Main Surveys 13·4 22·2
I
4·7 22·4 28·5
9·0 4·3
Combined Main and Subsidiary Suney.< 14·9 9·3 24·2 3·9
I
I
I
24•2 28·1
Structure The surface structure of the teeth examined in the two recent investigations is shown in Table III, and is expressed both as percentages and as average hypoplasia figures (AHF). • Data are. given for each type of tooth and for all types taken together. The figures show that a considerable improvement in the structure of the teeth of London 5-year-old children as a whole occurred between 1943 and 1945. Whereas 30.7% of the teeth were of good structure (Hy.) in 1943, the figure had risen to 38.0% in 1945-a statistically significant increase of 7.3 ± 0.49%. There was a smaller percentage of teeth showing each grade of M-hypoplasia in 1945 than in 1943 and the AHF was lower (0.91 compared with 1.04). The improvement in structure in 1945 was marked in the incisors and canines, but the molars showed little change. In both investigations the structure of the upper incisors, especially the centrals, was much worse than that of the lower incisors. The incidence of gross hypoplasia (G-Hy) was low in both surveys as compared with M-hypoplasia, 1.9% of the teeth in 1943 and 2.3% in 1945 being so graded, whereas there were 69.3% and 62.0% respectively with M -hypoplasia. The column headed " Hy Unclassified " includes teeth which showed types of defect which could not be graded as definitely M-hypoplastic or G-hypoplastic. In most types of teeth very few of these defects were found, but in the canines there was a somewhat higher incidence. · · • See note at foot of Table Ill.
OcT. 19, 1946
TEETH OF 5-YEAR-OLD LONDON SCHOOL-CHILDREN
Caries The incidence and extent of caries, expressed as percentages and as average caries figures (ACF),* are shown in Table IV. As in the previous table, data are given for each type of tooth and for all types taken together. The unbracketed figures in the column headed "C, " include missing canines and molars, which were assumed to have been extracted for caries (see p. 566). ·.he figures in brackets _show these teeth as percentages of the total number (see column 2). In Table IV it is seen that there was less caries in 1945 than in 1943. In the earlier period 69.9% of the teeth were cariesfree, while in the later the figure had risen to 73.5%-a difference of 3.6 ± 0.46%, which is significant statistically. Taking the more severe degrees of caries (C, and C,) together, the percentage se graded in 1945 was slightly lower than in
Total No. of Teeth Examined for Structure 1943
Good: Hy,
1945
1943
Upper: Centrals .. Laterals .. Canines 1st molars :: 2nd molars
3,324 3,465 3,707 3,268 3,427
1,262 1,341 1,369 1,282 1,342
18·2 27·2 32·5 8·2 6·0
Lower: Centrals .. Laterals Canines 1st molars:: 2nd molars
3,091 3,624 3,702 3,119 3,104
1,097 1,348 1,370 1,235 1,241
33,831 12,887
..
Totals
..
(Dental Disease Committee, Medical Research Council, 1936) that in controlled dietetic investigations on children a striking feature in the groups having a good calcifying diet rich in vitamiP D was the relatively high proportion of teeth in which the carious process was no longer active but had become or was becoming arrested. Many of the children concerned in the Sheffield investigations were under observation for a period of several years, and it was found possible in some cases to trace the gradual·arresting of the carious process until the final hard, smooth, and polished state was reached. When a tooth showing this " healing " or arrest was sectioned after being shed or extracted it was usually found to contain a large amqunt of well-calcified secondary dentine. On the basis of animal experiments (Mellanby, 1923, 1930) it seemed feasible to conclude that the deposition of this secondary dentine was
lll.---Comparison of Tooth Structure in 1943 and 1945
TABLE
Type of Tooth
567
BRITISH MEDICAL JOURN.&L
I
M-Hy,
1945
1943
%
25·0 38·8 40·8 8·7 5·2
33·9 46·9 50·8 32·1 29·2
71·7 61·5 51·9 18·4 7·5
85·1 79·5 69·7 22·3 7·5
30·7
38·0
-
I
1945
G-Hy
1943
1945
%
36·2 39·4 45·7 39·2 39·5
34·3 19·0 13·2 49·9 54·0
26·1 14·3 10·1 42·9 45·7
24·2 33·7 36·9 38·5 34·1
14·0 19·2 23·5 39·8 37·5
3·2 4·2 5·9 36·5 48·6
0·4 0·8 2·3 32·5 45·4
36·3
33·8
26·3
22·0
9·4 4·1 1·5 7·0 9·4 !
I
1943
1945
%
Hy Unclassified
AHF*
(Seep. 566)
M-Hy, 1943
%
I Very Defective:
M-Hy,
6·0 2·2 1·1 6·4 8·6
3·9 2·5 1·0 2·8 1·3
0·0 0·0 0·1
0·6 0·4 0·5 4·0 6·3
8·1
0·2 0·1 1·4 2·5 3·4
4·2
3·5
1·9
3-1
1945
%
1943
'
8·8 5·4
~~
1945
1943
1945
0·2 0·1 1·2 0·0 0·0
1·37 1·00 0·83 1·57 1·68
1-14 0·79 0·71 1·48 1·58
2·8 1·0
0·2 0·3 1·0 0·0 0·1
0·5 0·3 0·7 2·8 1·5
0·03 0·1 3·4 0·1 0·1
0·0 0·1 3·8 0·0 0·0
0·33 0·43 0·53 1·27 1·56
0·15 0·21 0·30 1-17 1·55
2·3
0·6
0·6
1·04
0·91
,.,
Total hypoplasia figure
• AHF (average hypoplasia figure)
Total number of teeth examined for structure (excluding those with G-or unclassified hypoplasia)
TABLE
Type of Tooth
Total No. of Teeth 1943
Upper: Centrals Laterals Canines 1st molars 2nd molars Lower: Centrals Laterals Canines 1st molars 2nd molars Totals
.. .. .. .. ..
.... .. ..
.. ..
IV.-comparison of Caries Incidence and Extent in 1943 and 1945
1945
1943
3,392 3,590 3,740 3,740 3,740
1,280 1,358 1,381 1,382 1,382
62·4 79·7 90·5 58·0 43·5
3,112 3,662 3,7:40 3,740 3,740
1,098 1,354 1,382 1,382 1,382
.'!6.196
13,381
1845
%
c,
c,
c,
1943
70·5 85·1 82·5 61-1 48·6
9·8 6·8 2·9 8·7 17·2
95·1 96·3 93·1 46·0 39·0
98·3 97·9 84·1 51·4 41·2
69·9
73·5
1945
%
1943
1943
1845
., /o
11·6 4·3 2·0 (0·2t) 20·0 (9·5t) 21·1 (7·6t)
1·5 1·3 3·3 17·0 15·0
0·8 1·3 4·3 21-1 19·5
0·7 0·4 1·2 (O·It) 29·1 (14·2t) 33-1 (14·0t)
10·1
12·0
16·2 9·2 4·6 13·3 18·1
2·7 2·0 2·4 7·9 12·9
0·9 0·6 0·7 7·2 15·1
7·4
6·2
I
1943
1845
17·2 8·8 4·2 17·4 23·6
5·0 3·2 1·7 8·3 17·7
Total Carious Teeth
c,
12·6 (4·7t) . Total canes figure
%
1945
%
ACF* 1943
1945
29·5 14·9 7·5 38·9 51·4
0·77 0·38 0·18 0·95 1·17
0·81 0·30 0·15 0·83 0·85
7·3 3·1 1·6 (0·4t) 13·2 (5·0t) 10·1 (2·5t)
37·6 20·3 9·5 42·0 56·5
0·0 0·2 0·8 (0·1t) 20·3 (7·8t) 24·1 (8·3t)
4·9 3·7 6·9 54·0 61·0
1·7 2·1 5·9 48·8 58·8
0·08 0·06 0·13 1·29 1·42
0·03 0·04 0·12 1-10 1·27
30·1
28·5
0·65
0·55
3:3 (2·5tl
1
·-
' t See above.
*ACF (average caries figure) Total no. of teeth (including extractions)
1943 (20.3% compared with 22.7%), and the same trend is apparent, except in the case of the lower canines, when each type of tooth is taken separately. In both investigations the upper incisors, which were of much worse structure than the lower, were also much more carious, the upper centrals being more affected than the laterals. The average caries figures (ACF) tended to be lower in 1945 than in 1943 for all types of teeth together as well as for each individual type. Arrest of the Carious Process A point of much interest and, we believe, of great significance is the arrest-<>r, as Miller called it, the spontaneous "healing" -<>f the carious process, which represents a measure of the defensive reaction of a tooth to attack by caries. It was shown in investigations in Sheffield (Mellanby, Pattison, and Proud, 1924 ; Mellanby and Pattison, 1926, 1928) and Birmingham
* See note at foot of Table IV.
related to the arrest of caries and tc the type of diet eaten at and after the time of the carious attack. In the survey's here described arrest was recorded only when the carious area had become definitely hard, though not necessarily smooth and polished. It is interesting to note in Table V that in 1943 11.7% of the carious teeth present in the mouths of the children examined showed arrest and that in 1945 the percentage was almost doubled-i.e., 21.5%. Had teeth showing earlier stages of arrest been included the figures for both surveys would undoubtedly have been much higher. TABLE
V.-Teeth Showing Arrest (Spontaneous "Healing") of the Carious Process No. of Carious Teeth Present
1943 1945
9,182 3,203
% Carious Teeth
Present Showing Arrest 11·7 21·5
OcT. 19, 1946
568
TEETH OF 5- YEAR-OLD LONDON SCHOOL-CHILDREN
BtUTISH
MEDICAL JOURNAL
-------------------------------------~----------
Treatment of Carious Teeth In Table VI are shown the percentages of carious teeth assumed to have been extracted (that is to say, the missing canines and molars) and the percentages which had been treated by silver nitrate application or had been filled. It will be seen VI.-Carious Teeth Extracted, Treated by Silver Nitrate, or Filled
TABLE
\ Total No. of Carious Teeth (Including Extractions)
I 1--:9-43-..- -..~1 1945
..
.. -
Extracted
Nitrate
Filled
Treated
15·7
6·7
2·7
3,54~
9-6
2·8
2·4
25·0
Jnc1sors
Total No. Examined
.. .. ..
..
..
.. .. ..
.. .. .. I
..
..
..
"I
14·8
VII.-Percentage Incidence of Caries in Teeth with Varying Grades of Structure
--
Jrade of Structurt'
G-Hy
Total
10,886
TABLE
Hy, M-Hy, M-Hy, M-Hy,
Treatment
1--------.---.---1 Percentage of % % S1lver % Carious Teeth
and difficult to remove by ordinary brushing, and, if removed, usually returns. In the surveys here recorded the most common stains observed' were black, very dark brown, or green. The black and dark brown usually took the form of a border to what appeared to be a film on the tooth, though it might be more widespread, and the green often seemed to extend from the gingival margin towards the incisal edge or cusps. The percentages of children whose teeth were all free from stain were 51.6 in 1943 and 35.5 in 1945. With black and dark brown stains on some or all of their teeth there were 10.6% and 11.3% and with green stains 34.9% and 46.5% respectively. The teeth of a few children had yellow or lightish-brown stains or a combination of two or more stains, but figures will not be given for them here, as there were too few in any group to be of significance.
1943 5,992 4,724 2,053 487 226
Camnes
1943 1·1 12·0 44·9 80·4 64·2
1945 2,837 1,399 538 105 185
Molars
Total No. Examined
%Carious
1943 3,126 3,248 707 75 90
1945 1·2 11·2 39·2 81·0 82·4
1945 1,514 947 189 16 24
%Carious
I
1943 1·5 7·9 26·7 61·1 23·3
1945
1-1
8·0 29·8 88·8 20·8
Total No. Examined
1943 1,281 4,310 6,133 867 319
1945 550 1,987 2,127 335 101
%Carious
1943 8·3 24·5 62·6 87·1 58·9
1945 7·0 25·0 88·5 92·3 52·5
NOTE.-This table does not include the few teeth shown under the heading" Hy Unclassified" in Table Ill.
that there was less treatment of all kinds in 1945 than in 1943. This may, of course, be because there were fewer dental surgeons to cope with the work. Relationship between Structure of Teeth and their Susceptibility to Caries Attention has been drawn by one of us (M. M.) and by others using the same criteria (Davies, 1939 ; Dental Disease Committee, 1936; King, 1940) to the fact that there is a direct relationship between the structure of the deciduous teeth, according to the standards used, and their susceptibility to caries: the less the M -hypoplasia the less, in general, the caries. In the investigations described in this paper the same relationship is evident, as is seen from Table VII. When the teeth were of good structure (Hy,) only 1.1% of the incisors, 1.5~~ of the canines, and 8.3% of the molars were carious in 1943, and the corresponding figures for 1945 were 1.2%, 1.1 %, and 7.0%. With each degree of M-hypoplasia the percentage of carious teeth increased in both surveys, until with very hypoplastic structure (M-Hy,) there were in 1943 80.4% of incisors, 61.1% of canines, and 87.1% of molars carious, and in 1945 81.0% of incisors, 68.9% of canines, and 92.3% of molars. The incidence of caries in teeth with gross hypoplasia was not as great as in those with severe M-hypoplasia. This is understandable because, although the enamel of part of a tooth may TABLE
Vlll.--Amount of Caries in Relation to Superficial Staining of Teeth
--------.------,,-----Children with (a) (b) (c)
No stain .. .. .. Black and dark-brown stains .. Green st~in .. .. ..
Percentage of Carious Teeth
1943 30·1 19·3 33·4
1945 23·1 15·4 33·0
ACF
1943 0·66 0·41 0·72
1945 0·48 0·30 0·88
be badly pitted, or even m1ssmg, the remammg enamel, laid down at a different period of growth, may be quite well formed. For this reason it was decided, in tabulating the relationship between structure and caries, not to combine teeth showing gross hypoplasia v1ith those affected by severe M-hypoplasia, as was done in some earlier surveys (Mellanby, 1934). Staining of Surface Enamel or of Films on the Enamel Very little appears to be known about the superficial staining seen on the teeth of many children. It is often unsightly
It was noticed that many of the children whose teeth showed the black and dark-brown stains were caries-free, and an attempt was made to discover whether the stains were definitely associated with the incidence of caries. Table VIII indicates that in each survey the percentage of carious teeth and the ACF of children with black and dark-brown stains were lower, and with green stains somewhat higher, than those of the children with no stain. It thus seems from these figures that black and dark-brown stains are associated with a lower incidence of dental caries, whereas green stains may be associated with a higher incidence, but we have no knowledge as to the reason for these apparent associations. Discussion An account is given of two investigations on the condition of the deciduous teeth of 5-year-old children attending L.C.C. schools in 1943 and 1945, and a comparison is made between these investigations and one of a similar nature made by one of us (M. M.) in 1929. Since, however, no data are now available in regard to the state of the individual teeth in 1929, the comparison is confined to the general dental condition. In 1943 this was much better as regards both structure and caries than in 1929, and in i945 it was still further improved. Though the 1943 and 1945 investigations were not controlled in the way that animal experiments can be regulated, the groups of children examined were comparable in that they were of the same age group and social class and resided in the same districts of the" L.C.C. area. From the dietary point of view there was a degree of similarity during the war years, because the rationing and " points " system of food distribution gave equal purchasing opportunities to all families. The main point of dissimilarity, so far as could be seen, was that the 1945 group of children had been subjected for a longer period to the war dietary than the 1943 group--a fact to which attention must be drawn. Data obtained from the classification of individual teeth emphasized the better dental condition of the children seen in 1945 as compared with 1943. For instance, the percentage of teeth of good structure (Hy 0 ) rose from 30.7 in 1943 to 38.0 in 1945, and of caries-free teeth (C.) from 69.9 to 73.5a statistically significant difference in each case-and the percentages of teeth with the more severe defects of structure (M-Hy,) and more advanced caries (C,), decreased appreciably in the intervening period. The amount of arrest or spontaneous " healing " of the carious process was almost twice as great
Ocr. 19, 1946
TEETH OF 5-YEAR-OLD LONDON SCHOOL-CHILDREN
in 1945 as in 1943-an indication that some powerful posteruptive influence had been at work. If, as seems certain, this improvement in dental condition is not accidental, but is related to some factor or factors of diet or environment to which the children were subjected an examination of possible factors may bring to light those responsible for the facts observed. It is claimed by some that carbohydrates play a prominent part in the initiation of caries. Others say that poor dental hygiene Js responsible, and yet others that heredity is an important factor. So far as our knowledge goes, however, there is no sound scientific evidence for any of these contentions. To test the carbohydrate theory, King (1946) investigated the effects of nightly supplements of boiled sweets and chocolate-coated biscuits on the deciduous teeth of a small number of infants living in two institutions. The supplements were given when the children had cleaned their teeth just before going to bed. There was no increase in carious activity in the children over periods of from 6 to 24 months and at the end of the test previously active caries had beco~e arrested. it must be stated that the children had a good calcifying diet containing cod-liver oil. This result does not support the view that carbohydrates are responsible for the disease. The two recent surveys on L.C.C. school-children also do not uphold the theory. Less active caries and a greater proportion of teeth showing arrest of the disease were seen in 1945 than in 1943, but there is no evidence that the consumption of carbohydrates among young children had diminished in the intervening period. It cannot be argued, either, that the reduction of caries in 1945 as compared with 1943 was in any way related to better dental hygiene, since as the war progressed civilian dentists became fewer and toothbrushes were more difficult to obtain (Magee, 1946). ..., If heredity were the potent factor in caries that it is sometimes claimed to be we should not see the deterioration in the dental condition of native races that is so evident when they come in close contact with Western peoples. An outstanding example of this is seen in the American negroes who have become completely Westernized in their habits and dietary. It is well known, too, that both children and adults of the primitive races in Africa who adopt the Western mode of life and diet-those. for instance, living for long periods in the ports and industrial areas-lose that freedom from caries which is so common while they remain in their natural habitat, and the sam.: deterioration is seen in Eskimos attached to trading stations. It would seem, therefore, that some other cause for the observed improvement in dental condition in 1945 as compared with 1943 must be sought. Previous investigations on children by one of us (M. M.) and, by colleagues using the same standards (Deverall, Dental Disease Committee, 1936; Davies, 1939; King, 1940) have shown that resistance to caries is related to dental structure as diagnosed in these surveys-that is to say, the better the structure the less the liability to decay. Unfortunately this relationship is not always appreciated by dental surgeons, many of whom recognize only the more gross forms of hypoplasia. It has also been shown that the chief factors required ior the production of well-formed teeth include a sufficiency of calcium, phosphorus, and vitamins D and A. and that these same factors in the diet after eruption of the teeth tend to retard the onset of caries and to arrest the disease when present. If vitamin D and calcium supplies are deficient other food factors come into prominence. Certain constituents of cereals, for instance, may under these circumstances be harmful from the point of view of the teeth. During the early stages of dental development mother and child must be considered as one unit. The pregnant and lactating woman must herself then be made as dentally fit as possible to avoid absorption of toxins and to enable her to masticate her food, and her diet must be such that the developing foetus, and later the infant, is supplied with the food factors necessary for the production of well-formed teeth. After weaning, the child itself must continue to receive a calcifying diet. There is no doubt that in this country the diet of the majority of people, and especially of the children, is far better to-day in this respect than it was, say, 25 years ago. During recent years,
and particularly during the immediate pre-war and the war , years, pregnant and nursing women, infants, and children have been encouraged (a) to consume more milk and eggs and so to obtain larger supplies of calcium and phosphorus, as well as of , v~mins D and A; (b) to take vitamin D- and vitamin Acontaining substances, either as cod-liver oil or as one of the proprietary products ; and (c) to eat more potatoes. Moreover, for a number of years now vitamins D and A have been added to some brands of margarine, and since the early days of the: war this has been made compulsory for all brands. Again,, calcium was added to some flours before the war, and since 1943 the addition has been a routine measure. It seems probable that the improvement·in dental condition of 5-year-old children during recent years is directly related to the enrichment of their diet in these respects. The children examined in 1943 showed a considerable improvement on the 1929 group, and, as has been indicated in the tables in this paper, the 1945 group, who had received calcifying supplements for longer periods than their predecessors in 1943, showed an' even greater improvement. Not only were their teeth better formed and less carious, but a greater percentage that had been attacked by caries had set up a resistance, as a result of which the carious process had been arrested. The advantage of this natural "healing" of carious cavities over treatment by filling or extraction is obvious. Evidence is accumulated to show that in some other countries, among them Norway and Sweden, there has heen a progressive decrease in caries incidence during the past few years and that it could be attributed to the increased consumption of cod-liver oil, calcium, and vitamin preparations. It is of interest to learn, in view of the controversy on the effect of carbohydrates on the teeth, that in Sweden the amount of chocolate and sugar consumed is high, and continued so throughout the war. Taking all known facts into consideration, therefore, it would seem that nutritional factors offer the most likely solution to the problem of tooth structure and freedom from caries, and it appears to us that the incidence of the disease could be still further reduced by giving diets rich in calcifying properties to everyone, but especially to all pregnant and nursing women and to infants. · It must be borne in mind, however, that in spite of the improvement in dental condition described here, we in this country have not yet gone very far along the road to perfection. There are even to-day over 70% of L.C.C. school-children between the ages of 5 and 6 years who have some decayed deciduous teeth, and there are other parts of the country where the situation is worse. It is evident, therefore, that we still have a long way to go before we can guarantee that a child will grow up without dental decay. Summary The dental condition of comparable groups of 5-year-old children attending L.C.C. schools in 1943 and 1945 respectively is described and discussed, and is compared with that found in 1929, The general dental health of the children examined in 1943 was much better than that of the 1929 group, and in 1945 there was a further appreciable improvement. The individual teeth in 1945 were significantly better in structure and had less caries than those in 1943. A point of special significance is that the percentage of carious teeth showing arrest of the disease was almost twice as large in 1945 as in 1943. The percentage of such teeth extracted, treated by silver nitrate, or filled was considerably smaller in the second survey than in the first. Superficial black or brown stains, which were observed on many teeth, appeared in both surveys to be associated with a lower incidence of caries, and green stains with a somewhat higher incidence, than the absence of stain. There was in both surveys a relationship between M-hypoplasia and caries, the more severe the degree of structural defect the higher being the incidence of the disease. Teeth with gross hypoplasia showed a medium amount of caries. It is suggested that the better condition of the teeth of 5-year-old children in 1943 and 1945 as compared with 1929 was due to the increased calcifying properties of the dietary of this country, and particularly of pregnant women, infants, and young children during recent years, and that the improvement observed in 1945 as compared with 1943 was due in the main to the longer period the teeth> examined had been influenced by the type 'of diet made availabk: immediately before and during the war years.
570 OcT. 19, 1946
·ADDISON'S DISEASE TREATED BY A GRAFT
UKlll.SH
MEDil.AL JOUK~A.L
110/76, and the same level was found by Sir Arthur Hurst at his examination at about this time. It was then that Addison's disease was first suspected by Dr. Wetherell and Sir Arthur Hurst. (4) Pigmentation : a smoky brown pigmentation was first commented on by Dr. Wetherell and Sir Arthur Hurst in April, 1944, and it had become more pronounced by the time we saw her in January, 1945. In April, 1944, she was under Sir Arthur Hurst's care in Oxford, and he notified Dr. Wetherell that he agreed with his opinion -and that the probable diagnosis was Addison's disease. Increased pigmentation and general asthenia troubled her most ; and a low systolic blood pressure, 110, was the chief physical sign. Her blood sodium at this time was 310 mg. per 100 ml. (the normal level being 320). Sir Arthur Hurst commented that no fall in blood chloride or rise in blood potassium was found, but that neither was a constant feature in early cases. He advised extra salt to the extent of four REFERENCES teaspoonfuls daily, and the patient commented on an immediBoard of Education (1931). Committee on Adenoids and Enlarged Tonsils. ate improvement, saying that she felt stronger and fitter. Sir Second Interim Report: The Association of Rickets and Dental Disease Arthur Hurst felt that this might have been due only to with AdPnoid~< and Enlarrted Tonsils, London. · Davies, J. H. (1939). Brit. dent. J., 67, 66. suggestion, but the improvement was so marked that he Deverall (Dental Disease Committee) (1936). Med. Res. Cncl. Sp. Rep. Ser. thought it was the direct result of the increased sodium No. 211. H.M.S.O., London. King, J. D. (1940). Ibid., Nu. 241. chloride intake and further evidence in favour of Addison's - - (1946). Lancet, 1, 646. disease. He advised continuation of this treatment. Magee, H. E. (1946). British Medical Journal, 1, 475. Mellanhv, M. (1918). Lancet. 2, 767. In October, 1944, the blood sodium level was 284 mg. per - - (1923). Brit. dent. J., 4t, I. - - (1923). Proc. roy. Soc. Med., 16, 74. 100 ml. The patient was supposed to be on full substitution - - (1927'. B-it. d·" J., 48, 737. therapy with sodium chloride, but Dr. Wetherell thought that - - (1929, 1930, 1934). Med. Res. Cncl. Sp. Rep. Ser, Nos. 140, 153, 191. H.M.S.O. London. her ingestion of sodium chloride had been distinctly "sporadic." - - and Coumoulos, H. (1944). British Medical Journal, 1, 837. He subsequently made arrangements for her to see Mr. Broster,. - - and Pattison, C. Lee (1926). Brit. dent. J., 47, 1045. - - (1928). British Medical Journal, 2, 1079. and she came into University College Hospital private wing - - - - (1932). Ibid., 1, 507. under our care in January, 1945. - - - - and Proud, J. W. (1924). Ibid., 2, 354. Ot)ler investigations had been carried out. Her blood count on two occasions was normal. No occult blood had been found in her stools, which contained no excess of fatty residue, no inflammatory material, and no pathogenic bacteria. No A CASE OF ADDISON'S DISEASE t~bercle bacilli were found. A test-meal showed complete SUCCESSFULLY TREATED BY A GRAFT achlorhydria. Her weight in adult life was normally 8 st. (50. I kg.), and it remained at 8 st. until the spring of 1944. BY She then lost weight to 7 st. 4 lb. (46 kg.), and has remained L. R. BROSTER, O.B.E., F.R.C.S. at that since. Her menstrual cycle has been regular throughout Surgeon to Charing Cross Hospital -5/28-day type. AND On examination in January, 1945; when she came under our observation, she had been under treatment with sodium chloride, H. GARDINER-HILL, M.B.E., M.D., F.R.C.P. four teaspoonfuls daily, and injections of cortical hormone, but Physician to St. Thomas's Hospital there was still considerable pigmentation of her entire body. This is the story of a young woman in whom, nine months There was a smoky brown discoloration of the nipples and in previous to our seeing her, a diagnosis of Addison's disease the axillae, and patches of pigmentation on her buccal mucous had been made on clinical and biochemical findings. The membrane. Blood pressure at that time was 120/80. There were no abnormal physical signs in her cardiovascular system. diagnosis was confirmed at the time of our examination, and one of us (L. R. B.) subsequently ingrafted an adrenal gland Chest and abdomen were normal, as were her secondary sex characters. She was normally developed. Her weight was from a patient with the adreno-genital syndrome (hyperplasia). As a result of this operation our patient lost her symptoms and 7 st. 4lb. A radiological examination of the abdomen showed a hazy area of calcification over the upper pole of the lefi signs of Addison's disease, and sodium chloride withdrawal kidney which was interpreted by the radiologist as indicating tests showed that her blood sodium no longer fell below normal. The last test (14 months after operation) showed that this calcification in the adrenal gland on that side. The Mantoux change had been maintained ; and she was now able to leave test was negative. During the first week of her stay in hospital her temperature off substitution therapy with sodium chloride without relapse. chart showed a slight and irregular pyrexia up to 99.6° F. (37.55° C.), but it never reached 100" (37.8° C.). Subsequently Case History her temperature was normal except for a slight recrudescence Miss W., aged 33 (Jan., 1945), had not been well for six years, of fever for a few days after operation. the onset of her illness coinciding with tbe outbreak of war in 1939. To establish the diagnosis of Adc:son's disease her substituThere were four groups of symptoms: (1) Depression and nervous symptoms which had been present since the start. For ·a time she tion therapy of salt and cortical hormone was discontinued for had thought that these were due to the war. (2) Gastro-intestinal . a week. At the end of that time her pigmentation and asthenia symptoms: during the whole period of her illness she had sutiered had definitely increased. Her blood pressure fell at the end on and off from what she described as a "nervy tummy." She felt of a week off treatment to 95/80. Serum sodium at this that it was on the move all the time and complained of attacks of time was 295 mg. per 100 ml., and serum potassium 21 mg. diarrhoea lasting for two or three days which alternate.d with bouts per 100 ml. We considered that these findings established the of constipation. No evidence of organic disease had been found diagnosis of hypocortical adrenalism. by Dr. Wetherell, and it would appear that these attacks did After this sodium withdrawal test she was put back on s-odium represent an irritable gastro-intestinal neuro-muscular mechanism. In April, 1944, an x-ray examination was carried out, but the only chloride treatment, and a week later the grafting operation was abnormality was a spastic descending colon. In May, 1944, .she was carried out by L. R. B. seht to Sir Arthur Hurst. He discovered that she had achlorhydria, and as a rcsuit of the acid therapy which he instituted the attacks of diarrhoe? practically disappeared. (3) Extreme lassitude had been Description of the Donor noticeable from 1943 onwards, but it had been difficult to assess Miss H., aged 21, a robust young lady, was first seen in the relative significance of psychological and physical factors. Dr. Wetherell, in April, 1943, found her blood pressure to be 1942. Her history was that at the age of 16 she began to
Acknowledgments Our thanks are extended to many who have helped us directly or indirectly with the investigations and the preparation of this report. We are especially grateful to Mrs. M. Kelley and Miss I. Alien for their assistance with analysis of the results, the compilation of the tables, and the arrangement of the text; also to Dr. W. J. Martin, of the Medical Research Council, for the statistical assessment of some of the figures. Others we would particularly like to mention arc the London County Council and Sir W. Alien Daley for their permission to carry out the inspections and for making arrangements for us to visit the schools; the carecommittee workers; the medical officers of health and others in the districts we visited who kindly suppiied us with much invaluable information; and the head teachers and their assistants, especially those who so willingly allowed us to pay them a second visit. H. C. held a scholarship from the British Council, and the expenses of the investigations were paid by the Medical Research Council. To both of these bodies we are grateful.
588
CORRESPONDENCE
MARCH 26, 1932)
again at a greater disadvantage than in the first instance, where the desire for ambulatory treatment overcame the skill that was available for the reduction of the fracture and its maintenance. Your correspondents admit that anyone who puts an unpadded plaster next the skin shoulders a certain responsibility, and that skilful application is necessary ; moreover, if fractures are situated higher up the leg than the ankle, sustained pull with skeletal traction is required as a prelude to, and not as a substitute for, the walking plaster. These admissions are in themselves significant, and are much more in accord with my own views on the matter. Having obtained reduction, and maintained it by methods of extension which I have described, I have the majority of patients on to their feet and walking with moving joints in some form of retentive apparatus within three to four weeks of their accident. Physiotherapeutic measures are reduced, and an early return to work is the rule. Treatment is in no way prolonged, and the security of the fracture and freedom of the skin from trauma is guaranteed. These statements are not made with the view of disparaging the advocates and modifiers of Dr. Bohler's methods, but to point out that good results are consistently obtained by a simple and safe measure, which enables the large majority of patients to return to work at an early date. To those who persistently. urge the advantages of allowing patients with fractured legs to walk about in plaster immediately after reduction I would only ask the question: " Would it be safe to let a fully reduced oblique or spiral fracture of the tibia stand any weight-bearing strain as soon as the plaster casing had been applied? '' Plaster splints, even though unpadded, are not applied direct to the fragments, and if there is not careful observation the slightest degree of wasting cause the plaster to lose its hold on the soft tissues over bone. Application of a new plaster is not always a simple procedure, and loss of position or angulation has been known to occur in experienced hands. The ambulatory ideal must be compatible with safety, and, unless surgeons are sufficiently dexterous to ensure that walking is possible as soon as the fracture has been reduced, it is better to employ less active measures which ensure safety. The term " ambulatory treatment" should b::: used more discriminately than it is at the present time, since many surgeons employ it to include treatment which simply allows the patient out of bed before union has occurred ap.d does not require the use of his limb ; while for others it means that the patient must be bearing weight on the injured limb almost immediately after reduction has been effected. I do not decry the employment of early weight-bearing through an unpadded plaster, if it can be guaranteed that the correctly reduced position of the fracture is never lost ; but I also urge that the patients can be treated with a minimum of discomfort, and can. obtain an early return to work, by methods which involve "confinement to bed for a week or so. When walking is started, unto~ard events are almost unknown. Safety, comfort, and early return of function are essential in the treatment in any fracture.-! am, etc., MEURICE SINCLAIR. London, \V., March l·Sth.
will
THE BARBITURATES IN ANAESTHESIA SIR,-Every surgeon and every patient who has had experience of the intravenous injection of one or other of the barbiturates will be grateful to Dr. Magill for his letter. It would appear that the warnings of the Council· of Pharmacy and Chemistry are a little late in the :field, for it is probable that experiments with the human subject, carried out in the ordinary routine of surgical work,
[
Ttt.F. R~IT(SH MEDICAL jOURNAL
already far outnumber those conducted by the pharmacologists on experimental animals, and the clinical observations leave no room for doubt. For myself, I regard the introduction of the intravenous injection of pernocton or nembutal as the greatest advance in the practice of anaesthetics during my professional life. I do not think it is too much to claim that it has revolutionized the psychic aspect of surgical operations, and immensely minimized the discomfort of the post-operative period. I confidently look forward to a time in the near future when what has been described as " the catch-ascatch-can " method of anaesthesia by open ether without adequate basal hypnosis will cease to be employed in any surgical clinic worthy of the name. Pernocton preceded by morphine or omnopon has been the method of choice in my own practice ever since it was first brought to my notice by Dr, Macintosh, and I find for it a field of usefulness far beyond the normal preanaesthetic medication. For example, an injection of pernocton may be all that is necessary in setting fractures, passing sounds, cystoscopes, or sigmoidoscopes, extracting radium needles, and many other procedures not commonly regarded as particularly painful, but nearly always most unpleasant. It is even possible to insert radium needles with pernocton hypnosis alone without the patient knowing or remembering anything about it, as I found a few weeks ago when operating upon a man of 92 to whom it was not desired to administer inhalation anaesthesia. For more considerable surgical procedures it is obvious that the intravenous use of the barbiturates in conjunction with local anaesthesia is a natural development that will find increasing scope.-! am, etc., CEciL RowNTREE. London, W.l, March 19th. DIET AND DENTAL DISEASE SJR,-You co.nclude your leading article on diet and dental disease in the Journal of March 19th with the words : " Hence the dental condition of this community [Tristan da Cunha] appears to provide strong support for the theory advanced by Mellanby and Pattisonnamely, that a cereal-free diet favours the normal development of the teeth." Surely the theory of Mrs. Mellanby, put .forward through a number of years a.nd given the greatest publicity, was not :this at all, but rather that dental caries was caused through a lack of vitamin D. It would seem that only since her own work, as published in the Medical Research Council's Report No. 159, has thrown great doubt upon this, has she fallen back upon the matter of cereals as being the most important factor. Now as cereals are essentially acid-forming fo~ds, it will be obvious that an excess of these in the diet will tend to make the acid end-meta.bolites of the food definitely overbalance the alkalis-in other words, that the important factor in the production of dental caries is a chronic acidosis. There is no occasion to hypothesize, as Mrs. Mellanby does, an anti-calcifying factor. Yet this suggestion, particularly stressed by me, Mrs. Mellanby has fought strenuously for many years. Nevertheless, the theory that the acid-base balance of the blood is a matter considerably affected, though not entirely covered, by an alkali-forming diet, has received a great amount of support from the work of a number of observers. In addition to my own writings on the subject, the Toveruds' of Norway have proved that in pregnant women the common negative calcium balance can be repla,ced by a positive balance by feeding additional vegetables and fruits, and not by col-liver oil, and they expressly state that this is an important factor in tooth development. Hess• shows that vitamin deficiency plays no part in the production of 1
1
Toverud, K. and G.: Acta Paed .. xii, Sup. 11. Hess and Abramson: Dental Cosmos, September, 1931.
MARCH 26, 1932]
CORRESPONDENCE
caries, but that the amount of alkaline end-products of the food does. Boyd and Drain• show that a perfectly balanced diet, whatever its constituents may be, brings about an arrest of caries, even though cereals be present in considerable amounts ; the balance of the diet being not only in its constituent parts, but also in amount to produce just the correct amount of energy. Jones, Larcen, and Pritchard• show that excess of vitamins in the presence of an acid-forming diet will not prevent rampant caries. And Helen 'Mackay and Rose• have recently published work showing that vitamin D has no relation whatever to dental caries. All this, moreover, is upheld by Mrs. Mellanby's own work, in which the replacement of olive oil by cod-liver oil saved only one tooth in every two children each year ; or, if temporary teeth alone are considered, five teeth in every 200 children each year.• Her figures are not presented like this, but a critical analysis shows that this is what they amount to. Mrs. Mellanby.hersel£ is evidently dissatisfied with these results, for she says in her article in the journal: " It appeared, however, that there might be other factors apart from vitamin D influencing the carious processes," as well there might be in face of these figures. In these circumstances it seems hardly right to give the credit of the theory that a diet containing an excess of cereals is the cause of caries to Mrs. Mellanby, when such a worker as Dr., Eric Pritchard, for example, has been preaching for years that the whole matter is a question of the acid-base balance of the blood. There are, however, items other than those of diet which will come into the problem, items which are of importance in the lives of the islanders of Tristan da Cunha. An acidosis may come about irrespective of the diet if the other side of the metabolic equation, intake versus output, is upset. The expenditure of energy, voluntarily or involuntarily, is an important factor in the balance, .arid as this is very much affected by all the circumstances of civilization, this also must receive consideration, if the best results are to be obtained. The children in Mrs. Mellanby's experiment ·were all in bed ; their energy expenditure therefore would be reduced to a minimum, a.nd consequently the diet factor would be the most important. With children up and about, however, this would add a very serious disturbing factor, and make the obtaining of a perfect ·balance much more difficult.-! am, etc.,. F. w. BRODERICK, M.R.C.S., London, W.t, March 19th.
[
THE BRITISH ' MEDICAL JOURNAL
589
be the state of affairs in every Eastern country visitedthat is, good teeth in the parents and extensive caries in the rising generation. Mr. Mummery, school dental officer, Malaya, has reported to that effect in the Malaya Medical journal. I got information of the same kind during tours in Java, Sumatra, Ceylon, and Siam. Even in North Siam, which is well off the beaten track, 46 per cent. of the school children suffered from caries. These appeared to be the common features in all countries. Caries is greatest in the larger centres of population, where the sellers of delicacies pleasing to the young palate are most abundant, and it affects most those children who have pennies to spend. In fact, dental caries would appear to be the first influence of the spreading tentacles of civilization on the outposts. There can be no question of vitamin D deficiency among children who bake and play in the tropical sun. Rice is the staple article of diet both of child and of parent. If cereal is the cause of caries, why is caries a recent development. Why have not the parents got as bad teeth as their children? Another line of inquiry that appears to have escaped the notice of our investigators is that of our pampered pets. These animals suffer excessively, not only from caries and pyorrhoea, but also from septic ulceration of tonsils and stomach, from obesity, rheumatism, skin diseases, and premature old age. There is something strangely familiar about this picture. It would be interesting to know if these animals suffer from rickets and from vitamin D deficiency and if excessive cereal is the chief defect in their dietary. Referring to the inhabitants of Tristan da Cunha, they also are unable to acquire the sweet tooth, because no sugar is grown or imported into the country. Caries has become very prevalent among young Japanese, who are put to sleep with a dummy consisting of a sweet wrapped up in -linen. One can only arrive at one conclusion from these observations, and that is that the cause of caries among primitive races is the same as it has been in this country-history repeats itself on the outposts-namely, the growing use of refined carbohydrates, both as sugar and as sweet biscuits, etc. This also is the conclusion of the British dental authorities. I hope to submit further evidence on this subject at an early date. -1 am, etc., D. H. c. GIVEN, M.D., D.P.H., D.T.M., March 19th.
·
Surgeon Commander R.N.
L.R.C.P., L.D.S.
SrR,-1 cannot.let .the1eading article in the journal of March 19th, on the subject of diet and caries, pass without comment. Having spent the last eight years in the study of health in Asiatic races, the following were my findings. According to my· personal experience, in· the Indian labourer the proportion of perfect teeth free from defect was 68 per cent. in one group of 400, to 84.2 in another of 1,000 ; in the Chinese from 48 per cent. to 69 per cent. in corresponding groups. The second group in each case represented new immigrant labour to M;alaya, and the first, labour coolies who had been some years· in the country. I found also that there were three classes of Chinese as regards dental standard: (1) Northern Chinese, with a standard on a par with the Indian, (2) Cantonese and Southern China inhabitants, and (3) Straits-born; with the lowest standard. The women had a dental standard about on a par with the men ; that of the children between the ages of 2 and 14 years was very defective, the proportions with sound teeth being India~ 27 per cent. and Chinese 4 per cent. This appeared to 3 Boyd and Drain: A mer . .Tourn. Dis. Cl!ild., October, 1928. • ]ones, Larcen, and Pritchard: nmtal Cosmos, 1930. • Mackay· and Hose: Dental Record, January, 1932. • Medical Research Council Report, Ko. 159.
SrR,-Letters have recently appeared in the journal, and also in the Times, stressing the importance of general factors in the aetiology of dental disease. While not wishing to belittle the work which is being dene in this connexion, I think there is some danger that we may forget the more important factor of local cleanliness. Caries occurs mainly in the teeth of the young, while pyorrhoea affects chiefly those who are getting on in years. On this account, some authorities consider that there must be some form of antagonism between the two. I suggest, however, that this antagonism is more apparent than real. The local condition predisposing towards caries and pyorrhoea is the same-namely, stagnation. When this occurs in ·pits and fissures of the enamel, caries is the result. When it occurs round the necks of the teeth, pyorrhoea is the result ; but, as this is a much slower process, it does not usually become troublesome before middle life. Now by the time middle life is reached, most of the vulnerable spots on the teeth have either been filled or the teeth lost, the result being that the individual enjoys a comparative immunity to caries. The organic content of the teeth :ilso probably becomes less as age advances, with the re.sult that they become less " palatable " to the micro-organisms concerneC:..
682
MARCH
BluTtsR
INCARCERATED AND STRANGULATED HERNIA
20, 1954
no hernia had been noticed before. There were 29 babies in this group and 18% of these died. Group 2 consisted mainly of older babies in whom an easily reducible hernia had been observed previously, but in whom the hernia had suddenly become irreducible ; obstructive symptoms were minimal. There were 16 babies in this group and no deaths. It has been shown that, in the age group 1 week to 3 months, strangulated inguinal hernia is the commonest, almost the only, cause of intestinal obstruction. Owing to the ease with which an inguinal hernia can be missed in a baby, it is essential that the inguinal region should be carefully examined in' every infant presenting with symptoms of acute intestinal obstruction. We wish to express our thanks to the surgeons of the United Cardiff Hospitals for permission to use the notes of cases under their care, and to Professor A. G. Watkins for his criticism and advice.
MEDICAL JOUilNAL
Methods Only the deciduous teeth of pure Lapp children between the ages of 2 and 14 years were examined, a distinction being made between pure Lapps and half-castes. Some of these half-castes were Finno-Lapps (whose numbers are steadily increasing as the Lapp population becomes less isolated), but
F1 Utsjoki
(l'~
-")
!
!~
~·;·~·
R Utsjoki
!
ia:;·
Karagasni<>m•
" - · Karasuendo Enontekio
·-. Hetta
REFERENCES
He.-zfeld. G. (1938). Potts, W. J., Riker, Stammers, F. A. R. Thomdike, A., and
Amer. J. Surg., 39, 422. W. L., and Lewis, J. E. (1950). Ann. Surg., 132, 566. (1951). Ann. roy. Coil. Surg. Engl., 9, 189. Ferguson, C. F. 0938). Amer. J. Surg., 39. 429.
• Vuotso
CHANGES IN DENTAL HYPOPLASIA AND CARIES AMONG THE CHILDREN OF FINNISH LAPPS, 1939-50
/
BY
R. V. HOLMES JONES, B.A. AND
M. J. MYNOTI, B.A. (From St. Thomas's Hospital Medical School)
In 1939 a small survey of Finnish Lapps was made in order to discover the state of dental health among children living a semi-nomadic existence far from civilization (H. Mellanby, 1940). Since that time Europe had been at war for six years and for seven more has enjoyed a precarious peace. It was thought that these disturbed living conditions might be reflected among other ways in alterations in the structure of the children's teeth and their susceptibility to decay. For this reason the present survey was undertaken during the summer of 1950. Most of the children examined belonged, as before, to the Inari Lapps, but a few families of nomadic Fell Lapps were also inspected. Since the ceding to Russia in 1944 of the Petsamo area in the far north of Finland, the Skoltje Lapps have ceased to exist as a separate entity. Some have b::come Russian subjects, while others are scattered throughout the rest of Finnish Lapland. The Fell Lapps inhabit the Enontekio and Kilpisjarvi districts, sandwiched between Sweden and Norway (see Map). In this area a walk was made from Hetta northwards to the Norwegian border in the company of the local postman, three " summer villages " being visited. A few more children were seen in schools at Karasuendo, on the Finno-Swedish border, the total number of Fell Lapps inspected being ten. Ninety-two Inari Lapps were seen in Vuotso and in Lapp huts scattered along the length of the Utsjoki river and the Finnish bank of the Teno river from Utsjoki to Karagasniemi.
\'~ (
Rovanieml
,
__
.,....... ,."""'--·-·/
.•
r./L'-._._........'
~/;J FINNISH LAPLAND. 1950 the majority were German-Lapps, a permanent reminder of the German occupation between 1941 and 1944. Each mouth was inspected with an illuminated mirror and a standard probe. The structure of the teeth was estimated by the method described by M. Mellanby (1927a, 1927b, 1934), the grades of M-hypoplasia being judged by rubbing a sharp pointed probe over the labial surface of the teeth. The extent of caries in each tooth was also judged by the same method as that used by Mellanby (1934), the· Dental Disease Committee (1936), and Mellanby and Mellanby (1948), being estimated as caries 0, I, 2, or 3 according to the size of the cavity. To obtain average hypoplasia and caries figures the total hypoplasia and caries figures for each group were added up separately and divided by the number of teeth examined for structure and caries. This gave the average hypoplasia figure (A.H.F.) and average caries figure (A.C.F.). A measurement of the extent of healing caries was not attempted. Results The results are compared throughout with those obtained in the 1939 investigation by Dr. Helen Mellanby. Structure of Inari Lapp Children's Teeth.-When the structure of the deciduous teeth of these lnari Lapp children is compared with that found in 1939 (Table 1), there is seen to be a slight increase in the A.H.F. The considerable deterioration in structure of the complex teeth (molars) since 1939 has been incompletely counterbalanced by the improvement found in the incisors and canines. However, further analysis of the results into various age groups, as set out in Table 11, shows that this general picture is erroneously simple. While the A.H.F. of the 2-5-years age group was slightly below the 1939 total average of 1.09, that of the 6-9-year-olds was higher. There were too few children
MARCH
DENTAL HEALTH IN LAPLAND
20, 1954 TABLE
Total No. of Teeth Examined
683
I.-Structure of Teeth of Jnari Lapp Children Aged 2-14 Years
I
% M-Hy1
% M·HYo
% M-HYo
% M-Hy,.
% Gross
A.H.F.
·1
216 221
~~~~~~~~~~~~~~~1~~1~ 736 I 32·4 4S·S I 54·0 I 38·9 12·9 I 12·5 I 0·4 2·0 I J.l I· 0·81 0·70
··I
437
1,377123.7j27-ilj47-3j36.22s:sj27-3j_3_·_1---7-·3-l-=-[2-21!.091----w3
1939
Incisors and canines Molars .. .. Total
'MED!~U&NAL
641
15·4
5-6
40·2
33·2
38·5
44·3
5·8
13-1
-
3·4
1·35
1·67
Teeth wtth gross hypoplasia for 1950 are mcluded in the percentages, but are excluded from the calculations of the A.H.F. TABLE
H.-Average Hypoplasia Figure for Teeth of lnari Lapps, 1950, Arranged in Age Groups
No. of children
..
Incisors and canines Molars .. .. All teeth
..
2-S Years
6-9 Years
..
48
23
92
..
..
0·59 1·63
0·98 1-81
0·70 1·67
..
0·97
1·39
H3
2-14 Years
between 10 and 14 years with teeth whose hypoplasia could be assessed to obtain representative figures for this age group. Caries in lnari Lapp Children's Teeth.-The incidence and extent of caries in the different age groups of Inari Lapps are set out in Table Ill. Of the 92 children studied, only 6 TABLE
111.-lncidence and Extent of Caries in Deciduous Teeth of lnari Lapp Children No. of Teeth Examined
Age Group
1939
1950
..
208 313 (57)
843 452
..
578
.. ..
2-5 years 6-9 0-14
....
Total
(66)
11,361
%Carious
A. C. F.
I
~~~
1939
1950
24·0 68·3 (43·9)
22·9 42·8 (57·6)
50·0
30·9
0·39 1·57 (0·92)
0·36 0·85 (1·07)
-1-15 - - --0·55
were caries-free. Nevertheless, this is an increase on the number reported by H. Mellanby-namely, 3 out of 70. When the total number of teeth is considered comparison shows that the incidence and extent of caries have sharply decreased over the intervening years. This change has occurred almost entirely in the 6-9-years age group. Relationship Between Structure and Caries.-Table IV shows that teeth with good structure-namely, those with no surface hypoplasia-are less liable to be attacked successfully by the carious process than those showing M-hypo· plasia. This relationship has been demonstrated in all previous surveys using M-hypoplasia standards (notably M. Mellanby, 1923, 1934; Mellanby and Coumoulos, 1946; Mellanby and Mellanby, 1948, 1950, 1951 ; King, 1940). Furthermore, from a comparison with the 1939 figures it will be seen that the percentage of hypoplastic teeth which are carious is significantly lower in 1950 than in 1939. Teeth of Fell Lapp Children from Enontekio.-Although
only 10 children in the Enontekio area were inspected (owing to the great difficulty in reaching the nomadic families) and eight of these were between the ages of 8 and 11 years, the difference between the teeth seen in this group and those of the settled Lapps was so pronounced that the figures seem worth mentioning: 81% of the deciduous teeth were decayed, as compared with 46% in the same age group (8-11 years) of the Inari Lapps. TABLE
lV.-Percentage of Caries in Normal and Hypoplastic Deciduous Teeth of lnari Lapp Children Teeth with No Hypoplasia Teeth with 1-3 Hypoplasia• No.
Simple, 1939 .. 1950 Complex, 1939 1950
.. Total, ..
1939 1950
.. ..
.. .. .. ..
79 335 40 37 119 372
I %Carious
I I
I
No.
%Carious
7·6 3·3 52·5 (43·2)
170 393 203 582
24·7
22-7 7·3
373 975
li·S
70·9 53·9
I
49·9 36·4
• Teeth with gross hypoplasia have been excluded from this and other tables dealing with structure.
Discussion
The chief finding of this survey is the decrease of caries incidence amongst the 6-9-year·old lnari Lapps, although the structure of their teeth, as judged by surface hypoplasia, is worse than just before the war. As diet is believed to be largely responsible for determining the structure of the teeth (Mellanby, 1934; Mellanby and Coumoulos, 1947), and also to influence the rate and extent of dental decay, the changes of food habits among these Lapps during and after the war have been investigated. Dr. H. Mellanby (1940) found that the staple foods among the Inari Lapps in 1939 were reindeer meat, dried fish, potatoes, rye bread, and margarine. The universal drink was coffee liberally sweetened with sugar. Two noteworthy points are that almost all the salmon was at that time sold to the tourist hotels and that very little fresh fruit was eaten. Although the Russo-Finnish war of 1939 did not appreci· ably alter the food habits of the Inari Lapps, throughout the second war (1941-4) and the German occupation, in the final stages of which 200,000 well-paid German troops were present in Finnish Lapland, much more " European food" was imported. Moreover, during this period the Lapps enjoyed an economic boom, working for the Germans and supplying them with meat and fish. So during the years 1941-4 the Lapps lived on a diet containing more cereals, sugar, and potatoes than in 1939 but much less meat and fish. In view of this it seems probable that the calcifying power of their diet at this time was low. However, in 1944, as one condition of ·the Finnish peace treaty with the Russians, the Germans were driven from North Finland. As the Germans retreated they employed a scorched· earth policy. In order to escape some of the con· sequences of this action the Inari and Utsjoki Lapps were evacuated to Kalajoki in central Finland, while many of the Enontekio Lapps moved over into Sweden. In the Kalajoki community the Lapps existed on a subsistence diet, and diseases such as typhoid were rampant, whereas in Sweden and Enontekio Lapps were well housed and fed. When they returned to their own country in mid-1945 almost all the buildings had been burnt or blown up (we saw only one house left standing since 1939) and living conditions were extremely crude for the next two or three years. During this time the Lapps lived largely on fish and meat, and food supplied by various philanthropic organizations. Since 1948 the diet has gradually been reverting to the 1939 pattern. The main differences to-day are that less fish is sold to tourists, and that the Lapps seem more conscious of the value of eating fresh fruit. In addition, expectant mothers through Finnish Lapland are now visited by the district nurses and considerable prenatal care is exercised. Although representative figures were not ·obtained, the teeth of the 1Q-14·year-old children might be expected to show a similar structure to those inspected in 1939, these teeth having been formed between 1936 and 1940. The period of formation of those aged 6-9 years coincided with the German occupation of Lapland, and it seems possible to account for the defective structure of the teeth of the children in this age group as being due to the particularly low calcifying power of the diet at this time. The children aged 2-5 years have recovered and slightly improved upon the pre-war structure, as would be consistent with a diet of higher calcifying power.
684
MARCH 20, 1954
BIUTISII
DENTAL HEALTH IN LAPLAND
When considering factors which might be expected to influence decay it will be realized that the teeth of the oldest group have had a chequered existence since eruption. The effects of these factors have been so balanced that the caries figures are now the same as in 1939. Teeth in the youngest group, with slightly better structure, show slightly less decay than in thl!t year. But the striking change is that the A.C.F. of children aged 6-9 is only just over half its 1939 counterpart in spite of the teeth having a worse structure. In broad terms, therefore, the post-eruptive influences since 1945 must have been less damaging than in the previous years. This can be explained either by an increased tooth resistance due to a higher post-eruptive dietary calcium intake or by a decrease in the factors favouring decay. However, if the calcifying power of the diet during this time is reflected in the tooth structure of the children under 5, the dietary calcium since 1945 has been substantially the same as before the war. Therefore it seems that the teeth of the 6-9-yearolds are less carious, not because they are more resistant, but because there are fewer external influences favouring decay. Although more meat and fish was eaten during those years the one factor in the diet which is known to have decreased is sugar. A tentative conclusion on this evidence must be that a low-sugar diet decreases the chance of caries. With regard to the caries figures of the Enontekio and lnari Lapps it is significant that in 1945 the former moved over to Sweden, where they fed well by European standards (with plenty of sugar and vitamin-fortified margarine), while in their homes after their return they were able to trade with smugglers travelling between Norway, Finland, and Sweden who largely carry spirits, sugar, and margarine. So in addition to their vitamins A and D intake (contributed mainly by the margarine and fresh fish) being as high as, or possibly higher than, that of the lnari Lapps, their sugar consumption also was much higher. Now since the state of their teeth is so much worse than that of the Inari Lapps, they must have been subjected to factors favouring decay to a much greater extent than the Inari Lapps' teeth. In this case a high-sugar diet might b& incriminated.
Smnmary and Conclusion The changes found in both Fell and settled Lapps fall in line with other wartime studies and the conclusion of Toverud (1951) that "the knowledge gained through the greatest dietary experiment forced upon us strengthens the value of more natural foods and less of easily fermentable carbohydrates in the prophylaxis against dental caries." The teeth of 92 settled and 11 nomadic Lapp children were inspected for caries and surface hypoplasia. The state of the teeth is compared with that existing in 1939. An attempt is made to correlate the changes found in the teeth with the alterations in diet during the intervening period. We would like to thank Lady Mellanby for her guidance and instructions before undertaking this survey ; and to express our gratitude to Dr. H. Mellanby for her help, advice, and encouragement. REFERENCES
Dental Disease Committee (1936). Spec. Rep. Ser. med. Res. Coun. Lond., No. 211. King, J. D. (1940). Ibid., No. 241. Mellanby, H. (1940). British Medical Journal, 1, 682. and Mellanby, M. (1950). Ibid .. 1, 1341. Mellanby, M. (1923). Brit. dent. i., 44, I. (1927a). Ibid .. 41, 737. (1927b). Ibid .. 48, 1481. (1934). Spec. Rep. Ser. med. Res. Coun. Lond., No. 191. and Coumou1os, H. (1946). British Medical Journal, l, 565. -- (1947). Ibid., 1, 753. and Mel19nby, H. (1948). Ibid .. :Z, 409. (1951). Ibid .. 1, 51. Toverud, G. (1951).-lnt. dent. J., :Z, 131.
MEDICAL JOURNAL
CHILDREN'S NURSING UNIT BY
JOS. A. GILLET, M.B., Cb.B., D.P.H. Medical Officer of Health, County Borough of Rotherham
Following on a high infant death rate in Rotherham during the winter of 1948 and early 1949, considered to be largely due to cross-infection in hospital, the health committee in March, 1949, approved a scheme for the establishment of a children's nursing unit as part of the home nursing service. It was to be at the disposal of the family doctor as a first line of defence so that a child could be nursed at home in its qwn environment, except when conditions were such as to make this impossible, or when special treatment necessitated removal to hospital. It was also appreciated that the value of the education of the mother in practical preventive methods and treatment during illness, with the necessary equipment, even in what might appear at first sight to be hopeless domestic conditioq.s, . would ultimately be of benefit to the community and that such action would help to reduce the pressure on hospital accommodation. Preparations for the Scheme Authority was given to obtain special nursing equipment, including infants' clothing, treasure cots, the necessary gowns, masks, storage cupboard, and nursing bags. Some of this equipment was given to the service, the treasure cots being presented by the Rotherham District Nursing Benevolent Association ; and the children's nightgowns, coats, vests, etc., were either knitted locally or received in gift parcels from New Zealand, the remainder being purchased. One of the Queen's Nursing Sisters on the home nursing staff undertook a postgraduate course covering children's diseases, and she was made responsible (under the direction of the home nursing superintendent) for this special service. Later on in the year, a second nurse received similar training. During 1952 both nurses undertook· further hospital duty as refresher courses. The doctors practising in the town were informed of the facilities available and the unit began to function in June, 1949. Cases are notified direct to the superintendent, usually by telephone by the general practitioners, and the special home nurse visits the home to assess whether the case is suitable and what equipment is needed. The equipment is kept in the nurses' home and special containers are packed and sterilized ready for use in infectious cases. During the winter months cases are so numerous that the two special nurses are unable to deal with them all, and each home nurse attends the overflow cases on her district, giving a specially detailed report on all cases after each visit. Additional assistance is also given to the unit by the Queen's candidates as part of their training. The frequency of visiting depends on the child's condition ; often it is necessary to pay three or four visits daily. The home nurse is in frequent consultation with the general practitioner, who is informed immediately if the child does not appear to be responding to treatment. The parents are encouraged to contact the nurses' home if they are unduly worried about their child's condition, and a nurse (usually the superintendent) pays a visit immediately. Night calls have been very few, and it is felt that the assurance of a visit from the nurse at any time removes a good deal of the parents' anxiety. Equipment Details of the equipment now used by the unit are as follows : 4 treasure cots ; 1 dozen sheets ; 2 pillows ; 3 enamel pails ; 6 wash basins ; 6 enamel trays. 6 by 4 in.
JAN. 5, 1952
TISSUE REACTIONS TO PROTEIN SENSlTlZATION
cells, can be poured through glass wool, to which the polymorphs adhere. The filtrate has only to be lightly centrifuged to obtain lymphocytes-alive if suitably handled. Do these cells carry the essential properties required by the hypotheses ? If so, under what circumstances? Similarly, many more experiments need to be performed before the explanation of the various types of " antibody " found in asthma can be regarded as " being on a scientific basis." Summary Protein sensitization in man is a suitable subject for
scientific study, especially when reinforced by animal experiments. Two main types-the asthma-urticaria and the tuberculin-trichophytiD type--are considered and contrasted. Some of the methods of controlling sensitization reactions are discussed. Tentative hypotheses suggesting further experimental work are outlined. RBPBRBNCBS
Biggart, J. H. (1932). J. Path. Bm:t., 35, 799. · Blackley, C. H. (1873). Experimental Resrarches on the Causes and Nature of Catarrhus Aestivus (Hay-fever-or Hay-asthma).
London. Bovet, D., and Staub, A. M. (1937). C.R. Soc. Bioi., Paris, 124, 547. Burnet, F. M., and Fenner, F. (1949). The Production of Anti· bodies, 2nd ed. Melbourne. Chase, M. W. (1945). Proc. Soc. exp. Bioi., N.Y., 59, 134. Code, C. F. (1937). J. Physiol., 90, 485. CookeJ R.. A., and Sherman, W. B. (1950). In Pathologic Pnysiolofy, edited by W. A. Sodeman, p. 706. London. Coulson, E. ., and Stevens, H. (1949). J. lmmunol., 61, 119. Cruickshank, C. N. D. (1951). Nature, Lond., 168, 206. · d'Abreu, A. L. {1940). Lancet, :Z, 421. Discombe, G. (1946). lbid;~., 1, 195. Ebert, R. H., Sanders, A. v., and Florey, H. W. (1940). Brit. J. exp. Path., 21, 212. ravour, C. B., Fremont-Smith, P., and Miller, J. M. (1949). Amer. Rev. Tuberc., 60, 212. Gaddum, J. H. (1948). British Medical Journal, 1, 867. Halpern, B. N. (1950). Acta allerg., Kbh., 3, Suppl. 1, 164. Hare, R. (1926). Heart, 13, 227. Harley, D. ,(1937). Brit. J. exp. Path., 18, 469. (1942). Studies in Hay-fever and Asthma. London. Kabat, E. A. (1947). Amer. J. Med., 3, 535. Koch, R. (1890). Quoted by Rich (1944). Lawrence, H. S. (1949). Proc. Soc. exp. Bioi., N.Y., 71, 516. Lewi!t T. (1927). The Blood Vessels of the Human Skin and 1·heir Responses. London. and Grant, R. T. (1926). Heart, 13, 219. Long, D. A., and Miles, A. A. (1950). Lancet," 1, 492. Loveless, M. H.. (1940). J. lmmunol., 38, 25. (1941). lb1d., 41, 15. Miller, J. M., and Favour, C. B. (1951). J. t>xp. Med., 93, 1. Raffel, S. (1948). 1. inject. Dis.• 8:Z, 267. Ramirez, M. A. (1919). J. Amer. med. Ass., 73, 984. Ratner1 B. (1939). Amer. 1. Dis. Child., 58, 699. Richr. A. R. (1944). The Pathogenesis of Tuberculosis. Springneld Illiilois. - and Lewis, M. R. (1932). Bull. Johns Hopk. HosTJ., SO, 115. Rimington, C., Stillwell, D. E., and Maunsell, K. (1947). Brit. J. exp. Path.1 Zl, 309. Salter, H. Hyae (1860). On Asthma: Its Pathology and Treatment. London. Seibert, F. B. (1944). Chem. Rev., 34, 107. Squire, J. R. (1950). Clin. Sci., 9, 127. Stull, A., Cooke, R. A., and Chobot, R. (1931). J. bioi. Chem .. 92, 569. Wadley, F. M. (1949) Amer. Rev. Tuberc.,, 60, 131. The annual report of the honorary secretary of the Joint ruberculosis Council briefly records the work of the council during the year. Probably the most important achievement was the completion and publication of forms of record for use in chest clinics. At the request of the Ministry of Health the council drew up a memorandum on the internal administration of hospitals, and members of the council also assisted the Ministry in drawing up a report on skiagraphic terminology and radiographic technique. A trial of a four-digit classification of tuberculosis was undertaken at the request of the World Health Organization.
DENTAL DISEASE AMONG 14-YEAR.OLD LONDON SCHOOL-CHILDREN
IN 1947 AND 1950 BY
MAY MELLANBY AND
HELEN MELLANBY, M.D., Ph.D. with the assistante of JOAN JOYNER. B.Sc., and MARION KELLEY (Prom the Nutrition Building, National Institute for Medical Research, Mill Hill, London)
The Education Act of 1944, which raised the schoolleaving age to 15, gave the opportunity for making dental surveys of the 14-year-old group. This age is suitable for the examination of the permanent teeth, as most types have erupted, with the exception of the third molars, while few deciduous teeth remain to be shed. It also provides an overall picture of the state of dental fitness of a section of children the majority of whom are about to leave school, and as such it will no doubt be of interest to the public health authorities. The two surveys with which this paper is concerned were carried out during the winter months of 1947-8 and 195Q-1, but for the sake of brevity they will be referred to as the 1947 and 1950 surveys. The London County Council very kindly afforded facilities for making the inspections, all of which took place in schools under their authority, the number of children examined being 1,216 in the earlier year and 1,089 in the later. These children were unselected samples distributed between modern, technical, and grammar secondary schools, the proportions from each bearing a rough relation to that of the total child population attending the different kinds of secondary schools in the area. In both surveys approximately 72% were from the modern schools, 12% from technical schools, and 16% from grammar schools. Since more children attend modern schools, any differences between the teeth of these children in the two surveys have more influence on the total figures than have the differences between the teeth of technical or grammar pupils. The samples of children from the latter kinds of school were too small to give more than an indication of possible differences between them and the modems, especially where individual types of teeth are concerned. The exaQlination procedure and the charts used for recording the dental condition of the children were basically the same as those employed in the surveys of 5-year-olds from 1943 onwards (see Mellanby and Coumoulos, 1946), but certain adaptations were made to suit the charts for use with the permanent dentition . (see Chart). Although external structure (as gauged by M. Mellanby's probe method),- the incidence and extent of caries, mottling of the enamel, tartar, gingivitis, alignment, and occlusion were recorded, in the present paper only the results relating to the incidence and extent of caries, gingivitis, and tartar are given.
"
Methods Each child's mouth was carefully examined by one of us with a standard probe and illuminated mirror, the results for each individual being separately charted.
8 JAN. 5, 1952
DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
BllmsB MEDICAL JoURNAL
second molars, remained unerupted. Each case of apparent non-eruption was judged on its merits ; for _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ Data. _ _ _ _ __ instance, when the. deciduous precursor was either in situ or had very Gln&lvltls 0. 1. 2. ) recently been shed, or the outline Tanar of the permanent tooth could be seen through the gum, it was then Mottllng 0, I. 2. l obvious that a given tooth had not M-hypoplasia (0. I. 2. l) I G erupted. In the case of the second Caries 0. I. 2.) molars the decision of non-eruption versus extraction was sometimes 7 6 s 4 ) 2 I I 2 ) 4 5 6 7 Teeth Present more difficult, but the. appearance 7 6 5 4 ) 2 I I 4 2 ) 7 5 THth P.--nc of the gum combined with the stage of eruption of other teeth, Caries 0, I, 2.] especially the other second molars M-hypoplasia (0. I, 2. 3) I G in the same mouth, usually proMottllng 0. I. 2. ) vided sufficient evidence one way or another. Tanar When no carjes was detected in Gingivitis 0, I, 2. ) any of a child's permanent teeth, State of m o u t h - - - - - - - and there was also no evidence of Allgnment _ _ _ _ _ _ any such teeth having been exOccluslon _ _ _ _ _ _ _- " - tracted or filled on account of Stain _ _ _ _ _ _ _ _ __ decay, that child was considered for the purpose of this investigation The expression of the incidence of caries alone, to be caries-free, though no doubt it might have been whether given as a percentage or as the D.M.F. (decayed, found to have decay had ancillary aids over and above missing, filled) figure, does not in our opinion provide a probe and mirror been used. If only a sml{ll amount a complete picture of the state of the teeth, as a group of caries was detected in a child, such as one, two or of individuals with small cavities would appear on paper three grade 1 cavities, and there had again been no to have the same amount of caries as a group in which extractions or fillings, that child was placed · in a the cavities were large. In these surveys, therefore, when separate category labelled " slight caries " to distinguish caries was considered to be present in a tooth an attempt it from children with more extensive lesions. These two was made to assess the extent by grading the lesion 1, groups, the" caries-free" and those with "slight caries," together give an idea of the proportion of children who 2, or 3 according to the following criteria : Grade Ct. Slight Caries.-(a) Pits and fissures suspected at 14 would be considered to have "good" mouths. Gingivitis, when present, was roughly divided into of caries on account of the probe sticking. (b) Indefinite approximal caries (i.e., presence strongly suspected). (c) Tiny three grades, depending on the degree of swelling and visible cavities up to about 1 mm. in diameter. hyperaemia, especially of the interdental papillae, Grade C2. Moderate Caries.-<:avities larger than those coupled with the extent of this in each mouth. Children in grade 1, but not involving more than one-quarter of the with " normal " gingivae were classified as 0. Their crown. gum tissue was a uniform pale pink with thin edges. Grade Ca. Severe Caries.--<:avities involving more than closely adherent to the tooth surfaces, the spaces between one-quarter of the crown. In this last category were also adjoining teeth being filled by the points of the interplaced all teeth assumed to have been extracted for caries, dental papillae. The appearance of the gum surface and those of which only carious roots remained. was matt, due to the presence of stippling (King, 1945) When a history was obtained of teeth extracted for as opposed to the shiny surface seen in abnormal tissues. regulation or following trauma, these were excluded Grade 1 (mild gingivitis) included children with shiny from all the results. Filled teeth were counted as having and slightly swollen papillae between a few teeth, as been decayed, since it is unlikely that any of the children was most eommonly found in the lower incisor region. examined would have bad " preventive " fillings inserted. Grade 2 (moderate gingivitis) contained those children In assessing the probable size of a cavity before treat- in whom large areas of the gingivae were slightly affected, ment a small allowance. was made for removal of extra or who had considerable amounts of swelling and tooth substance in preparation. For instance, very small hyperaemia round a few teeth, with the rest ,little amalgam fillings in fissures of the molar teeth were affected. Grade 3 (severe gingivitis) was used for those graded C 1 , and fillings anywhere which only just ex- children with very obviously thickened, reddened, and ceeded one-quarter of the crown were graded C 2 • From swollen gum tissue. In some individuals this might be this assessment of caries extent, an average caries figure confined to the anterior teeth, but in others it was more (A.C.F.) was derived according to ·the formula set out extensive. A few in this group had advanced gingival in the footnote to Table IV. It is fully realized that disease with ulceration and pocketing. this method of assessing the extent of caries can give Tartar deposits on individual teeth 'were graded on only an approximate result, as it relies largely on naked- the charts as 1, 2, or 3, according'to whether they covered eye inspection, but when it is employed by the same up to one-third, two-thirds, or the whole of the buccal investigators for successive surveys it gives comparable or lingual surface. From these figures an average results. assessment for each mouth was obtained, and the A small proportion of teeth (approximately 3%), children were then graded into four categories--o, 1, 2, chiefly upper canines, upper and lower premolars, and and 3. PERMANENT TEEl r1
Name _ _ _ _ _ _ _ _ __
No. _ _ __
Date ol81nh, _ _ _ _ _ __
kh~l
'
~--
5, 1952
JAN.
DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
In Table II an attempt has been made to gather together from the literature a few comparative caries figures for other groups, mostly children of fairly similar age who had also been examined with a probe and mirror. From this table it will be seen that in some communities, such as Hagerstown (U.S.A.) and NewT~BLE I.-children Caries-free or with Slight Caries. and the Average Number of Carious Permanent Teeth per Child foundland, caries incidence was high, only 4.6 and 0.8% (D.M.F.) respectively of the children examined being caries-free at 14 years of age. Children from Chicago, Trinidad, 1 4 2 3 5 and American Indian reserves gave intermediate figures Percentage Average of 14.4, 13.8, and 23% respectively of individuals carie!lwith Slight No.
::I
TABLE
Place
H.-Comparative Figures for Dental Caries in Different Parts of the World,
Author
Date of Survey
No. of Individuals Examined
Percentage Percentage of Average No. of Teeth Carious Decayed Teeth of Comments per Person Individuals orD.M.F. (D.M.F.) Caries-free per I 00 Teeth 0·56 2·01 84 Young adults (approx.) (approx.) Aver. 27 years Deciduous and p er· 1·5 so 5-16 manent teeth Indians distributed be~·12 11·1 23 14 and 15, tween 76 reserves in (approx.) 16 States Rural fishina com2·2 8·5 30·8 13-15 " munities as typtcal Described 5·2 19·2 4·6 14 East U.S.A. small " Age Group
Africa, Ke117a
..
M. Mellanby(1934)
1929
103
<\frica, Zanzibar
..
M. Mellanby (1934)
1929
154
U.S.A. American Indians in reaerve~ ..
Klein a,;d Palmer (1937)
(929-33
Scotland,
King (1940)
1937
185
Klein et al. (1938)
1937
364
Dean et al. (1941)
1939
2,832
12-14
475
11-15
247 {406 100 595
16-20 12-14 12-14 14
500 500 500 500 266 801
12 12 12 12 14 13-20
Iole
of
Lewia
U.S.A. 1 Hqentown, _ Madison U.S.A., Chicqo
..
Italy (four northern
cities) Trinidad British ouida Newf'oundlaad
.. ....
E~~~i Soutlo. Enaland, North Shields India, Lucknow
Schour and Masslcr (1947) King and Martin (1951) H. Mellanby (unpublished work) Weaver (1950) Weaver (1950)
..
M. Mellanby (unpubllshed work)
r945 1945 1948 1948
r 1949 1943
1~49
1951 1951
1,300
..
" "
.... .... ..... ..
...
14·4 (average) 53-4 38·4 13·8 13·0 0·8 25-8 50·6 4·8 26·4 65-8 60·8
21·7
4·73 (average) 1·05
---
2·4 1·3 4·3 2·4
2·02 5·37 4·91 8·39
18·4 30·7
2·71 3-4
I
0·95
town
Average of eight separate communities Deciduous and per· manent teeth Permanent teeth East Indian and N egro children 1·4 p.p.m. fluorine in water supply Nesligiblc fluorine
10 JAN. 5, 1952
DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
A proportion of the spaces for unerupted permanent teeth were still occupied by deciduous predecessors ; for example, in 1950 there were 139 deciduous teeth still retained, of which 33.1% were upper canines and 57.6% were second molars. No records were made of TABLE
Variety of School
1947
1950
Upper jaw: Central incison
..
{Modem Technical Grammar
99·0} 99·7 99·2 99·7
98·9} 99·8 98·8 99·1
Lateral incisors
..
{Modem Technical Grammar
97·8} 98·7 98·2 99·5
98·3} 98·6 98·2 97·9
..
..
{Modem Technical Grammar
97·3} 98·0 97·7 98·9
97·4} 96·0 96·7 94·4
I st premolars
..
{Modem Technical Grammar
97·8} 96·7 97·5 96·8
99·1} 98·5 98·6 97·6
2nd premolars
..
{Modem Technical Grammar
91·6} 91-1 91·9 94·1
92·8} 93·8 93·3 -95·3
..
..
{Modem Technical Grammar
90·5} 95·7 92·1 96·8
93·6} 93·8 93-6 93·8
..
{Modem Technical Grammar
93·8} 90·2 93·3 93·5
96·8} 85·6 96·4 95·9
Central incisors
..
JModem Technical LGrammar
99·8} 99·9 100 100
99·7} 99·3 99·6 99·4
Lateral incisors
..
{Modem Technical Grammar
100 100
99·7} 99·6 99·7 98·4
..
..
{Modem Technical Grammar
99·4} 99·7 99·5 100
88·7} 99·8 99·8 100
1st premolars
..
{Modem Technical Grammar
95·7} 93·4 95·4 95·7
97·4} 97·4 97·5 99·1
2nd premolars
..
{Modem Technical Grammar
83·2} 84·4 84·2 88·5
87·0} 89·0 87-8 89·9
..
..
{Modem Technical Grammar
83·2} 89·1 85·1 90·9
87·8} 89·0 87·0 82·2
2nd molars ..
..
{Modern Technical Grammar
93·7} 92·4 93·4 92·5
98-7} 98·3 95-8 958
Totals for upper and lower jaws
{Modem Technical Grammar
94·5} 94·9 94·8 96·2
95·9} 98·1 95·9 91·7
Canines
1st molars 2nd molars Lower jaw:
Canines
1st molars
TABLE
1
2
Type of Tooth
Total No. of Teeth (including Extractions) 1947
Upper jaw: Central incisors Lateral Canines I st premolars : : 2nd , .. 1st molars .. 2nd ..
.. ..
1950
99-7}99·8
N.--Caries Incidence and Extent in the Combined Schools 3
4
5
6
7
8
Teeth Graded
Teeth Graded
Teeth Graded
Teeth Graded
(Slight Caries)
(Moderate Caries)
(Severe Caries)
Total Carious Teeth (Equiv. ofD.M.F. per too Teeth)
A.C.F.*
c.
(No Caries)
1947
%
1950
%
c,
1947
%
2,279
2,170 2,171 2",173 2,128 1,910 2,177 2,101
99·1 99·3 99·9 99·1 96·1 33·6 67·6
99·& 99·1 100·0 99-1 18·9 38·6 66·4
..
16,364
14,838
84·7
85·8 88·1
Total for u. and I. Jawa
32,864
28,713
85·4
2-1
1·8
13·9
13·3
0·24
0·22
0·04 0·04
--0·4
0·9 0·7 0·1 0·9
0·5 0·2 0·05 0·9 3-1 61-5 33·8
0·01 0·01 0·001 0·02 0·07 1·38 0·46
0·01 0·003 0·001 0·01 0·08 1-11 1·10
0·1 0·1 0·06 0·4 1·4 25·0 10·8
2,429 2,427 2,420 2,323 2,055 2,431
-0·1
-0·4
1-1
18·5 20·2
2·0 28·3 10·7
5·5
5·8
6·1
&·6
5·9
8·1
5·8
5·3
1950
0·09 0·12 Hl2 0·22
0·4 0·4
...... .. ......
1947
0·8 9·6 0·7
0·3 0·0
86-7
%
%
0·15 0·10 0·002 0·08 0·08 0·88 0·21
0·5 0·3 0·1 0·2 1·3 16·4 20·0
86·1
1950
%
0·10 0·08
&·1
14,877
1947
8·4 6·8 0·2 6·0 5·7 49·7 15·4
5·5
16,500
4·4
3-8
1950
6·1 5·0 0·6 4·9 7·1 55·3 17·5
8·4
Total for upper jaw •.
.
%
6·3
......
H 2·3 0·3 1·8 3·3 20·0 13-6
Total for lower jaw
%
1947
0·1 2·4 2·8 20·3 10·5
90·8 83·2 99·9 96·0 94·3 50·3 84-6
Lower jaw: Central h;tcison Lateral , Canines .. 1st premolars 2nd .. tst mol.,;.; .. 2nd ..
%
1950
0·5 0·4 0·2 O·S 0·8 11·8 0·4
93·9 95·0 99·4 95·1 92·9 44·7 82·5
.
%
1947
c,
4·1 2·9 0·1 2·0 2·2 19·9 4·2
2.169 2,141 2.101 2,162 2,036 2,178 2,105
.. ..
1950
c,
2·5 2·3 0·2 2·6 3·0 23·5 3·6
2,415 2,392 2,380 2,379 2,237 2,427 2,270
..
JOUllNAL
decay in these teeth, all the figures for caries incidence and extent given in this paper referring to the permanent dentition only. An analysis of the caries results for both surveys and for each type of permanent tooth in the combined schools is given in Table IV. Column 2, compiled from the numbers of teeth inspected plus those extracted for caries, shows the total numbers on which the analysis is based. As is usual in most civilized communities, the tooth most frequently attacked by disease was the lower first molar (over 60% in each survey being carious), with the upper first molar coming next. The least attacked were the canines, the lower incisors, and the lower first premolars. The caries incidence for all types of teeth together was 14.6% in 1947 and 13.9% in 1950 (Table IV, column 7). When the different types of teeth are considered individually, however, it will be seen that there was more caries in 1950 among the upper incisors and rather less in the first molars. 1l1e A.C.F. for these teeth (column 8) showed corresponding increases in the upper incisors and decreases in the first molars. The very slight overall improvement in the caries position in 1950 compared with 1947, therefore, was not achieved by a uniform reduction of decay, but rather by the reduction in the incidence of first molar decay exceeding the increase experienced in the upper incisors. The caries incidence and extent in the three varieties of school are set out in Table V. From the total percentages at the bottom of column 7 it will be seen that in 1947 the technical schools had the lowest overall caries incidence and the modern schools the highest, though the difference between them was very small (13.7% compared with 14.8% of teeth affected). By 1950 there had been a slight reduction of caries in the modern schools (from 14.8 to 13.4%), whereas in the other two groups the incidence had apparently increased a little .(from 13.7 to 14.8% in the technical schools and from 14.5 to 15.4% in the grammar schools), though as the samples were small too much importance should not be attached to individual results for technical and grammar schools. It will also be seen from Table V, column 7, that the improvement in the caries position
111.-Percentage of Permanent Teeth of Each Type In Situ
Type of Tooth
B1Ul1811
MJmrc.u.
-0·3
0·6 21·7 1·7
0·9 0·4
-0·8
o-ot
0·7 18·0 2·8
66·4 32·4
3-6
3·2
15·3
14·4
C)-29
0·18
2·9
2·5
14·6
13·9
0·26
0·24
3-9
Total cartes figure No. or C, + UNo. or C,) + 3(No. of C ,) • A.C.F. (averaae caries fiaure) = Total numbel- of teeth, including cxtral:tions- Total JIWDber of teeth, illduding extrar.:tioas
JAN.
5, 1952
DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
of the modern schools in 1950 was largely attributable to the marked reduction in the caries incidence in the first molars, whereas in the other varieties of school there was an increased incidence in these teeth. The upper incisors showed more decay in all three kinds of school in 1950, but it was greater in the technical and grammar than in the modern schools. These differences are also seen in the average caries figures (column 8). The greatest discrepancies between the schools in the respective surveys occurred in the lower second molars in 1947 and in the upper and lower first molars in 1950. When the percentage of carious teeth found in the London children in 1947 and 195Q-namely, 14.6 and TABLE
~
I
Type of
School
Tooth
Teeth Graded C, (No Caries) 1947
1960
1947
%
%
%
{Modern Technical Grammar
35·8 67-1 74·9 64·2
1·0 1·7 1·0 19-1 15·8 18·1 22·3 16·6 13·5
{Modem Technical Grammar
85·2 86·3. 85·5
88·8 85·2 84·8
5·8 5·7 6·7
6·2 6·3 6·4
{Modem Technical Grammar {Modem Technical Grammar
Lower jaw:
!
Central incisors
'{Modern Technical Grammar {Modern Technical Grammar
..
{Modern Technical Grammar
Ist premolars ..
{Modern Technical Grammar
2nd premolars ..
{Modem Technical Grammar
..
{Modern Technical Grammar
1st molars 2nd molars
..
All types
%
1·3 1·2 1·2 15·6 17·2 19·5 19·6 16·9 24·6
{Modem Technical Grammar
2nd premolars ..
Canines
%
-
{Modem Technical Grammar
ht premolars ..
Lateral incisors
1947
-0·1 -0·3
{Modem Technical Grammar
..
37-4
3·0 3·3 2·9 2·3 3·3 1·6 0·2 0·7
-
2·0 1·0 2·0 3·5 1·8 3-4 18·5 23-9 23-8 14·1 9·6 14·3 0·5
4·6 6·9 3·0 4·0 5·8 3-8 0·1
2-1
2-7 2-7 3·1 19·0 27·8 20·4 11·2 9·2 8·3
0·3
--
0·2
0·2 0·4
-2·7
2·4 2·2
-1-1 --
2·4 3·0 2·4 2·0 3·7 2·7 0·2 0·3
--
0·1 0·4 1·2
-0·5
Teeth Graded C, (Moderate Caries)
1960
99·7 99·8 98·5 99-9 99·8 98·7 99·9 100·0 100·0 89·0 98·8 98·8 88-7 98·3 97·4 40·8 38·0 30·9 64·8 70·9 69·8
{Modem Technical Grammar
2nd molars
Teeth Graded C, (Slight Caries)
99·0 100·0 98·4 99·1 100·0 99·5 99·8 100·0 100·0 99·0 98·6 100·0 95·9 96·9 96·4 32·5
Lateral incisors
..
5
91·7 86·7 88·1 94·2 91·8 90·0 99·8 100·0 100·0 95·2 93-7 95·5 94·2 94·9 94·8 64·6 40·1 39-1 84·3 88·2 85·0
{Modem Technical Grammar
1st molars
4
94·0 93-I 94·4 95·3 92·6 95·4 99·3 99·0 100·0 94-9 95·2 95·9 92-9 94·9 91.5 45·4 41·7 43·8 81·6 87·2 82·9
Central incisors
Canines
V.--caries Incidence and Extent in Three Varieties of School 3
Upper law:
13.9-are compared with the findings in other groups in various parts of the world (see Table Il), it will be seen that the London children occupy an intermediate position. They have less decay than West Indian, Newfoundland, and some U .S.A. children, but more than children from Lewis (Scotland), and many more than groups of Africans and Indians. Table VI, which indicates the amount of dental treatment given to the London children, shows that approximately the same percentage of carious teeth had been extracted in the case of the children· examined in the two surveys-12.3 in 1947 and 11.5 in 195Q-while there was a slight falling-off in the percentage of carious
%
2·9 7·0 7·4 2·2 2·2 5·4 0·1
1-7 3-7 2-1 2·8 1·2 1·2 17·0 23·6 30·8 4·0 3·8 6·8
0·5
0·1
0·5
---
7
8
Teeth Graded C, (Severe Caries)
Total Carious Teeth (Equiv. of D.M.F. per I 00 Teeth)
A.C.F.•
1947
1950
1947
%
%
%
-
--0·8
--0·5
-
0·1 --
-
--
0·3 0·1 0·4
-
0·1
--
-
0·3 0·4
2·2 1·6 1·5 27·1 29·5 32·9 11·2 7-9 10·1
0·6 0·4 0·9 24·8 IS·9 11·8 2·1 0·4 1·2
5·7 6·0 6·1
4-7 6·3 7·3
3·3 2·0 1·6
-
%
8·2 13·3 11·8 5·8 8·2 10·0 0·2
5·1 4·8 4·1 7·1
4·8 8·3 4·5 5·8 6·1 6·2 45·6 69·9 80·9 16·7 13·8 15·0
-
5-l
8·5 54·6 58·3 56·2 18·4 12·9 17·2
---
-1·6
-
-0·5
--
1·0
0·5 -0·3
0·1
1950
6·0 6·9 5·6 4·7 7·4 4·6 . 0·7 1·0
0·4 0·3 0·5 1·2 0·9 9·8 8·8 9·8 0·8 0·8 0·9
0·7 0·5 0·9 0·4 0·6 13·5 7·9 6·7 0·4 0·7
0·3 0·4 0·6 1·4 1·2 1·8 22·3 33·5 30·9 8·8 9·8 16·0
0·5 0·7
-
0·8 0·4 1·5 0·3 0·4 0·9
0·6 Oc6 0·3 0·4 0·3 0·3 0·3
--
3-I 1-6 2·7 2·9 4·5 22·6 26·5 25·7 3·9 2·6 2·9
-0·5
0·3
1960
6
0·2
--
1910
0·10 0·11 0·09 o-o8 0·12 0·08 0·01 0·01
0·13 0·21 0·21 0·09 0·11 0·17 0·003
0·09 0·09 0·07 0·12 0·09 0·14 1·04 1·01 0·95 0·23 0·17 0·20
0·08 0·11 0·07 0·09 0·09 0·08 0·82 1·01 1-11 0·21 0·19 0·23
0·02
0·004 0·004 0·02 0·003 0·007 0·003 0·001
-
-
0·3 0·4 1·5 0·1 0·4 0·3 0·1
0·9
1947
-
-
0·02 0·01
-
0·01 0·002
-
--
-
-
-
-
1·0 0·4 1·2
0·02 0·03
3-1
18·0 14·7 20·2 3·0 2·6 1·8
4·1 3·1 3-6 67·5 62·6 64·2 32-9 25-1 35·8
3·7 2·6 69·4 84·0 69-1 35·2 29·1 30·4
0·07 0·05 0·07 1-44 1·24 1·21 0·48 0·34 0·50
0·02 0·008 0·02 0·08 0·07 0·04 1-18 1·27 1·40 0·51 0·44 '0·49
2·5 2·2 2·7
14·8 13·7 14·5
13·4 14·8 15·4
0·27 0·24 0·24
0·23 0·26 0·2\
1·0 1·4
0·7 0·8
-
-
I
• See footnote to Table IV. TABLE I
VI.~Treatment and Arrest of Decay
2 No. of Carious Teeth
Variety of Secondary School
Percentage Extracted
3
4
Treatment of Carious Teeth
Percentage of Total Carious Teeth with Moderate and Severe Caries Untreated (C, + C,)
Percentage Filled
Total Percentage Treated
5
Percentage of Carious Teeth Showing Arrest of Decay
Untr~ated
1947
1850
1947
1850
1947
1950
1947
1950
1947
1860
1947
1950
Modern Technical Grammar
..
.. ..
3,500 556 737
2,882 510 710
13·9 9·2 7-1
11·6 9·3 12·8
41·1 45·5 54·4
33·3 52·8 52·8
55·0 54·7 61·5
44·9 82·2 65·5
17·8 17·8 8·8
21-8 14·5 12·5
3·68 3-17 4·23
2•86 2·88 1·22
Total
..
4,793
4,122
12·3
11-6
43·6
39·3
55·9
50·8
16·4
19·3
3-69
2·86
12 JAN. 5, 1952
DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN TABLE
Place
Lo ndon
..
Author
..
Mellanby and Mellanby
lhlmSB MEDICAL JOURNAL
VII.-comparative Gingivitis Figures for Older Children Date of Survey {1947 1950
Sco tland, Isle ofLewis King (1940) ( rural) Sewfoundland H. Mellanby (unpublished) . idad Trm King and Martin Bn'tish Gui~~ (1951) lnd ia, Lucknow .. M. Mellanby (unpublished)
1937
.. .. ..
1948 !948 1951
No. of Children Examined
II
1,192* 1,069*
Age Group
Percentage of Children Free from Gingivitis
Percentage of( hildren with Mild Gingivitis
Percentage of Children with Moderate Gingivitis
Percentage of Children with Severe Gingivitis
Avera!!e Gingivtili Figure
14 years 14
26·3 14·9
30·5 39·0
33-8 39·1
9·3 7·0
1·26 1·38 HI
"
185
14
595
406 100 265 472
"
12-14" 12-14" 14 15-20 ::
-
3·8
13-15 "
21·0
28·7
17·0 11·0 27·2 28·8
--
...
I
43-8 39·2
I
-
-
.16·6
13·6
1-43
-
-6·0
0·95 t-30
-
I
23·0 25·0
7·0
1-08
1·10
• In a few mstances gmg!Vl!ts and tartar figures on the charts were found to be mcomplete; these charts were therefore excluded in preparmg Tables VII and VIII.
teeth which had been filled-43.6 in 1947 compared with 39.3 in 1950. There was therefore an overall reduction of 5% in the proportion of carious teeth treated as between the 1947 and 1950 surveys. A comparison of the figures for the three kinds of school shows that technical and grammar schools had had some increase in treatment. It was in the modern schools where this had been reduced, but it will be noted that it was the children in these same schools who showed a reduction 1 in caries incidence (see Table V). A small amount of apparently " arrested " caries was found in the two surveys. This occurred in 3.69% of all untreated carious teeth in 1947 and 2.66% in 1950 (see Table VI, column 5).
Gingivitis and Tartar The results of the gingivitis estimations based on the ..:riteria described above are given in Table VII. Here it will be seen that only 26.3% of the children in 1947 and 14.9% in 1950 were considered to have no gingivitis, approximately two-thirds in both years had a slight or moderate degree, while relatively few, 9.3 and 7% respectively, w'ere counted as having a severe type. It would therefore appear that gingivitis was a common condition among these children, and that its incidence had apparently increased between 1947 and 1950. A few comparative figures for other surveys are also given in Table VII, showing that gingivitis, at least in a mild form, is widespread, though its occurrence seems to have no simple explanation. It is always difficult to compare the findings for the incidence and degree of gingivitis of different workers, since the standards vary, quite apart from personal factors in the examinations. For this reason the investigations to which reference is made here are confined to those of ourselves and a former colleague, J. D. King, who has latterly made an experimental and ·clinical study of the subject. He employs a more detailed classification than we, so that his results for the West Indian children in Trinidad and British Guiana are not strictly comparable with our findings in London, Newfoundland, and India. TABLE
VIII.-The Association Between Tartar Deposits and the Occu"ence of Gingivitis 2
3
4
No. of Children
Percentage of Children with Gingivitis
Avera!!e Gingivttis Figure
1
Grade pf Tartar
t)
..
1 (sll~t) .. 2 (moderate) 3 (extensive)
.. ..
.. ..
1947
1950
469 364 285 74
366 400 259
1947 1950
1947 1950
44
65·5 71·2 84·9 94·6
81·7 85·5 87·3 87·7
0·99 1·17 1·59 2·14
1·24 1·34 1·54 2·00
1,192
1,069
73·7
85·1
1·26
1·38
Table VIII (column 2) gives the number of London children with various grades of tartar deposition from 0 to 3 (see above), from which may be calculated the incidence of the different degrees and the average tartar figures. The same table (columns 3 and 4) also gives the associated occurrence and extent of gingivitis. The areas of the mouth most commonly affected by tartar were, as is usual, the upper first molar and the lower incisor regions. Some 5% fewer children were free from tartar in 1950 as compared with 1947, but 7% more had only a slight degree; the average tartar figures (calculated on the same basis as the average caries figures) will be found to be almost identical for the two surveys. Although many of the children with no tartar had gingivitis, this was generally of a milder degree than that experienced by children having calculus. With increasing amounts of tartar the incidence of gingivitis was also raised, until with extensive deposits (grade 3) 94.6 and 97.7% respectively of the children in the two surveys had some degree of parodontal abnormality (Table VIII, column 3). The average gingivitis figure also increased considerably with moderate and extensive amounts of tartar (Table VIII, column 4). In the Trinidad and Jamaican children examined by King a high degree of association was found to exist between gingivitis and tartar deposition when the location of the two was restricted to the anterior part of the mandible (King and Martin, 1951). Conclusions ..., On the whole we were favourably impressed QY the state of these 14-year-old children's teeth. They were better than we had anticipated, especially when allowance was made for all the difficulties of the present time. Any ditferences between the overall caries incidence in the teeth examined in the two surveys were slight, but some shift of caries away from the first molars was discernible, and with this went an increase in the disease among other teeth, especially the upper incisors. Both surveys showed a high incidence of gingivitis, but there was appreciably more in 1950 than in 1947, and also slightly more tartar. Snnunary Two surveys of 14-year-old London County Council school-children from modem, technical, and grammar schools provide the clinical material for this paper. The inspections were made with a probe and mirror. The proportion of children found to be free from caries, according to the standards used, was 11.5% in 1947 and 16.1% in 1950. These results are compared with figures from different parts of the world, including other areas of Britain.~~
A detailed analysis of the incidence and extent of caries in the different types of teeth is given for all the schools
]AN.
5, 1952
DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
taken together in the two surveys. A separate analysis for the three kinds of school is also given, but with few exceptions the differences between them were not large. A total of 14.6% of the teeth in 1947 were carious, whereas for 1950 the figure was 13.9%. Comparative figures for caries incidence in other groups of children are given. Only small differences were found between the two surveys as regards the amount of caries in the different types of teeth, but in 1950 more upper incisors and fewer first molars were carious than in the first survey. The amount of treatment (fillings and extractions) which the teeth had received is briefly considered. An overall reduction of 5% was noted in 1950 as compared with 1947. Some degree of gingivitis was found to occur in 73.7% of the children examined in 1947 and in 85.1% of those seen in 1950. That this is a common finding in this age group is substantiated by figures for other surveys. Tartar deposits were frequently found, and there appeared to be some relation between the amount of tartar and the incidence and extent of gingivitis. We wish to thank the London County Council and Sir Alien Daley for permission to carry out the inspections, and we are much indebted to the head teachers and staffs of the schools for all the help they gave with the actual examinations. Our thanks are also due to Miss I. Alien, of the Medical Research Council's Statistical Department, for advice; and to the Medical Research Council for financing the work. REFERENCES
Dean, H. T., Jay, P., Arnold, F. A., jun., and Elvove, E. (1941) .. Pub/. Hlth Rep., Wash., 56, 761. King, J. D. (1940). Spec. Rep. Ser. med. Res. Coun., Lond., No. 241. (1945). Dent. Rec., 65, 9, 32, 55. - - and Martin, W. J. (1951). Brit. dent. J., 90, 35. 63. Klein, H., and Palmer, C. E. (1937). Pub/. H/th Bull., Wash., No. 239. - - - a n d Knutson, J. W. (1938). Pub/. Hlth Rep., Wash., 53, 751. Mellanby, M. (1934). Spec. Rep. Ser. med. Res., Coun., Lond., No. 191. - - and Coumoulos, H. (1946). British Medical Journal, 2, 565. Schour, 1., and Massler, M. (1947). J. Amer. dent. Ass., 35, 1. Weaver, R. (1950). Brit. dent. J., 88, 231.
= INTESTINAL MACROCYTIC ANAEMIA BY
G. M. WATSON, D.Ph., M.B., B.S., M.R.C.P.* AND
L. J. WITIS, M.D., F.R.C.P. r From
the Nutfield Department of Clinical Medicine,
the Radcliffe Infirmary, Oxford)
The occasional association of pernicious anaemia with intestinal stricture was discovered by Faber in 1895. ln the succeeding years more cases were recorded, and in 1924 Sey;derhelm and his associates claimed to have reproduced the syndrome in dogs. In 19J9 Little, Zerfas, and Trusler found a blood picture typical of pernicious anaemia in youag man on whom several operations had been performed to cure an intestinal fistula which followed acute appendicitis. This appears to be the first record of pernicious anaemia in association with intestinal anastomosis as distinct from stricture. Other cases of this kind have since been reported, and the lesion has usually been either a gastro-jejuno-colic fistula or a stagnant loop of intestine. Tonnis et al. (1932) reported a brilliant series of experiments on culs-de-sac of the small intestine in dogs, and showed that the anaemia which sometimes developed would respond to liver extract.
a
*Australian National University Research Fellow.
In 1939 Barker and Hummel reviewed 51 cases of human pernicious anaemia associated with intestinal stricture or anastomosis, and we later brought the total to 60 (Cameron, Watson, and Witts, 1949a). In these 60 case reports anastomosis was the basic abnormality in 23, while in 37 one or more strictures were present. The strictures were mostly of the small intestine, but six were in the colon. Of the anastomoses 14 were enteroenterostomies or entero-colostomies, and nine were gastro-colic or high jejuno-colic fistulae. · The syndrome of gastro-colic fistula is now well known, its principle features being diarrhoea. steatorrhoea, malnutrition, and anaemia. Renshaw and his eo-workers (1946) have made a careful clinical and experimental study of this condition. Dogs in which a gastro-colic fistula was made by operation developed a syndrome similar to that seen in man, including anaemia which in some cases became macrocytic and hyperchromic. In the dogs and in human cases it could be shown that there was little passage of gastric contents to the large bowel, and consequently the symptoms could not simply be due to diversion of food from the small intestine ; rather were they due to. contamination of the stomach and small intestine by colonic matter. In the cases of anaemia associated with stricture or anastomosis the fundamental abnormality appears to be the presence of a stagnant or obstructed portion of small intestine. All these mechanisms may lead to infection of the small intestine with colonic organisms. Prominent Features The salient features of pernicious anaemia in association with intestinal stenosis or anastomosis can be briefly enumerated. The tongue is often sore, but there is free acid in the gastric juice in more than half the cases. Intrinsic factor has been demonstrated in one case (Schlesinger, 1933), although it was absent in the only other case in which it was looked for (Castle et al., 1931). Steatorrhoea is not necessarily present, but there have been few careful observations on tha fat excretion. Subacute combined degeneration occurs in a fairly large proportion of cases. The bone marrow is megaloblastic, and the anaemia, which is macrocytic, responds to treatment with liver, though it is sometimes rathe,r resistant. No information is avai:able about the response to vitamin 8 12 , folic acid, or antibiotics. The anaemia may be permanently cured by surgical correction of the intestinal abnormality, though this cannot be promised with certainty. The syndrome has declined in frequency in recent years owing to· the decreased incidence of intestinal tuberculosis, which has been the most frequent cause of stenosis of the small intestine, and to technical improvements in surgery, which avoid the formation of stagnant loops of intestine. Present Investigation The essential feature in macrocytic anaemia of intestinal origin appears to be stagnation, whether from stenosis or in a stagnant loop. The syndrome differs from Addisonian pernicious anaemia in that the secretion of hydrochloric acid and intrinsic factor by the stomach may be normal ; and from sprue in that there need be no steatorrhoea. It seems particularly appropriate for experimental study because it is impossible to produce a megalocytic anaemia by operations on the stomach in animals (Cameron, Watson, and Witts, 1949b), and
AETIOLOGY OF DENTAL CARIES
OCT. 22, 1932]
[
THE BRITISH MEDICAL jOURNAL
749
==========================~~====================-~-~-~----
enamel, which is not necessarily " chalky" in character. The rachitic fault, moreover, occurs in certain definite parts of the tooth corresponding to a given period of growth. Caries does not. Amongst the teeth most affected by vitamin shortage in rickets are the lower incisors ; yet these teeth are almost immune to enamel caries. Surely if vitamin shortage in early life predisposed the teeth to caries, the lower incisors would be amongst the most susceptible, instead of being amazingly immune. Mackay (1931), in a report on ·the association of vitamin D deficiency and dental caries, showed that there was only slightly greater incidence of caries in a group of rachitic children, "22 per ceht. of whom showed hypoplasia of the enamel, than in a control group of normal children in which only 2.5 per cent. showed hypoplasia. In any case the permeable point in the tooth surface which becomes carious is quite often not a developmental fault at all, and therefore has no relation to avitaminosis. The depth of fissures is a morphological characteristic. Recession of the gums which gives rise to cervical caries is a fault of the parodontal tissues rather than of the tooth, and recurrent caries is a matter of technique. Thus at most vitamin deficiency can only account for one of the four types of caries observed clinically-namely, the interstitial group. Even so, the deficiency would have to extend over a period of about twelve years to affect all the teeth in the way that caries does, and should logically be most intense in the tvrelfth year, when the wisdom tooth is developing. It seems more likely that the poor calcification of the wisdom tooth is a racial retrogression. Interstitial and fissure caries appear to be definitely racial and hereditary in character. Tamil and Chinese coolies working together show an extraordinary difference in the incidence of caries. J. W. Field (1929) recorded that 100 Tamils had seven carious teeth while 100 Chinese had 163. Their diet was similar and so was their exposure to sunlight, though the chewing by the Tamils of betel nut with its caustic content might have had an antiseptic effect on the saprophytes. Up to the Third Dynasty Elliot Smith reports that the Egyptians were free from caries. At this time an invasion of a foreign race occurred, and caries became as prevalent as it is in England to-day.* Even on Tristan da Cunha (Sampson, 1932), where hereditary and not racial factors predominate, of the 156 people examined 26 had an average of eight teeth each, either carious or missing, while 130 were caries-free, and these 26 were largely the " foreign " element of the population, in contradistinction from the 130, who were chiefly descended from the original stock. In clinical practice in England it is a matter of common experience that good teeth run in families, so that whatever the factors may be which produce the faults and crevices in which caries develops, they appear to be hereditary. IMMUNITY TO CARIES
There are certain cases of this which are significant. The human subject presents two types of immunity to caries. In one we find. a perfect set of teeth with shallow fissures and faultless enamel. In the other type there are deep fissures and numerous discoloured patches of enamel which show traces of early caries, but the caries has now become completely arrested. The former type appears to have no flaws in which the organisms can lodge, the latter appears to have a mouth which has become inimical to the growth of the saprophytes concerned. If, as he gets older, the man with perfect enamel gets recession of the gums, the exposed necks of the teeth often decay, yet the enamel remains immune, showing definitely that his immunity had been due to absence of faults in the enamel.
* See
page 760.
On the other hand the presence of faults alone is not sufficient to produce caries, as M~ Mellanby has shown in her experiments on dogs where faulty enamel was constantly produced, but caries never supervened. Indeed, the dog is immune to caries, and yet it has both deep fissures and permeable lamellae with dead tracts of dentine under them (Fish, 1929). The same observation may be made in the human subject, for as we have seen the hypoplastic teeth of rickets are not especially prone 1o caries. There is clearly a factor of susceptibility to an organism or a group of organisms without which caries cannot supervene. The apparently spontaneous arrest of caries is due to acquired immunity and not to a vital reaction in the tooth, since caries often becomes arrested in old broken-down dead roots as well as in deep fissures in vital teeth. Normally, a change to relative immunity takes place as children grow up. No doubt this is to some extent due to the fact that most permeable faults have by this time been treated, or the tooth has been lost, but it may result in part from a change of diet from milk and sticky carbohydrates to savouries and th~ use of tea, alcohol, and tobacco. In the same way the use of betel nut may account in some degree for the relative immunity of the Tamil. CONCLUSION
Thus all the evidence seems to point to caries being a saprophytic phenomenon occurring in morphological fissures, developmental enamel faults, or in the permeable necks of teeth. In no case can its occurrence be prevented by vital reaction on the part of the formed tooth, though its extension may be delayed. The prevention of decay appears to be possible only by rendering the mouth unsuitable as an environment for the saprophytes concerned, or by breeding a race free from morphological crevices and de¥elopmental enamel faults, whose gums will never recede. REFERENCES
Boedecker, C. F., and Applebaum, E.: Dental Cosmos, 1930, xxii, 1001 Field, J. W.: British Medical journal, 1929, i, p. 707. Fish, E. W.: Dental Record, 1929, xlix, 151. Idem: British Dental joumal, 1932, liii, 563. Jefferies: British Dental journal, 1932 (in the press). Mackay, H. M. M.: Lancet, 1931, ii, 1230. Sampson, W. E. A.: Britis/1 1Je11tal journal 1932, p. 397. Smith, G. Elliot: Archaeological Survey of Nubia, 1907--8, ii, "Report on Human Remains at Cairo."
THE AETIOLOGY OF DENTAL CARIES* BY
MAY MELLANBY My only claim to address you is that of one who has devoted many years to physiological and biochemical research, chiefly in relation to teeth and their associated tissues. My approach to the subject of dental disease is therefore somewhat different from that of the clinician, and though we must ultimately arrive at the same destination, we travel by different roads. As none of us can claim to have reached the. goal, it is perhaps only n.atural that we should each tep.d to emphasize the points elucidated in the course of our own work. No doubt the very fact that Dr. Fish and I have approached the subject from different angles and hold such opposing views prompted the committee to invite us to open this discussion. *Read in opening a discussion in the Section of Comparative "Iecticine at the Centenary Meeting of the British Medical Association, London, 1932.
750 OcT. 22, 1932)
AETIOLOGY OF DENTAL CARIES
ANIMAL RESEARCH
My real interest in dental problems arose about 1917, .vhen I noticed that the teeth of my husband's experimental animals varied in character. The teeth of the rickety puppies were irregularly arranged in the jaws and were often rough and pigmented, while the teeth of those free from disease were white, shiny, and in perfect alignment. The failure of all recognized methods of preventing dental disease indicated the need for a different method of approach to the problem, and the opportunity arose, in these puppies, to study the factors modifying the development and resistance of the teeth and related tissues. A diet was found on which the puppies grew well while their teeth were of poor quality. By making small, and apparently insignificant, additions or alterations to this diet the structure of the teeth and jaws could be completely altered. It was shown that: 1. For the production, in puppies, of well-formed teeth an adequate supply of fat-soluble vitamins, especially vitamin D, is essential. (This vitamin can be synthesized in the body by the exposure of the skin to sunlight or to the rays from an ultra-violet lamp.) 2. Cereals antagonize the action of vitamin D and tend to produce badly formed teeth when this vitamin is d~~~. . 3. The diet must contain some calcium and phosphorus, the chief components of teeth and bones, but the amount necessary depends largely on the vitamin D available. When vitamin D is plentiful the quantity and ratio of calcium and phosphorus (above a certain minimum) are of little importance, but when the supply is small, and especially wheri cereals form a large part of the diet, calcium and phosphorus assume a much greater significance. It is, for instance, possible by raising the calcium in some diets, especially when butter is the source of the vitamin, to convert an insufficiency of vitamin D into a sufficiency. 4. If a mother is fed during pregnancy and lactation on a diet deficient in vitamin D, the offspring show defective calcification of the deciduous teeth ; but the defects are less marked than those found in the permanent teeth when the puppies themselves are fed on the same deficient diet, for the mother sacrifices her own stores ot essential substances, and may in the process subject herself to hium if the dietetic conditions are severe. These experiments have recently been repeated, and the main results confirmed and extended by many other investigators. Vitamin C has been shown to influence the structure of guinea-pigs' teeth (Zilva and Wells, 1919, and later Hojer and others), but as far as I know it is rare to find defects in man of the type induced in these animals by a deficiency of vitamin C. On the other hand, the structural defects commonly found in human teeth are in many respects similar to those found in puppies fed on diets deficient in vitamin D, and the fact that human dietaries are often deficient in this vitamin suggests that the defects in the teeth of the experimental dogs and man are of similar origin. Each vitamin has certain specific functions, and as we learn more about these substances the terminology has to be altered. ·The term " vitamin A " now has a narrower meaning than it originally had when it covered the anti-infective growth factor (to which it is now limited) and the anti-rachitic or calcifying factor (now called vitamin D). Both vitamins are fat-soluble, growthpromoting, and affected by heat and oxygenation, and it .vas for this reason that their actions were at first thought to be due to one entity. In my earlier publications the term " vitamin A " therefore includes both the calcifying and the anti-infective vitamins.
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Although caries-like lesions have been produced experimentally in some animals, dogs' teeth appear to be immune to the disease. The normal variations in the minute enamel structure in different species, together with a natural or acquired immunity to the disease, may account, in part at least, for the difficulty of producing caries in some animals as compared with others. For these and other reasons experimental results are not necessarily applicable to the human subject, but they give a lead, and further work on these lines should prove fruitful. HYPOPLASIA AND CARIES
Owing to the difficulty of obtaining a working basis by means of animal experiments, l have adopted an indirect method of testing the liability of human teeth to caries. A large number of shed and extracted teeth (mainly deciduous) were examined, both superficially and histoJogically, for structure and caries. In the majority the surface enamel was rough, and the minute structure of enamel and dentine was defective, the latter containing interlobular spaces. It was, in fact, clear that the ordinary standard for " hypoplasia " (giving about 3 per cent. of deciduous human teeth as hypoplastic) was not comprehensive enough, and that only comparatively gross defects were ordinarily included in this term. I have therefore used the term " hypoplasia " to denote defective structure of any degree or kind, and the term " gross hypoplasia " for those forms of superficial enamel defect which are commonly recognized. Hypoplasia was found in over 75 per cent. of the human deciduous and in the majority of the permanent teeth examined. The deciduous incisors, largely developed in utero and during lactation, were better calcified than the .later-formed molars. For instance, about 60 per cent. of the incisors appeared normal on histological examination, as compared with 1 per cent. of the second molars. Nol only were the great majority of teeth in my collection defective in structure, but there was definite association between structure and caries. The worse the structure, the greater was the liability of the teeth to decay. Only 20 per cent. of the normal teeth were carious, as compared with 94 per cent. of the severely hypoplastic. This close association was found also in groups of Sheffield, Birmingham, and London children. In my experience, there is generally less hypoplasia and caries among the richer children and those living in institutions than among the poorer. Although the association between hypoplasia (as I have described it) and caries has been shown to be a close one, " gross hypoplasia " is not so definitely associated with dental disease.
RICKETS
If structural defects are due to a deficiency of vitamin
D, and these defects are associated with a liability to caries, it would be expected that the teeth of rickety children would be more liable to disease than those of the average child. The evidence, though not unanimous, generally confirms this expectation. Lawson Dick (1916) found that hypoplasia (gross) was common in the 600 rickety children he examined, and concluded that it was probably the chief factor in premature decay. J. G. Turner states that caries is rather more common in rachitic cases, and M'Gonigle, who examined some thousands of children, comes to a similar conclusion. Again, Wilson and Surie, working among native Indians, conclude that rickets and caries are coexistent. In the Board of Education inquiry (1929) it was found that most of the 1,300 London school children examined showed signs of rickets and caries. Rose and Mackay, on the other hand, compared the
OcT. 22, 1932]
AETIOLOGY OF DENTAL CARIES
amount of dental caries in some children, whom they had treated for rickets as babies, with that found in children who at a similar age had suffered from other diseases. They found that although hypoplasia (gross) was confined to the rachitic group, caries was only slightly greater in that group than in the other. The number of rickety children examined (42) was small ; it is possible, too, that the treatment they received would delay the carious process. Again, on the basis of recent work it is probable that many of the control children had also passed through a stage of defective calcification, possibly of less severity but longer duration. Some years ago Mr. J. W. Proud, L.D.S., and I examined the teeth of about 200 children diagnosed both at school and in infancy as rachitic, and found a higher percentage of caries in their teeth than in those of the average child. PossiBILITIES oF DIETETic CoNTROL
Having proved to my own satisfaction that the better the structure of the teeth the less the liability to caries, and that structure could be controlled by diet, my next step was to see whether it was possible by variations in diet, especially in the vitamin D and cereal content, to alter the rate of initiation and spread of caries. To this end, from 1921 onwards a series of tests· was made in Sheffield, in conjunction with Dr. Lee Pattison, on groups of children, most of whom had badly formed and carious teeth. It was shown that: 1. When the vitamin D content of the diet was increased, and especially when at the same time all cereals \Vere omitted, the initiation and spread of caries were greatly reduced, while the " healing " or arrest of carious areas was very marked. 2. When the vitamin D content of the diet was decreased and extra cereal-for example, oatmeal-was given, the development of dental caries was increased. An extension of the Sheffield investigations on a larger scale and over a longer period has been made in Birmingham on behalf of the Medical Research Council by Mr. A. Deverall, L.D.S., and Miss M. Reynolds, S.R.N., and the results corroborate those obtained in Sheffield. Boyd and Drain (1928) made some significant observations on a group of children suffering from diabetes. In the course of treatment these children were given a diet devoid of cereals and consisting largely of milk, cream, butter, eggs, meat, cod-liver oil, vegetables, and fruit (that is, a diet rich in vitamin D and calcium), and the process of dental caries was stopped. Later they fed some non-diabetic children on a similar diet, and again found that active caries was arrested. Bunting also found that of the methods investigated for combating dental caries, dietary measures such as the inHe, clusion of much milk were the most important. however, believes that protection is through a change )n environment rather than through an increase of resistance of th~ teeth themselves. Further evidence bearing on the experimental and clinical observations has rec:ently been obtained from Tristan da Cunha, the inhabitants of which rarely suffer from dental caries ; their diet includes foodstuffs containing vitamin D and calcium, but is devoid of cereals, and the children are breast-fed for long periods. Other examples of peoples comparatively free from dental disease are the Eskimos and some tribes in tropical lands. Under natural conditions the diet of the former is rich in fat-soluble vitamins and free from cereals. In tropical countries breastfeeding is prolonged in many native tribes, and although the diet consists largely of cereals and the vitamin D content may be low, the skin is exposed to the sun's rays,
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751
and the necessary vitamin D is thus synthesized in their bodies. As soon as civilization reaches these peoples the conditions are altered in relation to both diet and clothing. Ultra-violet rays are often prevented from reaching the skin, even of young children. During a· visit to Africa some years ago I examined the mouths of hundreds of natives, and found that, although the majority had excellent teeth, the more the tribes conformed to civilized conditions the worse was their dental condition. Heredity has certainly failed here. In order to test the resistance of erupted teeth, animal experiments were made resulting in the deposition of secondary dentine. A potent calcifying. diet during the period of irritation resulted in abundant well-formed secondary dentine ; if the calcifying factor was deficient there was no apparent reaction or the secondary dentine formed was imperfect in structure. Here, then, is further evidence that dental reaction can be influenced by nutri. tional factors. Contrary to Dr. Fish's experience, I did not often find a "fully calcified barrier" between primary and secondary dentine. This problem, together with that of the character and significance of translucent zones and '' dead tracts,'' will· be discussed by others who are much more competent to speak on the subject. SUMMARY AND CONCLUSIONS
To summarize, fat-soluble vitamins (especially vitamin D) are essential both for calcification of the teeth and for their resistance to disease. The quantity required depends on other factors of diet and environment, including calcium, cereals, and ultra-violet light. The natural foods containing vitamin D, with which calcium and vitamin A are often associated, are, unfortunately, comparatively expensive. They include egg yolk, milk, suet, butter, and I -cheese. (Milk is an excellent food, but I am not yet convinced that there is sufficient evidence that fresh· milk is better than the pasteurized product.) Cod-liver oil and some other fish oils are the richest known natural sources of vitamin D ; it is present in fat fish (for example, herring, mackerel, and salmon), and also in animal fats (except that of the pig). Vegetable oils as prepared for consumption in England do not usually contain the vitamin. Cereals are cheap, easily stored and transported, and are therelore very common articles of diet ; they are not only devoid of vitamin D, but contain some toxamin, which tends to hinder calcification ; the greater the part they play in the dietary the greater must be the intake of vitamin D and calcium to antagonize their effect. The clinical work mentioned is only the beginning of this important aspect of nutritional science, for we do not even know the optimum amount of vitamin D required in relation to the other factors of diet and environment. The literature published during the past decade shows that more attention is being focused on dental caries as a disease resulting from metabolic rather than purely local disturbance. If I have played any part in this new outlook I shall feel justified in having entered the field of dental research. In conclusion, while I readily admit that the liability of a tooth to decay must depend upon many factors, both intrinsic and extrinsic, I believe that the structure of the tooth is a factor of the highest importance, that this depends in turn upon the diet during the period of growth, and that after eruption its resistance to caries can also be influenced by dietetic conditions. We must, therefore, I believe, concentrate upon the development of more perfect teeth and later also upmi. increasing their resistance to decay. The practical application of our present knowledge should in time help to diminish the scourge.
JULY 9, 1932)
CORRESPONDENCE
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75
The campaign was inaugurated in April, 1931, and by making it contract with unnatural force and frequency the first annual meeting was held on June 30th, 1932. for several days on end. Assuming, however, that in The report on the year's work stated that office accom- special cases this is deemed to be desirable, the most modation and clerical assistance had been provided by the suitable means for bringing it about must be decided. It is generally stated that ergotoxine produces a proPaddington School for Mothers, and that the London Public Medical Service had co~operated in dealirig with · longed spasm of the uterus, and Dr. Burn claims that the prolonged and persistent contraction is a special advanthe remuneration of the doctors working under the tage. I venture to suggest that this spasm is less real campaign. Valuable assistance was given by the School than is usually supposed. In the manometric tracings for Mothers, the health visitors, the public assistance officers, and the doctors of Paddington. In the months of of the intrauterine pressure in the puerperal uterus, a October and May reports were sent to the medical officer rise in the base line is present only for a short time after of health, by the doctors, on the health of each infant the administration of reasonable doses of ergotoxine ; in none of my cases has it exceeded one and a half hours, on their lists. and after this time the effect is that of strong contractions occurring at intervals. As previously pointed out, a considerably greater spasm can be obtained by the use of B.P. liquid and solid ergot extracts given in doses which cause no ill effect, than by ergotoxine given in dosi's THE ACTION OF ERGOT PREPARATIONS ¥.·hich may cause undesirable symptoms. The duration of the spasm in these cases is usually about one and a SIR,-Dr. J. H. Burn's letter in the Journal of June 25th criticizes certain statements contained in my article half hours, and is followed for a long period by strong contractions occurring at regular intervals. The duration on the clinical action of ergot preparations. I have read the letter with interest, and welcome this opportunity of this second effect is moce than two hours, but my tracings were not continued long enough to measure the of saying that nothing in the paper in question was intended to imply that ergotoxine was without impor- exact time. The question thus becomes a simple one. Is it better tance, or that when suitably administered it was other to give a dose of ergotoxine-preferably by injection-at than a useful therapeutic agent. Beyond this, however, long intervals, or a dose of liquid extract of ergot by I cannot agree with Dr. Burn's observations. the mouth every four or six hours? It seems to me He accepts my view that the reason why ergot came to be immaterial which method is used. to be used in obstetrics was because of its remarkably Finally, Dr. Burn suggests that a use for the " new " prompt and energetic action when given by the mouth. principle might be its administration during labour to This action I have been able to show is not due to ergotoxine, but to another constituent of ergot as yet stimulate uterine pains in a manner similar to pituitary extract. Ergot ceased to be used for this purpose many unidentified. In view of his. admission, it is difficult to understand why Dr. Burn should object to the statement years ago on account of the high foetal mortality following its administration. · The prtlvis ad parttlm became the that these findings stand in opposition to previous beliefs pulvis ati mortem. There is no reason to believe that and show that ergotoxine plays a subsidiary part in the this undesirable effect was due only to ergotoxin~. and clinical action of the drug. It is possible that he has overlooked Fig. 4 of the article, which was not specially it seems probable that the foetal death was due to that very spasm which my tracings have recorded, and which referred to in the text. This figure shows a portion of a continuous tracing in which the action of ergotoxine is brought about by the unidentified principle. For these is contrasted with .that of ext. ergot ·liq. (1914). Two reason$ I must strongly dissociate myself from any suggestion that these extracts might be used during milligrams of ergotoxine given ·by the mouth showed an almost negligible effect on uterine contractions during parturition. In the above remarks no mention has been three hours following the administration, whereas two made of ergotamine. All that is said of ergotoxine is drachms of liquid extract of ergot given after this period meant to apply equally well to the other ergot alkaloid. After careful consideration I can find no reason .to alter produced a vigorous effect in thirteen minutes. the statement made in the concluding paragraph of my The second part of the letter deals with a different article, which reads : matter, and one of much greater importance. Dr. Burn points out that ergot is now used in different circumstances " It can be stated with reasonable certainty that the than was the case 100 years ago, and states that the characteristic action of ergot known to the old obstetricians action which is now desired is the one associated with is due to a substance which has a prompt and energetic action, and which is not ergotoxine, ergotamine, tyramine, or ergotoxine, and not the one which follows the administrahistamine. From this it follows that the ergot alkaloids, tion of the active principle which I have described. This hitherto supposed to be all-important, play in reality but is a matter which was not discussed in my paper, and I a subsidiary part in the clinical action of the drug." may perhaps be allowed to make a few comments on - I am, etc., it now. CHASSAR MoiR. Obstetric Unit, Uniw·rsitv College The chief uses of ergot in present-day practice are (1) Hospital, July 4th. to check post-partum haemorrhage, (2) to lessen the likelihood of uterine haemorrhage in the first twenty-four hours or so of the puerperium, and (3) to promote involuDIET AND THE TEETH tion of the uterus. The first condition-the checking SrR,-In the Journal of March 19th is a paper by Mrs. of post-partum haemorrhage-is not likely to be well fulMellanby and Dr. Pattison, in which they again demon· filled by ergotoxine given alone, because its action, even strate that a dietary rich in vitamin D and calcium and phosphorus leads to good dentition. They again after intramuscular injection, is too slow. Dr. Burn stress their cereal toxamine theory, and it seems to be agrees that in treating this condition the rapidly acting time that the facts be examined without the usual pre" new " principle of ergot may have a use as an alternajudice coming irito the matter. If the Mellanby Diets tive to pituitary extract. Regarding now the second and 8 to 4 are examined closely some astonishing facts are third indication, it may well be questioned whether the revealed. I have used Sherinan's figures for analyses avoidance of haemorrhage and the involution of the as the authors of the paper did. In dietetic work I have uterus are more likely to be helped or hindered by causing always understood that the first essential in testing the the uterine muscle to go into a prolonged spasm, or effects of any food material is to have dietaries which
Correspondence.
76
}ULY
are strictly comparable, and adequate in all respects except the one under review. In much of Mellanby's work I do not find any of these postulates filled. The origin of the cereal toxamine theory was the fact that puppies did not do well on diets containing cereals. The dietary in Experiment 46, reported in No. 140 of the Medical Research Council Special Reports, is typical of the rest. In it we find that separated milk, lean meat, and linseed oil supplied a caloric intake of about 200 only, and the addition of white bread increased the intake to 330 up to 600. It is no wonder that in all Mellanby's work we find the puppies that grow more rapidly are those which were given more or less sufficient calories on which to live. The dietary was woefully deficient in every particular apart from a dietetic knowledge, and obvious to anyone who has bred litters of puppies. In this matter it is as well to stress the fact that Hopkins's postulation of " accessory food factors " found universal acceptance because he presented evidence that lack of calories had nothing to do with his rats, and that is a classical lesson which should not be forgotten. It is now general kLJ.owledge that cereals as a whole are very poor in calcium and rich in phosphorus. For instance, 15D grams of white bread will contain approxi~ mately 0.03 gram of calcium and 0.14 of phosphorus, which gives a Ca: P ratio of 1:4.6 ; similarly 150 grams of oatmeal will contain approximately 0.1 Ca and 0.588 P, with a ratio of I : 5.9, and so on through the cereals. The essentially carnivorous dog is forced in this experimental work to obtain over 50· per cent. of its energy require~ ments from cereals which contain th~ essential salts for calcification in a ratio very different from that required in the ideal dietary. The dietary is an ideal highphosphorus-low-·calcium rachitogenic one without any necessity to postulate a harrnful substance in the cereals. Now if we examine the Mellanby-Pattison human dietaries 8 to 4 we can construct the following table: Diet
II.
Total Ration
'.I·
Total Nutrients
I:·
4.3 5.1 4.7
5
5.4
4
5.8
8 7 6 5 4
7.6 16.3 14.5 17.9 17.4
8 7 6 5 4
7.8 6.6 6.8 7.5
6.8
21.75 18.1 18.7 17.6 18.0 Carbohydrate 38.5 58.3 55.3 58.2 59.0 Fat 39.75 23.6 26.0 24.2 23.0
Foon
THE BRITISH MEDICAL JouRNAL
IxnKE
rN
GRnrs PER
Calorie~ ... }>rotcin ... Carbohydrate ... l•'at l\Iilk l\Ieat
Calchnn ... l'hosphorus
Kn.or.R·D!
OF
BonY
\YEICHT
DietS
Diet 4
Per cent. Variation
127.0 4.6 8.0 8.4 63.1 7.6 0.09 0.10
90.0 3.1 10:5 4.1 20.0 4.7 0.04 0.06
-40.0 -33.0 +30.0 -51.0 -68.3 -38.0 -55.6 -40.0
It is now clear that not a single component of the diets remained constant. They are not comparable. The widest variations are seen to be in the milk and calcium intake, which is a truly astonishing state of affairs. What was the matter with these children on Diet 8 that they were in bed for the six months of the experiment? We see that their calorie intake was as much as 127 per kilogram, whereas, I believe, active, as opposed to bed-ridden, children of that age require abut 90 calories only. This excess of calorie feeding was, of course, conditioned by the large amount of fat in that diet. The milk ration will also bear analysis . . We see that it varies more than any other article in the diets. J\IiLK
I Diet
8 7 6 5
To tit( Calories
4
Calcium
IAmount I Per cent. of Total 1.4 1.07 1.29 0.9 0.64
82.3 82.3 85.7 81.8 64.0
Phosphorus Per cent. Amount
Per cent. of Total.
Hatiou
Per cent. of Total Calories
1.1 0.83 1.0 0.69
57.9 52.0 55.5 49.3 33.3
59.3 50.9 54.8 47.5 33.3
34.5 25.2 27.6 20.9 15.3
of ri'otnl
o.s
'
Protein
8 7 6
r
CORRESPONDENCE
9, 1932)
14.3 14.3 14.3 13.7 13.1 25.4 46.3 42.4 45.1 46.2 58.9 42.1 44.7 42.3 40.8
It is at once obvious that the authors did not find that " surprisingly little difficulty was experienced in providing substitutes for cereals," as we see that the carbohydrate in Diet 8 has dropped to supplying only one-quarter of the calories instead of the generally accepted half. The change from the cbnditions in Diet 7 is very marked, as there is a decrease of 53.4 per cent. in the energy supplied by carbohydrate. In this series of diets the protein content has been the only constituent which has remained constant. The fat content varies from 23 to 39.75 per cent. of total nutrients ; and more astonishing than anything else in the whole of the diets is the variation in the milk content. This ranges from one-third to well over onehalf of the ration. The different ages of the children emphasize the variety of the rations. If we assume the average weight of the children in Experiment 8 to be 19 kilograms and those in Experiment 4 to be 27 kilograms, we can express the diets in terms of grams per kilogram of the body weight, and can then arrive at the percentage variation of each constituent in these two rations, which are chosen as they are at the extremes of the scale.
Sherman and Hawley's (1922) work has not been refuted by any experimental evidence ; they proved that the calcium of milk is utilized by the growing child to a much higher degree of efficiency than an equal quantity of calcium in vegetables which were prepared with great care to make them acceptable to the children. In view of this work and the subsequent confirmatory results it is regrettable that in the Mellanby diets the milk content varied from 63 to 20 grams per kilogram of body weight, and the calcium from milk varied from 1.4 to 0.64 gram per day. From the time that Hoobler (1912) studied the calcium retention of the infant we have known that a high fat content in the dietary leads to greater retention of calcium. Aschenheim (1913) soon confirmed these results, as he found increased calcium excretion with low fat diets, and though they were probably adding vitamin D without knowing it, the Mellanby diets show a variation in fat content, and so vitamin A and D content, which should not have been permitted. In Diet 8 we find 70 grams of butter and cream and 0.4 gram of radiostol ; in Diet 7, 28.4 grams of butter and cream, and, I presume (it is not clearly printed), 0.25 gram radiostol. With such a wide variatim) in vitamin· A and D content it is manifestly absurd to attempt to saddle the cereal of Diet 7 with any defective dentition developing while on the ration: I know that Mellanby deprecates the term " optimal amount," but she should therefore be all the more careful to have strictly comparable amounts of such minutiae as vitamins and minerals in her rations. This she has not attempted to do. It is remarkable that " incrc::tsed oatmeal " in Diet 4 is only 51 grams, or roughly 2 grams per kilogram of body weight. As oatmeal is especially singled out for its malign influence on the deposition of calcium, it appears somewhat remarkable to me that the crofters and farm labourers of North-East Scotland should have any teeth or straight bones in view of the shockingly large amounts of " toxamine " they have G.bsorbed for years, including their growth years. I can assure Mrs. Mellanby
}ULY
9, 1932)
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==============:r-=--=~=--==-=--=======:::-----~that I have lived in a bothy and have seen the teeth these men have and the porridge they eat. As a group, they are very superior to the townspeople in every physical particular ; oatmeal and milk is far more important in their dietary than potatoes and meat. Here in West Africa the tribe with which I am at present concerned live on cereals, the millets, a little sour milk, and occasionally meat. Their teeth are not good, but the women have very much better teeth than the men. Many perfect sets are to be seen. The reason is personal hygiene. The Munshi tribe eat cereals, yams, and sesame. The incisors are filed to points, yet I found no dental decay in over 200 people examined. The difference to the Hausa is that they get adequate calcium and phosphorus in their beniseed and vitamin D from the sunlight. The Tris~n da Cunha report (published in the same issue) remarks on the fact that milk is plentiful and is fully used, and that eggs of hens anp penguins form a fair proportion of the people's dietary. They are thus supplied with adequate vitamins and the most perfectly assimilable form of minerals for calcification. They eat a little cereal flour, apparently about 47 lb. a year per man, woman, and child, or about an average of 4 grams a day. It is a fair presumption that the flour is eaten when it arrives in the island, and so more than 50 grams a day will be taken until it is finished. During these periods of cereal-eating one should expect to find caries develop, and then be healed when the administration of " toxamine " had ceased. Apparently this is not ~· The argument that other seaboard populations enjoy as admirable a dietary as the islanders, yet suffer from caries, needs amplification. Where are these populations which are as stringently isolated as the people of Tristan da Cunha? Are they of European stock also? Is their isolation so complete that they are compelled to eat fish, extremely digestible ; eggs, full of first-class protein and vitamins ; and milk, full of all the salts that the human needs in their most assimilable form along with their cereals? The Tristan da Cunha teeth are admirable, with or without cereals, because the islanders have perforce to eat admirable calcifying foods. Examination of Mrs. Mellanby's work as a whole and of the latest human experiments in particular shows that the dietaries used are not comparable, and such misleading basal facts have led her into her anti-cereal theory. Diet 8 is listed as cereal-free ; it could also be listed, as opposed to Diet 7, as vitamins A and D rich, fat rich, or carbohydrate poor. Such variations are not permissible in firstclass research, and I maintain that up to the present no evidence whatever has been produced that cereals are actively harmful. One must not fail to see the wood for the trees. There can be no question but that cereals are deficient in the particulars I have enumerated as well as in vitamins when used as their flours. But because cereals are cheap and easily prepared the poor use them as a substitute for foods which are biologically of more importance. It is this substitution of a poor food for richer foods which has caused Mrs. Mellanby to postulate actively harmful effects from their use. Because the Hausas in times of famine use water instead of sour milk in their porridge, and they die of all sorts of nutritional diseases, I should not dare to postulate an actively harmful principle in water. The Hausa has substituted something valueless for something of value, not something harmful for something beneficent. - I am, etc., Dietetic. Research Laboratory, W. E. McCULLOCH, M.D. Katsina, 1\. :'\igeria. " FALLEN IDOLS " SrR,-My work has lain largely in the field of rhinology, but, like Sir James Berry, I recall the period when acute appendix belonged essentially to the domain of the phySICian. Many cases, which it fell to my lot to treat as :1n internist, rapidly yielded to heavy dosage with sodium salicylate, like an acute tonsillitis. Yet, with one or more recurrences, the risk of serious complications impelled one to refer such cases to surgical colleagues for interval
appendicectomy. But I believe that " the great change in fashion "-that is, the early operation in acute appendix, which arose in 1896, and which Sir James Berry attributes in part to Dr. H. P. Hawkins's monograph-was in part due to the influence of epidemics of influenza. I am reminded, moreover, that at that time an infected antrum or other sinus infection was rarely operated on or even diagnosed. Now the " grippe," that swept Europe in 1889 and Great Britain in 1890--91, and the subsequent epidemics, caused an enormous increase in the incidence and severity of nasal sinusitis. A new clinical group arose, and in meeting its requirements rhinologists developed new diagnostic and therapeutic methods. Successful results in so many cases of semi-acute and chronic sinusitis probably led to undue enthusiasm in applying these newly acquired resources to the acute cases. Hence, maybe, changes in the clinical picture rather than change of fashion led to new methods being applied alike both in the surgery of acute appendix and acute sinusitis, and what eventually becomes accepted as correct treatment will be determined by the light of riper experience. May I suggest that sinusitis and appendicitis are furthermore linked by the possibility that increased incidence of sinusitis and other forms of focal sepsis may have in some measure determined the increased incidence of appendicitis and other gastro-intestinal secondaryinfections.-I am, etc.,_ Bristol, July 2u
'' THE USE OF THE SELF '' SIR,-Dr. A. J. Brock, in his letter in your issue of June 25th, has made certain statements, both as to the aim of my technique and my method of employing it, which, if unanswered, must leave your readers with an erroneous impression. First, Dr. Brock writes: "His !.Aiexandc>r's] job, he tells us, is the> correction of imperfect or inadequate functioning.' Apparently he aims at teaching his pupils to ' make a betttCr use of themselves,' and this hy an ' energetic scheme of exercis<·s ' " : and again, " Mr. Alexander obviously finds that of those who practise the exercises with determination a large number have not time to fall ill, while others who are already ill forget their troubles in the t>nthusiasm: of the game." Throughout the subject-matter of my hook, and also in the letter you were good enough to publish on June 18th, I emphasized (1) that my work is solely concerned with the restoration and establishment of a trustworthy sensory appreciation of the use of the psycho-physical mechanisms, by means of a technique which depends upon the employment of a consciously dil·ecled primary control, and (2) that any improvement in " imperfect or inadequate functioning '' which accrues from the application of this technique comes about, not as a direct, bnt as an indirect result of improvement in direction of use and of the restoration of .trustworthy sensory .appreCiation·, Anyone who will do me the justice to read carefully the first chapter of my nook (especially pages 33 to 35), where I describe in detail the application of my technique, must see that in every instance the preliminary step if! the inhibition of any misdirection of use that has become habitual, and that therefore such a method presupposes of necessity the elimination of what is involved in any scheme of " exercises," whether " energetic " or otherwise, or of what Dr. Brock calls " psycho-physical gymnastics.'' Secondly, I join issue with Dr. Brock when he writes that " every practitioner with a modicum of intelligence soon learns it [that is, the fact that the individual is in essence a psycho-physical unity, and a functioning unity at that] from experience." I would ask how the practitioner puts into practice in his diagnosis and treatment what he has learned " from experience " about this fact.
JUNE
24, 1944
IMPROVED DENTITION' OF LONDON SCHOOL-CHILDREN
THE IMPROVED DENTITION OF 5-YEAR..()LD LONDON SCHOOL-CHILDREN A COMPARISON BETWEEN
1943 AND
1929
BY
MAY MELLANBY (Nutrition Building, National Institute for Medical Research, N.W.1) AND
HELEN COUMOULOS, D.D.S.Athens (Girton College, Cambridge)
Historical It is now established that certain nutritional factors play a prominent part in determining the structure of the dental tissues and their resistance to disease. Interest in this subject was first roused by the investigations on animals and children made by one of us (M. M.) which began in 1917 and have continued up to the present time. (a) Animal Experiments
It was shown in experiments on puppies and other young animals that perfect and imperfect teeth could be produced at will by small variations in the diet during the period of tooth development (Mellanby, 1918). "The chief among these determinants were the fat-soluble vitamins, and especially vitamin D (which in the earlier days was called the calcifying vitamin). This substance acted in association with the calcium and phosphorus of the diet, and for optimum effect required a sufficiency of these elements: in the absence of vitamin D, even large quantities of calcium and phosphorus in the diet did not result in perfectly formed teeth and jaws. A deficiency of this vitamin in the mother's diet during pregnancy and lactation, especially with a low intake of calcium, caused the decidmms or milk teeth, and to a less extent the permanent teeth, of her puppies to be imperfectly calcified, even when, after weaning, their own food contained abundance of these substances ; if the puppies continued on the same defective diet as the mother their permanent teeth were very badly formed-more so, -in fact, than if the mother's diet during pregnancy and lactation had been good from the point of view of tooth development. It is seen, therefore, that the mother's diet during these periods may to some extent affect the teeth of her offspring for life. In the living animal, teeth of perfect structure were translucent and felt smooth when their surfaces were rubbed lightly with a probe, whereas varying degrees of roughness were encountered when the teeth were of imperfect structure. It was shown that there was a close correlation between the surface appearance or texture of the teeth, determinable in situ, and their minute architecture as seen in microscopical sections made after death.
(b) Investigations on Children When a large collection of children's shed and extracted teeth was examined and graded according to the standards developed and adopted by M. M. on the basis of the animal experimental work, perfect structure and all grades of imperfection were found, although some 80% came into the latter category. Teeth of good structure were on the whole found to be much less carious than those of defective structure, 78% of the former, compared with 6% of the latter, being caries-free. This 'relationship, however, did not necessarily apply to the comparatively few teeth with gross enamel defects obvious to the naked eye-forms of dental hypoplasia which used to be, and indeed still are, the only ones generally recognized. From 1922 onwards a series of investigations on children in a Sheffield tuberculosis hospital (1924, 1926, 1931, and 1934) and in three Birmingham Cottage Homes (1934) were made in co-operation with medical and dental colleagues. These investigations showed that those dietary factors which promoted ·.veilcalcified teeth also influenced them after full eruption and tended to retard to some extent the onset and spread of t:aries. Thus there was in the Birmingham study significantly less incidence and spread of caries in a group of children receiving additional vitamin D and olive oil than in the control group getting extra olive oil without the vitamin : for instance, in the permanent teeth already erupted at the beginn;ng of the
BRITISH MEDICAL JOURNAL
837
investigation an increase of only 8% of carious teeth was found in the vitamin D group in 2t years, compared with 13.8% in the control group. Moreover, there was an even greater difference in those which erupted during the actual period of the investigation, the structure of which teeth may have been influenced by the diets (i.e., 7.6% of these teeth were carious in the vitamin D group, compared with 17.8% in the control group). In these series of investigations the most important dietary factors for delaying the onset and spread of decay were milk, cod-liver oil, and irradiated ergosterol (vitamin D,). With low vitamin D and calcium it was found that increasing the cereal content of the diet allowed the disease to spread more rapidly than in the controls with comparatively little cereal, probable reasons for this being that there are some anticalcifying substances in cereals. The above facts and many other experimental and clinical results were brought together in three special reports of the Medical Research Council published in 1929, 1930, and 1934 (M. Mellanby) .. More recently these investigations on the initiation and spread of caries in children's teeth have been repeated and extended in different parts of the world (Anderson et al., 1934 : McBeath, 1932, 1934; McBeath and Zucker, 1938; McBeath and Verlin, 1942; McKeag, 1930; Schiotz, 1937), so that to-day medical and dental clinicians as well as scientific investigators are realizing more and more that nutrition plays an important part in dental disease. They do not always, however, fully appreciate the long period during which dietetic factors must be operative in order to promote good dental structure and increase resistance to disease. For instance. they often expect results after a few months' administration of cod-liver oil, whereas the treatment should begin in early intra-uterine life and continue during the period of growth, and in a modified way probably throughout life. The direct cause or causes of dental caries in human beings, as distinct from the predisposing factors, are not yet known, but in the work referred to above there was enough evidence to demonstrate that a great improvement could be obtained if the dietary of pregnant women, infants, and children were changed to one of higher calcifying quality. The teeth of the new generation would then be of better structure and less prone to decay. It seemed, indeed, that such a step must form the basis of any policy likely to lead to mass improvement of teeth-a point of view which has been constantly urged by one of us for many years. The dietetic changes advised were : (I) an increased consumption of milk, eggs, and other foods comparatively rich in calcifying factors ; (2) a decreased intake of cereals, such as bread, oatmeal, and oatmeal preparations ; and (3) the addition to the diet of cod-liver oil or some other source of vitamins D and A, especially the former. (c) National Dietary Changes related to Above lnvesti[?ations During recent years interest has become focused on public health in relation to food, and the Government has made a special effort to improve the standard of nutrition of pregnant women, infants, and young children. In the past quarter of a century antenatal clinics and infant welfare centres have been established in increasing numbers to advise on the feeding of both mother and baby. Rickets, so common in the 1920's and earlier, has become comparatively rare in England owing largely, no doubt, to the increased consumption of milk and to the greater therapeutic, as well as the prophylactic, use of codliver oil and other substances containing vitamin D. The condition of the teeth of the group of children examined in the present investigation could not have been greatly iQfluenced by school feeding, since the majority did not go to schooluntil they were 5 years old, though a few went to nursery classes or schools ; but it is of interest to remember that as long ago as 1906 the London County Council made official arrangements for the supply of school dinners to necessitous children, and in 1910 milk and cod-liver oil could be supplied to children whose home conditions were unsatisfactory or when malnutrition was threatened or present. In addition there were an increasingly large number of other children receiving milk, on payment, as the result of voluntary school milk clubs. Only in 1934, however, when the Milk Marketing Board was set up, was a scheme put into operation to supply milk (at first onethird of a pint and later two-thirds of a pint a day) to children, irrespective of their physical condition, in any part of the
838
JUNE
24, 1944
IMPROVED DENTITION OF LONDON SCHOOL-CHILDREN
country at the reduced rate of td. per one-third pint bottle, or free iri necessitous cases. With the war have come other advances: cheap milk, codliver oil, and orange juice, and a priority of -eggs, have become available to all pregnant and lactating women, to infants, and to young children. Dinners are provided at most schools, and their quality has been greatly improved ; their provision no longer depends on financial or medical necessity, but has been developed as part of the Government's wartime food policy, and many parents take advantage of the scheme. Calcium carbonate has been added to bread (7 oz. to 280 lb. of flour), and the nutritive value of all margarine has been improved by the addition of vitamin D. and vitamin A. (d) Reasons for Present Investigation While these steps have been taken with the object of bettering the general nutrition of the community and especially of guarding against diseases of childhood such as rickets and concomitant ills, it is obvious that the changes in the dietary are in the main those which the animal and human investigations mentioned above have shown to be necessary for improving the nation's teeth. It seemed of considerable interest, therefore, to see whether there was any evidence that such an improvement had in fact taken place. Fortunately, it was possible to make an inquiry into the question which would provide an answer so far as children attending L.C.C. schools are concerned, for in 1929 a dental examination of some 1,300 unselected 5year-old children (i.e., children who had not yet come under the full influence of the school dental service) in these schools was made by one of us (M. M.) for the Board of Education. The surface structure of the enamel and the presence and extent of caries in each tooth were recorded; later some of the findings, together with other records made on the same children, were published by the Board of Education (1931). By using the same criteria and examining the same age group attending these schools to-day it would therefore be possible to see what, if any, improvement had taken place in the intervening 14 or 15 years. ' Dr. W. Alien Daley, the School Medical Officer to the London County Council, was approached, and the Council's permission to carry· out an investigation was readily given.
The Present Investigation When any school visited in 1929 was closed or was no longer used as an infants' department, one or more other schools in the same neighbourhood, as near as possible to that previously inspected, were taken as substitutes. In addition, a few schools in other districts were visited, but they are not included in the main tables. In 1929 the schools were divided, with the help of the local Care Committees, according to their level in the social scale. For the purpose of the present investigation, therefore, the Care Committees were again approached, and after consultation they made- a rough classification into four grades ; but they could not guarantee that their groupings were comparable with those made in 1929, which were indicated by the signs B+, B, B-, and C. Moreover, tlrere is now a greater mixing in the schools than hitherto of children from families of different social and financial levels. This is due to many causes, including the clearance of slums and the building of large blocks of flats, the transference of families from one area to · ano!her owing to destruction of homes from enemy action, evacuat10n schemes, etc. Then, again, the financial status of many families has been. altered, either raised or lowered, as a result of the war. · . In the present survey the dental examinations were shared by us, the majority of children being inspected by H. C. From time to time during the course of the survey, and especially at the beginning, the teeth of many children were examined separately by both investigators, the two records being compared so that as far as possible the same standard would be kept ; this was especially necessary for the grading of structure, in which the personal factor plays a prominent part. We were in agreement in most cases; where differences did occur they were generally small. Detailed examinations of all teeth were made for signs of M-hypoplasia (see next paragraph), gross hypoplasia (the generally recognized varieties), and caries. Other conditions of the teeth, including their alignment, the presence of mottled enamel, and the state of the gums, were noted, but are not considered in this paper. Since results of the 1929 investigation were given as percentages of children showing varying degrees of hypoplasia and caries, ~imilar figures will be given here. A more detailed analysis of our findings will be published later.
BRITISH
MF.o:cAL JouRNAL
(a) The Structure of the Teeth
The standards used for structure were similar to those adopted in the 1929 Board of Education survey, which were evolved from the results of the investigations referred to above. Individual teeth were taken to be of normal or perfect structure when their surfaces were smooth and shiny, like those of the teeth of puppies given a mixed diet relatively rich in vitamin D and containing the necessary calcium and phosphorus. Teeth showing imperfections of surface structure were classified into three grades : slightly defective, defective, and very defective. These types of defects will be referred to as M-hypoplasia, a term first used by J. D. King in 1940 to distinguish them from the previously recognized gross or G-types, which are rarely seen in deciduous teeth. The M-type defects were originally described by M. Mellanby (1923, 1927, 1934), who found that some 80% of 1,500 deciduous teeth were so affected. The surfaces of the teeth with M-hypoplasia show varying degrees of roughness which are not always visible to the naked eye when the teeth are in situ, but can easily be detected when their surfaces are lightly rubbed with a probe ; the degree of roughness as indicated by the " feel " of the probe can be judged· with practice. A sufficiently reliable clinical assessment of the enamel surface texture is obtained if the test is confined to the buccal aspect of the teeth. When each tooth had been considered separately a general computation was made for the structure of all the teeth of a given child, keeping so far as possible to the method of assessment used in the 1929 investigation but dividing the children into only four groups instead of seven: Good structure, Little M-hypoplasia (I and 2), Some M-hypoplasia (3 and 4), and Much M-hypoplasia (5 and 6). The figures in parentheses refer to the 1929 grouping. The few cases of gross hypoplasia were included in Group 4. Although 1,604 children were examined in the main survey and included in the caries incidence tables, 33 of them had lost too many teeth for it to be possible to classify for structure, reducing the number for this purpose to 1,571. In Table I the structure of the teeth in the two investigations is set out. It is clear that in the 14 years that have elapsed the TABLE
-
.
I.-Incidence of M-hypoplasia in Deciduous Teeth Total
of I Number Children 1943 1929
I
Percentages of Children Showing : None
Little
Some
Much
1·2 0
18·1 7·8
47·4
33· 3 58· 5
1,&71 1.139
I
33-6
picture of deciduous tooth structure has changed for the better. Even so, there are very few children with a full complement of perfectly calcified teeth ; however, 'in 1943 18.1% had only slight M-hypoplasia, compared with 7.8% in 1929, and there were fewer with much M-hypoplasia-33.3% as against 58.5% respectively. In Table 11 the findings are given when the schools are divided according to their estimated social status. · There are no great TABLE
Il.-lncidence of M-hypoplasia in Deciduous Teeth at the Different Social Levels Total No. of, Children
None
Little
Some
Much
.. ..
180 133
0·& 0
2&·8 12·8
49·0 30·8
24·7 56·4
..
&82 423
1·0 0
14·8 9·9
&0·2 36·4
34·0 53·7
&58 190
1·8 0
18·0 4·7
45·1 30·0
35·1 65·3
243 393
D·B 0
20·2 5·4
44·9 33·3
34·2 61·3
Social Grading of School Highest grade (B +) 1943 .. 1929 2nd grade (B) 1943 .. .. 1929 3rd grade 1943 .. .. 1929 .. 4th grade (C) 1943 .. .. 1929. ..
cB ·-)
..
Percentages of Children Showing :
differences in these groups in 1943, although the tendency is for the highest-grade schools (B+) to have teeth of rather better structure than the schools in the other three grades, which differ little on the whole. In 1929 there was a suggestion that the quality of structure was worse in the lower-grade schools. (b) Incidence of Dental Caries
For the grading of caries each tooth was examined by probe and mirror and put into one of four categories, as follows : No caries that could be diagnosed as definite caries by our methods of examination. (No radiographs were taken.) Slight caries: Very early and suspected fissure and approximal caries. Moderate caries : Cavities involving destruction up to roughly one-quarter of the tooth, crown. Advanced caries: Destruction of more than one-quarter of the tooth crown.
IMPROVED DENTITION OF LONDON SCHOOL-CHILDREN
24, 1944
JUNE
Fillings and arrested caries were classified very ·roughly according to the extent of the crown involved and included as carious. If ·deciduous molars or canines had been lost it was assumed that they had been extracted for advanced caries, since they should normally be present at the age under review. When each tooth had been graded separately the children were divided into four groups according to the total amount··of caries present ; the method of assessment used was as nearly similar to that of 1929 as possible: No caries,* Little (1 and 2), Some (3 and 4), and Much caries (5 and 6). The figures in parentheses relate to the 1929 classification, when seven groups were distinguished instead of four. Table Ill gives a comparison of the relative amount of caries for the two investigations: 22.4% of the children in 1943 were "cariesfree," compared with 4.7% in 1929 ; and only 29.3% had much TABLE
Ill.-lncidence of Dental Caries in Deciduous Teeth Percentages of Children Showing:
Total Number of Children
I
1843 1929
·I
I
1,804 1,293
No Caries
Little Caries
Some Caries
Much* Caries
22·4 4·7
25·9 11·7
22·4 20·8
29·3 62·8
I
I
• Only 6% of the children in this category in 1943 would correspond with the C6 group (very bad caries), compared with 54% in 1929.
caries, as against 62.8% previously. Actually the improvement is even greater than these figures suggest, because in 1943 only about 6% of those in the "Much" caries group could be classed in the C6 category (very bad caries), compared with 54% in the earlier investigation, which included a number of edentulous children. No edentulous child was seen in 1943. In both investigations the· amount of caries varied considerably from one school to another ; in 1943 the percentages of caries-free children ranged from 5 to 37 and of "Much" caries from 50 to 11.5. In 1929 the comparable figures were 0 to 15.4% and 79 to 39% respectively. Table IV indicates that in 1943 there was distinctly less caries in the B+ schools than in the other three grades, which differed little TABLE
IV.-lncidence of Dental Caries in Deciduous Teeth at the Different Social Levels
I
I
Social Grading of School
No Caries
Little Caries
Some Caries
Much Caries
..
193 147
29·5 6·1
28·5 17·7
21·2 15·6
20·7 60·6
.. .. ..
598 480
20·8 6·5
27·7 . 11·3
22·0 22·6
21·5 59·6
569 210
22·9 3-8
23·8 10·5
21·1 22·9
32·5 62·8
246 456
11·5 2·8
211·2 10·5
27·2 19·5
Highest grade (B +) 1943 . . .. 1929 2nd grade CB) 1943 1929 3rd grade CB·-) 1943 .. 1929 .. 4th grade (C) 1943 .. 1929 ..
..
Percentages of Children Showing: Total No. of Children
I
.. ..
I
28·1 67·1
among themselves. In 1929 there was a slight tendency for the amount of caries present to increase from the better to the poorer schools. (c) Subsidiary Sun·ey
As already mentioned, a subsidiary survey was made of several schools in districts not visited in 1929. The findings are therefore given separately. The amount of hypoplasia was about the same as that found in the schools in the main survey, but there was less decay: 35% of the children had no definite caries. TABLE
V.-Incidence of M-hypoplasia in the Subsidiary Survey
Social Grading of School H~est
grade (B +) 3r grade (B-) .. Total
..
..
Percentages of Children Showing:
Total No. of Children
None
Little
Some
Much
134 128
0·8 0
12·7 14·8
61·9 46·1
24·6 39·1
262
0·4
13·7
54·2
31·7
The schools an came into the B+ and B- categories. In the former, 135 children were seen, of whom 40.7% had no definite caries and only 11.1% had " Much " caries. The teeth of the 131 children * There are children included in this group in whom very early caries was present in two or three teeth, and whom to-day we should probably prefer to include in a separate group between caries-free and little caries; but the standard here used is that adopted in 1929, when so few children were seen with anything approaching a cariesfree momh.
TABLE
BRITISH MEDICAL JOURNAL
839
VI.-lncidence of Dental Caries in the Subsidiary Survey Percentages of Children Showing :
Social Grading of School
Total No. of Children
No Caries
Little Caries
Some Caries
Much Caries
Highest grade (B +) 3rd grade (B -"') ..
135 131
40·7 29·0
25·2 19·1
23·0 25·2
11·1 26·7
266
35·0
22·2
24·1
Total
..
..
---18·8
in the B- schools were not as good from this point of view as those in the B+ schools, but nevertheless 29% of the children were" caries-free" and 26.7% had "Much" caries. The percentages of " caries-free " children in the individual schools ranged from 27 to 44 and those with "Much" caries from 38 to 8. (d) Arrest of Caries
In the Sheffield investigation carried out by one of us (M. M.) in co-operation with Dr. Lee Pattison, and referred to above, a striking featut"e noted in groups of children having a good calcifying diet was the relatively high proportion of decayed teeth in which the caries was no longer active--in other words, in which the caries had become arrested. Many of these children were examined at regular intervals over long_ periods, and it was found possible to trace the gradual arresting of the carious pJocess. It is therefore significant that in the present survey typical arrest was found in at least some teeth of 28% of all the children wi~h caries. (e) Association of M-hypoplasia and Carie9 A close association exists between the quality of a tooth and its resistance to decay, as has been mentioned above:· To assess this relationship accurately it is necessary to consider individual teeth, but it was thought that a rough indication might be obtained correlating the structure of the teeth and the amount of caries per child, taking· for this puJ1)ose only those cases in which no canines or molars were missing. None of the few children with perfect and under 5% of those with nearly perfect dentition were placed in the two worst categories of caries, whereas 38% of the children · with "Much" hypoplasia had also "Much" caries and only 8% were " caries-free." It is interesting to note that 34% of those with " Some " hypoplasia had no caries and 40% had " Little " ; this suggests that some post-eruptive influence (direct or indirect) was at work, though it must be borne in mind that these children were under 6 years of age and the molars still had a long period in the mouth in which they might become carious.
,Y
Discussion The data obtained in this survey show clearly that there has been a distinct improvement since 1929 in the dental condition of 5-year-old children attending London County Council elementary schools. The quality of the teeth is now better ; in 1943, 19% of the children had teeth of good structure, compared with 8% in 1929, while the percentages with very defectively formed teeth (i.e., teeth with "Much" M-hypoplasia) were 33 and 58 respectively. The reduction in the incidence of dental decay is even more striking: in 1943, 22% of the children were "caries-free," compared with 5% in 1929, while only 29% had "Much" caries in 1943, as compared with 63% in 1929. When the schools were grouped according to social status there was little difference in dental condition as regards both structure and caries between the various grades, though the teeth tended to be rather better in the highest-grade schools in 1943 and in the two highest grades in 1929. These observations, however, do not show whether the improvement is of recent occurrence or whether it has been gradual in this social stratum of London during the past 14 or 15 years. Since, however, the teeth of the 1943 5-year-old children were in the main formed in the immediate pre-war years and the first year of the war, the cause of the improvement in these particular children must be sought among factors operative at and since that time and contrasted with the conditions in the years 1922-9, when the teeth of the children examined in the previous survey were developing. Can the improvement be attributed to the changed dietary referred to earlier, which has increased the intake of vitamin D and calcium by ·the provision of cheap milk and of cod-liver oil to infants and young children, together with the addition of vitamins D and A to the margarine and of calcium carbonate to the bread ; or is it due to other unknown influences which have been brought to bear on child life in London during these years? No categorical answer can be given to this question, because there still remains much to be discovered not only about the relation of nutrition to dental conditions but also about the
840
JUNE
24, 1944
fMPROVED DENTITION OF LONDON SCHOOL-CHILDREN
BRITISH MEDICAL JOURNAL ~-~-
The facts emerging from this investigation can be regarded as immediate cause of caries. All we can do in attempting to answer the question is to argue from established knowledge heartening and as providing evidence that we are at last taking steps in the right direction to attack successfully the most and see to what extent this explains the observations. widespread of the ills of civilized man. Florid rickets-the It is known that the structure of the deciduous and permanent teeth of young animals is affected by the diet during their cruder manifestation of defective calcification---'has been virperiod of tooth development, both in utero, during lactation, tually eliminated in England by better feeding of pregnant and and especially after weaning, when much greater defects in lactating women, and of infants and children. It is possible dental structure of the offspring may result from diets poor in that the elimination of dental caries may not be attainable until calcifying properties. The mother has a large quantity of its immediate cause is known, but even without this knowledge calcium in her bones and sometimes stores of vitamin D in it is probable that a continuation and extension of the present her body ; these substances she undoubtedly sacrifices to some nutritional policy and its more whole-hearted adoption by the extent to her offspring when she herself is deficiently fed, but public would bring about further improvement in the architecture of teeth and in their subsequent resistance to decay. these offspring will have little or no stores of vitamin D after weaning, so that a poor calcifying diet taken at It would then at least be possible to present to dental surgeons this time very soon exerts its baneful influence. The same a situation which they could tackle hopefully. principle probably applies in the case of the child, and it is Summary therefore very important that the pregnant and lactating woman, The results are given of two large-scale dental surveys of 5-yearand later the infant itself, should have diets rich in the factors old children in the same or comparable schools of the London necessary for the production of well-calcified teeth. County Council in 1943 and 1929. During the intervening period a greal improvement has taken The experimental evidence that dental· structure is largely controlled by the ingesti!)n of enough vitamin D, calcium, and place both in the structure of the deciduous teeth and in their resistance to decay. (a) 19.% of the children had teeth of perfect phosphorus is so strong that it is difficult to avoid the conclusion that the improvement in dentition of the 1943 children or nearly perfect structure in 1943, compared with 8% in 1929, and only 33% had very defectively formed teeth (i.e., teeth with much has resulted largely from the changes in dietary in the imme- M-hypoplasia), compared with 58% in 1929. (b) In 1943 22% of diate pre-war and early war period. If this is the case, and the children were, according to the standards used, " caries-free," if mothers and children are taking and continue to take full compared with about 5% in 1929. advantage of the additional improvements in dietary that I:Wlve That there is still great room for improvement i~ dental condition been placed !lt their disposal during the last year or two, it is demonstrated by the fact that even at the present time between s~ems safe to predict that children's teeth now being formed '56 and 95% of children in individual schools visited in th~ two surveys had dental decay in at least some of their teeth. wdl be even better than those of the children seen in the 1943 It is thought that the observed improvement in the dental condisurvey. While, therefore, the reason for the improvement in dental tion of this age group may be largely due to the changes in feeding habits which have been .developing in recent years-in particular to structure seems clear, the cause of the reduction in dental caries the introduction in 1934 of the cheap milk scheme of the Milk is less certain. Since M. M.'s early investigations on children's Marketing Board and later to the wartime food policy, which teeth showed that those of good structure were less liable to included (a) increased allowances of milk together with cod-liver caries than those of poor structure, and since the structure of oil and fruit juices to pregnant and lactating women, to infants, and the teeth in this survey was better than in 1929, some reduction to young children ; (b) the addition of vitamins A and D, to in the amount of caries was to be expected from this cause margarine ; and (c) the addition of calcium carbonate to bread. alone. The reduction observed, however, was greater than These are dietetic changes that investigations on animals and chilcould be explained on this basis, so that some other contributory dren carried out by one of us (M. M.) since 1917 have established as essential for the improved dental condition of the general child factors were evideptly at work. population. Investigations carried out by M. M. and her colleagues and Our thanks are due to many people who have helped us directly others have shown that the dietary factors which promote wetlor indirectly with this investigation. These include : the London calcified teeth also tend to retard the onset and spread of caries, County Council and Dr. W. Alien Daley for their permission to apart from their influence on structure. The dietary of the carry out the inspections, for making the necessary arrangements at the schools, and ·for their kind interest in the progress of the survey ; young children in the 1943 survey has been improved from the Care Committee Organizers for grading the schools and for other this point of view even beyond the standard reached during valuable assistance; and Miss Irene Alien for general help, and the immediate pre-war period and early part of the war, when especially for working out the results given in the tables. Last, their teeth were being formed, and it is considerably better but by no means least, we want to thank the head teachers of the than the dietary at the corresponding period in the lives of infant schools and their assistants, without whose willing and co-operation the work would have been impossible. H. C. the 1929 group of children. It might be surmised, therefore, interested holds a scholarship from the British Council. and other expenses that the reduction in caries in 1943 as compared with 1929 is were paid by the Medical Research Council ; to both of these due in part to the better structure, which is related to better bodies we are very grateful. BIBLIOGRAPHY calcifying dietary, in part to the post-eruptive influence of the Anderson, P. G., et al. (1934). J. Amer. dent. Ass., 21, 1349. even better dietary condition of the war years, and possibly in Board of Education (1931). Committee on Adenoids and Enlarged Tonsils. part to other unknown changes. What these other factors are Second Interim Report: The Association of Rickets and Dental Disease with Adenoids and Enlarged Tonsils, London. that may share the responsibility for the diminution of caries in Dental Disease Committee (1936). Med. Res. Cncl. Sp. Rep. Ser. No. 211, these children can only be conjectured. Some would say that H.M.S.O., London. King, J. D. (1940). Ibid., No. 241. changes in the carbohydrate intake or the fluorine intake or McBeath, E. C. (1932). J. dent. Res., 12, 723. of food consistency, or a greater use of the toothbrush have - - (1934). Amer. J. pub/. Hlth., 24, 1028. and Zucker, T. F. (1938). J. Nutrit., 15, 547. played -a part. Unfortunately the basis of these suggested - - and Verlin, W. A. (1942). J. Amer. dent. Ass., 29, 1393. factors is too insecure at the present time to allow their effects McKeag, R. H. (1930). Brit. dent. J., 51, 281. Mellanby, M. (1918). Lancet, 2, 767. to be assessed adequately. - - (1920). Dimt. Rec., 40, 63. If the present national food policy has been responsible, as - - (1923). Brit. dent. J., 44, l. - (1927). Ibid., 48, 737. seems likely, for much of the improvement of the teeth here - - (1929). Med. Res. Cncl. Sp. Rep. Ser. No. 140, H.M.S.O., London. reported, this only emphasizes the importance of still greater - - (1930). Ibid., No. 153. - · - (1934). Ibid., No. 191. efforts on the part of central and local government in the - Pattison, C. Lee, and Proud, J. W. (1924). British Medical Journal, 2, 354. same direction, for even to-day 78% of these 5-year-old chil- - - - - (1926). Brit. dent. J., 47, 1045. - - - - (1928). British Medical Journal, 2, 1079. dren have some decayed teeth. Parents must be taught to realize - (1932). Ibid., 1, 507. that the consumption of milk and vitamin D is a sine qua non Schiotz, C. (1937). Norske Tandlaegefor. Tidskr. for improvement of the teeth of their children, and they must be induced to co-operate more willingly in this health-giving In an address to the Conference of the Children's Nutrition project. Much has already been done by the staffs of welfare Council (Wales) at Cardiff on May 13, Mr. Eddie Williams reminded centres, school medical and dental officers, Care Committee his audience that the object of the Council was " to ensure that no workers, and teachers ; but unfortunately there still remains a child, by reason of the poverty of its parents, shall be deprived of at least a minimum of food and other requirements necessary for fair proportion of parents who, for one reason or another, fail full health." He strongly advocated the institution of school meals to take full advantage of the dietary supplements at their throughout Great Britain. disposal.
JUNE
DENTAL CARIES IN LONDON SCHOOL-CHILDREN
10, 1950
DENTAL STRUCfURE AND CARIES IN S·YEAR·OLD CIDLDREN A'ITENDING LONDON COUNTY COUNCa SCHOOLS RESULTS OF FIVE SURVEYS (1929-49) BY
HELEN MELLANBY, M.D., Ph.D. AND
MAY
~LLANBY
(From the Nutrition Building, National Institute for Medical Research, Mill Hill, London)
In 1929, at the request of the Board of Education, the teeth of 5~year-old children attending L.C.C. schools were examined. Fourteen years later a similar survey was undertaken, with the idea of seeing whether there had been any improvement or deterioration in this period (Mellanby and Coumoulos, 1944). It was then decided to make a series of two-yearly inspections, using the same criteria, and the latest of these was made in 1949. The object of the present paper is to summarize the most recent findings and to compare them with those 'of the previous surveys. In the earlier work it was shown that the dental condition of this age group, as regards both structure and caries, had improved from 1929 to 1947 (Mellanby and Mellanby, 1948). Since we made no examinations between 1929 and 1943, it is not possible to say at what rate the improvement took place or whether it was regular during that period, but there is no doubt that it was very definite and significant (Mellanby and Coumoulos, 1944). Many more children had teeth with good structure in 1943 than in 1929, and the percentage of caries-free plus almost caries-free children rose from 4.7 to 24.2 during the 14 years. In 1945 the percentage in this latter category was 28.1, while in 1947 it had risen to 37.5. It was therefore with great interest that the 1949 survey was made. As it was realized that it would not be possible to examine as many children in 1949 as in 1943 and 1947namely, 1,870 and 1,590 respectively-it was decided to limit the number to approximately that of 1945, when 691 children were seen. So far as possible the same schools were visited as in that year, but, since there were many more 5-year-old children on the registers, a random sampling method was used to obtain the requisite number. Six hundred and ninety-two children were examined ; their TABLE
Total No. of Teeth Examined for Structure
Type of Tooth
Upper jaw: Central incisors Lateral incisors Canines 1st molars .. 2nd molars Lowerlaw: ·• Central incisors Lateral incisors Canines 1st molars 2nd molars ..
..
.. ..
Total
..
1943
1945
1947
1849
3,324 3,707 3,268 3,427
1,262 1,341 1,369 1,282 1,342
2,931 3,023 3,119 2,869 2,960
1,230 1,308 1,3811 1,248 1,307
3,091 3,624 3,702 3,119 3,104
1,097 1,348 1,370 1,23S 1,241
2,S3S
1,044 1,333 1f372 1.172 1,171
3,46S
3,097 3,109 2,700 2,15S
33,831 12,887 29,098 12,548
average age was 5 years 6 months-one month older than the average for each of the previous three surveys. The inspections were conducted in the same way and according to the same standards as before (Mellanby and Coumoulos, 1946; Mellanby and Mellanby, 1948). To get some indication of the extent of the lesions, apart from the percentage of carious teeth, a number (1, 2, or 3) was allotted to each carious· tooth, according to the severity of the disease (Mellanby and Coumoulos, 1946). The total so obtained for any group of teeth was then divided by the number in the group, thus giving the average caries figure (A.C.F.). The greater the number of teeth with little or no caries the lower the A.C.F. A similar principle was adopted in order to assess the extent of M-hypoplasia (A.H.F.), the number 1 being given for M-Hy 10 2 for M-Hy2 , and 3 for M-Hy 3 • The few teeth showing gross and unclassified hypoplasia were excluded from these calculations. As in the other investigations of this series, any missing incisors were assumed to have been shed. Very few of the 13.3% of missing lower incisors would have been carious, and as only 5.2% of the upper were absent any decayed among them would have made little difference to the caries total. Missing canines (0.2%) and molars (upper 6% ; lower 13.4%) would have been extracted at this age and were therefore included in the severe caries (C3 ) category. As many workers now use the D.M.F. (decayed, missing, and filled) method of expressing their results, we have added the corresponding nomenclature as subheadings where applicable (see Tables 11 and Ill). In order to reduce the size of the tables for this paper, the four grades of structure (Hy 0 to M-Hy3 ) given indi. vidually in previous papers have been combined into two categories, as have the four grades previously given when assessing caries (C 0 to C 3 ). Results From the tables it can be seen at a glance that the gradual improvement in the dental condition previously noted was not maintained. There was indeed a falling off in 1949. Structure.-lt is clear from Table I that there were fewer well-formed teeth in 1949 than in the previous survey; 79.8% of all teeth were graded as Hy0 or M-Hy 1 in 1949 as compared with 84:5% in 1947, but there were more, on the average, than in 1945, when 71.6% came into this category. The percentage of some individual types
I.-Tooth Structure in 5-year-old London Children
.
.
Percentage of Teeth with Percentage of Teeth with Percentage of Teeth with Good or Fairly Good Gross or "Textbook " Poor Structure Structure Hy8oplasia (M-HYo+a> (Hy,.+M-Hy,) ( -Hy) 1943 194S
1947 1949
1943 194S
61·2 78·0 86·5 47·9 44-7
82·8 88·6 93-6 64·7 S3•8
79·1 89·3 93·8 &8·2 46-11
43-7 32-1 14·2 18·8 2H 16·S 8·2 8·8 14·7 11·2 4·4 8·1 S6·9 49·3 34·9 43-1 63-4 S4·3 46·1 113·4
99-1 98·7 88·8 93·2 S6·9 61·9 41·6 45·0
99·6 99·4 96·3 87·8 77·8
98·4 98-7 98·9 82·9 72·8
S2-l
74-1 83-3 40·3 3S·2 9S·9 9S·2
67·0 71·6 84·5 79·8
1947 1849
1943 194S 3-9 2·S 1·0 2-8 1·3
6·6
5·4 H
2·8 1·0
1947 1849
1·37 1·14 0·68 1·00 0·79 0·61 1·83 0·71 O·S9 l·S1 1·48 1·28 1·68 1·S8 1-44
0·83 0·73 o-70 1·41 1·114
0·33 O·IS 0·06 o-43 0·21 0·10 O·S3 0·30 0·19 1·17 0·77 11·27 1·56 1·55 1·02
0·13 0·42 0·117 1-24 1-18
O·S
40·S
s.J-S
0·2 0·1 1·4 2-S 3-4
0·3 0·7 2·6 l·S
0·2 0·2 0·3 0·3 0·3
0·4 0·2 0·0 0·8 0·4
30·S
2S·S
14·2 19·4
1·9
2·3
0·8
0·7
S4·9
O·S
1947 1948
2·3 2.1 0·2 0·8 0·2
0·2 0·1 0·7 1-7 11·8 38·3 21·9 18·7
0·3
1943 194S
1
3·0 2·7 0·7 0·4 0·1
0·4 0·8 2·4 3S·6
3·8 4·6 6·4
Extent of M-hypoplasia (A.H.F.)
.
1
1·04 0·91
0·67 0·88
A few of the teeth included in the column headed " Total No. of Teeth Examined for Structure" could not be classified into any of the grades shown in this table. Therefore the percentages do not add up to 100 in all instances.
1342
JUNE
10, 1950
DENTAL CARIES IN LONDON SCHOOL-CHILDREN
of teeth in the better-structure group was as high or nearly as high as in the best year so far recorded (1947). The average hypoplasia figures (A.H.F.) for all types of teeth are given in the last column of Table I. Only a small amount of gross hypoplasia was found in any of the surveys, the latest figure being about the same as that obtained in 1947. Caries.-From the figures given in Table 11 it is seen that 1947 was the year in which there was the greatest TABLE
H.-caries-free Children and Caries-free Teeth Among London 5-year-olds Children
Year
Total No. Examined
1929 1943 1945 1947 1849
Teeth
% Caries- %Caries-free free (i.e., with +Those noD.M.F. Almost Teeth) Caries-free
•
1,293 1,870 691 1,590 882
Total No. of Teeth
Percentaae Caries-free
36,196 13,381 30,839 13,328
69·9 73·5 79·7 73·3
4·7 24·2 28·1 37·5 24·8
14·9 24·2 28·1 14·8
I
• The percentage of canes-free children at this time was negli&~ble. 0
0
percentage of children free from caries-namely, 28.1 %. In 1949, as in 1943, only 14.9% were in this category. The proportion of caries-free teeth, however, was higher in 1949 (73.3%) than in 1943 (69.9%), though not as high a'S in 1947 (79.9%); it was, in fact, the same as in 1945, when it was 73.5%. The distribution of caries among
was again observed in 1949, as in the previous surveys of this series and in the earlier investigations of the authors and of other workers (M. Mellanby, 1923, 1927, 1934; Deverall, 1936; Davies, 1939 ; King, 1940; H. Mellanby, 1940), that the teeth of. poorer structure, as judged by the degree of M-hypoplasia, were more prone to decay than were those which were better formed. Summary
The main findings in a series of dental surveys among 5year-old children attending public elementary schools in the London County Council area have been given ; the results of the last four surveys made at intervals of approximately two years are, for the reasons stated earlier (Mellanby and Mellanby, 1948), set out in more detail than those of the original survey of 1929, on which the others were based. At the time of the fifth and latest survey of 1949 proportionately fewer children were caries-free-namely, 14.9%-than on the two previous occasions, when the figures were 28.1 and 24.2% respectively ; the position had, in fact, reverted to that of 1943. In 1929 the number of children so classed was negligible. The percentage of caries-free teeth (73.3) had not fallen in 1949 to the same extent relatively as the percentage of cariesfree-children, but was comparable to the figure obtained in the third survey made in 1945 (73.5%). Dental structure, on the other hand, although not in general as good as in 1947, was better than in 1945. It is difficult at present to suggest a reason for this apparent lapse between 1947 and 1949, following the previously observed improvement in the dental condition of children of the same
III.-caries Incidence and Extent in 5-year-old London Children
TABLE
I
i! FreePercentage of Teeth From or with only
Percentage of Teeth p c · T h with Definite Carious ercentage anous eet Extent of Caries Slight Caries Cavities (i.e., D.M.F. (A.C.F.) per I 00 Teeth) (C,+C,) (C,+C,) I---~-94-3--19-4~5-~19_4_7--1~8-49--I--1~94~3-19_4_5__19~4~7~1~M~8~I--1~9~43~19~4~5~1~94~7~1~M~8~i~-~~~97.43~194~5~J7 94=7~1~I~O~I--,=9~4~3~17 94=s~t~94~7~1=M~8 Total No. of Teeth
Type of Tooth
I
I
Upper jaw: Central incisors Lateral incisors .. Canines 1st molars .. 2nd molars .. Lower jaw: Central incisors Lateral incisors Canines .. 1st molars .. 2nd molars ..
3,392 3,590 3,740 3,740 3,740
1,280 1,358 1,381 1,382 1,382
2,974 3,095 3,180 3,180 3,180
1,274 1,351 1,384 1,384 1,384
72·2 86·5 93·4 66·7 60·7
75·5 88·3 94·2 69·4 66·3
83-4 92-7 95·0 75·9 79·6
78·2 90·0 83-1 71-2 74·2
27-8 24·5 16·5 20·7 13-5 11·7 7·3 10·0 5-l 1·8 6·6 5·8 33-3 30·6 24·2 28·9 39·2 33-7 20·4 25·8
37·6 20·3 9·5 42·0 56·5
29·5 22·2 30·1 14·9 10·6 14·& 1·5 6·9 8·1 38·9 30·6 35-7 51-4 34·4 44·2
0·77 0·38 0·18 0·95 1-17
0·61 0·30 0·15 0·83 0·95
0·42 0·20 0·13 0·65 0·64
0·56 0·28 0·17 0·78 D-78
3,112. 3,662 3,740 3,740 3,740
1,098 1,354 1,382 1,382 1,382
2,576 3,114 3,180 3,180 3,180
1,081 1,338 1,384 1,3M 1,384
97-8 98·3 95·5 53-9 51·9
99·2 98·5 94·8 58·6 56·3
99·0 98·8 97· 3 62·4 68·2
88·8 88·1 88·4 55·5 57·8
2·2 0·8 0·9 H 1·7 1·5 Jot 1·8 4·5 5·2 2·7 3·8 46·1 41-4 37·6 44·11 48•1 43-6 31-7 42·2
4·9 1·7 1-7 3·3 3-7 2-1 1-7 2·1 11·5 6·9 5·9 4·1 54·0 48·6 43-3 114·0 61·0 58·8 43·0 81·3
0·08 0·06 0·13 1·29 1-42
0·03 0·04 0·12 HO 1·27
0·03 0·03 0·07 1·00 0·95
0·011 0·011 0·10 1·21 1·28
22·7 20·3 15-1
30·1
0·65 0·55 0·42 0·54
77·3 79·7 84·9 80·8
36,196 13,381 30,839 13,328
Total
the various types of teeth is seen in Table Ill. Though the 1949 results were in general very similar to those of 1945, more decay was found in the lower molars and less in the upper. Tbe percentage of carious lower first and second molars increased from 48.6 and 58.8 to 54.0 and 61.3 respectively, and the carious upper molars were reduced from 38.9 and 51.4 to 35.7 add 44.2% respectively. The A.C.F. for all types of teeth are given in the end column of Table Ill. Structure and Caries.-Table IV shows the relationship between structure and caries in the last four surveys. It TABLE
llamsH
MmiC.U. JOUIINAL
18·1
26·5 20·3 26·7
age group ; it may represent merely a periodic fluctuation, or it may mark the beginning of a progressive deterioration. It is hoped to make a sixth survey in 1951, when it will be seen how the trend has resolved itself. Discussion of the possible factors influencing the results should then be more profitable. We wish to acknowledge our indebtedness to Sir Alien Daley and the London County Council for permission to carry out the inspections ; to the head teachers and staffs of the schools for their willing co-operation in the scheme; to Mrs. M. Kelley and Mrs. J. Joyner for their assistance in connexion with the preparation of the report; and to Miss I. Alien, of the Medical Research Council's Statistical Department, for help and advice.
IV.-Percentage Incidence of Caries in Teeth with Varying Grades of Structure in 5-year-old London Children Percentage Carious Structure of Teeth
Incisors
Good or fairly good (Hy.+M-Hy,) .. Poor (M-Hy,+,) 00
Gross hypoplasia
00
00
..
..
..
.. .. 00
Canines
Molars
1943
1945
1947
180
1943
1945
1947
1MB
'
1943
1945
1947
1Nl
5·9 51·7
4·5 46·0
6·f 37·5
8·8 32·3
4·8 30·1
3-8
33·0
4·3 14·2
11·8 22·4
20·8 65·6
21-1 70·0
26·2 44·2
38·4 &0·8
64·2
62·4
36·0
38·7
23-3
20·8
34·4
-
58·9
52·5
34·4
38·0
--
JUNE 10, 1950
DENTAL CAJliES IN LONDON SCHOOL-CHILDREN REFERENCES
Davies, J. H. (1939). Brit. dent. J., 67, 66. Deverall, A. (1936). Spec. Rep. Se'r. med. Res. Coun., Lond., No. 211. King, J. D. (1940). Ibid., No. 241. Mellanby, H. (1940). British Medical Journal, l, 682. Mellanby, M. (1923). Brit. dent. J., 44, l. (1927). Ibid., 48, 1481. - - (1934). Spec. Rep. Ser. med. Res. Coun., Lond., No. 191. - - and Coumoulos, H. (1944). British Medical Journal, l, 837. - - (1946). Ibid., 2, 565. - - and Mellanby, H. (1948). Ibid., 2, 409.
CANCER OF THE BREAST TREATED BY OOPHORECTOMY
anisocytosis was rather marked ; leucocytes appeared normal (Figs. lA to 2B illustrate the case.) Operation.-On July 7, 1948, a bilateral oophorectomy was performed and the skin nodule from the right shoulder region was excised. Pathologist's Report on Specimens.-" (a) Both ovaries:There is an enlargement of one ovary by a cyst with water .,contents (2.5 by 2 cm.) ; the other ovary appears normal. Microscopy shows that the ovarian cyst has a thin lining of luteal cells. In the other ovary there is a wide, ill-defined zone of theca-cell formation; otherwise there is no abnormality. (b) An elliptical piece of non-ulcerated skin (2.2 by 1 cm.) with underlying fat (1.2 cm. deep) in which there is a firm white growth merging into the dermis and projecting on one part of the cut surface. Microscopy reveals a secondary spheroidal-cell carcinoma arranged as compact groups, narrow cords, and isolated cells in the subcutis and deep layers of the dermis."
BY
RONALD W. RAVEN, O.B.E., F.R.C.S. Surgeon to the Westminster Hospital (Gordon Hospital); Surgeon to the Royal Cancer Hospital The treatment of advanced cancer remains an important problem, and any encouragement we gain in an endeavour to help these patients should be made known so that others may benefit. The case record is therefore presented of a patient with advanced cancer of ·the breast who was treated solely by bilateral oophorectomy ; the disease disappeared entirely during the six months following the operation, and she was free from demonstrable disease 22 months later. This patient called attention to the fact that the various lumps increased in size immediately before menstruation, and it was this observation which made me decide to perform the operation. The experience of others has been sought in the literature and is presented to enable an assessment to be made of the present position in order to plan for a further step forward.
FIG. 1A.-Tumour in ·right pre-auricular region. Before bilateral oophorectomy.
FIG. lB.-Tumour in right pre-auricular. region has disappeared after bilateral oophorectomy.
FIG. 2A.-Skin nodule below left clavicle. Before bilateral oophorectomy.
FIG. 2u.-Skin nodule below left clavicle has disappeared after bilateral oophorectomy.
Case Report A married woman, aged 50, with two children, was seen on April 13, 1948, with multiple lumps. History.-Two years previously she noticed a swelling of the right side of the face in the region of the parotid salivary gland and pre-auricular lymph nodes. In July, 1947, a small painless lump, which increased in size, appeared above the inner end of the left clavicle. In December~ 1947, she noticed a large lump in the left breast and a small lump on the outer aspect of the left arm. Other similar nodules developed in the skin over the right shoulder, chest wall, and right loin. These lumps varied in size with the menstrual cycle, being largest just before menstruation began. Her general health was good ; there was no loss of weight. Menstrual History.-Menstruation started at the age of 16; the cycle varied from 21 to 26 days ; the duration of periop was 7 to 8 days. During the past two years she has lost clots. Examination.-Her general condition was good and no abnormality was detected. A nodular lump 3.4 by 2.2 cm. was seen in the right parotid region. In the left supracl::lvicular region a hard irregular swelling 5 by 2.5 cm. was found. There was no abnormality in the right breast. A hard irregular lump 3.5 cm. in diameter was found in the upper and inner quadrant of the left breast, attached to overlying skin and somewhat tethered to underlying structures. Hard fixed lymph nodes were present in the left axilla. In the right axilla there were no enlarged lymph nodes. Multiple nodules WFfe seen in the skin over the right shoulder, left arm, chest wall, and right loin. The abdomen was normal. Radiological examination of the chest, dorsal and lumbar spine, and pelvic bones n:vealed no metastases. A blood count showed : red cells, 4,080,000 per c.mm. ; white cells, 6.400 per c.mm. ; Hb, 78% ; C.I., 0.98 ;
Subsequent Progress.-on August 17 the lumps were smaller ; and some skin nodules had di~appeared. On October 26 the swelling in the right parotid region had practically disappeared ; the lump in the left breast was very soft, 2.5 cm. in diameter. On January 25, 1949, there was a residual area of slight thickening at the site of the original tumour in the left breast, a small lymph node in the left axilla, and an area of thickening in skin of the left arm. On February 22 all lumps had disappeared ; the tissues of the left breast were soft and pliable and resembled a normal breast ; there were no enlarged lymph nodes in the left axilla ; the face was normal ; and all the skin nodules had disappeared. On May 23, 1950, the patient was well, with no sign of carcinoma.
Historical Basis" As long ago as 1896 a new treatment was introduced for advanced cancer of the breast by G. T. Beatson, of Glasgow. The patient was referred to him by Dr. J. W.
ETIOLOGY OF DENTAL CARIES. The appearance of the ~ixth edition of Lippincott's Quick Rrferrnce !Jook tor Jlcdicine and Surge~·y.• by Dr. GEORGE E. REHBERGER, two years aftc"r the fifth edition is ample proof of the wide popularity of thi s compendium. The presrnt issup has bee_n brought up to date by substantial changes in about thirty articles.
E'l'IOLOGY OF DENTAL CARIES. Mn s.
:\fELI.Axm:'s TIEPOllT
o:-.
DENTAL STRUCTUllE
IN Does.
" IT is well known that some people with n()g) ccted mouths have teeth fre·e from caries, whereas others who take great ca re in matkrs of oral hygi ene have extensive caries. In fact, th e most rigid adherenco to the commonly. accepted PREPARATIONS AND APPLIANCES. rules of dental h:vgiene constitutes no safeguard against a d r·nta l di sPase ." This pnssage, taken from the intro1\IonrFIED HAY's PHARYNGM COPE. Du. E. E . BunNIER (Margate) \Hit es : This instru ment , wh ich duc tion to Diet oncl the 1'ccth: An Expcrim1'nta~ Study,' has been made to my design by 1\Iessrs. l\fayer and Phelps, is by May Me llanhy, expresses in a nutshell the criticism, a modifica tion of Hay's pharyngoscope. It is very much on clinical grounds, of the hithe rto generally prevailing; smaller, and consequently better borne by a . sensitive patient, view that the production of dental caries d epends almo~t and is especially useful in examining children. The lens, ext:lmi,·ely on co nditicns external to th e teeth. It sugg·cst s, moreover, tl:nt, in looking for the etiology of dental disease, the possi bility must not be neglected that some constitutional factor might be r-esponsible; in short, that in dental structures there might he a d€Jensive mechanism, in maintaining whose integrity the body as a whole may take some part. A hint as to the direction in which such a dcfeusi\'C mechani sm is to be sought appeared in Professor Edward Mellanby' s well-known work on the function in the animal being placed at the extreme end of the instrument, gives a most economy of vitamin D . 'l'his vitamin , Professor 1\fellanby l'xcellent view of the post-nasal space and of th e larynx. The pharyngoscope should be introduced in the mouth with showed, has a specific controlling e ffect over the function the light switched on, pressing lightly on the tongue to get of bone formation, as much over the development of the under the arch of the soft palate; th e patient should be told jaws as over that of other bony parts. Mrs ~ Mdlanby, to close his mouth and breathe through the nose so as to bring following up this point, made the further observation that, the soH palate forward. not only the formation of the jaws but the ar~;hit cdu ro A To:-;srL-Hnr.mN G FoRCEPS . of the teEth wa ~; directly d ependent on the prese nce at the Dr. A. G. V ARIAN (Wal ford) calls attention to the merits of right time of vitamin D in the diet. a new ton sil-holding forceps , hei·e illustrated . He writes : The During th e t\\·clve years that have elapsed bince this advanta~es of the instrument over ollh' rs I have personally used are as follows : (1) Th e sliding , deta chable fa stener prevents ohsc>nati on wns made, Mrs. 1\fellanby, with financial the teeth fl-om biting through t]H, tissue of the ton sil, since, support from the .Medical R esparch Council, th e pan PI by mean s of it, one can judge the exact amount of pressure - practitioners of Sheffield, and the Dental Board of the United Kingd om, has continued her inves tigation of tho etiology of dental diso rders, and in the volume issue d thi s week by the Modi< a! lkseard t Council (the fir st of a seri<'s of three)' she gives an account of her experime ntal studies ~ecessary to obtain a suffi cient hold. (2) It never slips or tears on diet and dental structure in dogs. Her main conaway; it holds, but does not bit e through . (3) It is solidly clus iorf is that " the minute structure of the developing built of sta inl ess steel, has strength ·to stand hard· work, and t uot h and the reaction of the d eveloped tooth to caries ca n be taken apart for cleaning. I have found it highly satis· are influenced by the chemical nature of dietetic infactory in every way, and can thoroughly recommend it to gredients, \Yhich, after being digested and absorbed, arc those who know the annoyance of most types. lt has been made fur me, on my instruction s, Ly Down Bros. , Ltd. carried into the blood stream to tlw tissues of the body, and thus to the t ee th. They also indicate that the structure A SAFETY RADit:M NEEDLE. of the periodontal tissues is depe nde nt on the chemical Attention was called in th e Jou/'nal of .January 4th (p. 29) nature of the food during the developmental period, and to the mechani cal problems of radium therapy, and, in parti· cular, to the danger arising from the liability to detachment that the diet during this early period is also related to the future onset of periodontal disease." or breakage of rad ium need les and tubes. In this co nnexion we have received a letter from the managing direclot· of \Vat son and Rons (Eiectro· 1'1tc Earlier Gronp of ExpeTiments. M edi cal), Ltd ., of Sunic Hou se, Parker Street, Having, in the earliet· chapters of the report, cleared the gronnd by describing the normal proces.~es of develop. ment, eruption, and shedding of th e teeth in dogs, an in the di et !ration, has a flat hea d with two holes for th e of a vitamin of so m ewhat similar distribution an1l prothread. Th e cells {c) are · placed in position and the need le is pertic-3 to vitamin A. The differe nces in distribution closed with a mandrel (B), the leng th of which varies according het11·een this vitamin and the unknown factor favourable to the numh<'r of cells. The mandrel also has a flat head with to calcification we re sufficiently marked, however, to suggest two holes. The thread is passed through th e hol es of the that th e two suhstanccs were not identical, a-nd the latter, 11 eedlc and of the mandrel, thus fixing th e two firmly together. eventually diffe r·c nti a ted as a separate entity, is now known such a needl e is very strong, and th e danger of a thread breaking is minimized by two being used. At the point of the as vitamin D, or the calcifying o1· antirachitic vitamin. "';edlc there _is a narrow chann el (A) w!lich allows th e passage 'Medical Resea rch Council. Di et ami the Teeth: An Ex.pe•'imontnl of a very tlnn mandrt>l for the e xpul siOn of the radium cells Study. Part. I. Dental Strndure in Dogs. By May Mellanby. II.M. after use. Stationery Office. 1929. 17s. 6tl. net. 9 Lfppinco ff' 8 Quick Reference BotJk f or Jlediciue antl Surge.ry. By licorge E. Rchhrrger, M.D. Sixth ed ition , r evised. London: J . B. Lippincott Coml'a ny. (:Sup, t·oy. Svo ; i llust rat ed. 65s. net.)
I
A
FEB. rs, rg3o]
ETIOLOGY OF DENTAL CARIES.
"'hen this inYestigation was started the distinction bdwren Yitamins A and D had not vet bec>n c>stablisl](>d, and Mrs. :1\-Iellanln· pre,entina IH'r a'crount in historieal srqnence, does not identify th: calcification-promoting s11hstance with ,-itamin D till chapter x, in the t•arliPr chapters refernng to it as the " calcifying vitamin " or a " fat-soluble Yita1nin." Such a method of pres€ntation has undoubted advantages; the reader watches the facts as they aC'ClllllHlate, and at the appropriate moment s-ees the conclusions in the process of formation. On the other hand, perhap' some greater clarity might lltwe been gained if, in the course o_f the nanative, earlier experiments had het•n C'onsistentl~· mterpreted in the light of more recent discoveries.
Influence of Fitamin D. The development of perfect teeth, it was found, could be ensured by giving an adequate supply of >itamin D, either as it appears in natural foods-fo:· example, eggyolk, milk, suet, and eod-li>er oil-or as it may be artificially produced, by irradiating the ergosterol content of food, or by irradiating the animals' skins. In the presconce of this vitamin it was diffieult to choose a diet so low in its <'nlcium and phosphorus conteni, or otherwise so unfavourable to calcification, as to interfere• materially with the normal development of the dental tissu€s. On tlHJ other hand, it was easy to choose a diet defieient in vitamin D, for the foods containing this substance are few in number and, in general, expensive. It would s-eem to follow-·-if the factors controlling the dentition of the dog and the human subject are the same-that the ordinary diet of the pom·er classes in this country, which consists in the main of bread, oatmeal, barley, sugar, fruits, jam, vegetables, lean meat, and white fish-all of them vitamin D defic-iPnt mbstances-will tend to produce imperfect tEeth. Other Food Constituents. Proh•ins, carbohydrates, most vegetable fat5, and foods suc-h ns cereals, oranges, and egg-white, gave no €videncc of c·aleifying power. Bacon fat appeared to have but little effect, and hydrogenated animal fats none at all. An increase in the cer·eal intake had a deleterion~ effect on calcification, apart altogether from its effect on the rate of growth. Of the cereals tested, oatmeal had the greatest deraleifying power, and white flour the least; iNtermediate between t!H:'sc were maize (next to oatmeal), then barley, rye, wholemeal flour, and ri('e. Wheat and maiz<' germs also had an unfavourable effcd on calcification. In evPrv ease, howeYcr, the influence of cereals could he entirely oYercome by including in the diet a sufficiency of vitamin D. It was not found possible to ascribe the anti-calcifying eff,ect of cPreals to any one known constituent, such as (a) the absolute or rclativ,e amounts of calcium and phosphorus, or (b) the carbohydrate, fat, or protein, or (c) the acid~base ratio of the mineral substances. The eYidence suggested that cereals contain an anti-calcifying faetor (" toxamin ") of unknown composition, which actively int·erferes with the normal development of the teeth. This unknown substance is d€stroyed by boiling with dilute hydrochloric acid, and, to a. less extent, by boiling with alkalis_; it may also be destroyed or antagonized in the process of malting.· When_present in the grain it is stable to fairly high temperatures, and· it resists digestion with diastase and, partially, with trypsin ..
Calcium and Phosphor11s. For the production of• p-erfect teeth the diet must naturally contain some ealcium and phosphorus, though only small quantities of these are required if the diet is rich in vitamin D. If the vitamin D intake is >ery low extra calcium may have some beneficial effect, but in the complete absence of vitamin D perfect calcification will not occur, lwwcver much calcium and phosphorus is given in the diet. liiaternal Feeding. Proprr maternal feeding on the lines indicated is of great importance in the production of good teeth in the developing ~ffspri»g. Poorly calcified deciduous teeth were
produc<'d in the offspring h~- feeding the mothPr on a dtct d0ficicnt in Yitamin D. The defpd~ 'o prodtH·<•d wen·, ho\\"EVN, le.<' same diet. It seems probable that, under 0ertaia <·onditions, storer'~ tis:;ues before pr<'gnanc~ anc! tlH' amount present in her diet during 1wegnune~· ancl lactation. The maternal feeding "·as found to affect also the future structure· of the permanent teeth, for when the moth2r':; diet contained abundant vitamin D, and the offspring, after \\'eani11g, \\·ne fed on a diet dPficient in this substance, the permmwnt tc•eth, though defPctive in structure, were not nearly so dcfecti>e as those of puppies "·hose motlwrs' diet had also been deficiPnt in this vitamin. In ~hort, a c!cfici<'ncy in the mother's diet during pregmmc~· may influence the offspring throughqnt its !if<'. F'urthcr evidenee of vitamin storagP was afforded by the facE that when the diet of ·a pnppy was c·hang<'d from one rich in vitamin D to one deficient in this substance, ckcalcification did not occur at once, and ddecti,·e formation of the d('ntal strudnres appeared after a eomparati,·ely long intenal. Effect of Irradiation. Though Yitamin D has such a limited distribution it can be produced by ultra-Yiolet irradiation of foods containing the pro~vitamiu ergosterol. Thus, olive oil and p<>anut oil, though ordinarily without effect on the t£>.eth, became powerful calcifying agents after irradiation. The aetivity of milk and butter was greatly enhanced by irradiation, and substances which normal~- interfered with calcification--for example, oatm('al and ftour'---by this UH:'ans were made to assist the process. The application of ultraviolet radiations tQ. the skin was not nearly so €ffective in p1·omoting calcification as a. diet rieh in vitamin n. Exposure of dogs to sunlight, though beneficial to calcification of the teeth in eertain condition;;, proved in somo of the cases ta: he practically ineffective when the did n·as markedly anticalcifying.
' ROYAL MEDICAL BENEVOLENT FUXD. AT the last meetin!l's of the conimittee of the Roval Medical
Benevolent Fund tl1e following sums were voted ~ Decembei· £1,342, January, £1,037-making a tob~l of £2,379; no ff'wer than 113 necessitous 1nedical men, their widows, or families being helped thereby. During the winter months the number of applicants is inevitably large; for somP. the occasion is illness or the lack of ordinary comforts, but for most it is the death of a husband or father who has bf'en unable to make provision for wife Dr family. The committee urgently appeals for subscriptions, donations, and legacies. Cheques should be forwarded to the Honorary Treasurer, R.oyal Medical Benevolent Fund, 11, Chandos Street, Cavendish Square, London, W.l. The following are particulars of five cases recently helped. ""idow, aged 50, of L.R.C.P. and S., whose husband died snddenlv in September, 1029, at the age of 51, from heart failure. The widow ·who is in very delicate hea.Hh, was left an income of £50 per annum' with children dependent on her. Voted grant of £36 and a special gift of £14. M.D., aged 60, marriccj, .S}tfie!ing .frpm .tubercu,Josi.s and in !l.~anatorium. Pract~ce has hf'cn sole~, and -W!J_eri proceeds-' are. lflYestcd W1If giye an income of £135. Applicant has one son and two daughters· the two eldest have secured posts. Voted £40. ' Widow, aged 60, of M.R.C.S., L:it.€.P. Her husbnnd suffered ill hea!ih all his life, and was never able to work- sufficiently to save any moriey. At his death in November the widow and one daughter were left wltii " capital of £200. The daughter fortunately has been trained and will obtain employment. Yotcd £26 and special gift of £10. Two daughters, aged 61 and 58, of L.F.P.S., whose only income ls £TT each, gifts from friends, and deposit interest on the sum of £57. Yoted J!36 each. Daughter, aged 70, of M.R.C.S. Has been in bed during the whole of the' last twelve months. Income from charities £30, old age pension £26. Voted £30.
The Royal Medical Benevolent ··Fund Guild still receives many applications for clothing, especially for coats and skirts fsts, and suits for working boys. 'l'be Guild appeals for second-hand clothes and hou.sehold . articles. The gifts should be sE'nt to the Secretary of the Gmld, 58, Great Marlborough Street, W.l.
BRITISH
MEDICAL
JOURNAL
LONDON SATURDAY AUGUST 28 1948
THE REDUCTION IN DENTAL CARIES IN 5·YEAR·OLD LONDON SCHOOL-CHILDREN (1929·47) BY
MAY MELLANBY AND
HELEN MELLANBY, Ph.D., M.B., Ch.B. (Nutrition Building, National Institute for Medical Research, Mill Hill, London} The present paper is a continuation of a series describing the dental condition of 5-year-old London County Council school-children in 1929, 1943, and 1945 (Mellanby and Coumoulos, 1944, 1946). Between July and the end of October, 1947, 1,590 such children were examined with the object of finding whether the improvement observed in 1943 and 1945 had been maintained. The children lived in the same areas of London, and in the majority of cases attended the same schools as those used for the earlier surveys. A few of the schools previously visited were no longer available ; substitutes in the same localities were then provided by the London County Council. As before, only children who had attained their fifth birthday but had not yet reached their sixth were selected, the average age being the same as in the other surveys. Although the presence of any permanent teeth erupting ·or erupted was recorded, this report refers only to the deciduous dentition., In this 1947 survey the methods and standards adopted were similar to those used previously, full details of which can be found in the earlier papers. Methods
Structure.-The structure of the individual teeth of each child was assessed according to the method devised and first used by M. Mellanby as early as 1923 and since then also employed on numerous occasions by others, including King, Coumoulos, Deverall, H. Mellanby, and Davies. In essence the method consists in rubbing the labial surface enamel of each tooth with a fine probe of standard size and sharpness (S.S. White Stainless No. 37}. After some practice it is possible to grade teeth in the mouth by the smoothness or roughness felt with the probe. It was shown many years ago that .this external enamel texture could be correlated with good and poor microscopic structure (M. Mellanby, 1934). On sectioning, smooth teeth showed what were judged to be well.calcified enamel and dentine, whereas external roughness was usually associated with a less well-calcified minute structure, in particular with dentine containing interglobular spaces. The various macroscopic grades of surface roughness or defect are referred to as M-Hypoplasia (M-Hy) to distinguish them from gross or "textbook" hypoplasia (G-Hy), which is the only type whose existence is commonly recognized by dentists. Gross hypoplasia, the aetiology of which is not fully understood, is uncommon in deciduous teeth in this country ; it is readily visib~e to the naked eye, the teeth so classed having obvious enamel pits or, in some instances, areas from which the enamel is lacking. In surveys of this kind there are always some teeth whose structure it is difficult or even impossible to grade. This situ-
ation may arise, for instance, when a tooth has some structural defect which does not correspond to any of the grades described below. These teeth are included in Tables under the heading " Hy unclassified." A small proportion of teeth were so carious and others had such heavy deposits of tartar over certain areas that no opinion could be formed about their original surface structure. Where for either reason it was impossible to make a satisfactory estimate of the average structure the teeth are recorded as being present in the mouth but are not included in the structure tables. By the probe method described, each tooth whose structure could be assessed was graded according to the following symbols: Hy0 : No hypoplasia; smooth shiny surface-good structure. M-Hy,: Slightly rough surface-slightly defective tooth. M-Hy,: Rougher 'surface-definitely defective. M-Hy,: Vecy rough-vecy defective. G-Hy: All varieties of gross or " textbook '' hypoplasia. Caries.-Bach tooth was examined for caries with a standard probe (S.S. White Stainless No. 12) and illuminated mirror. Any decay that could be diagnosed by this method was graded as 1, 2, or 3. Grade 1 included very early and suspected fissure and approximal caries and cavities up to the size of a pin-hole ; grade 2 included all cavities from pin-hole size up to one-quarter of the crown ; and grade 3 contained thc,>SC teeth with more than one-quarter of the crown decayed, in~luding those of which only the roots were left, and all missing canines and molars, which were assumed to have been extracted on account of caries. Obvious undermining decay was taken into account in judging the size of a cavity. Any incisors not present were counted as naturally shed. A child's dentition was regarded as caries-free only when no caries, active or arrested, was recorded on the chart. A mouth containing one, two, or three teeth which were included in grade 1 caries, but none in the other grades, was described as being "almost caries-free." This system of classification was adopted in order to obtain figures which could be compared with those obtained in the 1929 survey, when so few children were completely caries-free, according to the above standards, that the two groups· ''caries-free" and "almost caries-free" were combined; even so the total was then only 4. 7%. Other ConditionS.-B~ides structure and caries, a number of other conditions were noted for each mouth. These included . the arrest of the carious process, treatment of caries, mottling of enamel, the state of the mouth, spacing of the teeth, obvious tartar, gingivitis, occlusion, attrition; and the' presence or absence of stain, but not all these conditions are considered in this report. 4573
410 Auo. 28, 1948
BluTISH
DENTAL CARIES IN LONDON SCHOOL-CHILDREN
MEDICAL JOURNAL
total hypoplasia figure so obtained for any group of teeth by the total number of teeth in the group, excluding those showing gross hypoplasia. Thus the greater the number of teeth classed as of good structure (Hy,) or included in the less severe grades of M-hypoplasia, the lower the AHF. As is seen from the average hypoplasia figures (AHF), TABLE I.-Percentages of Caries-free Children there was an improvement in structure in each type of tooth from 1943 to 1945 and from 1945 to 1947. The I Total No. of % Total % Year Almost actual reduction in the AHF in the latest survey as comI Examined Children Caries-free Caries-free % pared with the previous one was greatest in the upper 1,293 4·7• 1929 .. .. .. centrals and lower first and second molars, but the per1,870 14·9 9·3 24·2 1943 .. .. . . 1945 .. 691 3·9 28·1 .. .. 24·2 centage reduction was substantial in all the lower teeth, 1,&90 18·1 9·4 1947 .. 37·& .. .. as in the upper centrals. The least change in percentage reduction of the AHF in 1947 as compared with 1945 • Percentages of caries-free and almost caries-free children not separately estimated in 1929. occurred in the upper molars, but these teeth are often covered by a thin film of tartar, and it appears to us possible The number of children whose dentitions were of. good that their hypoplasia figures may be less reliable than those structure showed obvious improvement from survey to for other types of teeth. survey, and the upward trend Turning to the proportion of teeth showing the various 0/o observed in 1943 and 1945 in gnides of structure, it is seen that 47.1% were of good 40 the proportion of children structure (Hy,) in 1947, as compared with 38.0% in 1945 who, according to the probe and 30.7% in 1943. The progressive improvement from and mirror method, could be survey to survey was distributed among all types of teeth 30 described as caries-free or except the upper molars, which showed little change in nearly so continued in 1947 structure in all three surveys. A possible reason for this will Zil (see Table I and Graph). It be considered in a future paper. In 1947 both the first and was found that, whereas only second lower molars were much better than in 1945. This 4.7% of the children examined was particularly evident in the case of the second molars, in 1929 could be so classed, whose improvement in this. period was approximately the figure had risen iln 1943 to 179% (i.e., from 7.5 to 20.9%). As in the previous surveys, the upper teeth of all types were on the average of poorer -~ 24.2%, in 1945 to 28.1 %, and 00''-----structure than their counterparts in the lower jaw. The ;;. ;;. -;;_ in 1947 to 37.5%. . erThe percentage of teeth incidence of gross hypoplasia was lower in 1947 than Showing increase in percentage present in the children's formerly, whether the teeth were considered en masse or of caries-free and almost caries- mouths at the time of the in individual types. free children, 1929 to 1947. 1947 survey differed only Caries.-As has been already stated, the amount of caries slightly from the percentages found at the· earlier inspec- in the 5-year-old L.C.C. school-children underwent a contions. The respective figures for 1943, 1945, and 1947 were siderable reduction in 1941 as compared with 1945 and 1943. 92.2, 94.4, and 93.9%. Table Ill shows the incidence and extent of caries in each type of tooth and in all types together for the three surveys. Like the structure of the teeth, their condition as regards Detailed Results, 1943--7* caries is expressed in two ways-first, as percentages of teeth Structure.-Table 11, which compares the results of the included in the various grades, and, s~condly, as the average three surveys, shows the percentages of teeth included in caries figure (ACF). For the latter the same principle is the different grades of structure and also gives a computa- adopted as for the AHF. The number 1, 2, or 3 is allotted tion of the extent of defective structure expressed as the to each carious tooth according to the severity of the average hypoplasia figure (AHF). The AHF is arrived at disease, and the total caries figure is divided by the number by allotting a number to each grade of M-hypoplasia (l for of teeth in the group concerned. The smaller the ACF M-Hy,, 2 for M-Hy,, and 3 for M-Hy.) and dividing the the less the degree of caries in the group as a whole. The table indicates that there was improvement at each succes•The detailed 1929 results do not appear in these tables, as they sive inspection in all types except the lower central incisors, were not published and the charts were lost early in the war.
General Resnlfs Before the detailed analysis of the data obtained in the latest survey is considered in relation to that of the earlier investigations a brief general comparison may be made.
I
....
TABLE
Type of Tooth
H.-comparison of Tooth Structure in 1943, 1945, and 1947
Total No. of Teeth Examined for Structure
Good: Hy.
M-Hy,
1943 194S 1947
1943 1945 1147
1943 1945 1947
%
%
M-Hy,
Very Defective M-Hy,
I
Gross Hy
%
ib 2·2
%
.. .. ..
3,324 3,465 3,707 3,268 3,427
1,262 1,341 1,369 1,282 1,342
2,931 3,023 3,119 2,989 2,110
18·2 :zs-o 41·2 27·2 38-6 •·• 32·5 40·8 4&·1 8·2 8·7 8·1 6-o 5·2 1·2
33-9 46·9 50·8 32·1 29·2
36·2 39·4 45·7 39·2 39·S
38·8 42·8 48·& &&·8 48·8
34·3 26·1 13·4 19·0 '14·3 8·0 13·2 10·1 4·2 49·9 42·9 33·& S4·0 4s-7 43-2
9·4 4·1 1·5 7·0 9·4
Lower Jaw: Central incisors Lateral incisors Canines lst molars 2nd molars
3,091 3,624 3,702 3,119 3,104
1,097 t,348 1,370 1,23S 1,241
2,53&
71·7 61·S 51·9 18·4 1·S
M·3 81·1 79·1 34·1 •••
24·2 33·7 36·9 38·S 34·1
14·0 &·3 19·2 9·11 23·5 17·1 39-6 &2·9 37·5 &8·9
3·2 0·4 0·2 4·2 0·8 0·4 S·9 2·3 0·8 36·S 32·S 11·3 48·6 4S·4 11·0
0·6 0·4 0·5 4·0 6·3
26·3 22·0 13·11
4·2 3·5 0·7 I 1·9 2·3 0·8
Totals
3,oar
3,109 2,700 2,7&&
.. 133,83112,887 29,011
8s-t 19·S 69·7 22·3 7·5
30·7 38·0 47-1
*AHF (average hypoplaaia &gure) -
l6·3 33·6 37·4
AHP
1943 194S 1947 1943 1945 1947jt943 1945 1947! 1943 1945 1947 ft943 1945 1947
Upper Jaw: Central incisors Lateral incisors Canines 1st molars 2nd molars
.. .. ..
lHy Unclassified I
I 1
%
%
0·8 0·2 1·1 0·2 6·4 1·4 8·6 2·9
3·9 2·5 1·0 2·8 1·3
6·6 5·4 1·1 2·8 1·0
3·0 2·7 0·7 0·4 0·1
0·2 0·3 1·0 0·0 0·1
0·2 0·1 1·2 0·0 0·0
0·03 0·5 1-1 0·03 0·0
1·37 1·00 0·83 1·57 1·68
1·14 0· 79 0·71 1-48 1·58
0·88 0·81 0·59. 1·28 1·44
0·0 0·1 0·0 0·1 0·1 0·1 3-1 0·11 8·1 0·9
0·2 0·1 1·4 2·5 3·4
0·5 0·3 0·7 2·6 1·5
0·2 0·2 0·3 0·3 0·3
0·03 0·1 3·4 0·1 0·1
0·0 0·1 3·8 0·0 0·0
0·0 0·03 2·7 0·1 0·0
0·33 0·43 0·53 1·27 1·56
0·15 0·21 0·30 1-17 1·5S
0·08 0·10 0·19 0·77 1·02
I
I 0·6
0·6 0·051 1·04 0·91 0·87
Total hypoplasia figure Toa.al. No. of teeth examined for structure (excluding those with gross or unclassified hypoplasia)
AUG. 28, 1Sl48
DENTAL CARIES IN LONDON SCHOOL-CHILDREN TABLE
BRITISH
MEDICAL JOURNAL
411
rn.--comparison of Caries Incidence and Extent in 1943, 1945, and 1947 ·-~-
I I
Type of Tooth
Upper Jaw: Central incisors Lateral incisors Canines .. 1st molars 2nd molars ..
..
Lower Jaw: Central incisors Lateral incisors Canines .. 1st molars .. 2nd molars ..
..
Totals
I .. I ..
.. .. ..
.. .. .. .. .. ..
'
Total No. of Teeth
I
!
C,
I
t943 t945 1947
1945
1947
3,392 3,590 3,740 3,740 3,740
1,280 1,358 1,381 1;382 1,382
2,974 3,095 3,180 3,180 3,180
62·4 79·7 90·5 58·0 43·5
% 70·5 85·1 92·5 61·1 48·6
93·1 89-4 89·4 85·8
3,112 3,662 3,740 3,740 3,740
1,098 1,354 1,382 1,382 1,382
2,576 3,114 3,180 3,180 3,180
95·1 96·3 93·1 46·0 39·0
98·3 97·9 94·1 51·4 41·2
98·3 98·3 95·9 58·7 67·0
36,196 13,381 30,839
! 69·9
-----
c,
I
1943
1
1943 1945 1947
77·81
I
7·4
ACF*
I i
1943 1945 1947
1943 1945 1947
I
% 16·2 17·2 13·8 9·2 8·6 6·1 4·6 4·2 4·2 13·3 17·4 14·3 18·1 23·6 11·7
11·6 7·3 4·3 3·1 2·0 1·6 20·0 13·2 21-1 10·1
1·5 0·8 0·6 1·3 1·3 0·9 3·3 4·3 2·3 17·0 21·1 18·8 15·0 19·5 11·9
0·7 0·0 0·3 0·4 0·2 0·2 1·2 0·9 0·4 29·1 20·3 18·8 33·1 24·1 18·8
4·9 1·7 1·7 3·7 2·1 1·7 6·9 5·9 4·1 54·0 48·6 43·3 61·0 58·8 43·0
10·1 12·0
12·6
30·1 26·5 20·31 0·65 0·55 0·42
6·2
%
8·5
8·3
1
2·9 2·2 0·9 8·9 8·7
8·6
37·6 20·3 9·5 42·0 56·5
% 29·5 14·9 7·5 38·9 51·4
I
22·21 10·8 8·9 I 30·8 34·4 1
0·77 0·38 0·18 0·95 1·17
% 0·61 0·30 0·15 0·83 0·95
0·42 0·20 0·13 0·85 0·84
0·08 0·06 0·13 1·29 1·42
0·03 0·04 0·12 1·10 1·27
0·03 0·03 0·07 1·00 0·96
Total can,:;::'e::.s:7.figur'ii::::~e===~ Total No. of teeth (including extractions)
1
I_nc_is~o_rs_______________________c_a_ni,n_es_______________________M __o_la~rs___________
1
____________
Hy, .. M-Hy, M-Hy, M-Hy, Gross Hy
1943 1945 1947
IV.-Percentage Incidence of Caries in Teeth with Varying Grades of,Structure
1 Grade of Structure
6·2
I
1943 1945 1147
2·7 0·9 0·7 2·0 0·6 0·5 2·4 0·7 1·4 7·9 7-2 5-7 12·9 15·1 11·2
73-5 79·7
c.
1
% 9·8 5·0 5·6 6·8 3·2 3·3 2·9 1·7 1·9 8·7 8·3 8·5 17·2 17·7 14·0
*ACF (average caries figure)=
T\BLE
c,
I
Total Carious Teeth
Total No. Examined
I
Total No. Total No. %C · % Carious Examined % Carious Examined o anous l--~~9~4~3--1~94-5---19_4_7-:--t~9-43--t~94_5__1~94-7-l-~t9~4~3--l-94-5---tl4~7-r-~~94-3~1~94~s~1~14~7~ 1 ·~~9~4~3~t~94~5~~19~4=7-- t943 t945 1147 5,992 2,837 7,921 4,724 1,399 2,789 2,053 536 649 487 105 33 226 165 178
1·1 12·0 44·9 80·4 64·2
1·2 11·2 39·2 81·0 62·4
2·4 18·7 36·8 61·5 38·0
3,126 3,248 707 75 90
1,514 947 169 16 24
3,886 2,050 152 10 32
1·5
H
7·9 8·0 26·7 29·6 61-1 68·9 23·3 20·8
1·8 8·2 15·1
•.•
34·4
1,281 4,310 6,133 867 319
550 1,927 1,987 8,033 2,127 3,124 335 164 101 32
8·3 24·5 62·6 87·1 58·9
7·0 25·0 66·5 92·3 52·5
11·9 30·7 43·4 60·4 34·4
NoTE.-This table does not include the few teeth shown under the heading " Hy Unclassified "in Table U.
where both incidence and extent of caries remained the molars with no hypoplasia and with M-HY, and M-Hy2 As in the case of the same in 1947 and 1945. Here so few teeth were carious were 11.9%, 30.7%, and 43.4%. even in 1943 that little improvement could be expected. incisors, there were relatively few molars in the M-Hy3 . The proportion of caries-free teeth of all types increased grade, but 60.4% of them were carious . from 69.9% in 1943 to 73.5% in 1945 and 79.7% in 1947. Other Conditions.--There was less arrest or "spontaneous In the latest survey the most striking increase in this respect healing" of decay in individual teeth in 1947 than in 1945, was in the upper and lower second molars, where there though more than in 1943 (see Table V). The reason for was most scope for improvement. It is of interest to note this is not clear. The amount of treatment of carious that although in 1947 over 70% of the children examined teeth (see Table VI), which was lower in 1945 than in had at least some caries, yet the disease occurred in only 1943, had risen in 1947 nearly to the 1943 level, and the about 20% of the teeth, including fillings and extractions. percentage of extractions was almost identical in these two The proportion of carious teeth had diminished by approxi- surveys. mately 33% since 1943. Reference has previously been made (Pickerill, 1923; Relation between Structure and Caries.--All previous Ayers, 1939; Pincus, 1941 ; Pederson, 1946; Mellanby surveys using M-hypoplasia standards for structure showed and Coumoulos, 1946) to the superficial stains commonly that the better-formed teeth were less liable to decay. This seen on children's deciduous teeth, and to the fact that was also true of the 1947 survey, as can be seen by reference mouths in which black ;md dark-brown stains occur appear to Table IV. For example, the incisors with no hypoplasia to be associated with a lower incidence of caries, and green had a caries incidence of 2.4%, whereas those with grades stains with a higher incidence. In the 1947 survey this M-Hy, and M-Hy, had a caries incidence of 16.7 and was again the case (see Table VII). 36.8 %, respectively. Of the very few incisors in the M-Hy3 grade 51.5% were carious. The corresponding figures for Discussion An account has been given of a further survey, made in TABLE V.--Teeth showing Arrest ("Spontaneous Healing") of the Carious Process 1947, of the dental condition of 5-year-old children attending London County Council schools. Comparison has been % Carious Teeth Present No. of Carious Teeth made between the results of this work and those obtained Present Showing Arrest in the examination of children of the same age group 11·7 1943 9,182 21·5 1945 3,203 attending the same or neighbouring schools in 1929, 1943, 1947 6,270 14-2 and 1945. The main findings as regards the incidence of
--1--1
,' 1
TABLE
VI.--Carious Teeth Extracted, Treated by Silver Nitrate, or Filled Treatment Total No. of Carious Teeth (Including % % I%Silverl Extractions) Extracted Nitrate Filled
1943 1945 1147
......
10,886 3,545 6,245
15·7 9·6 15·6
I
6·7 2·8 2·4
II
2·7 2·4 4·4
Total Percentage of Carious Teeth Treated 25·0 14·8 22·4
TABLE
VII.-Percentage Incidence of Carious Teeth in Children with and without Superficial Staining of Teeth
Children having : (a) No stain .. .. •• (b) Black and dark-brown stains (c) Green stain ••
..
..
Percentage of Carious Teeth
ACF
1943 1945 1147
1943 1945 1147
30·1 23-1 19-8 19·3 15·4 12·4 33·4 33·0 28·0
0·66 0·48 0·41 0·41 0·30 0·2& 0·72 0·69 0·64
412
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DENTAL CARIES IN LONDON SCHOOL-CHILDREN
BRITISH !\IEDICAL JOURNAL
------------------
caries per child, observed over this period of 18 years, are set out in Table I and the Graph. It will be seen that the improvement has been great, especially between 1945 and 1947. In the first period of 14 years the average increase in the percentage of caries-free or nearly caries-free children was at the rate of 1.4% per year; in the second period of approximately two years it was 1.95% ; and in the third period, also of about two years, it was 4.7 %. Tables Il and Ill indicate that the structure of the teeth also has greatly improved from 1943 to 1947 and that the incidence and extent of caries per tooth have been substantially reduced. These surveys were preceded by experimental investigations on animals, begun in 1917, and by controlled studies on children which were the natural outcome of the animal work. The earlier experiments were devoted to a study of the food factors which affected the structure of the teeth, and ultimately it became possible to state the chief dietetic conditions favouring good and poor structure. For the former it was essential that the diet during the period of tooth. development should be rich in available calcium and phosphorus and in vitamins D and A. Indeed, it was this work, in association with the researches of E. Mellanby on the subject of rickets, which first helped !o prove the existence of a calcifying vitamin (vitamin D). The factors resulting in defective structure were mainly associated with both the quantity and the type of cereals consumed when vitamin D and calcium were deficient in the diet. The clinical investigations on children showed the importance of the animal experiments in demonstrating the factors controlling dental structure ; for these human studies pointed to the conclusion that, other things being equal, well-calcified teeth, according to the criteria used, were less liable to caries than badly calcified teeth. Another fact of importance made clear by the animal experiments was that those diets which produced teeth of good and poor structure, respectively, also increased or decreased the resistance of teeth to a stimulus such as attrition, quite apart from their original structure. Thus teeth of either good or poor structure, when worn by friction, produced well-formed secondary dentine when the diet was of a highly calcifying nature, but produced badly calcified secondary dentine or none when the diet was deficient in calcifying properties. Examination of children's teeth which had been subject to attrition indicated ,the same kind of reaction to this stimulus. A matter of greater importance, however, as was shown by investigations in Sheffield and Birmingham, was that a diet of high calcifying properties given after eruption of the teeth, whatever their structure, could prevent or retard the onset of caries, or, if the disease had already developed, bring about the deposition of well-calcified secondary dentine and ultimately the arrest of the carious process (Mellanby, 1934). This effect of the post-eruptive diet in altering the resistance of teeth to caries, as opposed to the control of their development and structure by the diet before eruption, was substantiated by surveys made in 1945 on three groups of 5-year-old children, one group attending private schools, another attending London County Council schools, and the third comprising mainly destitute or illegitimate children living from an early age in public institutions and in most cases attending the institutional schools (Coumoulos and Mellanby, 1947). As a group, the institutional children had worse-formed teeth than the L.C.C. or private-school children, but nevertheless had relatively less caries. On the basis of previou~ experimental and clinical evidence and of the conditions under which the children were reared it seemed fair to postulate that the pre-eruptive diets of the private school children were better in calcifying properties
than those of the children who became the responsibility of the institutions, and thus their teeth were of better structure ; but on the other hand it appeared that the posteruptive diets of the institutional children, who received regularly a diet rich in calcifying properties which included cod-liver oil, were on the average better in this respect than those of the private'-school group, so. that, in spite of the poorer structure, the teeth became more resistant to invasion and allowed less caries to develop. Thus all these studies emphasize the importance of feeding children, first via the mother and later independently, on diets which will result in better calcification and greater resistance of the teeth. It might be asked, then, whether there is evidence that the rapid improvement in the dental condition of the London County Council school-children, as regards both structure and freedom from caries, between the years 1943 and 1947, and especially between 1945 and 1947, as compared with the period 1929 to 1943, is due to causes indicated by the earlier experimental and clinical investigations. Certainly on the basis of that work such improvement would be expected to result from the series of changes in the dietary of this country during the war years. It was well known to those familiar with the subject that one of the main defects of the pre-war British dietary was its poor calcifying qualities. Early in the hostilities, when restrictions in both quantity and quality of food necessitated the best possible use of available supplies, one of the first steps taken by the Government, on the advice of nutritional scientists, was to direct foods with high calcifying properties to those classes needing them most-namely, expectant and nursing mothers and infants. For example, from July, 1940, all expectant mothers could claim a milk priority of 1 pint (568 ml.) a day. After the chilq was born two pints (1.14 litres) a day were allotted between mother and child for the first year, so that if the mother fed the baby herself then the two pints were available for her own consumption. From the age of 1 to 5 years the child's own allocation was 1 pint a day. This was reduced to half a pint (284 ml.) for home consumption when school age was reached, but could be supplemented by 1/3 or 2/3 pint (190 or 380 ml.) daily at school. In December, 1941, ~od-liver oil was made available at a reduced rate through welfare centres, clinics, and food offices to children aged 6 months to 2 years, and in February, 1942, provision was extended to all children up to the age of 5 years. Expectant mothers were eligible for the oil from these official sources from December, 1942 ; and in April, 1943, vitamin A and D tablets were instituted as an alternative. At this time the vitamin D content of the Ministry of Health's cod-liver oil compound was raised from lOO to 200 international units per gramme, and has remained at this level. More eggs have also been available to mothers and young children than to nonpriority classes. Besides these special allocations there have also been, during and since the war years, a series of nutritional changes which have affected the whole population of the country, including, of course, the mothers and growing children. In this case also the calcifying as well as certain other qualities of the diet have been improved. For instance, sin~ 1940 all margarine has had to contain vitamins D and A. In July, 1940, the vitamin D content was at the rate of 30 international units per ounce (approx. l i.u. per gramme); in November, 1941, it was raised to 60 i.u. (2 i.u. per gramme) and in January, 1945, to 90 i.u. per ounce (3 i.u. per gramme) ; the vitamin A content has been from 450-550 i.u. per ounce (16-20 i.u. per gramme) throughout this period. With a weekly ration of 3 to 4 oz. (85-113 g.) of margarine for the average person,
Aua. 28, 1948
DENTAL CARIES IN LONDON SCHOOL-CHILDREN
it has been possible for each to receive between 12 and 50 i.u. of vitamin D and 200 to 300 i.u. of vitamin A per day from this source alone. Again, from 1942 onwards calcium has been added to all flour ; at first the rate was 7 oz. (200 g.) of calcium carbonate per sack of 280 lb. (127 kg.); later in 1946 the amount was doubled. This addition of calcium was necessary because the raising of the extraction rate of the flour from the pre-war level of 70-73% to the wartime level of 85%, or even higher, greatly increased the phytate content of the flour, and phytate is known to decrease the availability of calcium in the food. This additional calcium was· also an important adjunct to the dietary of non~priority people because of the limited amounts of milk, eggs, and cheese available. The larger amount of added calcium was sufficient to neutralize the harmful anticalcifying properties of the phytate, and any excess was available to help in promoting or maintaining the calcification of bones and teeth anti for other physiological functions which required optimal calcium supplies. Prior to the war many mothers had neither the desire nor the means to procure for themselves or their children adequate supplies of such foods as milk, eggs, and cod-liver oil. Recently, however, there has been an increasing awareness, on the part of both the medical and the lay population, of the nutritional benefits conferred by these foods ; and, generally speaking, money has not been a limiting factor, since Government subsidies have brought ·them within the reach of most families. If, however, people cannot afford to buy milk even at the subsidized rate, it may be obtained free of charge for expectant mothers and children under 5 years of age ; and cod-liver oil, which was previously supplied at reduced rates, can to-day be had without cost under the welfare service. It appears, then, from the foregoing account of recent diet changes, that an important reason for the more rapid improvement in, the dental condition of children between 1945 and 1947 as compared with the preceding years is clear-cut. For the first time in the course of these surveys all the expectant and nursing mothers and all the children up to the age of 5 years have been in a position to obtain increased quantities of calcium and vitamin D via established milk, cod-liver oil, and egg priorities, and they have benefited further by other Government measur~s outlined above ; so that throughout the whole antenatal and postnatal life of the latest group of children examined, who were born between November, 1941, and October, 1942, the diet available has been of consistently better calcifying qualities than that of the subjects of the earlier surveys. The pre-eruptive diet has produced better-calcified teeth than were formerly observed, and the post-eruptive diet has tended still further to increase the already higher resistance of these teeth to caries. It must not be forgotten, however, that even to-day the majority of children in the young age group studied have some carious teeth, and it seems most likely, on the basis of the present hypothesis, that this is due, in part at least, to the fact that many mothers do not avail themselves of all the special foods at their di,sposal. In order, therefore, to get some idea of what proportion of the mothers whose children were examined in 1947 actually took up their special allowances, a point was made of asking any who were present at the examination some simple questions on the subject. The numbers involved are too small to be of significance, but they give an indication of the general trend. Of the 224 women questioned, 68% stated .that they drank their priority milk, and 65% of the children were said to have consumed a pint of milk a day during the pre-school period. In answer to the question, " At what age did you begin to give this child cod-liver oil ? " 30% of the mothers said that it was
M.EDI~~RNAL 413
given from the age of 8 weeks or less, but the amount and the length of time for which it was given varied. It was estimated that about 14% of the children had not had any cod-liv~!r oil or alternative vitamin concentrate at any time, while the remaining 56% had had one or other of these supplements for some period during the first five years of life. Theie figures suggest that there is still need for greatly increasing the numbers of women .and children making use of the food priorities mentioned. This, of cour~, does not mean that the problem of caries would thus be solved. Indeed, it probably cannot be solved while the actual factors directly initiating the condition remain obscure, but when these are brought to light it may be possible to control the disease more directly and efficiently. Meanwhile the evidence grows stronger from year to year that the best way at present available to make a primary attack on this great health evil is to feed pregnant and nursing women, infants, and children along the lines which a,re known to produce well-constructed teeth and jaws and to increase resistance to decay-in other words, to ensure that both pre-eruptive and post-eruptive diets are relatively rich and balanced in available calcium and phosphorus and in vitamin D. Summary The dental condition of 5-year-old children attending London County Council schools in 1947 has been described and compared with that of similar groups examined in 1929, 1943, and 1945. The progressive improvement found in the two previous surveys has also been observed in 1947. The rate of increase in the percentage of caries-free or almost caries-free children between 1945 and 1947 has been more rapid than between 1943 and 1945, and certainly much more rapid than between 1929 and 1943. The same trend has occurred between 1943 and 1947 in the structure of the individual teeth and the incidence and extent of caries, the improvement being greater in the second two years than in the first two. As in the 1943 and 1945 surveys, it is again suggested that the improvement is due to the increased calcifying properties of the dietary of this country, and particularly that of pregnant and nursing women, infants, and young children. The marked improvement in 1947 is thought to be mainly due to the fact that for the first time in these surveys the diet has been of consistently better calcifying qualities over the whole antenatal and post-natal life of the children concerned. We wish to express our 'thanks to the London County Council and Sir Alien Daley for permission to undertake this survey ; to the head teachers of the schools and their staffs for their willing co-operation; to Mrs. M. Kelley, Miss I. Alien, and Miss J. Robinson for their help in the preparation of this report; and to the Medical Research Council for financing the work. BIBLIOGRAPHY
Ayers, P. (1939). J. Amer. dent. Ass., 26, 3. Coumoulos, H. (1946). Nature, 158, 559. - - and Mellanby, M. (1947). British Medical Journal, l, 751. Davies, J. H. (1939). Brit. dent. J., ()1, 66. Deverall, A. (1936). Spec. Rep. Ser. med. Res. Coun., No. 211. Lmtdon. King, J. D. (1940). Spec. Rep. Ser. med. Res. Coun., No. 241. London. Mellanby, H. (1940). British Medical Journal, l, 682. Mellanby, M. (1929, 1930, 1934). Spec. Rep. Ser. med. Res. Coun., Nos. 140, 153, and 191. ·
- - (1937). Brit. dent. J., 62, 241.
- - and Coumoulos, H. (1944). British Medical Journal, 1, 837. (1946). Ibid., 2, 565. Pederson, P. 0. (1946). Tandlaegebladet, 50, 210. Pickerill. H. P. (1923). Brit. dent. J., 44, 967. Pincus, P. (1941). Ibid., 70, 52. (For fuller references to related work see Mellanby, M., and Coumoulos, H., 1944 and 1946.) New regulations made by the Minister of Health about health visitors and tuberculosis visitors apply not only to those employed by local authorities, as formerly, but also to the employees of voluntary organizations. They also cover part-time visitors as well as whole-time.
