'xiAn- 
 
 .J 
 
 TREASURY DEPARTMENT 
 UNITED STATES PUBLIC HEALTH SERVICE 
 
 HUGH S. GUMMING, Surgeon General ' 
 
 CHILDREN'S TEETH, A COMMUNITY 
 RESPONSIBILITY 
 
 A PRACTICAL PLAN FOR ORGANIZING PROTECTIVE 
 AND REMEDIAL MEASURES 
 
 TALIAFERRO CLARK 
 
 Surgeon 
 
 AND 
 
 HARRY B. BUTLER 
 
 Director of Mouth Hygiene Unit No. 1 
 United States Public Health Service 
 
 REPRINT No. 622 
 
 FROM THE 
 
 PUBLIC HEALTH REPORTS 
 
 November 19, 1920 
 (Pages 27()3-2779) 
 
 i[^'Z.{^c>H^ 
 
 WASHINGTON 
 
 GOVERNMENT PRINTING OFFICE 
 
 1920 
 
 <mp»?^ 
 
LIBRARY OF CONGRESS 
 
 IIVEO 
 
 FEB4-1921 
 
 DOCUMENTS DiViSION 
 
4^ L534-S-S- 
 
 r .cs- 
 
 CHILDREN'S TEETH, A COMMUNITY RESPONSIBILITY.^ 
 
 A l*ractical Plan for Organizing Protective and Remedial Measures. 
 
 By Taliafereo Clark, Surgeon, and Hakry B. Butler, Director of Mouth Hygiene Unit 
 No. 1, United States Public Healtii Service. 
 
 Introduction. 
 
 For a number of years the United States Public Health Service 
 has been engaged in studies and investigations of the physical status 
 of school children, and as a result of these investigations it has re- 
 peatedly drawn attention to the overwhelming preponderance of 
 dental defects over those of all other classes. 
 
 The bad effect of decaying teeth, of inflamed gums, and of suppu- 
 rating areas in the- oral cavity on the health and development of 
 young children is obvious, and no effort should be spared to prevent 
 the occurrence of such conditions. 
 
 The provision of dental facilities, both preventive and operative, 
 for school children, is a measure which promises to yield the most 
 fruitful results in conserving their health. 
 
 This article has been prepared as a result of the long-felt need of 
 this form of health supervision, and in response to the numerous 
 requests received for information pertaining to the establishment of 
 school dental clinics. 
 
 Investigations made by the United States Public Health Service 
 and other agencies show that among. the classes of defects observed 
 in school children that of dental defects is not only larger than any 
 other, but larger than all the others combined. 
 
 The examination of approximately 2,500 rural school children by 
 United States Public Health Service officers revealed 49.3 per cent 
 of the children with two or more decayed teeth. It is of interest to 
 know that the percentage of decayed teeth varied with the sexes and 
 age groups, the highest being 45.5 per cent among the 8-year-old boys 
 and 37.5 per cent in the 7-year-old girls. Among this same group of 
 children 18.3 per cent of the boys and 10.5 per cent of the girls stated 
 they had never used«a toothbrush, and but 13.9 per cent of the boys 
 and 40.9 per cent of the girls stated that they used the toothbrush 
 daily. 
 
 1 Eeprint from tlie Public Health Reports, vol. 35, No. 47, Nov. 19, 1920, pp. 2673-2779. 
 
 3 
 
4 children's teeth, a community responsibility. 
 
 In a report of a recent and very extensive survey of the mouth 
 conditions in the State by the North Carolina State Board of Health 
 it is stated that 75 per cent of the children examined evidenced be- 
 ginning decay of the teeth and less than 10 per cent of them had ever 
 visited a dentist, and that 90 out of every 100 parents had never made 
 any attempt to have the dental defects of their children corrected. 
 
 Statistics quoted relate largely to rural children. However, re- 
 ports from several of the larger cities reveal a very high percentage 
 of dental decay in the children attending school, ranging from 30 
 to 62.7 per cent, depending largely on the dental attention that had 
 been given these children during the years previous to the ex- 
 aminations on which the statistical report was based. 
 
 In view of the lack of attention to the dental needs of the children 
 of the land, it is not surprising that of 925,873 men who were found 
 unfit for military duty by the first selective draft examinations, by 
 reason of physical causes, the second highest of all causes of physical 
 rejections was that of dental defects. 
 
 Why Teeth Decay. 
 
 Dental decay is caused by the action of bacteria, or germs, which 
 normally inhabit the mouth. These germs, acting in the presence 
 of food debris and certain elements in the saliva, result in the for- 
 mation of an acid which attacks the enamel covering the exposed 
 parts of a tooth, after which the underlying softer parts become 
 rapidly destroyed. Many other factors are actual and potential 
 causes of dental decay and its progress, such as — 
 
 1. Low resistance of the teeth to decay because of developmental 
 defect (antenatal and postnatal). 
 
 2. Faulty diet (both of the mother during pregnancy and of the 
 child). 
 
 3. Neglect of dental attention through ignorance of the parents. 
 
 4. The cost of dental attention, a serious consideration with fami- 
 lies of low economic status. 
 
 5. Failure of the child to call attention to the condition of the 
 teeth, eitl^er because it is too young or because of fear. 
 
 6. Lack of dental facilities, so common in rural sections. 
 
 EflFect of Dental Decay. 
 
 It is still very little realized by most people <!hat the teeth play a 
 very important part in determining general health. Careful scien- 
 tific investigations of recent years, however, have shown that uncor- 
 rected denl:al defects in children may seriously injure the growth 
 and development of the body and greatly lower the child's resist- 
 
childeen's teeth, a community eesponsibility. 5 
 
 a nee to communicable disease. From the standpoint of school prog- 
 ress carefully kept records have indicated toothache as one of the 
 most frequent causes of absence from school and that neglected 
 mouth conditions are responsible for a very high percentage of re- 
 tardation in school work. In addition to these immediate results of 
 dental neglect, the X-ray has pointed to diseased teeth as the starting 
 point of many of the so-called degenerative diseases of later life the 
 onset of which might have been delayed or prevented by proper 
 dental attention during childhood. 
 
 1. GROWTH AND DEVELOPMENT. 
 
 A very high percentage of undernourished children show marked 
 evidence of dental decay. The examination of a group of 270 of 
 this class at present under the supervision of the Public Health 
 Service revealed 33 per cent of them with from 1 to 4 cavities 48 
 per cent with from 4 to 8, and this same group showed some with 
 9, 10, and 11 cavities. 
 
 Young children are notoriously capricious in the choice of food, 
 and when to this tendency there is added imperfect mastication 
 through faulty or painful teeth, the child often refrains from eating 
 the foods best adapted to its needs, even when such foods are offered. 
 In addition to this, the poison absorbed from rotting teeth may 
 seriously affect the child's nutrition and vital resistance. A clean 
 mouth, free from sepsis, is a prerequisite for the proper growth and 
 development of children. 
 
 2. resistance to communicable diseases. 
 
 It is quite generally accepted that an individual falls victim to 
 a communicable disease because of the size of the dose of the infect- 
 ing agent, the virulence of the ^infecting organism, or an increased 
 susceptibility which is due to lowered vital resistance. Of the many 
 causes operating to lower resistance it is reasonable to suppose that 
 the absorption of septic material from rotting teeth and diseased 
 gums plays an important role. Conversely, it is also reasonable to 
 suppose that a clean, healthy mouth will tend to increase the vital 
 resistance of children and render them less susceptible to the com- 
 municable diseases. Converging evidence from many sources tends 
 to show that bad teeth do exercise a harmful influence. In Bridge- 
 port, Conn., where during the last five years special attention has 
 been paid to the operation of dental clinics, reports by the city board 
 of health indicate that there has been a very considerable reduction 
 in the incidence of communicable diseases in that city during the 
 period following the establishment of school dental clinics in the 
 year 1914. During this period diphtheria showed a decrease from 
 
6 
 
 CHILDREN S TEETH, A COMMUNITY RESPONSIBILITY, 
 
 26.6 per cent to 18.7 per cent, measles 20 per cent to 4.4 per cent, 
 and scarlet fever from 14.1 per cent to 0.5 per cent. 
 
 The effect of the general application of dental measures, both, 
 preventive and operative, in the schools of Bridgeport in bringing 
 about a reduction in the amount of communicable diseases may be 
 questioned by reason of the fact that the incidence of the communi- 
 cable-diseases in the general population varies from year to year. 
 However, the general inference of the decline in the percentage of 
 communicable diseases in Bridgeport pari passu with the extension 
 of dental work in the schools is strengthened by a report of the 
 improvement in the percentage of communicable diseases following 
 the employment of- a dentist and systematic dental service in St. 
 Vincent's Orphanage, Boston^ Mass. The average number of chil- 
 dren in this institution during the period of observation was 325, 
 and the work was in progress from April, 1912, to November, 1913. 
 A comparative record of the health conditions for several years 
 immediately preceding the employment of a dentist and during the 
 period of service is quoted as follows ; 
 
 
 Period. 
 
 Disease. 
 
 May, 
 1913, 
 
 to 
 Nov., 
 1913. 
 
 May, 
 1912, 
 
 to 
 May, 
 1913. 
 
 Apr., 
 1911, 
 
 to 
 May, 
 1912. 
 
 Nov., 
 1910, 
 
 to 
 Apr., 
 1911. 
 
 1909 
 
 to 
 
 1910. 
 
 1908 
 
 to 
 
 1909. 
 
 1907 
 
 to 
 
 1908. 
 
 Diphtheria 
 
 1 
 
 
 
 6 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 1 
 
 
 4 
 8 
 6 
 25 
 3 
 
 6 
 
 
 
 
 
 1 
 10 
 12 
 4 
 40 
 8 
 2 
 10 
 
 
 
 
 
 2 
 
 3 
 
 8 
 
 5 
 
 50 
 
 16 
 
 2 
 
 17 
 
 
 
 
 
 
 
 
 
 6 
 
 Mumps. 
 
 8 
 
 Scarlet fever 
 
 17 
 
 Pneumonia 
 
 3 
 
 
 24 
 
 Tonsillitis 
 
 19 
 
 Whooping cough 
 
 7 
 
 Chicken pox 
 
 15 
 
 Typhoid 
 
 
 
 Croup 
 
 4 
 
 Tuberculosis, eye.. 
 
 a 
 
 Tuberculosis, lungs 
 
 
 
 
 
 Total 
 
 7 
 
 
 
 2 
 
 52 
 
 87 
 
 103 
 
 103 
 
 
 
 jMouth hygiene — Fones,p. 466.] 
 
 - 3. PRESERVATION OF FACIAL SYMMETRY. 
 
 The preservation of the pulp (commonly referred to as the 
 " nerve ") in the " baby teeth " is of the greatest importance. If 
 this is not in normal condition the roots of the first set of teeth will 
 fail to absorb, and many of the irregularities in the permanent teeth 
 may be directly attributed to this cause. The loss of a temporary 
 tooth before proper time also may result in the eruption of the 
 permanent tooth to follow before thorough calcification has taken 
 place, in which case it is more subject to decay. Very frequently 
 little, if any, attention is paid to these temporary teeth, parents 
 assuming that they will be replaced later by the permanent teeth 
 
children's teeth, a community responsibility. 7 
 
 and, therefore, that attention to them is unnecessary. It is rare to 
 find a child who has not had toothache at some time. Even dentists, 
 as a rule, pay little attention to these teeth, because young children 
 are difficult to work for. This is unfortunate because in reality 
 more can be done for an individual by proper attention to the first 
 set of teeth than by repairing the ravages of decay in the perma- 
 nent set after they have taken their places in regular manner. 
 
 Among 7,059 children examined during a recent investigation of 
 mouth conditions by the Public Health Service, 1,822, or 25.81 per 
 cent, of them were found to have lost one or more of the six-year 
 molars. Because this tooth is the first permanent tooth to appear, 
 and erupting back of the last temporary tooth, it is frequently mis- 
 taken for a temporary tooth. This is nothing short of a calamity. 
 Not only does the loss of this tooth mean the loss of masticating 
 surface, but the tooth also determines to a considerable extent the 
 relative positions of the other permanent teeth. Forming, in a man- 
 ner, the keystone of the dental arch, with its loss this arch col- 
 lapses to a greater or less degree, markedly modifying the facial 
 symmetry of the developing child. It is important to remember 
 that in young children the first permanent molar is the sixth tooth 
 back counting from the center. Parents should be instructed to 
 watch it carefully for beginning dental decay in order that steps may 
 be taken in time for its preservation. 
 
 4. DEGENERATIVE DISEASES. 
 
 The child is father to the man in more ways than one. Not only 
 is this true from the standpoint of the acquirement of habits of 
 thought and action during the developmental period, but also from 
 the physical standpoint. Reference has been made to the fact that 
 the percentage of children in need of dental attention is highest 
 among those of 7 and 8 years of age. The neglect of the teeth in 
 early, life usually means an infected mouth with abscesses at the 
 roots of the teeth which, unless cared for, persist in later life. It 
 readily may be seen that such abscesses may act as reservoirs of in- 
 fectious material which may enter the blood stream and be carried 
 to the remote parts of the body, frequently causing rheumatism, heart 
 disease, kidney trouble, and other ailments which may materially 
 shorten life. It has been said that one-fourth of all of the people 
 who die annually in the United States have their life shortened from 
 5 to 10 years by these so-called degenerative diseases. 
 
 Mouth Hygiene as a Branch of Preventive Medicine. 
 
 Nearly every country has awakened to the importance of mouth 
 hygiene. In England to-day there is a movement of national magni- 
 tude well under way, which is a result of investigations conducted 
 
8 children's teeth, a COMMUliJ'ITY RESPONSIBILITY. 
 
 by a parliamentary committee. The conditions revealed by this in- 
 vestigation were so startling that remedial measures have been 
 adopted with the object of benefiting all the people. 
 
 The latest governmental movement in this direction is in New 
 Zealand. Here we find that there has been appointed a national 
 bureau of mouth hygiene with a director and corps of assistant di- 
 rectors who will care for the mouths of all the school children at 
 government expense. 
 
 In America we find that several of the States have State bureaus 
 of mouth hygiene under the direction of their health departments. 
 New York has established such a bureau. Among the later States 
 to adopt the measure is Tennessee; and West Virginia has such 
 movement well under way. Delaware will this year (1920) have 
 a mobile clinic visiting the rural schools. Pennsjdvania has a simi- 
 lar unit in operation under its child hygiene department, and Vir- 
 * ginia will do a similar work in the immediate future. North Caro- 
 lina has been engaged in this work for several years. 
 
 THE DENTAL HYGIENIST. 
 
 In America a forward step has been taken in dental hygiene by 
 the training of women specialists for purely preventive work. These 
 " dental hygienists " limit their work to the cleaning and polishing 
 of all surfaces of the teeth above the gum margins. Experience 
 shows that this treatment is most helpful in securing that important 
 condition, healthy gums, and besides, prevents much dental decay. 
 In their specialty the dental hj^gienists often exceed the dental man 
 in skill and have special qualifications for handling young children. 
 
 Recognizing the special adaptation of women to this work, and the 
 virtue of the old adage that prevention is better than cure, some 
 12 States have already enacted legislation legalizing the practice 
 of dental prophylaxis by women. Among the States that have 
 legalized this work are Maine, Massachusetts, Connecticut, .New 
 Hampshire, New York, Michigan, Minnesota, Iowa, Oklahoma, Colo- 
 rado, and Tennessee. In three other States this movement is assured 
 in the immediate future. 
 
 MOUTH HYGIENE. 
 
 Measures for conserving the teeth of children may be divided into 
 two classes (1) Practical, preventive, and correctional work, by the 
 establishment of school dental clinics, and (2) education methods. 
 
 1. PREVENTIVE AND COERECTIONAL WOKK. 
 
 School dental clinics may be regarded as a valuable economic 
 asset, as shown by results secured in a number of communities. 
 Mouth hygiene movements and the establishment of school clinics 
 
children's teeth, a community responsibility. 9 
 
 become an investment yielding splendid returns, especially by re- 
 ducing the amount of time lost in school attendance and the number 
 of children who repeat grades. This in itself should be sufficient rec- 
 ommendation of this movement even to those who are not specially 
 interested in the health aspects of this work. Not only can the 
 children attending school be greatly benefited by this work, but its 
 influence extends into the home from which the child comes and 
 furnishes a partial solution of the problem of reaching the ^hild of 
 preschool age. 
 
 School dental clinics may be of two types : (A) Centralized clinics 
 and (B) Itinerant clinics. 
 
 A. CENTEALIZED CUNICS. 
 
 A centralized school dental clinic conveniently located and properly 
 manned will, as a rule, be productive of the best results. In the estab- 
 lishment of these clinics the children themselves should be encouraged 
 to furnish some portion of equipment or part of the furniture and 
 to decorate both the clinic and waiting room. The cooperation of the 
 junior membership of the American Red Cross will be found to be 
 of valuable assistance for this purpose. In other instances the man- 
 ual training department of the school should be encouraged to pro- 
 vide some of the needed furnishings. By this means the children 
 are stimulated to take an active interest in the work of the clinic. 
 
 The advantage of a centralized clinic, where the school population 
 is sufficiently large to justify the expenditure, is that it reduces not 
 onl}^ the overhead charge, but also the expenditures for equipment. 
 The method of operation is very simple. An inspection of the 
 children attending the various schools is made either by the school 
 nurse, mouth hygienist, school physician, or dentist, preferably by 
 the school dentist. Cards are issued to the children requiring dental 
 attention, admitting them to the clinic on a specified day at a given 
 hour. It will be found desirable to assign a particular day of the 
 week for the children attending the respective schools. 
 
 Great care should be observed to keep a careful record of each 
 case, for which purpose the acompanying form is reommended. 
 
 B. ITINERANT SCHOOL DENTAL CLINICS. 
 
 The mouth hygiene needs of the smaller towns and less thickly 
 settled rural communities can best be met by organizing itinerant 
 school dental clinics. These should operate usually from the county 
 seat or from one of the larger towns as a base and proceed to the 
 outlying schools of the district where dental facilities are usually 
 entirely absent. Preliminary to the visit of the clinic to a designated 
 school, careful inspection should be made of the children and all 
 
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 CHILDKEN's teeth, a community RESPOl^SIBILITY. 
 
 observed dental defects recorded, following which, permits should 
 be given to the children entitling them to dental treatment at a desig- 
 nated place on a given day. 
 
 EQUIPMENT. 
 
 Depending on the resources of the community and the amount of 
 dental work which it is purposed to do in the schools, the equipment 
 of a centralized school dental clinic may be as complete as desired, 
 including X-ray equipment and laboratory facilities. 
 
 The following is recommended as the main equipment of a mobile 
 school dental clinic : 
 
 /. Equipment of an itinerant school dental clinic for 'both operative and pre- 
 ventive work. 
 
 Article. Quantity. 
 
 Acid, trichloracetic bottle — 1 
 
 Alloy, copper-; ounces 3 
 
 Alloy, true dental do 6 
 
 Blowers, chip. No. 38 number 2 
 
 BlowerSj chip, extra bulbs for, num- 
 ber 6 
 
 Bottles, medicine, |-ounce, ground- 
 glass stopper number — 12 
 
 Bowl, plaster do 1 
 
 Brushes, tooth-polishing gross 6 
 
 Burnishers, No. 30 and No. 34, num- 
 ber 2 
 
 Burs for straight handpiece, Nos. I, 
 2, 6, 34, 35, 560, 568, 700, 702 
 
 (I dozen each) dozen 4J 
 
 Burs for contra-angle handpiece, 
 Nos. I, 2, 4, 6, 33i, 35, 39, 
 557, 558, 560, 568, 701 (h dozen 
 
 each) dozen 6 
 
 Campho-phenol bottle 1 
 
 Cement, Ames copper boxes 3 
 
 Cement, S. S. W., pearl grey — do 3 
 
 Chair, portable dental, with case, 
 
 number 1 
 
 Chisels, Nos. 3, 85 number 2 
 
 Clamp, rubber dam, assorted, num- 
 ber 6 
 
 Cotton, holder number — 1 
 
 Cotton, rolls 2, 3 (8 of each), num- 
 ber 6 
 
 Cotton, rolls, assorted number 3 
 
 Composition, Modeling boxes 6 
 
 Covers, aseptic paper do 3 
 
 Cuspidor and stand, portable, with 
 
 case number 1 
 
 Disks, assorted boxes — 24 
 
 Engine belts number 2 
 
 Engine, dental, all cord foot power, 
 
 f portable, with case number 1 
 
 Engine oil bottle 1 
 
 Excavators, Nos. 37, 57, 58, 63, 64, 
 
 ' *67, 68, 81, 83 number__ 9 
 
 Explorers, No. 5 do 1 
 
 Bugenol bottle 1 
 
 Floss, dental, waxed_„ tubes 12 
 
 Forceps, rubber dam clamp, num- 
 ber 1 
 
 Forceps, rubber dam punch, per- 
 fected number 1 
 
 Forceps, tooth extracting, Nos. 150, 
 
 151 number 2 
 
 Handpiece, contra-angle do 1 
 
 Handpiece, straight do 1 
 
 Lamp, alcohol, with flame shield, 
 
 number 1 
 
 Lancets, Nos. 2, 5 number 2 
 
 Liquid for synthetic porcelain, 
 
 bottle .- 1 
 
 Ligature, wire. Angles box 1 
 
 Mandrels, No. 303 ^^-dozen 1 
 
 Matrix retainer. Ivory's number 1 
 
 Matrix retainer, extra bands for, 
 
 number 24 
 
 Mercury, holder number 1 
 
 Mercury, jugs, No.J do 1 
 
 Mirrors, mouth, with L handle, num- 
 ber 6 
 
 Morter and pestle number 1 
 
 Napkins, aseptic, dental boxes 3 
 
 Oil stone, Arkansas hone 1 
 
 Paper, bibulous package — 1 
 
 Pliers, 4-inch, round-nose, flat, num- 
 ber 1 
 
 Pliers, dressing, Nos. 2, 17_number — 2 
 
 Pluggers, Woodson do 3 
 
 Points, carborundum, mounted, 
 
 box 1 
 
 Points, orange wood boxes — 6 
 
 Porcelain, synthetic shade 6, num- 
 ber 1 
 
 Porcelain, synthetic shade 3, num- 
 ber 1 
 
 Pumice stone, powdered pound — 1 
 
 Sandurac gum ounce — 1 
 
 Scalers, McCall's, Nos. 10, 11, 
 
 12 number — 3 
 
 Scalers, phyorrhea do 4 
 
 Scissors, gum curved on flat — pair — 1 
 
 Shears, 9-inch do 1 
 
 Shears, small, plate (curved collar), 
 
 pairs — 1 
 
CHILDREN S TEETH, A COMMUNITY RESPONSIBILITY. 
 
 13 
 
 Slab, glass, mixing, No. G — uumbei- 1 
 
 Spatulas, Nos. 22, 24 do 2 
 
 Spatulas, rubber do 2 
 
 Sterilizer, small do 1 
 
 Sticks, orange wood bundles 4 
 
 Stopping, gutta-percha boxes__ 3 
 
 Strips, finishing, assorted do 2 
 
 Syringes, water number__ 2 
 
 Syringes, water, No. 21A, extra bulb 
 for numl)er 
 
 Trays, impression, assorted for chil- 
 dren number 
 
 Wax, impression, yellow boxes 
 
 Wheels, corborundum, assorted, num- 
 ber 
 
 12 
 
 In communities where the work will be confined to purely preven- 
 tive work the following equipment will be found satisfactory: 
 
 //. Equipment of a portable school dental clinic for preventive work only. 
 
 Article. 
 Portable dental 
 
 number 
 
 Portable dental cuspidor, with case, 
 
 number 
 
 Portable dental engine, all cord, foot 
 
 power, with case number 
 
 Engine oil bottle 
 
 Engine belt number 
 
 Handpiece, coutra-auglo do 
 
 Polishing brushes gross 
 
 Scalers, pyorrhea number 
 
 Mouth mirrors do 
 
 Quantity, 
 chair, with case, 
 
 Porte polisher do 
 
 Wood points boxes- 
 
 Dappen glasses number- 
 Water syringe do — 
 
 Chip blowers do 
 
 Pliers, dressing do — 
 
 Bibulous paper package- 
 Absorbent cotton rolls. 
 
 Sterilizer number- 
 Aseptic dental napkins boxes- 
 
 Campho-phenol bottle- 
 
 Eugenol do — 
 
 THE COST OF EQUIPMENT. 
 
 The cost of the equipment for a centralized clinic will vary with 
 the amount of work it is purposed to do. However, very complete 
 dental outfits, including a satisfactory X-ray machine, may be pur- 
 chased for from $1,250 to $1,500. 
 
 The equipment recommended for an itinerant dental clinic, ex- 
 clusive of an automobile for transportation, should cost approxi- 
 mately $250. Owing to the need of carrying this equipment in 
 special cases designed for convenience of transportation it is not 
 possible to purchase the complete outfit from any one dental manu- 
 facturing concern. However, persons interested in securing an outfit 
 of this character should prepare proposals covering all the articles 
 listed, which should be submitted to several dental manufacturing 
 firms with the request that said firms bid on such articles as they 
 are prepared to supply. In fact, it will be found that certain firms 
 specialize in the manufacture of portable dental engines, others in 
 dental cuspidors, and some others in portable dental chairs. The 
 operative and prophylactic instrurtients may be purchased from any 
 dental supply firm. 
 
 THE SCOPE OF THE WORK WHICH MAY BE UNDERTAKEN. 
 
 The amount of dental Avork which should be undertaken in the 
 schools may be considered from many different angles. In some 
 countries, as in New Zealand, all necessary dental work is under- 
 taken; in other places the corrective work is limited to the six-year 
 
14 children's teeth, a community responsibility. 
 
 molars ; while in still other communities nothing but preventive work 
 is considered. 
 
 Ordinarily the work should be limited to prevention and to partial 
 correction for children under a given age, preferably 12 years. This, 
 of course, would include the much-needed attention to the important 
 six-year molars. No operative work should be undertaken, however, 
 without first securing the consent of the child's parent or guardian, 
 because in a number of instances it will be found that the parents 
 desire to have the necessary work done by a private dentist. 
 
 Each community will necessarily have to determine the amount of , 
 corrective work which will be undertaken, and upon this determina- 
 tion will depend the personnel required to operate the clinic and also 
 the equipment to be purchased. 
 
 All emergency work should, of course, be undertaken; but in the 
 matter of fillings, it should be limited to cement, synthetic porcelain, 
 gutta-percha, or amalgam (silver). 
 
 Owing to the great prevalence of dental decay in children and the 
 very common neglect of this condition in very young children, and 
 also because of the quite general lack of dental facilities in outlying 
 districts, school dental service should be provided at community ex- 
 pense as a part of the school system. Furthermore, because in every 
 community there are a number of children suffering from dental 
 decay, whose parents are unable to pay a fee for this work, it is 
 undesirable that a fee system should be arranged requiring a fee 
 for the treatment of children whose parents can pay and free treat- 
 ment in the case of necessitous children. Such system assumes the 
 aspect of charity, which should be sedulously avoided. In all in- 
 stances where special and expensive fillings are desired the parents 
 should be required to pay for the material. 
 
 In different communities where fees are charged, these range from 
 10 cents to $1.50 for each child. In clinics where this latter charge 
 is made, the work is completed in all respects. 
 
 PERSONNEL. 
 
 The plan of employing a part-time operator should not be gener- 
 ally encouraged, because with personal interest constantly in his 
 mind the general work of the clinic must suffer. 
 
 If a comimunity be too small to employ a whole-time operator, a 
 possible solution is offered in joining with some other community, 
 each using the clinic part of the time ; in which case the clinic should 
 be of portable type and furnished with facilities for transportation. 
 
 If the clinic be small and funds for maintenance limited, a dental 
 hygienist -should be employed in preference to a dentist, for the 
 
children's teeth, a community responsibility. 15 
 
 reason that she will not only be able largely to prevent conditions 
 which the operator would be called upon to relieve, but she woiild 
 also be able, as a result of her examinations, to notify the parents of 
 the children of their special dental needs before these have become 
 serious. 
 
 In the larger centralized clinics, 1 dentist should be employed for 
 each 2,000 school children, and dental hygienists in the proportion of 
 2 to 4 hygienists to 1 operator. If the corrective work is to be limited, 
 the proportion of hygienists to operators should be increased prob- 
 ably to 12 hygienists to 1 operator, in which case the number of 
 children to each operator can be greatly increased. 
 
 II. EDUCATIONAL MEASURES. 
 
 Educational measures should be considered from the standpoint 
 of the teacher, the child, the parent, and the school authorities and 
 taxpayers. 
 
 TEACHERS. 
 
 Teachers should be given in normal school courses at least a work- 
 ing knowledge of mouth hygiene and of such measures as may be 
 carried out by them without special equipment. They should be 
 shown the value of mouth hygiene not only from the standpoint of 
 the preservation of health, but from that of its effect on reducing 
 absences from school and the number of children who repeat grades. 
 In a record of causes of absences from school in the case of 1,000 
 school children in Valparaiso, Ind., it was found that absences 
 amounted to a total of over 32 school years during 1 school year, and 
 the highest percentage of causes of absences, as given by the pupils, 
 was for toothache. 
 
 Many means are available for the instruction of teachers, such as 
 lectures, moving picture films, and the use of instructive charts and 
 pamphlets. Teachers should also be instructed, by practical demon- 
 strations, in dental prophylaxis, the proper conduct of a tooth-brush 
 drill, and the sanitary precautions which should be observed. 
 
 Special points for the consideration of the teacher. — 1. Decay does 
 not take place upon the cutting edges of the teeth or upon other 
 surfaces which are kept polished by grinding and biting food. The 
 reason for this is that the organisms which cause them to decay can 
 not thrive upon polished surfaces ; therefore, any surface of a tooth 
 which can be kept polished will be free from decay. 
 
 2. Children will be unable to remove the green stains which have 
 formed on their teeth with an ordinary toothbrush, and this should 
 be carefully removed by a dentist or mouth hygienist and the sur- 
 faces carefully polished. The child will then be able to keep this 
 stain from reappearing in the majority of instances. 
 
16 childken's teeth, a community responsibility. 
 
 3. The most important tooth in the mouth is the six-year molar, 
 which appears during the sixth year, and at that time is always 
 number six counting from the front (naturally if a first tooth has 
 been lost, the space should be counted as though the tooth were still 
 in position). The six-year molar comes in directly back of the last 
 baby tooth, and there are four of them, two in each jaw. If one 
 or more of these are lost there will not be a normal development of 
 the jaw. 
 
 4. Dental decay and other diseased mouth conditions may lessen 
 the child's vitality and greatly reduce his capacity for school work. 
 Particularly is this true in cases of abscesses and inflamed gums. 
 The normal gums are a bright pink. When they appear red at the 
 edges or bleed upon brushing some form of inflammation exists and 
 the child is in need of dental attention. 
 
 5. A child with a bad mouth is a possible menace to the health 
 of the other children. 
 
 6. A dollar or an hour spent in the cause of clean mouths will 
 give great returns in health and school efficiency. 
 
 THE PUPIL. 
 
 Many attractive ways have been devised for teaching mouth hy- 
 giene to school children. The charts and films recommended for 
 use in the normal schools can be used for the purpose. First of 
 all the children should be taught a proper method of making a 
 mouth toilet. This should include the brushing of the teeth and care 
 of the toothbrush. Little rliymes and stories will prove very useful, 
 and many of these are to be had. Compositions prove a splendid 
 feature and may be undertaken at intervals. Likewise, children 
 should be encouraged to make posters illustrating some phase of 
 mouth hygiene. 
 
 Method of hrushing the teeth. — Smearing the nails with clay or 
 vaseline and endeavoring to cleanse them with an old toothbrush 
 will enable one to form an opinion as to the most effective method 
 of brushing the teeth. Brushing across the nails will leave mate- 
 rial along the sides of each nail ; brushing up and down the nail will 
 leave the area about the root of the nail uncleansed ; but if the brush 
 be used in a rotary manner, the bristles describing a small circle upon 
 the nail, it will be found that all the material will be removed. This 
 motion is to be recommended in brushing one's teeth upon the sur- 
 face next to the lips and cheek. For the inner or tongue side the 
 brush is used as one, would use a hoe, the rotary motion being im- 
 practicable, but in using this motion the brush should not be pushed 
 back, as this will tend to carry food debris and germs beneath the 
 gum margins, which is the thins most to be avoided. The stroke 
 
Public Health Reports, Reprint 622. 
 
 16-1 
 
children's teeth, a community responsibility. 17 
 
 begins up on the gum ana moves in the direction of the main axis 
 of the tooth toward the tip or masticating surface, as shown in the 
 accompanying cuts. 
 
 For the masticating surface a plilling and pushing motion back-' 
 ward and forward is recommended. 
 
 If the gums bleed when the teeth are orushed, some abnormal con- 
 dition exists and a competent dentist should at once be consulted. 
 A healthy gum is not easily injured. 
 
 A thorough rinsing of the mouth should follow to remove such 
 material as has been dislodged by the previous processes. A number 
 of good tooth powders and tooth pastes are on the market, and 
 their use is not objectionable though not absolutely necessary. A 
 very effective mouth wash is ordinary lime water, which may be 
 diluted in reasonable degree should the taste of the stronger solu- 
 tion be objectionable.^ 
 
 Toothbrush drills. — The great advantage of the toothbrush drill 
 does not lie in the actual brushing done at the time, but in the forma- 
 tion of the habit and the acceptance of this procedure by the child 
 as a part of the daily routine. 
 
 This drill is carried out in various manners; the repetition of 
 the several strokes with the brush 12 or 16 times is the usual 
 procedure. 
 
 Toothbrush drills should be held out of doors whenever possible. 
 If after wetting a brush with water the thumb is run over the bristles, 
 it will be noted that a spray flies from the brush to some distance. 
 Care should be exercised that this spray may not reach one's neigh- 
 bors during these drills, creating a condition worse than that caused 
 by promiscuous coughing and sneezing. 
 
 •» The details of a toothbrush drill must be worked out according 
 to the facilities offered — whether there be running water available 
 or not and whether this be a single bowl or a trough with various 
 jets, as is provided in some schools. 
 
 1 " It has been found that lime water is the hest solvent for the gluelike accumulations 
 of food and mucus which collect on and between the teeth where the brush can not 
 reach. It is so much more effective than the better tasting antiseptic (socalled) mouth 
 washes that it should be used by everyone. It is simple to make and very inexpensive. 
 
 " Buy 5 cents worth of unslaked lime at a paint store. Place a half cupful in a 
 quart bottle and nearly fill with cold water. Shake thoroughly. After several hours, 
 when settled, pour off as much water as possible down the sink without losing any of the 
 lime in bottom of the bottle. This water is the washings of the lime and should not 
 be used. Again fill the bottle with cold water, shake well, and allow to settle. This 
 is the lime water and should be decanted into a 10 or 12 ounce bottle for use at the 
 washbowl. The quart, bottle can again be filled with cold water, shaken, and allowed to 
 settle for future use. This operation may be repeated as long as there is any lime left 
 in tlie bottle. 
 
 " Use the wash without diluting. Thoroughly rinse until it foams in the mouth, then 
 
 rinse the mouth with warm water. 
 
 " Use after each meal. 
 
 — Alfred C. Fones, D. D. S., Bridgeport, Conn."' 
 
18 children's teeth, a community eesponsibility. 
 
 Toothbrushes should not be kept in the schools, but should be 
 brought from the home carefully wrapped, preferably in oiled paper. 
 
 Care of the toothhimsh. — After using the brush it should be care- 
 fully rinsed and placed apart from others where it may become dried 
 out. It should not be kept in water or any solution, but should be 
 placed when possible where it may receive the direct sun rays for a 
 time. Not only is sunlight nature's destroyer of germs, but the life 
 of the brush will be materially lengthened by this means. 
 
 A small toothbrush with comparatively few bristles should be 
 used. The larger sizes are inefficient, and if the brush be too closely 
 bristled, the bristles will not reach the spaces between the teeth. 
 
 Use of the toothpick and dental floss. — The use of the toothpick is 
 to be condemned. It is most desirable to preserve those portions of 
 the gums which lie between the teeth, and the use of a toothpick is 
 most injurious to this tissue. 
 
 In the improper use of the dental floss much damage is often done. 
 If the floss be held tightly between the fingers and forced through 
 between the teeth, a heavy blow is delivered directly upon this tissue, 
 the floss usually following the neck of one tooth and separating the 
 gum from the tooth at this point, with an eventual recession of the 
 gum following. Floss should be drawn carefully and gently between 
 the teeth with a pulling motion. Thus used, the point where the 
 teeth are in contact with each other and which can not be thoroughly 
 cleansed with the brush are successfully reached. 
 
 EDUCATION OF PARENTS AND GUARDIANS. 
 
 In order that the community may reap the maximum return from 
 expenditures incurred in operating school dental clinics the work in 
 the schools should be accompanied by follow-up work in the homes 
 to impress upon the responsible heads of families the importance of 
 mouth hygiene from the standpoint of the growth and development 
 of their children and the necessity of securing dental attention for 
 children of preschool age. If the cooperation of the parents is thus 
 secured, many children will enter school in better physical condition 
 and without the necessity of losing time from school by reason of 
 unsound and aching teeth. In fact, without the active cooperation 
 of the parents the greatest benefit will not accrue to children who 
 receive attention in the school, because of the necessity of home 
 supervision to insure that they carry out and put into practice the 
 teachings received in the school. 
 
 Diet. — It must be remembered that the diet plays an important 
 part in determining whether or not the child is to have sound teeth 
 or teeth that are poorly resistant to decay. This even extends back 
 to the period before the child is born. Expectant mothers should be 
 
childken's teeth, a community responsibility. 19 
 
 taught to include in their dietary foods rich in phosphorous and 
 lime, such as most fresh fruits and the green vegetables. 
 
 Furthermore, the effect of the absence of certain accessory food 
 factors in causing scurvy and rickets (conditions that are invariably 
 associated with bad teeth) makes it highly important that the chil- 
 dren of preschool age, and older children as well, be required to eat 
 each day articles of food that are rich in antiscorbutic and anti- 
 rachitic substances, such as fresh fruits, green vegetables, and butter, 
 and encouraged to drink an abundance of milk. The too free con- 
 sumption of sweets should be discouraged. 
 
 SCHOOL AUTHORITIES AND TAXPAYERS. 
 
 Mouth hygiene is a business proposition. Regardless of one's 
 means of getting a living, we are all in the business of educating 
 our cliildren. To manage this business we employ a superintendent, 
 but in no other business, as is so often the case in this, would we 
 allow our interests to cease with his employment. 
 
 The per capita cost of educating a child is obtained by dividing 
 the total school budget by the number of children in attendance. If a 
 child fails to make grade, the situation is exactly the same as though 
 a manufacturer found that after passing through the plant an 
 article was defective and unsalable. Furthermore, if it was found 
 that a large proportion of the ^products of the plant were unmarket- 
 able, would not immediate steps be taken to remedy the condition? 
 The establishment of school dental clinics and the teaching of mouth 
 hygiene is one of the important remedial steps which should be taken 
 in the school plants.. A reduction in the percentage of retarded 
 children not only means fewer school buildings and reduced over- 
 head charge, but also makes possible the employment of better 
 teachers. As a matter of dollars and cents, mouth hygiene offers 
 splendid returns for each dollar expended in the better growth and 
 development of the children and by assuring better physical types. 
 
 O 
 
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