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THE PREVENTION OF DENTAL
CARIES.
i
Typical models of child's mouth, aged Io, brought up in
accordance with the principles advocated, without resort to any
artificial aids to keep the teeth and gums clean, healthy, and free
from any trace of caries.
The right side (the left on this page) of each model was dipped
into carmine, let dry, then brushed. This was repeated twice.
The photographs indicate how imperfectly the crevices and inter-
dental spaces of teeth are cleaned. Incidentally it may be noted
that the models show a particularly perfect set of teeth without
crowding and consequently relatively easy to clean. The child,
one of the 14 referred to, page 51, having been brought up on food
requiring mastication, has worn the cusps especially of the tem-
porary teeth, so that the crevices are relatively easily brushed.

THE PREVENTION OF
DENTAL CARIES
By
*}
Jºsim WALLACE, D.Sc., M.D., L.D.S.
Dental surgeon and Lecturer on Dental Surgery and Pathology,
London Hospital.
Hon. Dental Surgeon to the West End Hospital for Nervous
Diseases.
SECOND EDITION.
London :
Published at the Office of Úbe Øental Recorb,
Alston House, Newman Street, W.
I912.
PREFACE to the Second Edition
THE first edition of this little book has been received
most generously by the medical and dental press.
One journal (The Medical Magazine) gave up some
forty pages to an almost complete reproduction of its
contents. Another (The Hospital) devoted three
successive articles to an exposition of the principles
therein advanced. Others accorded to it a leading
article or a lengthy review, and more or less vigorously
indicated the necessity for all medical men to become
conversant with its contents. There is consequently
but little wonder that the first edition was sold out
within six months of its publication, and no apology
seems necessary for having it reprinted.
J. SIM WALLACE.
I5o, Harley Street, London, W.
Jan. Io, Ig|2.
CONTENTS.
INTRODUCTION . º g g q, q. *
I. THE PREVENTION OF CONDITIONS which PRE-
& DISPOSE TO DENTAL CARIES . te §
HYPOPLASIA g * • sº *
IRREGULARITIES OF THE TEETH . *
RECESSION OF THE GUMs . gº º
II. MUCUS AND SALIVA IN THE PREVENTION OF
DENTAL CARIES wº * g sº 2
III. PREVENTION OF CERTAIN DIETETIC HABITs
WHICH TEND TO INDUCE DENTAL CARIES
IV. THE PREVENTION OF THE ExcITING CAUSES OF
CARIES . * § tº ſº ſº te
V. THE NORMAL SELF-cLEANSING PROCESSEs. *
VI. DIET IN INFANCY AND CHILDHOOD 49
&
VII. REASONS FOR INSISTING ON THE NATURAL
HYGIENIC METHOD OF PREVENTING DENTAL
CARIES . º *g * º dº §
PAGE
25
3I
37
43
VIII. ARTIFICIAL METHODS OF PREVENTING DENTAL
CARIEs—
** MOUTHWASHES © * * e
ANTISEPTICS .
TOOTHBRUSH . sº * * ©
TOOTHPOWDER . tº * g *
IX. ON DISSEMINATING P&NOWLEDGE NECESSARY FOR
THE PREVENTION OF DENTAL CARIES &
BIBLIOGRAPHY ſº dº e . . . & g
viii. º,
53.
54.
55
59
•c,
THE PREVENTION OF DENTAL
CARIES.
INTRODUCTION
DENTAL Caries is one of the most easily and certainly
preventable of diseases, and there would seem now
to be no valid excuse for the bringing up of children
with decayed teeth, together with all the pathological
results which they give rise to. Unfortunately, so
far it is only those who have become interested in the
subject, and who are themselves possessed of the
required knowledge to come to correct conclusions
on the subject, who know the simple secrets of pre-
vention. That is to say, a goodly proportion of the
dental profession and here and there a few medical
men who have paid attention to the long and laborious
investigations which have led to the solution of this
important problem. It is with the idea of letting what
is already known to a few become more widely known,
among medical men more especially, that I venture to
publish this pamphlet. Those who find the subject
of interest or importance would do well to make their
knowledge more secure, by acquainting themselves
not only with the outlines of the means of preventing
the disease as presented in these pages, but also with
at least a general knowledge of the pathology and the
etiology of the disease, because for some considerable
tifle, incredulity, ignorance, prejudice, vested interests
and the commercial spirit are likely to continue to
make a stubborn resistance to the diffusion of the truth.
4 º'
2 INTRODUCTION
It would be a great service to mankind if a goodly
number of medical men would become thoroughly
acquainted with the subject so as to rid the land of
ideas which are now definitely known to be wrong,
and indeed often actually markedly instrumental in
causing the disease. Medical men and physiologists
engaged in teaching medical students should certainly
make sure that it is not their precepts which are largely
responsible for the widespread prevalence of the disease.
Those who would like to supplement their knowledge
may be recommended to consult the more recent
standard text-books, e.g., J. F. Colyer’s “Dental
Surgery and Pathology,” or the larger “System of
Dental Surgery,” edited by Mr. Norman Bennett,
about to be published by the Oxford Medical Press.
Therein they will find the groundwork of the subject
sufficiently thoroughly treated to let them master all
important points. The references at the end of this
pamphlet will also help anyone with regard to any
special point on which he may desire to have further
information.
It would be difficult for me to speak too strongly on
the great importance of the study of this subject at
the present time ; not only because dental caries is
such a general, and in its ultimate results so frequently
such a fearful scourge, but also because there has been
such an extraordinary change during the last few years
in the conceptions of the dental profession with regard
to the cause and the prevention of the disease. For-
meriy, the cause was vaguely supposed to be hereditary,
constitutional, intangible and irremediable ; now it
is definitely known to be simple, definite, tangible
and remediable. Correspondingly from the most
doleful pessimism the profession has passed into a
most optimistic attitude. Instead of listening to papers
on “The Teeth as the Beginning of the End of the
Civilized Race,” we now hear of “the decimation of the
ranks of the dentists which will follow when once the
eyes of the public are opened to this scourge and its
INTRODUCTION 3
possibilities of prevention.” And “that we look
forward with every belief in the ultimate conquest of
the disease. We see a future people free of it, and
marvelling that those of to-day could have suffered
so long and so patiently. We imagine them asking
themselves what strange perversity could have filled
the mind of people who were willing to spend thousands,
nay, millions, of pounds a year on the cure of a disease,
upon discovering the cause of which they would not
spend a penny. Can we wonder at them if they think
thus 3 For everywhere we see signs of this dreadful
malady; it ruins the beauty of many, it enfeebles
those who would be otherwise healthy, it helps to fill the
workhouses and poor infirmaries with preventible .
sickness, it is the direct and indirect cause of a waste of
fabulous sums of money.”
From multitudinous researches which seemed to
bring us no nearer to the practical solution of the
problem of dental caries, we have come to hear that
caries is essentially a preventable disease. From a
feeling of shame that the dental profession were unable
to solve the problem of prevention it is now said that
by having done so we have “ennobled the avocation
of the dentist in the medical and scientific world.”
Instead of anticipating the continued increase of
dental caries, we confidently anticipate its more or
less complete extinction. And for those who dread
their annual visit to the dentist we can give the most
satisfactory assurance that this, though it may con-
tinue to be expedient, will be but rarely necessary.
Moreover, we can say that we are on the eve of a more
or less systematic crusade. A crusade, no doubt,
initiated by us in establishing rational methods for the
prevention of caries, but now about to be passed on to
those whose position and authority fits them in some
ways more satisfactorily for carrying home the truth
to the mass of the population. Thus, Dr. James
Wheatley (Medical Officer of Health for Shropshire)
has set Medical Officers of Health an excellent example.
4 INTRODUCTION
}
After studying the subject for himself he brought
it forcibly before the medical profession in his branch.
He then lectured to the school teachers in his neigh-
bourhood, and finally prepared leaflets for the instruc-
tion of the parents of the school children in his county.
Like many others who have studied the subject, he
came to appreciate its enormous importance not only
from the point of view of the teeth, but also from the
point of view of health in general. Thus, like others
who have troubled to study the subject, he re-echoed
the sentiments of those who feel that the principles
of dietétics suggested by a study of the food in relation
to the teeth, will yet be found to give rise to the greatest
triumph over disease that has as yet been recorded
in the annals of medicine. I have heard, further, that
other Medical Officers of Health are about to proceed
in like manner. We cannot wonder at this ; in fact,
we could only wonder if other Medical Officers of Health
did not do so, because the principles are so well estab-
lished, and there is no other method known which would
have any appreciable effect. In preventing the disease.
Moreover, the method costs nothing; and, indeed, if
a considerable tax were put on sugar a large amount
of revenue would be derived, while a corresponding
amount of good would follow.
It would seem from many considerations, besides
those to which attention is directed in the following
pages, that the most important principle in dietetics
will prove to be that which claims that the diets which
are recommended should be such as will leave the
different parts of the alimentary canal in a healthy or
hygienic state. When once it is pointed out, this
appears so obviously the first and most necessary
consideration that it would seem incredible that it
should continue to be overlooked in the future. The
amount of nutrition, or the digestibility, or the absorb-
ability, or the number of “calories’’ which may be
derived from an article of diet, should always be pre-
ceded by the consideration whether it leaves the mouth
INTRODUCTION 5
and alimentary canal in a healthy or hygienic state.
Yet it is obvious that in the past this consideration
has been entirely overlooked ; and it would be difficult,
if not impossible, to find a well-known writer on dietetics
(except Dr. Harry Campbell) who has paid sufficient
attention to the subject to be able to give any idea
whether the articles of diet which he may be recom-
mending are calculated to ruin the dental armamen-
tarium or keep it in a hygienic state. Similarly the
treatment of diseases resulting from the frightful state
that the mouth and teeth get into as the result of
unhygienic methods of feeding without knowing how
to alter those unhygienic habits, is peculiarly unscien-
tific, and, instead of curing the trouble, has led in the
past to an untold amount of chronic ill-health.
CHAPTER I
PREVENTION OF PREDISPOSING CAUSES
UNCERTAINTY may still exist with regard to the reasons
why the teeth in certain mouths fall a prey to caries
while in others they do not, but the pathology of the
disease and the nature of the immediate or exciting
cause is definitely and accurately known, and
fortunately beyond the limits of controversy. It is
now universally admitted that dental caries results
directly from the fermentation of carbohydrates in
the crevices of, or between teeth, or more generally in
such situations as carbohydrates are liable to lodge
unduly and permit of fermentation. The facts upon
which this generalization is based are of so great
importance from the point of view of prevention that
a few words on causation may at the outset be desirable.
Various gonditions, such as warmth, moisture and the
presence of bacteria, do not require to be discussed at
present. These conditions are so constant they hardly
need be more than referred to. The variable condition
or antecedent, which when present caries inevitably
follows, and which when absent caries cannot take
place, must be more fully noted. This antecedent
or condition is the undue lodgment or stagnation of
fermentable carbohydrates in more or less immediate
contact with the teeth and undisturbed by the free
access of saliva. This being so, what must be
considered is how the undue lodgment of carbohydrates
may be prevented. It is obvious that the teeth them-
selves may be of a shape such as will predispose to the
lodgment of carbohydrates, or they may be so arranged
7
8 PREDISPOSING CAUSES
as to predispose to undue retention of viscous and
fermentable food-stuffs, or their relation to surrounding
parts (gums) may be such as to predispose to stagnation.
In other words, the predisposing causes of caries are
abnormal pits and crevices, irregularities of the teeth,
recession of the gums and abnormal relations of the
gums, more especially round the wisdom teeth.
Practically all these predisposing causes may easily
be prevented. All the predisposing causes have their
importance and each will be considered separately.
THE PREVENTION OF DEVELOPMENTAL DEFECTS IN THE
TEETH (HYPOPLASIA) -
It is generally recognized that the pits and grooves
(hypoplasia) which result from the defective formation
of the enamel are caused by disease during its forma-
tion. Measles and scarlet fever are said to be the
diseases most commonly giving rise to such defects;
but other severe constitutional diseases may produce
similar results. It is, of course, obvious that such
diseases should, if possible, be prevented and the
general hygienic precautions against them should be
taken. In addition to what may be called the recog-
nized methods of preventing such diseases it should be
observed that a dirty mouth is always dangerous to
the health of young children, and it is doubly objection-
able should such infectious diseases also be contracted.
It happens that at the age (I-3 years) when the teeth
susceptible to hypoplasia are being formed, the food is
most frequently presented to children in a soft or
pappy form, which has little or no detergent effect on
the teeth and, moreover, during these years the tem-
porary teeth are seldom brushed sufficiently to keep
them clean. It thus happens that these infectious
diseases may be made more severe and prolonged or
complicated by the insanitary state of the mouth and
the consequent pollution of what food the child may
PREDISPOSING CAUSES 9
take. As the fact of a child having measles or scarlet
fever during the formation of the enamel (of the sus-
ceptible teeth) does not necessarily result in hypoplasia,
it is possible that the keeping of the mouth clean may
Sometimes be sufficient to prevent hypoplasia should
unfortunately the infectious disease take place at such
time. It would indeed appear that the malnutrition
—which may sometimes be prolonged and severe—
resulting from an unhygienic state of the mouth and
alimentary canal may in itself be the cause of many
cases of hypoplasia ; for perhaps the most common
reply to questions with regard to any particular child
which shows hypoplasia in later life is that it was very
delicate—possibly rachitic—and subject to severe
indigestion during childhood. Defective development
of the enamel has also been attributed to the bottle-
feeding of infants. When this is not carefully carried
Out, especially with regard to sterilization of the milk,
disease and malnutrition are likely to supervene, and
it is further noteworthy to find that hypoplasia is more
common among the children of the poor than of the
well-to-do.85 This may be presumed to indicate that
the less hygienic the surroundings the more likely
is the disease to occur. To sum up it may be said that
in addition to ordinary hygienic precautions and breast-
feeding, it seems probable that hypoplasia might largely
be prevented by keeping the mouth clean. (The
methods of doing this will be referred to subsequently.)
THE PREVENTION OF THE IRREGULARITIES OF THE
- TEETH -
Abnormalities in the position of the teeth are much
more important as predisposing causes of caries than
the abnormalities in form which have just been con-
sidered. While hypoplasia, according to statistics
compiled by Mr. Sidney Spokes,85 is present in from
4.6 per cent. to 7.1 per cent. of the permanent teeth
I3
IO PREDISPOSING CAUSEs
according to the class examined, irregularities in posi-
tion such as may predispose to caries no doubt exceed
80 per cent, among adults in this country; and fre-
quently the greater number of the teeth may, to a
certain extent, be predisposed to caries in this way.
The predisposition to caries, however, is not by any
means always in direct proportion to the amount of
the irregularities. Indeed, certain gross irregularities
giving rise at places to practically complete stag-
nation, especially when there is a tendency for
tartar to be deposited, do not, except in an indirect
way (to be noted hereafter), predispose to caries. The
irregularities which most surely induce caries are those
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which make the food consumed become lodged or
impacted between the teeth. Nevertheless it may be
said in general that “any departure from the normal
arrangement favours the lodgment and stagnation of
food,” 1 and consequently favours the onset of caries.
Both abnormal relations of the upper to the lower
teeth and abnormal relations of neighbouring téeth in
the same arch are recognized to predispose to caries
by inducing the stagnation of foods. Certain irregu-
larities in the molar and premolar regions also tend to
bruise the enamel and render it liable to rapid decalci-
fication.25 Thus when the level of the crown of a molar
is distinctly below the level of its neighbour the




PREDISPOSING CAUSES II
approximal aspect of the higher tooth is almost in-
variably first and most rapidly attacked by caries,
the thick rounded cusp of the lower tooth bruising the
relatively thin enamel of the neighbouring tooth.
The flat and relatively thin enamel nearer the neck of
the tooth is readily bruised by the rounded part of the
molar tooth lying against it when during mastication
it may be subjected to a pressure occasionally amount-
ing to more than I2O lbs. -
The means at our disposal for preventing these
irregularities may briefly be noted. Breast-feeding
and general hygienic surroundings are important in
being conducive to the normal development of the
jaws and in the prevention of crowding of the teeth.
This might be expected on general principles, but it
has been statistically proved in an investigation by
Mr. J. F. Colyer,9a who has shown that breast-fed
children of the better classes have broader arches than
breast-fed children of hospital patients. No doubt
this results from the more hygienic surroundings of the
higher classes. He shows further that breast-fed have
broader arches than bottle-fed children. This would
seem to indicate that the hygienic conditions or the
nutritive quality of the food of the breast-fed children
is more satisfactory than that of the bottle-fed. That
it is chiefly due to the insanitary conditions almost
necessarily associated with bottle-feeding is indicated
by the fact that children hand-fed with bottles with
rubber tubes (which cannot be properly sterilized)
have still narrower arches than those who are brought
up on the more modern, more cleanly and easily
sterilized teat attached directly to boat-shaped bottles.
From Mr. Colyer's measurements it may at least be
inferred that not only is attention to the general
sanitary surroundings important in the prevention of
irregularities resulting from crowding but also that the
more sanitary the feeding apparatus, the better are the
jaws developed, and the results of his measurements
seem to corroborate the generalization that the
I2 PREDISPOSING CAUSES
crowding of the teeth is in general proportionate
to the ill-health or disease which may have existed
during the development of the jaws.” -
Another point of some importance is the recognition
of the early efforts of nature to secure correct anta-
gonism or occlusion of the teeth. . It seems probable
that the instinct to gnaw more or less continuously
during the coming into place of the incisor teeth
indicates that the child should be supplied with a type
of food which will allow and induce it most effectually
to secure the correct occlusion of the incisors. In days
gone past it was the custom to let an infant “cut, its
teeth '' on a crust. It is obvious that gnawing such a
foodstuff will tend to make the child habitually place
its lower jaw in such a position that the incisors will
occlude normally and the development of the jaw
associated with this position and the effect of the
tongue in moulding the arch will tend to bring about
the correct occlusion of the incisors.47 The correct
occlusion of the other teeth will almost invariably
follow as a matter of course. From this time onwards
food which stimulates efficient mastication develops
the muscles of mastication, including the tongue,48
and correspondingly stimulates the development of
the jaws so that crowding of the teeth tends thus to be
prevented. This has been experimentally proved in
rabbits by Dr. Laurence Baker,7 for by filing the teeth
On one side of the mouth so that mastication could not
be performed on that side, it was found that the bones
of the jaw and indeed of the nose and base of the skull
also, did not grow so perfectly as did the bones on the
side on which mastication was performed. Similarly
when from certain causes a child does not masticate
effectually on one side of its mouth for a few years
a noticeable difference in the size of the different sides
of the jaws has been detected. More important than
this, however, is the fact that chronic ill-health during
the development of the child tends to prevent the
normal development of the jaws, and recent observation
PREDISPOSING CAUSES I3
seems to show that chronić ill-health and concomi-
tant emaciation in children is largely, indeed almost
Solely, the result of a system of dietetics which has
resulted in the foisting on children of all ages foods
which leave the mouth in a state of chronic fermenta-
tion. The constant swallowing of the fermented
products, and associated bacteria, the diseased state of
the gums and teeth, the absorption of poisons direct
and indirect, are now recognized as most fertile sources
of chronic ill-health. Foods of a firm and fibrous
nature which stimulate the pleasurable activity of
efficient mastication tend to keep the mouth and teeth
clean and healthy. On the other hand, the soft foods
which children are so generally compelled to consume
do not clean the mouth, but leave it sticking with
fermentable carbohydrates which no doubt constitute
an excellent nursery for pathogenic bacteria, and induce
a state of chronic fermentation which leads to the pro-
longed ill-health depicted in the pale and emaciated
faces with ill-developed jaws and contracted arches of
teeth so generally seen at the present day.
It is important also to prevent mouth breathing in
children, because this is a fertile source of crowding
of the teeth. To prevent mouth breathing it is neces-
sary to prevent adenoids and associated pathological
conditions. Adenoids may easily be prevented, as
they result directly or indirectly in nine cases out of
ten from cold and damp air. In the tropics, of course,
and warm countries generally special precautions are
hardly nécessary, as cold and damp air is seldom
present and neither are adenoids. In cold and damp
climates, such as our own, statistics41 seem to prove
that all that is necessary is to prevent the direct ingress
of cold and damp air, more especially into children’s
bed-rooms during winter. (Some laryngologists now
advocate that the door of children’s bed-rooms should
be kept open in cold and damp weather rather than the
window).30 To ventilate and warm chiefly by means
of open fires and, if possible, to avoid damp localities
I4 PREDISPOSING CAUSES
and houses. Other conditions should be taken into
account. Thus, excessive clothing of children leading to
perspiration and chills, together with constant liability
to catarrhal infections, say, at schools, especially
when over-crowded and ill-ventilated, frequently
results in adenoids. So too over-clothing and conse-
quent perspiration at night in cold and damp rooms,
associated with too little clothing by day, may be
presumed to have a like effect. -
Subsidiary, though frequent, causes of irregularities,
Such as caries and the extraction or at least injudicious
extraction of teeth, need not now be referred to ; such
extractions are not necessary when the requisite pre-
cautions for the prevention of caries are taken. To
sum up, irregularities of the teeth may be prevented by
bestowing ordinary attention on hygienic surroundings,
by food which stimulates efficient mastication, and by
rational ventilation. It may be thought that too little
consideration has been given to the various steps
between the actual predisposition brought about by
the irregularities of the teeth—i.e., the conditions
favouring the undue lodgment of carbohydrate food—
and the original remediable antecedent or condition
which should not have been allowed to be present ;
but it is presumed that all subsidiary conditions which
are necessarily correlated with the links briefly sketched
out are obvious and recognized. Thus, though the chief
links in the chain between cold and damp air and
irregularities of the teeth are indicated, mention has
not been made of the fact that with regard to acute
naso-pharyngitis, “exposure to cold and damp plays
the chief exciting rôle,” and that “exposure to cold
really means lessened resistance of the tissue to germ
vitality, and germ entrance into the substance of the
(mucus) membrane,”12 that this leads to other catarrhal
infections, and that the blockage of the nose arrests its
development (von Ziem), yet the significance of these
facts cannot be overlooked. Furthermore, although
it is well recognized that the connecting links in the
PREDISPOSING CAUSES I5
causation might be broken at some particular stage—
thus adenoids may be removed by operation—yet
necessary though this is when adenoids are present,
the ideal method of prevention aims at avoiding the
necessity for operation—in other words, the prevention
of adenoids. Similarly when irregularities of the
teeth are present they ought to be corrected.
THE PREVENTION OF RECESSION OF THE GUMS
Recession of the gums is another predisposing factor
in dental caries which, to a great extent, may be easily
prevented, for this condition results largely from the
stagnation of debris about the necks of the teeth.
How this might be prevented by food of such a
consistency as would act as a continual natural and
inoffensive brush for the teeth and gums need hardly be
referred to. It is recognized that teeth which are
displaced in such a way as not to receive the natural
pressure and strain of mastication are peculiarly liable
to recession of the gums. Nor need the fact be men-
tioned that teeth which are constantly well used are
more firmly rooted in the alveolar process, so that they
do not become prematurely functionless through loosen-
ing. People who have teeth arranged in such a way
that they are functionless become “long in the tooth,”
and those who do not put their teeth to the principal
function for which they are so well adapted likewise
become long in the tooth ; so that the caries which we
so frequently see in later life between and at the necks
of the teeth is strongly predisposed to by the habitual
use of food which does not stimulate efficient mastica-
tion. We may, indeed, say that after the gums have
receded this predisposition to caries is the most impor-
tant factor in its causation, especially when associated
with irregularities.
It is the albuminous matter and the mucus, together
with the salts it contains, lodging about the necks
I6 PREDISPOSING CAUSES
of the teeth, which is associated with or may induce
tartar formation and infections resulting in recession.
It is, therefore, important to note certain bacteriological
considerations associated with mucus. It readily
undergoes acid fermentation, but after a time the acid
fermentation stops and putrefaction begins.22 A thin
film of mucus bathed and miscible with saliva does
not give rise, however, to such acid fermentation as
would injure the teeth. If a piece of litmus paper
be moulded over the gums and teeth it will be observed
that just at the junction of the gums and teeth the
reaction indicates slight alkalinity, while the part
which covers the gums indicates slight acidity. It is
at these gingival margins that the mucus tends most
to deposit, and if the deposit of mucus, together
with the associated bacteria, is thick, the deepest part
more especially will most certainly have reached the
stage of alkalinity. Here:-however-that-is-itts#At the
gingival margins, complete stagnation of the mucus
is not permitted, because there is a continual exuda-
tion of albuminous corpuscles from the gingival organ,
and this, together with the exudation of a little serous
matter, greater no doubt when mastication is vigorous,
supplies the pabulum for the bacteria which liquefy
and disintegrate the mucus and albuminous matter,
thus keeping up a continual flux which normally
prevents tartar formation. It is possible that these
so-called salivary corpuscles by possessing chemiotactile
properties may keep the space between the necks of
the teeth and the gingival margin free from invading
bacteria, while as they make their exit from the space
they may also englobe bacteria and prevent masses of
bacteria adhering about the necks of the teeth. Of
course, if carbohydrates preclude the beneficent action
of the saliva and are continuously lodging on this
mucus and albuminous matter, which always contains
numerous bacteria, caries may result along, or rather
at some very slight distance from, the gum margin,
though of course no physiologically correct diet allows
PREDISPOSING CAUSES I7
this to happen. On the other hand, if the food which
lodges is of an albuminous but non-detergent nature,
then the mucus may not be sufficiently or frequently
removed and ultimately may tend to allow of the
deposit of tartar. As a matter of fact, we know that
in such situations tartar is most frequently deposited,
especially is this the case when from any reason
mastication is more or less in abeyance together with
the dependent and associated self-cleansing processes.
Tartar does, of course, protect the necks of the teeth
from caries; but it is an irritant to the gums and leads
to their recession from the necks of the teeth; more-
Over, being an irritant it gives rise to a certain amount
of exudation of albuminous plasma from the inflamed
parts. This supplies the saprophytic micro-organisms
with undue supplies of pabulum appropriate for their
development, and thus further enhances the chances
of infection of the gums by micro-organisms which
tend further to destroy the gums. It has been found
that almost pure cultures (Spirillum Sputigenºum) may
often be made from the bacteria associated with this
hyperamic state of the gums,28 but it has been noted
also that in such cases caries is conspicuously absent.
From this it may be presumed that the micro-organisms
associated with this condition are but feebly able,
if at all, to decalcify enamel under such circumstances.
Such conditions of the gums ultimately, however,
give rise to recession and consequently to a predis-
position to caries for the spaces that subsequently
come between the teeth, become more and more remote
from the hyperaemic gum and associated saprophytic
micro-organisms, and such spaces are more and more
liable to lodge carbohydrates. It is evident, therefore,
that in order to control the formation of tartar the
food must be of such a consistency as will stimulate
efficient mastication and prevent the stagnation of
mucus and consequently the undue proliferation of
bacteria. It is suggestive and notable that all clean
and healthy mouths contain bacteria, e.g., Streptococcus
I8 PREDISPOSING CAUSES
brevis, which is both acid-forming in the presence of all -
fermentable carbohydrates (e.g., sugar, starch, lactose,
maltose, glucose, dextrin)15 and liquefying in an albu-
minous medium. It would seem as if Nature had made
a virtue of necessity, and being unable to exclude
micro-organisms from the mouth altogether had turned
them to good use. It is difficult to imagine a better
method for the prevention of caries at these places
where the friction of the food, lips, tongue and cheeks
cannot thoroughly dislodge adherent mucus, for while
it provides a slippery and protective coating favouring
the easy washing away of foodstuffs, the bacteria
incorporated in the mucus and albuminous matter
(no doubt normally but slow acid producers) provide
for the continual liquefaction and removal of the
adherent mucus itself, together with all accumu-
lations of debris, whether it be albuminous shreds or
incipient tartar deposit. When we imagine what state
the mouth would necessarily get into if there were no
bacteria to liquefy albuminous foodstuffs, or to disin-
tegrate the film of mucus and help to dispose of or
prevent the formation of tartar, we realize that the
bacteria of the mouth appear to play a useful part as
scavengers in cleaning it. We recognize how important
it is that a method should obtain for keeping up a con-
tinual flux, thus preserving the teeth from destruction
by acid on the one hand, and from the deposit of tartar on
the other. Fortunately, both these objectionable results
may be prevented by similar means, namely, a sufficiency
of food which will stimulate efficient mastication,
enough to ensure a fair amount of friction, and polishing
of the teeth and a corresponding stimulation of the self-
cleansing processes, to be more fully referred to later.
MUCUS AND SALTVA IN THE PREVENTION OF DENTAL w
CARIES
Mucus is important as a lubricant and, mixed with
saliva, a vehicle for the removal of food particles. It
MUCUS AND SALIVA I9
lubricates the mucous membrane and teeth on the one
hand and the food on the other, thus facilitating the
passage of the food from one part of the mouth to
another during mastication, and finally ensuring its
complete, or practically complete, removal from the
buccal cavity. The mucus is secreted in amounts
proportionate to the requirements of the particular
kinds of foods for this purpose. Likewise the saliva
facilitates the same physiological processes and the
quality and quantity secreted is also proportionate
to the requirements of the food consumed.31 Saliva.
has also a marked effect in preventing acids taken in
food or developed by bacteria from decalcifying the
enamel, and this effect seems to be much greater than
could be accounted for simply by its power of neutral-
izing the acid.17 Mucus is freely miscible with saliva,
so that even if mucus has no similar power in protecting
the enamel from decalcification it does not hinder such
beneficent action of the saliva. The variations in the
amount and quality of the saliva and mucus corre-
sponding to the quality of the food consumed appear
to be common to all, whether “susceptible * or
“immune * to caries. That this is so is not a subject
of controversy, but nevertheless the fact that the
normal physiological processes supply with marvellous
ingenuity the means of securing the cleanliness of the
mouth and teeth seems to be most persistently over-
looked by many who believe that the mouth is clean,
or otherwise, according to whether it has or has not
been brushed with a toothbrush.
Many now recognize that food demanding efficient
mastication prevents caries on the masticating surfaces,
but seem to doubt whether it has any such effect at
the necks of the teeth. The following argument was
recently put before me. It was contended that the
food got into the crevices at the necks of the teeth after
meals. It was admitted that it did so under abnormal
conditions of the gums or if the food was of a sticky
type. To this it was objected that it always must do
2O MUCUS AND SALIVA
so, for if a set of teeth mounted, say, on some substance
to represent the gums were dipped into liquid, e.g.,
water, and some coloured material, and then taken Out
again it would be seen that the water and colouring
matter clung about the gingival margins and between
the teeth. The reply to this was, of course, that such
would certainly take place, but as the viscous mucus
covers the teeth and crevices at the edge of the gums,
much as the water would, that is to say, it would
certainly be present between the teeth and at the
gingival margins, and being adherent to the teeth yet
slippery to the food, the food does not tend to lodge
in such crevices. As a matter of fact if a normal
mouth be examined after a meal not ending with fine,
“short,” specially lodgable foodstuffs it will be seen
that food does not lodge in such situations. If, further,
say a child (with normal and regular teeth and healthy
gums) is given chocolate or toffee, and then the mouth
is inspected a few minutes later, it will be seen that it is
the crevices in the masticating surfaces which are
specially liable to lodge such foods, and not the crevices
of the gingival margins. Food is crushed down into
the crevices of the masticating surfaces, and is not
crushed down into the gingival crevices, but it slips
past them. In the case of the interdental spaces,
if any viscous foods or food particles get there, they are
easily and effectually washed away with the saliva
which is always passing between, at least if vigorous
mastication is being performed, and the teeth and
gums are normal in their relations, which, however, it
may be remarked, they seldom are in the neighbour-
hood of the wisdom teeth. -
Before the role of the foodstuffs in the etiology, as
distinct from the pathology, of caries was recognized,
that is to say, before it was recognized that the chief
factor in the causation of caries was the tendency of
certain carbohydrates to lodge unduly about the teeth
on the one hand, and that the chief factor in the pre-
vention of caries was the tendency of certain other
MUCUS AND SAILIVA 2]
foodstuffs to brush fermentable carbohydrates away
from the teeth, it was most generally assumed that
teeth decayed in some mouths and not in others,
because of some unexplained susceptibility or immunity
existing either in the substance of the tooth or in the
secretions of the mouth. Dr. Black's investigation
into “The physical character of the teeth * 5 in
relation to their diseases seemed conclusively to nega-
tive the assumption that susceptibility or immunity
resided in the substance of the tooth, and gave rise
to the idea that a thorough investigation of the oral
secretions must reveal the cause of susceptibility and
immunity. But numerous, and in some cases thorough,
though the investigations have been, it may certainly
still be said that we have little or no knowledge of any-
thing existing in the saliva or mucus which can account
for the susceptibility to caries which is assumed to
exist in some mouths.
Independent of normal variations in the saliva,
resulting from variations in the nature of the food
and other physiological variations, there are occa-
sionally abnormal variations in the saliva, and these
variations do have an effect on the rapidity of the
carious process no doubt. Thus, for example, diseases
which eventuate in the arrested flow of saliva have been
recorded, and diabetes may predispose to caries through
the Saliva containing glycogen. Such diseases should,
of course, be prevented or controlled. If disappoint-
ment is felt that we are able to say but little with regard
to the constitutional variations of the saliva and
mucus as predisposing factors in the causation of caries,
consolation may be taken from the fact that in England,
where the rôle of the foodstuffs in the etiology of caries
is generally appreciated, the rôle of the saliva and
mucus as predisposing factors are correspondingly
felt to be of little consequence. And we do not now
believe such statements as, for example, that “in the
practical considerations of case as they are presented
to us when we have the care of families of children, the
22 DIETETIC HABITS
hereditary predisposition to caries is of the first
importance.” 6 Yet this was the view which was held
even by those who denied that the chemical composi-
tion of the tooth had anything to do with the predis-
position to caries. Indeed, we now believe that the
hereditary predisposition to caries resulting from the
hereditary variations in the oral secretions is to all
intents and purposes a negligible consideration, for it
is admitted that what we took for hereditary predis-
position turns out on more critical examination to have
been similarity of environment.10 It had not been
noted in this connection that similar dietetic habits
ran in families and thus accounted for the apparently
markedly hereditary nature of the disease. Similarly
we are inclined to put little importance on the faint
differences in the alkalinity or acidity of the saliva
or slight variations in the amount of viscidity of mucus,
when, notwithstanding such variations, we are able by
altering the dietetic regime to make anyone practically
immune to caries. If it be assumed that the dietetic
Yegime alters the constitution in such a way that the
saliva and mucus become healthier, and that in this
way the change to immunity is brought about, then at
any rate we have explained the necessary steps to be
taken to prevent saliva and mucus causing caries.
THE PREVENTION OF CERTAIN DIETETIC HABITS WHICH
TENID TO INDUCE DIENTAL CARIES
It is well to recognize that certain habits and pref-
erences, if indulged in, tend to give rise to caries and
may be prevented. Thus, for example, the bolting
of lumps of food, which, by robbing the teeth of the
natural detergent effects of such foods, ought to be
prevented. This habit usually comes about in young
children through habituating them to a more or less
exclusively soft diet, in older children it has a like cause,
often aggravated by tender or even decayed teeth.
DIETETIC HABITS 23
It is obvious that the teeth in these cases must be put
right or got rid of by the dentist, and a diet consisting
of food which stimulates mastication (e.g., crisp toast,
dry rusks, etc., and in older children apples, meat, nuts,
etc.), allowed to form part of the meal. Other habits
such as eating sweets or farinaceous foods, together
with milk on going to bed, must be simply stopped.
With regard to the habit of eating sweets and highly
sweetened foods, and the attempt to break the habit
or the craving for such foods, more difficulty may be
experienced, more especially if such habits and cravings
have already been established. From an analysis of
cases in which a large amount of food requiring mastica-
tion formed part of the daily regime it would appear
that the desire for sweets originates to a certain extent
from the habit of giving young children an almost
exclusively soft diet, for in the majority of cases to be
referred to, when the children were brought up on food
requiring mastication, they seemed to prefer spending
their spare cash on toys and not on sweets. In two
cases under my own care the elder one (II years) has
never spent one penny on sweets, and the younger
(6 years) only one penny (probably more for the pleasure
of imitating his nurse than for the desire of eating
sweets), but this has not occurred a second time, no
doubt because the desire for toys exceeds his desire for
sweets. In these two cases there was no injunction
against buying or eating sweets (so long as they were
not eaten between meals). The parents were what
may be called notorious sweet-eaters in childhood.
Other cases, although not so marked, seem to confirm
the supposition that the craving for sweets varies in
the manner indicated with the nature of the diet.
Possibly such craving results from cheating the palate
by the soft diet passing the palate quickly, while the
amount of carbohydrate consumed can hardly be
instinctively appreciated. No doubt, also, when
children habitually end their meal with fresh ripe fruits
they are more difficult to please with sweets, for fruits
24 DIETETIC HABITS
are sweet enough themselves and the aromatic flavours
of fruit are but imperfectly imitated by the extra-
'ordinary chemicals which are incorporated with sweets
to give them the flavours present in fruits. Moreover,
if the adoption of such a type of diet will not stop the
craving for sweets, there is no reason why the habit
should not be stopped as far as possible by command.
There are reasons for believing that in a natural state
the supply of sugar was so limited that under such
conditions an almost unlimited desire for it could not
have been harmful. Nature supplied the restriction.
In modern times it may be that parents must make the
restriction if otherwise correct feeding does not prevent
the desire. 4.
CHAPTER II
THE PREVENTION OF THE IMMEDIATE OR.
EXCITING CAUSE OF CARIES
IN our survey of the predisposing causes, a general
statement of the cause of caries was made which is now
generally admitted; but it should perhaps be men-
tioned that a somewhat different conception of the
cause of the disease was, and still may be, held. It
is important to have an even more definite conception of
the nature of the immediate or exciting cause when
entering upon a consideration of the means to be taken
for its prevention. Until recently it appears to have
been assumed that the bacteria were to be regarded
as the exciting cause and that meals containing
fermentable carbohydrates supplied the pabulum
necessary for the bacteria. That, in fact, except in the
case of an exclusively meat diet, the carbohydrates in
the meals always supplied the necessary and invariable
conditions requisite for the micro-organisms to cause
caries, provided only that the resistive forces in the
tooth or in the saliva, did not nullify or counteract the
effects of the acid produced by the micro-organisms.
Why, under such circumstances some teeth decayed in
some mouths and did not decay in others was explained
by assuming the existence of some unrecognised sus-
ceptibility or immunity. It was assumed as a natural
corollary to this hypothesis that the rational way of
preventing caries was to make the mouth as nearly
as possible an aseptic chamber by the use of antiseptic
mouthwashes. Nevertheless, in England at least,
it was held that what had been established
ſº 25
26 IEXCITING CAUSE
was the pathology of the disease, and that the
etiology or the cause of the disease remained
an unsolved problem. The following three quota-
tions will indicate the attitude which came to be
taken up.
(I) “If we wish to deal with dental disease, we must
first of all possess a correct knowledge of its cause.
Do we possess that knowledge It is now more than
fifteen years since Dr. W. Miller’s excellent work on
the ‘Micro-organisms of the mouth appeared, in which
he clearly demonstrated that caries of the teeth was
due to the abstraction of the lime salts by acid, followed
by the peptonizing action of bacteria, the acids being
formed from the fermentation of carbohydrate food.
There seemed to be a general belief, at any rate amongst
those practising dentistry, that the cause of caries had
been found, and the fact seemed to be lost sight of that
all that Dr. Miller had done was to demonstrate the
phenomena of caries, and although his researches had
shown the channels in which, further investigation
should be pursued, the actual cause of caries
was still unknown, and is to the present day
unknown.”20
(2) “In spite of Tome's classic definition of dental
caries, and in spite of the researches of Underwood,
Miller, Black, Leon Williams and others, we can no
more tell why one mouth is immune and another
riddled with caries than we could before these inves-
tigations were made.”18
(3) “It is frequently stated that the true cause of
dental caries has yet to be discovered, and although
we know the pathology of the disease through the
investigations of Dr. Miller, the etiology is a very
different matter. The truth of this is obvious, and yet
. nearly all the searchers after the etiology have
pursued further pathological studies in their endeavours
to discover it.”28
t is now generally recognized, however, that the
fact of the prevalence of caries in some mouths and not
EXCITING CAUSE 27
in others (and all partaking of a mixed diet), is by no
means necessarily a proof that there is any more
susceptibility or immunity to the disease in the one
case than in the other, for the idea has gained ground
that some foods commonly consumed actually clean
the teeth, while other foods more commonly con-
sumed by children leave them sticking with ferment-
able carbohydrates, and that even the alteration in
the sequence of foods—in one case finishing the meal
with the detergent foodstuffs—may effect a profound
difference in the lodging of carbohydrates consumed
at meal times, and therefore in the prevalence of caries.
This conception has been developed so far, that some
now believe susceptibility and immunity in regard
to dental caries is, if not a misconception altogether,
at least an almost negligible factor which, at the present,
day, throws no light whatever on the means at our
disposal to prevent the disease. Doubtless this is so,
and no methods of preventing the unknown suscepti-
bility to caries having been discovered or suggested,
we must direct further attention to the means at our
disposal for preventing caries by recognizing that the
cause of caries is the prolonged retention or Stagnation
of fermentable carbohydrates in more or less immediate
contact with the teeth and undisturbed by the free access
of Saliva. It being unnecessary now to consider how
this is influenced by the predisposing causes (these
having been already referred to), it only remains to
consider how the foodstuffs themselves are instrumental
in preventing the onset of dental caries. For this
purpose we may divide foodstuffs into two classes,
namely, those which tend to leave viscous and fer-
mentable carbohydrates about the teeth and those
which tend to brush them away. When we observe
what actually happens during mastication we see that
it is chiefly food of a fibrous nature which stimulates
efficient mastication. The more or less liquid part
and suspended particles contained in the fibrous meshes
are expressed and swallowed, while the fibrous part
28 EXCITING CAUSE
is again and again subjected to crushing and disinte-
gration between the teeth. If an apple, for example, is
thoroughly masticated, the sweet juices are expressed
and during the early part of the process these sweet
juices are tasted. At the end of the process, however,
the disintegrated fibrous mass is practically tasteless.
The sweet carbohydrates and suspended particles are
swallowed first, while during the process the more
fibrillar part has been stimulating mastication, in-
salivation and dislodgment of food particles and
bacteria. Similarly meat and potatoes or any of the
common combinations of foods which are so naturally
chosen and consumed by adults exhibit a similar
phenomenon, but when we turn to the foods which
children are at present compelled to live upon very
largely, e.g., milk, porridge and milk, sloppy milk
puddings, bread soaked in milk, potatoes and gravy,
bread and jam, etc., we realize the absolute impossi-
bility of efficient mastication being carried on. We
realize further that what really is stimulated is simply
a mechanical movement of the jaws which helps to
plaster the sticky carbohydrates into the crevices of the
teeth in which the bacteria—fed from previous meals
and incubated in the intervals—are lying in readiness
for the production of further quantities of acid destined
to decalcify the enamel of the teeth. Hitherto, as
has been noted, it was customary to regard bacteria
as the exciting cause of the caries, but when we consider
the fact that it is only when carbohydrates are made
to lodge unduly with the ever-present biactera that
acid is produced, we might perhaps with greater
propriety say that it is the carbohydrate which is the
exciting cause. Indeed, this is now very frequently
done, for it is only when carbohydrate lodges unduly
that the micro-organisms are excited to acid fermenta-
tion. Moreover, if no carbohydrate lodged in the
mouth the bacteria which are best adapted for that
medium would be present only in innocuous numbers—
probably many species would be prevented from
EXCITING CAUSE 29
proliferating in the mouth altogether—while the
bacteria which find in the albuminous desquamated
epithelium and other proteid substances their
natural foods might actually be antagonistic to the
presence of acid-forming and possibly also to
pathogenic bacteria. Still keeping to the view that
the bacteria are to be regarded as the exciting
cause of caries we recognize that the foods control
the bacteria. . -
(I) Fibrous foods which stimulate efficient masti-
cation clean the bacteria out of the mouth altogether
to a great extent. This is obvious, but to make assur-
ance doubly sure I made some experiments” which
resulted in showing that a given quantity of toast
chewed before breakfast, then set aside in an incubator,
developed acid much more rapidly and in much greater
amount than an equal quantity of toast similarly
chewed after breakfast. A similar result, including
not only the relative but also the absolute quantity
of acid produced, followed the same experiments with
stone-milled flour (bread toasted). Most foods being
practically sterile do not introduce bacteria into the
mouth.
(2) Fibrous foods which, by stimulating mastication,
remove sticky carbohydrates, remove also the nutri-
ment which is most necessary for the development
of bacteria most active in a carbohydrate medium,
*.e., (a) acid-forming bacteria, and (b) bacteria which
give rise to viscous fermentation. This latter class of
bacteria is often overlooked, but inasmuch as it is only
when the acid formed by bacteria is protected from
neutralization or dilution with the saliva that decalci-
fication of the enamel results, it is obvious that viscous
fermentation must be reckoned with and should not be
allowed, much less encouraged in the mouth. Thus,
therefore, cane sugar when not sufficiently diluted or
eaten with something of a detergent nature may possibly
under certain circumstances be more destructive to
the teeth than the more directly fermentable sugars.
3O EXCITING CAUSE
The formula which is given34 to represent the con-
version of cane sugar into mannite and gum is as
follows:—
25 (C12H22O11) + 25 (H2O)
= I2 (C12H2O O10) + 24 (C6 H14 O6) –H I2 (CO2) + I2 (H2O)
(Gum). (Mannite).
With regard to the fermentation of the grape sugar
groups and the cane sugar groups Miller comes experi-
mentally to the conclusion that “the one is apparently
about as detrimental to the teeth as the other.”23b
Probably this results from the fact that in a mixed
bacterial culture such as we have in caries, some
bacteria are inverting the cane sugar while others
at the same time are producing acid from the inverted
sugar. It would be a mistake to argue that because
some species of bacteria cannot convert cane sugar that
it is less harmful to the teeth than the grape sugar
because it is not pure cultures which have to deal
with the sugar in the mouth.
As has been indicated in the preceding pages, food-
stuffs reduce the number, and probably also the number
of species, of the micro-organisms of the mouth, and
as it has been maintained that one of the most
important methods of preventing caries is as far as
possible to sterilize the mouth, it may be as well to note
that the sterilizing of the mouth cannot be regarded as a
natural means of preventing the disease. While,
therefore, by no means claiming that the mouth could
be sterilized, we may at least say that the foodstuffs
can control the micro-organisms so effectually that the
teeth of civilized man may be as clean and free from
caries as are the teeth of the lower animals, or certain
savage races which do not use any artificial methods
of cleaning the mouth. Further, we recognize the use-
ful part which, when controlled, these micro-organisms
may play. It is significant that there are no anti-
septics naturally present in the mouth, and moreover,
that the bacteria of the mouth are as constantly
NORMAL SELF-CLEANSING 3I
present in the mouths of susceptibles as immunes,
Dr. Miller has shown that the number of bacteria
is almost as great in the Saliva of “immunes * as in the
Saliva of “susceptibles,” and that acid production by
the bacteria, though slightly greater in susceptibles
than in immunes, is so only as a rule.24 Similarly
leptothria: in nominata, which “invariably occurs in
every mouth, though by no means always in the same
numbers ”23a lends no support to the view that the
constantly present bacteria necessarily induce caries.
Dr. G. V. Black comes to a similar conclusion : he
says “As I have cultivated micro-organisms a great
deal, and especially In relation to this matter, I wish
to say distinctly that the same micro-organisms are
found growing in the mouths of persons who are
immune to decay, as are found in the mouths of persons
who are susceptible to decay, and those whose teeth are
decaying rapidly, and the same micro-organisms will
grow in the saliva of either one when used as a cultiva-
ting medium.”4 We see from this that to call the
micro-organisms of the mouth the cause of caries would
throw little or no light on the means of preventing the
disease, and we are driven to accept the definition of
the cause of caries already given.
NORMAT, SELF-CLEANSING PROCESSES
The normal or natural self-cleansing processes are
generally recognized to exist, but they are seldom
studied or described, and yet it is by recognizing the
nature of those self-cleansing processes that we are
enabled to indicate scientifically what natural or arti-
ficial means may best be relied upon for the prevention
of caries. The consideration of these processes with
regard to artificial methods of cleansing will be referred
to hereafter ; in the meantime it will be well to recall
certain points in natural oral hygiene (more especially
with reference to the nature of the foods consumed)
32 NORMAL SELF-CLEANSING
for, however simple it may be to arrange dietaries
in such a way as to secure physiological cleanliness of
the mouth, it is highly desirable to recognize the main
features of the normal and natural processes by which
physiological cleanliness is maintained, however com-
plex these processes may be. For convenience in des-
cription we may consider the processes under different
headings, although they are more or less intimately
associated and dependent upon each other.
Firstly, we have the mechanical process. This
depends, to a great extent, on the physical consistency
of the food. When the food is of a firm and somewhat
fibrillar consistency, it stimulates the pleasurable
activity of efficient mastication. The teeth and gums
are rubbed and scoured, particles of food are dislodged
from the teeth, expressed from the bolus of food,
entangled in the mucus saliva and sucked or pressed
back towards the pharynx, and swallowed. In other
words, food of such a consistency has a detergent effect.
Highly refined or “short ’’ and soft food has, on the
contrary, a different effect when taken into the mouth;
it is simply crushed or squashed into the crevices of the
teeth, and if it is at all of a sticky nature it remains
impacted there. Bread and jam and cake may be
taken as examples of such foods which tend to lodge
about the teeth.
Secondly, we have the chemico-physiological process.
Food, when taken into the mouth, stimulates a flow
of Saliva, and carbohydrate food, especially if slightly
acid45° and firm in consistency, stimulates the secretion
of Saliva rich in ptyalin. The mastication helps to
incorporate the ptyalin in the food, and the solid starch
becomes partly converted into soluble sugar, which is
ultimately expressed from the more fibrous part of
the food and swallowed in a liquid or nearly liquid
form. The more fibrous part is subjected to further
mastication and lubrication with mucus before swallow-
ing. This is, of course, the natural method of treating
carbohydrate food, and, in passing, it may be said the
NORMAL SELF-CLEANSING 33
physiological method of leaving the mouth free from
carbohydrates at the end of a meal. It should be
remembered, however, that much sugar hampers the
action of the ptyalin.
Thirdly, we have the hydrodynamical process.
With each act of mastication the saliva is mixed with
the food, forced in certain directions between and
about the teeth, between the food shreds, and ulti-
mately it, together with dissolved and suspended
particles, is swallowed. We may note here, again, that
if the food is soft, and pappy, this hydrodynamical
process is practically lost, as such foods do not stimulate
efficient mastication.
Lastly, we have a Saprophytic or bacterial process.
In the whole history of man or animal, the mouth has
never been free from micro-organisms, and the bacterial
flora of the mouth seems to play a part in its hygiene.
There is no pepsin or other ferment in the mouth which
can digest or liquefy the various albuminous shreds and
particles which are apt to lodge between the teeth.
But there are many of the mouth bacteria which have
this power. In fact, these bacteria digest and liquefy
the albuminous shreds which lodge about the teeth,
and so allow of their dissolution. They give rise to a
continual disintegration and removal of food particles,
and tend to keep the teeth clean at those very situa-
tions which are not kept clean by the natural friction
of the food, tongue and lips. It cannot be said that
all the bacteria which may be in the mouth are bene-
ficial under all conditions, for even some of those
which have the power of liquefying albuminous matter
have also the power of producing acid when the lodging
food particles are of a starchy, viscous or sugary
nature. The strictly liquefying mouth bacteria, how-
ever, seem to be quite innocuous to the teeth, and if
the dietary is arranged physiologically, these beneficial
mouth bacteria are favoured, while on the other hand,
the harmful—the more pronouncedly acid-forming
bacteria—are, in my opinion, at least, prevented from
34 NORMAL SELF-CLEANSING
proliferating. This might be considered an obvious
deduction from the fact that the kind of bacteria, which
proliferates best is that which is appropriate to the
given medium. But it is not merely a deduction, for
Mr. K. Goadby has observed that the number of
putrefactive rather than the acid-forming bacteria.
preponderate in the mouths of Zulus and Kaffirs with
good dentitions and also in monkeys, and this seems
to result from methods of living which favour the
cleaning away of fermentable carbohydrates.
In perfect mouths no doubt bacteria for cleansing
purposes are but little if at all required, for the mucous
membrane comes up nicely over the necks of the teeth,
finishing off almost like a fine film closely applied to
the neck of the tooth, so that the gum margin and
tooth present hardly a visible crevice where food
debris could lodge. When also, together with such
arrangement of the gum margins, the teeth are per-
fectly regular and well-formed, extremely few food
shreds or particles are likely to lodge after any physio-
logically correct meal. Such perfect conditions should
exist in the great majority of children at least, for in
those children to be referred to later, who were dieted
physiologically, the conditions referred to remained
practically perfect.
While recognizing the beneficent rôle of physio-
logically correct meals, it may also be noted that
together with the foods taken at meals there are also
generally a number of adventitious bacteria taken
into the mouth, especially after eating certain kinds
of food, e.g., cheese. They may remain there for some
little time, but they do not appear to hold their own
in the mouth, what are called the mouth bacteria
being more adapted for the environment. Those
adventitious bacteria are gradually swallowed till in a
short time none are to be found in the mouth. Dr.
Miller has shown experimentally that even bacteria,
which can hold their own for a time when added to
saliva, are, when taken into the mouth, rapidly got rid
NORMAL SELF-CLEANSING 35
of from the mouth. Thus after rinsing the mouth
thoroughly with a bouillon culture of Bacillus prodi-
giosus containing over 2,000,000,000 bacilli, so as to
give them a good chance of establishing themselves,
he found an astonishingly rapid decrease of bacteria,
so that at the end of four hours the prodigiosus had
disappeared from the mouth. Thus while adventitious
bacteria find their way into the mouth they are rapidly
got rid of, while the mouth bacteria remain and pro-
liferate with such tenacity that, as Dr. Black's extended
research shows, about twelve species are practically
constantly to be found in the mouth if diligently
searched for. This number is augmented in some
mouths, for if abnormal conditions exist in any mouth,
bacteria appropriate to the abnormal environment
are not long in finding the suitable nidus for their
existence and development. The mouth is so exposed
to bacterial infection that whenever it presents a suit-
able soil for the development of any common species
of bacteria, then such bacteria will gain a foothold,
and without such suitable soil it seems impossible
for any species of bacteria to have more than a transient
existence in the mouth.
It may be mentioned here that a bacteriological
method for the prevention of caries has been sug-
gested.14 It consists in endeavouring to sow some
adventitious bacteria in the mouth which will be antag-
Onistic to or crowd out the (acid-forming) bacteria
already present. As this method is accompanied by
regulations regarding artificial cleansing and the use
of lotions antagonistic to the development of acid-
forming bacteria, and is then followed by regulations
as to diet, and as the results have not and cannot
be claimed to be better than the results which have
been obtained even from regulations in diet alone,
it would be difficult to say that the bacteriological
procedures have anything to do with the good results
which have been claimed by its author. Moreover,
the method seems only to be applicable after caries
36 NORMAL SELF-CLEANSING
has actually manifested itself, and so can hardly be
considered satisfactory. The suggested method has
much interest, however, in showing the different
attitude of bacteriologists towards the bacteria in the
mouth, from that which existed in the days when
antiseptics and artificial brushing were the sole methods
relied upon for preventing caries, and when attention
to diet and dietetics as a means of preventing decay
found no place in our text-books on dental Surgery.
CHAPTER III
DIET IN INFANCY AND CHILDHOOD IN
RELATION TO THE PREVENTION OF
DENTAL CARIES -
THE diet in infancy and childhood may be considered
at three stages. Firstly, the diet of the toothless infant.
This should be mother’s milk, and as there is unanimity
upon this point, all that is necessary to advocate further
is that investigations into the causes of deficient lacta-
tion in women should be made, for it seems certain that
the substitution of other kinds of milk and all means to
find a perfect substitute must always remain unsatis-
factory. The second stage to which it is necessary
to direct attention is one of transition, transition on
the one hand from the toothless infant to the child
with a complete set of temporary teeth, ond on the other
from the milk diet to the solid and varied diet for which
the child’s teeth and alimentary canal are so admirably
adapted. This period of transition is most important.
It will be remembered that while “ the child starts
life edentulous and gradually acquires teeth, other
parts of the alimentary tract in the healthy subject
undergo eoncordant changes.” Now for the first six
or nine months of a child’s life it has been accustomed
to extracting liquid from the mother's breast, and
through all the ages of man’s evolution nothing was
mixed with this milk. When, with increasing age and
concomitant changes, the first article of food was pre-
sented to the child it was given at a different time from
37
38 DIET IN CHILDHOOD
the sucking of the milk. It must be obvious that in
a state of Nature it was utterly impossible to soak food
in milk in order to effect the transition from mother’s
milk to the ordinary foods of children and adults.
Moreover, there is no precedent which could in any way
be interpreted as justifying the method of transition
from milk to solid food which has been so universally
adopted by the medical profession. How the transi–
tion from milk to solid food is recommended may be
exemplified by a few extracts from a recent authori-
tative textbook published “to aid the young
practitioner * of medicine. After nine months, the
author says, “Dilution of the milk is not necessary.
. . . Some solid food may be added in the shape
of boiled bread, or porridge, or pudding. These
additions must be small in quantity at first.” Then
when the child is twelve months old, he says, “The
porridge may be made thicker and of coarser oatmeal.
A little potato and gravy or half an egg may be given
once a day. Soft bread and butter or dripping may be
taken.” A transition from milk to solid food such
as is exemplified in the above, never existed in the
evolution of man or animal. For simplicity, attention
may be limited to bread soaked in milk, for it illus-
trates the pap feeding principle as well as anything
else, and it is the most generally recommended food
for infants who are beginning to be allowed something
solid in addition to milk. Now what happens when an
infant hitherto accustomed to milk is given bread well
soaked in milk : The first noticeable effect is that the
infant gulps down the milk-soaked bread and milk
without any attempt at retaining it in the mouth or
mixing it with saliva. The starchy matter in the bread,
is, therefore, washed into the stomach without any
insalivation without any conversion of the starch,
and without any preparation for digestion in the
stomach. The physiological effect which the retention
and mastication or gnawing of food in the mouth
produces is practically lost, and the flow of digestive
DIET IN CHILDHOOD 39
juices in the stomach is correspondingly lessened. The
palate is cheated, for large amounts of carbohydrates
are washed rapidly past it, and instead of appreciating
the amount of converted starch, or rather of uncon-
verted starch, which the child has consumed, it craves
for more of that very substance of which it has already
consumed too much, in other words, it develops an
abnormal craving for sugar. Further, by becoming
habituated to swallowing solid food it soon loses that
automatic mechanism which arrests solid food in the
mouth till it has become liquefied and prepared for
deglutition. - --
At a later stage, say, about the thirteenth month,
when the first temporary molars have taken their
positions, what happens when the child is restricted
to this soft diet 2 The previous troubles continue and
the teeth get dirty and tender from want of use ;
later they become carious and the tenderness
increases, while for the sme reason mastication is
not performed and so these troubles and others
resulting therefrom become more or less thoroughly
established.
But it may be asked, Why, then, has the milk-soaked
diet been brought into existence 2 Well, no doubt
it is because milk was considered the most excellent
food for children. But it was found that cow’s milk,
when it was given to children undiluted, formed large
clots in the stomach and thence consequently led
to various intestinal troubles. This did not dissuade
those in authoritative positions from still advocating
undiluted milk. No, they said, soak bread in the
milk so that the clots will be broken up. And
if there is choking and spluttering see that it is
thoroughly soft and well broken up before the child
gets it. - -
Now why should a hint not be taken from Nature ?
Mother’s milk when the child reaches nine months or
a year does not become more solid, rather the reverse.
Suppose we give cow’s milk, why should we make it
40 DIET IN CHILDHOOD
less diluted than it was before, seeing that the time is
beginning to approach when the child will and can eat
solid food and drink liquid water ? The child has been
accustomed for all the months it has existed to have
its mother's nipple in its mouth (or an artificial sub-
stitute), and from this it has been able to express or
suck liquid food. When it is determined to give the
child solid food, why not let it get a solid piece into its
mouth ? In other words, why not let it have a slice
of bread, or better perhaps, toasted bread and butter ?
No doubt the child feels that toast and butter is not
its mother's breast, and it certainly subjects the toast
to the influence of its teeth. It gnaws it and sucks
it ; the gnawing induces a flow of saliva and the
ptyalin converts the starch. The child continues to
suck much as it sucked its mother's breast, and its
palate appreciates that it is actually sucking liquid
out of the solid toast. Gradually the toast disappears,
practically in the form of liquid down the child’s
throat, thoroughly prepared for further digestion in
the stomach. Before the fourteenth month, or at
least before the first temporary molars erupt, true
mastication, of course, is not performed. It is gnawing
which is indulged in, and it certainly and instinctively
is indulged in by all children. After the child has had
its toast to supplement its milk diet, say, twice a day
for a month or two, then other things may be added,
such as rusks and milk puddings made sufficiently
Solid, and as there is not an excess of albumen in the
milk (it having been diluted), boiled fish and chicken
may be given in Small amounts.
I have had some little experience with this method
of feeding infants, and can say most unhesitatingly
that coughing, choking or spluttering has been con-
spicuous only for its total absence. And those who
have adopted similar methods with children from
the beginning have been impressed or even astonished
by this fact. But this is not all, the desire for hard
food remains. The teeth do not become tender nor
DIET IN CHILDHOOD 41
the mouth dirty nor the teeth carious. The palate is
not cheated, and the desire for excess of food or sweets
does not exist. The alimentary canal performs its
functions in a natural and healthy manner, and
by the age of 2%, when it has its full set of
temporary teeth, the child can and may be allowed
to triturate practically any food which adults
habitually eat.
With regard to the third stage, that is, the diet of
children after they have their twenty temporary teeth,
but little need be said here. The principles on which it
is based, however, are the result of careful enquiry,
experience and a study of the evolution of man and his
diet, together with a recognition of the needs of civilized
life. t *
It should consist of three meals daily, and nothin
between meals except water when desired.
It should contain a sufficiency of solid food of a
consistency which will ensure thorough cleansing of
the teeth by the food and stimulate the pleasurable
activity of efficient mastication so as to prevent the
child acquiring the habit of bolting its food.
Different ways of doing this will no doubt suggest
themselves, but perhaps the simplest way is to have
toast, baked bread, or crusty bread rolls instead of
plain bread or porridge.
Lastly, the meal should be arranged physiologically.
All that need be said at this point, however, is that the
meal must not terminate with concentrated and easily
fermentable carbohydrates which lodge or stick about
the teeth. Thus, therefore, no meal should end with
bread and marmalade or jam, nor should it end with
sweet milk puddings or foods with a large amount of
sugar. If these things are eaten they must be
followed by fresh fruit, and of all the fresh fruits
which clean the mouth and teeth the apple is the
best. -
The nature of the diet after the child has a complete
set of temporary teeth is of so much importance that,
D
42 DIET IN CHILDHOOD
in order to indicate the exact nature of the methods and
principles of dietetics involved and the various reasons
for advocating them, it may be well to mention a few
points in the history of the investigations which led,s
as far as I am concerned, to the advocacy and adoption
of the methods.
CHAPTER TV
THE NATURAL HYGIENIC METHOD OF PRE-
VENTING DENTAL CARIES AND REASONS
FOR INSISTING ON ITS ADOPTION
ABOUT twenty years ago circumstances had caused
me to become keenly interested in the problem of
heredity, and rightly or wrongly I came to be a firm
believer in the then new doctrine that acquired char-
acters were not inherited, and a fortiori that mutila-
tions were not inherited. Equally was I opposed to the
Lamarckian doctrine, that use and disuse of any organ
had an effect on the hereditary potentialities of such
organ. These being my beliefs, it was impossible for
me to subscribe to the dictum that dental caries was so
markedly hereditary that no one would even suggest
the contrary. To me the theory of the hereditary
degeneracy of the teeth was unthinkable, and from the
point of view of prevention it was absolutely useless.
But just because the hereditary view was untenable
so much the more was the true solution of the problems
of causation important, for if the etiological factors
were essentially environmental, then this it would be
in our power to alter for the better. Nor did the
various developmental theories appear to help much
in the solution of the problem, for although certain
facts, such as the elimination of phosphates from bread,
seem to offer a plausible explanation of the generalized
augmentation in the amount of caries, nevertheless
the fact did not in any way account for the prevalence
43
44 HYGIENIC METHOD
of the disease in certain families and its absence in
others, which equally consumed the same bread.
Moreover the fact that less phosphates are absorbed
from wholemeal breadić than from white bread abso-
lutely negatived this view. The theory that in districts
where the water is deficient in lime salts there was more
caries than in districts where the lime salts in water were
abundant, did not in any way account for the increased
prevalence of caries in the same district, nor for the
variable amount of caries in any one district. More-
over, it was not my experience that the amount of
caries did vary with the proportion of lime salt in the
drinking water. Still one other developmental theory
had to be considered, namely, the theory that the soft
nature of our civilized foods gave rise to a type of tooth
which was specially liable to decay. This seemed to
me quite untenable, because the crowns of the tem-
porary teeth, which are so “susceptible * to decay,
are formed partly before birth and completely before
the child has left off sucking liquid milk. It became
apparent that the then prevalent theories would not
bear analysis. We had all the facts at our disposal,
which utterly condemned such theories as we have
referred to. We had, indeed, too many facts which,
for want of a correct theory, seemed only to confuse
investigators and make the subject appear more hope-
lessly complicated. There seemed to be only two
ideas which appeared to contain a germ of truth. The
first was the once popular belief that sugar was bad
for the teeth. Now, although this idea probably
had originally no better foundation than that children
with carious teeth frequently brought on toothache
by eating sweets, yet the idea was not antagonistic
to the pathology of the disease, and what is of more
consequence, it seemed on the whole to be supported by
facts which were frequently brought before us in our
routine practice. It is true that the amount of caries
was by no means constantly related to the amount of
sugar consumed. Moreover, occasionally cases cropped
IHYGIENIC METHOD 45
up which appeared to contradict the hypothesis, and
nothing is more destructive to a theory than demon-
strable facts which cannot be made to harmonize
with it. •
It was pointed out that children living in sugar-cane
plantations and chewing sugar-cane for many hours
a day were remarkably free from caries, and this supplied
a generally accepted fact which more or less expunged
the Sugar hypothesis among the educated classes.
The second idea which appeared to contain a germ of
truth was the relation between attrition of the teeth
and freedom from caries. This was also a general
statement and was not always true in particular cases,
or even in particular races; still, in general, it was
admittedly true. We see, however, that neither of
these hypotheses seemed to be of practical value,
because in the same country and under supposed similar
dietetic regime we found a considerable percentage of
people with perfect teeth, and also a large number with
their teeth most hopelessly ravaged by caries. Indeed,
the question of the food in relation to the prevalence
of dental caries gradually came to be regarded among
dentists as an untenable theory, while the supposed
susceptibility of some and immunity of others became
an accepted fact, and the solution of this problem of
susceptibility and immunity became the all-important
and all-absorbing subject among the prominent and
thoughtful members of the dental profession. Not-
withstanding all this, however, there was a lurking
belief that although nothing had been found in the
modern foods which appeared to help us to solve this
problem of why some teeth were ravaged by caries
while others were perfectly free from the disease, yet
I had hope that a more thorough investigation into the
foods and dietetic habits of the “susceptible * and of
the “immune " might throw some light upon the
subject.45 It was necessary to have some hypothesis,
of course, to direct one’s investigation to profitable
account. Indiscriminate search, however scientifically
46 |HYGIENIC METHOD
tabulated, seemed to me to offer little hope of doing
anything but making confusion worse confounded.
In my preliminary investigations many hypotheses
were made and were successively more or less com-
pletely killed by the facts which were revealed. Still
certain things became apparent, and one was that the
diet and dietetic habits of children in the same country,
even in the same districts, differed considerably ;
another was that what might be considered natural
foods as opposed to the highly refined or artifically
prepared foods, were consumed in quite different
quantities by different people. These early investiga-
tions and a knowledge of the pathology of dental caries
led me to investigate whether the refined foods of the
present day might be more lodgable than the less refined
and less prepared foods of past ages. An investigation
into the relative lodgability of the various foodstuffs
in the crevices of the teeth was therefore undertaken.
I made about 600 observations#4 in one mouth after
meals and found that the “short,” highly refined
carbohydrate foods tended to lodge unduly in certain
crevices about the teeth, while the foods of a more
fibrillar or fibrous character did not tend to lodge
in such situations so readily. Indeed, it gradually
became apparent that the more fibrous foods had a
detergent effect, that they stimulated efficient masti-
cation and consequently might be presumed to prevent
the undue lodgment of bacteria and mixed foods
which were known to give rise to acid fermentation
and to the destruction of the teeth. The crevices
in the teeth of the mouth referred to were abnormal
and contained fillings, so that it was necessary to
verify all such observations in other mouths. It con-
sequently has been my practice for the last ten years
or so to inspect the crevices of all children’s teeth
immediately they sit down on the dental chair, and then
ask them what they had eaten last. Moreover, with
two children constantly under my observation, I have
been able to vary the foods at pleasure and observe
HYGIENIC METHOD 47
the lodgability of any particular food or the detergent
effect of any particular food. In these ways a very large
number of observations have been made which taught
me that some foods are likely to lodge about the
teeth and cause caries, while other kinds of foods tended
to clean away lodging foodstuffs and therefore to
prevent caries. This hypothesis also received general
confirmation from an investigation into the state of
the teeth of savages, for it was found that the amount
of caries varied inversely with the coarse and fibrous
‘nature of the foods. The relative freedom from caries
among those people and races whose teeth had under-
gone attrition still further corroborated the theory,
and furnished an explanation of the fact that the teeth
of children who chewed sugar-cane were relatively free
from caries, for sugar-cane is a highly fibrous foodstuff,
and detergent in its effects, while the sticky sweets
consumed by civilized children are not detergent
and therefore induce caries. On reconsidering the
subject it was evident that the refined foods of the
civilized were even more nutritious and more easily
digested than the foods of the savages, so that we had
no ground whatever for the assumption that the teeth
were deprived of nourishment or lime salts or anything
else which would injure their development. More-
over, it became evident that the chief chemical change
in the foodstuffs was a decreased consumption of the
carbohydrate known as cellulose, and the chief physical
change was also to be found in the refinement and
softening or elimination of the cellulose. We may now
refer to some of the general changes which the food of
civilized man has undergone since he emerged from the
Savage state. -
Cellulose in the natural or uncooked state is, as a rule,
of a consistency which stimulates vigorous mastica-
tion, but in civilized countries the cellulose is cooked,
softened and often altogether extracted from the food,
so that the detergent effect which this has in its natural
state is almost completely lost. Indeed, it may be
48 HYGIENIC METHOD
presumed that in the state in which it is frequently
presented it helps to clog the crevices rather than to
brush away the bacteria and fermentable food particles
which may lodge about the teeth. In fact, the absence
of cellulose in a form which should stimulate the
pleasurable activity of efficient mastication practically
nullifies the mechanical, the hydrodynamical and, to a
certain extent, the chemico-physiological self-cleansing
process of the mouth.
The next carbohydrate to which we may briefly
refer is starch. This, when cooked or boiled, becomes
of a pasty nature, and it is easily converted into
sugar, which becomes rapidly fermentable. Starch,
therefore, when taken in the food, unaccompanied
by food of a detergent nature, is eminently fitted
to lodge and undergo acid fermentation in the
mouth. -
Lastly, we may refer to Sugar. Sugar has long been
supposed to have a deleterious effect upon the teeth.
The investigations of Miller, however, tended to show
in his opinion that it was to be considered as less harm-
ful to the teeth than starch, and the fact, or at least
the supposed fact, that children who consumed large
Quantities of sugar from the sugar-cane were relatively
free from dental caries gave rise in the minds of most
dentists to the idea that the “sugar-bogey’” had been
slain. And although most would admit that neither
starch nor sugar could be beneficial, there was, of course
little use of talking about preventing children eating
both sugary and starchy foods. Miller based his
criticism largely on the fact that sugar was readily
soluble and was, therefore, “soon carried away, or so
diluted with saliva as to be rendered harmless.”
Clinical evidence, however, supports the idea that the
sugars are more harmful than the starches, no doubt
from the fact that in addition to inversion cane-sugar
undergoes a mannitic fermentation, forming a gummy
substance which not only clings about the teeth, but
also tends to catch other particles of food, and to retain
HYGIENIC METHOD 49.
them in contact with the teeth also. Secondly, sugar
hampers the action of the saliva, and lastly, the method
of eating Sugar in the form of bonbons causes a con-
tinuous supply of this fermentable material to be
available for the acid-forming bacteria lodging in the
crevices of the teeth. With regard to the relative
excellence of the teeth among the natives in
the sugar-cane plantations, this is, of course,
largely due to the fact that the fibrous cellulose of
the cane stimulates the self-cleansing factors most
thoroughly.
Whether cane or grape sugars are the most harmful
does not appear to be definitely settled ; it seems pretty
certain, however, as a clinical fact that sugar as usually
consumed, sweets, marmalade, jam, etc., is markedly
harmful to the teeth. I can imagine someone saying,
“Well, perhaps these changes in the foodstuffs referred
to may account for the increased prevalence of dental
caries in a general way, but do these changes account
for the great variation in the amount of caries which
we see in different mouths at the present day ??”
We see many children, for example, with almost every
tooth more or less carious before they are more than
five years old. On the other hand, we occasionally
see children of the same age with every tooth free from
any trace of disease, yet all have been brought up in
the same country and the changes in the foodstuffs
are common to all. -
Now it was these very groups of cases which used to
fascinate me most. It was, indeed, these extreme
cases that first made me come to the conclusion that
the dietetic habits of the children with the perfect
teeth were essentially different from the dietetic habits
of those with the bad teeth.
We may illustrate the two different types of diet
which are often more or less consistently followed, by
the following dietaries:—
Firstly, we shall refer to the kind of meal which does
not produce caries :—
50 HYGIENIC METHOD
Breakfast. Fish, bacon, toast and butter, coffee
and tea.
Luncheon. Meat or poultry, potatoes, salad, baked
bread, pudding, fresh fruit, water.
Supper. Rusks, toast, or bread rolls and butter,
chicken or fish, an apple, tea or coffee.
Secondly, we may outline the kind of meal which
induces dental caries:—
Breakfast. Porridge and milk, bread and marma-
lade. Then perhaps a supplementary breakfast a few
hours after of a glass of milk and a sweet biscuit.
Luncheon. Mashed potatoes and gravy, or minced
meat, milk and pudding. -
Supper. Bread soaked in milk, or bread and jam,
cocoa and cake, and a supplementary Supper on going
to bed of a glass of milk and a biscuit, or just “a tiny
piece of chocolate.”
On comparing these two different types of diet,
we observe that one is of a kind which stimulates
mastication and the last thing taken leaves the mouth
clean, or at least free from carbohydrates, so that even
when soft food is part of the meal the mouth will be
physiologically clean at the end of the meal. The
other type is intended to represent the kind of meal
which is calculated to lodge about the teeth and to
ruin them within a few years by making efficient
mastication and the self-cleansing of the mouth
practically impossible, and by leaving the mouth
sticking with fermentable carbohydrates and a
virulent crop of acid-forming micro-organisms which
have had their development encouraged by the
previous meal. -
Since discovering, about ten years ago, the general
type of diet which gave rise to caries, it has been my
custom to question all children carefully about their
diet, if their teeth were free or practically free from
caries, and in every case it was found that the food
habitually consumed was of the detergent type, or, if
not altogether so, at least that it was consumed in
HYGIENIC METHOD 5I
such a way as to leave the mouth physiologically
clean at the end of the meal; I cannot tell exactly
now how many children I have examined, with perfect
teeth. The number probably does not amount to
fifty, for perfect teeth are very rare in England. One
thing is certain, however, I have not yet seen one single
child where the teeth were perfectly free from caries
which was not brought up on a type of diet such as
I have indicated does not produce dental caries. On
the other hand, many mouths were seen devastated by
caries, and I have certainly seen several hundred such
mouths, but in these cases the type of diet habitually
consumed and the dietetic habits engendered have
invariably been such as result from the caries-producing
type of diet which I have illustrated.
This is a brief outline of the somewhat prolonged
investigation which has, in my opinion, resulted in a
solution of the problem of the prevalence of dental
caries, and for the assertion that susceptibility and
immunity are almost invariably assumed, through lack
of knowledge of the cause as distinguished from the
pathology of the disease. I have tried to indicate some
of the evidence upon which the theory was based and
the evidence also which corroborated the theory. It
now only remains to bring forward even more startling
evidence, and to make it more obvious to those who
did not or would not take the trouble to follow the
facts and arguments which demonstrated the truth of
the theory. It appeared to me that the most satis-
factory way of doing this would be to get people with
infant children to put the theory into practice. Four-
teen children have been subjected to this test, and at
ages ranging from 5 to 7 years their teeth were examined
with the result that not one tooth of any of these children
showed the slightest trace of caries. This may not seem
a large number, but when we remember that in England
a similar number of children of the same class would
certainly have had eighty to ninety carious teeth
among them at the same age, we see that according
52 HYGIENIC METHOD
even to this alone there is overwhelming probability
or practical proof that the theory is correct. Over
and above this we must remember that this applica-
tion of the principles of prevention is but a small part
of the evidence which has enabled us to prove the truth
of the theory.
W
CHAPTER V
ARTIFICIAL METHODS OF PREVENTING
DENTAL CARIES
THERE are several different procedures which in practice
are usually combined in cleaning the teeth artificially.
It will be convenient, however, to consider these under
different headings, while bearing in mind that certain
combinations are frequently to be preferred to any one
artificial procedure.
MOUTHWASHES
The simplest and most inoffensive artificial procedure
is the rinsing of the mouth after meals with water.
It is well when explaining the value of this, to tell
patients to observe the water which is ejected from
the mouth after rinsing it about the teeth, for by the
disappearance of the milkiness of the ejected water
they will be able to see and appreciate how much has
been washed away by this process. Several mouth-
fuls of water may thus be used until the ejected water
comes from the mouth practically free from milkiness.
The efficacy of such a mouthwash depends on its
simple mechanical or rather hydrodynamical effect
on the more or less loose remains of foodstuffs and
bacteria. The usefulness of the mouthwash may be
enhanced somewhat by the addition of aromatic
flavourings which not only may be made to leave the
mouth with a pleasant and cleanly feeling, but also
will stimulate the salivary secretion and thus prolong
53
54 ARTIFICIAL METHODS
the action of the washing-out process with the natural
mouthwash. A slight acidity in the mouthwash
is also beneficial in stimulating the flow of saliva, and
though it may be very transient and slight, the effect
of the acid on the mouth bacteria should tend to inhibit
the growth of the micro-organisms, more especially
the acid-forming micro-organisms.
ANTISEPTICS
The mouthwashes may also be made antiseptic.
Much good was at one time expected to be derived from
their habitual use, but this arose no doubt to a certain
extent from mistaking the pathology for the etiology
of the disease. At all events, the prevention of the
undue lodgment of carbohydrates was not the aim
or object of antiseptics. The fact that the micro-
organisms of the mouth secluded and incorporated
with debris, etc., are able to resist the transient presence
of antiseptics in such strengths as would not injure
the mucus membrane was overlooked to a great extent,
and it has been shown that in order to get any appre-
ciable bactericidal action it is necessary to keep the
antiseptic mouthwashes—which have so far been
devised—in the mouth for a very inconveniently long
time. Furthermore, antiseptics do not dissolve the
bacteria or viscid food remains which more or less
constantly cover the bacteria at those parts of the
teeth which are not kept clean by the friction of the
food. Even those antiseptics which give off nascent
Oxygen and are supposed to penetrate, do not appear
to have any appreciable effect. Thus if some of the
materia alba is observed before such antiseptic wash
is used, and then immediately afterwards, no appre-
ciable difference is observable even though much bub-
bling of nascent oxygen has taken place. Lastly, no
antiseptic has yet been brought forward which will
help rather than retard the liquefaction and consequent
removal of albuminous substances which may have
ARTIFICIAL METHODS 55
collected in abnormally great and therefore harmful
amounts. Nevertheless, antiseptic mouthwashes have
their uses, but these are for the sake of Surgical clean-
liness before a surgical operation or for the treatment
of some diseases of the mouth rather than for daily
use in the prevention of caries—and their use must be
preceded by thorough and careful cleansing by eacpert
hands if anything approaching asepsis is to be hoped
for. But that such thorough cleansing and sterilizing
the mouth is desirable—indeed imperative—before
operations on the tonsils, larynx, etc.,21 and no doubt
more especially operations on the Oesophagus and
stomach, seems to have been proved beyond the
possibility of a doubt. Under such circumstances it is
certainly preferable to risk a slight superficial distur-
bance of the mucous membrane of the mouth than
septic infection of a wound.
In a general way it may be said that the mucus
membrane (or skin) is the first line of defence against
pathogenic micro-organisms when this is intact and
healthy, and in ordinary daily life it is most essential
that the mucous membrane of the mouth should be in a
perfectly healthy state, and nothing should be used in a
routine way which may injure its vitality. Unless
it is known to be unhealthy or not intact, it is doubtful
whether the risk of injuring the mucous membrane
by the daily, use of antiseptics can be advantageously
recommended. In this connection the Lancet,
after reviewing some investigations on this subject,
concluded by saying, “It is obvious that further
investigations must be undertaken before the daily use
of an antiseptic mouthwash by healthy persons can be
recommended.”26 And a like conclusion was indicated
in the British Medical Journal.27
THE TOOTHERUSH
The use of the toothbrush is, or has been, relied
upon more generally than any other procedure.
ty
• * * *
56 ARTIFICIAL METHODS
Unfortunately it is not so satisfactory as used often to
be supposed, for even when carefully and skilfully used
it is difficult to get it to brush the teeth on their
approximal surfaces. Nor is its use free from the
likelihood of abuse. The delicate gingival margins are
often injured, more especially over the front teeth,
especially those which are prominent and situated on
the left side of the mouth, when the brush is frequently
too vigorously used by right-handed persons. When
but gentle pressure is used so as to avoid injury to the
gum margins the bristles of the brush do but little good
in removing any adherent matter from the crevices of
or between the teeth if it is at all of a sticky nature ;
so that after the toothbrush has been used one may
easily scrape away soft adherent matter even from
between the front teeth, and if a phantom set of teeth
or a stearined model is covered with a somewhat
sticky and coloured material and then brushed as well
as the intelligent layman may be presumed to do it,
it will be seen that the crevices, say, of the molars, are
but imperfectly cleaned and the interdental spaces are
not cleaned at all. The illustrations on frontispiece
of a stearined model treated in this way indicate how
ineffectual the toothbrush always is in cleaning away
adherent matter except at those parts of the tooth
which are not liable to have food adherent to them,
and where consequently the teeth are not liable to
decay.
Some of the mouth bacteria are very adhesive and
require distinctly vigorous brushing to dislodge them
from crevices or partly secluded spots and the tooth-
brush can hardly compare with detergent foods for
their removal. When we remember that during
mastication the jaws exert a pressure of from 60 to 90
pounds3 on meat and fibrous foods of a detergent kind
generally, we realize the certainty with which the
crevices of the teeth on the masticating surface will be
cleaned of adherent micro-organisms. Especially is
this so, when we take into consideration the fact that
• * * * *
ARTIFICIAL METHODS 57
the pressure and grinding motion is repeated hundreds,
perhaps sometimes thousands, of times during the tak-
ing of a substantial meal. Of course, if soft foods are
eaten the micro-organisms cannot be removed from
the crevices, and the carbohydrates which are taken
during the meal may, to a certain extent, be gently
pressed into the crevices and thus simply stimulate
the growth of the bacteria and the acid that they
produce. It is when matted masses or plaques of
bacteria are thus furnished with carbohydrate food and
protected from the beneficient effects of the saliva,
that caries is certainly produced. Even though at the
end of the meal the superficial part of such carbohy-
drates were brushed away to a considerable extent,
sufficient might be left to supply the bacterial
plaque with pabulum enough to produce caries
more or less rapidly. This is important and may
be represented somewhat diagrammatically by the
accompanying drawing of a section through a molar
tooth.
In the one case
(Fig. A) the crevices
are supposed to have
been freed from
micro-organisms by
efficient mastication :
of detergent food A - {
, ºf ºººo # *{p & ºva. , during the meal, but
*T*ssº. 2- a little carbohydrate
\ is represented as
s” ..., |having been left.
: (3 & K-Wºº &V ºn ! When this begins to
t # ferment it will begin
$3 / superficially, as the
bacteria of the mouth will necessarily come in
contact with the outer part of the carbohydrate first.
Further, the number of micro-organisms derived from
the saliva after a meal is relatively small, and as they
eat down into the carbohydrate, so at the same time
E
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58 ARTIFICIAL METHODS
is the carbohydrate washed away more or less by the
saliva. . - -
In the other case (Fig. B) the bacterial plaque
not having been brushed away by food requiring
efficient mastication, the carbohydrate which remains
in the mouth lies as a covering over the plaque and the
micro-organisms immediately give rise to acid fer-
mentation and decalcification of the tooth. The micro-
organisms are actually present in Situ in masses and
protected from the neutralizing of the acid formed by
the overlying carbohydrate.
It is hardly sufficiently realized how difficult it is
to clean crevices with a toothbrush except, perhaps,
by those who have tried to clean an ordinary hair
comb, or to polish crevices in metals with a brush.
In this latter case when the crevices are anything like
as deep as they usually are in molar teeth it appears to
be quite a hopeless procedure. Nevertheless the teeth
can be cleaned to a certain extent with a toothbrush—
provided that unhygienic meals have left them dirty—
and if it is attempted to clean only the masticating
surfaces of the molars and premolars, good without
harm will assuredly result ; but if any serious attempt
is made to clean the interdental spaces with a tooth-
brush of any kind yet devised, a serious risk is run of
injuring the gingival margins with the bristles of the
brush.
From the point of view of the dental toilet rather
than from that of the prevention of caries the tooth-
brush has its uses. It should, however, be gently and
carefully used, and if such gentle use does not keep
the teeth clean to all appearances, then it is imperative
to have the teeth cleaned periodically by skilled hands
furnished with all the necessary instruments and
accessories required. *
Before recession of the gums has taken place the
crevices between the teeth and the interdental spaces
are normally easily kept physiologically clean when
appropriate food is masticated, and there should be no
ARTIFICIAL METHODS 59
real necessity for artificial cleaning. Later in life,
however, if the gums have receded, and more especially
if in addition to this irregularities and abnormal spaces
exist, it is necessary to aid the normal self-cleansing
processes artificially. For this purpose, in addition to
the toothbrush, mouthwashes may be freely used and,
if necessary, the toothpick also. A quill toothpick is
the most satisfactory and care should be exercised so
that the gums may not be injured.
TOOTHPOWDERS
Toothpowders may be used, not for the prevention
of caries, but to remove discoloration from the teeth.
Unfortunately their use is frequently the cause of
erosion more especially over the neck of some of the
more prominent teeth. The serious results, more
especially of the gritty toothpowders, have been fully
exposed by the late Dr. Miller; and it would seem that
great care should be used in the selecting of a tooth-
powder for daily use. Nothing of a more gritty nature
than precipitated chalk should be used. Generally,
however, toothpowder seems to be quite unnecessary
even to keep the teeth looking quite white and clean,
except among Smokers. *
In some mouths, too, a dark stain—which can be
removed with a steel instrument—is formed either in
spite of the use of a toothpowder or possibly sometimes
on account of it. If careful observation is made it
will be seen that the toothbrush with toothpowder
brushes the most prominent part of the tooth so
thoroughly that the enamel is kept polished and even
worn away; the next part of the tooth not so exposed
to the brush and toothpowder appears to have the
mucous coating brushed away so that this dark tartar
has nothing to prevent its deposition, and being very
adherent to the tooth it is not brushed away. The
third Zone, i.e., between the teeth and close to the gum
60 ARTIFICIAL METHODS
margin, where the mucous is only brushed partly away
the enamel remains clean under this. The dark stain
frequently leads to the further use and abuse of
toothpowders. However, as has been observed, tooth-
powders do not prevent caries; and as their use is
rather a matter of appearance than for the prevention
of caries they need not be referred to further here.
In conclusion, it may be said with reference to the
artificial precedures in general that they are not all
innocent and innocuous. Rinsing the mouth after
meals, however, does good if adherent carbohydrates
have been left in the mouth, and this procedure cannot
be harmful, although equally satisfactory results may
be derived from drinking water or certain other more
refreshing fluids (preferably slightly acid and not too
sweet) after a meal,89 while brushing the teeth with a
medium or even hard brush used gently is generally
useful from the point of view of appearance at least.
Brushing the teeth after every meal and on going to
bed can scarcely be recommended as a routine pro-
cedure ; it diverts people's attention so thoroughly
from the knowledge that their teeth ought to be
cleaned by the normal physiological processes, and
from the fact that when the meals are properly
arranged, they do actually clear the bacteria out of
their mouths and leave no carbohydrates behind
which would injure the teeth or give rise to the undue
proliferation of micro-organisms. Of course, if or
when unhygienic meals are or must be taken, especially
at night, then the resulting unhygienic conditions
should be mitigated by carefully cleaning the mouth
with toothbrush and mouthwash. It is, as a rule,
quite inconvenient for most people to brush their
teeth regularly except in the morning before breakfast.
And to encourage people to bestow a little more care
over their teeth when they do brush them once a day.
is much more useful than a perfunctory, hurried and
perhaps too vigorous brush round. It takes at least
twenty-four hours for the mucus-or what it becomes
.*
ARTIFICIAL METHODS 6I
to accumulate round the teeth—when reasonable
habits of mastication are indulged in-to anything
approaching the amount which could conceivably
be anything but beneficial to the gums and teeth, and
though the stomach, no doubt, can deal with them it
is rather desirable that the bacteria should be brushed
out of the mouth (to a certain extent at least) before
the breakfast. If they are not they will be taken into
the stomach to a great extent during the meal to be
disposed of there. When not immoderate in number
or exceptional in kind the digested bacteria may
possibly be turned to use in producing immunity to
ubiquitous pathogenic micro-organisms;40 but such
immunity does not extend to caries, because ſcaries
is a fermentative process external to and uninfluenced
by any vital reaction of the tissue it invades, at least
in the early stage, and because, moreover, there is no
such thing as true immunity to the disease. For-
tunately there is not now much fear that artificial
methods will take precedence over the more natural
methods, for it has been pointed out that “there has
been a remarkable consensus of opinion as to the
Superiority of early mastication, the use of hard and
resisting food, and the general exercise of the jaw
muscles . . . as compared with soft feeding and
artificial cleansing.”11—and the above statement Is
more indisputable to-day than it was when written
Some six years ago. It is most important that no
artificial procedure should be advocated which will
appear to countenance unphysiological procedures.
It is not only dental caries that has to be considered,
and even though we could devise a system of artificial
cleansing of the teeth which could be relied upon to
prevent caries it would do infinite harm should it
induce people to continue using the unphysiological
diet, which is the cause of so many diseases besides
caries at the present day. As things stand, however,
fortunately the only thoroughly reliable method of pre-
venting dental caries is the natural or physiological
62 ARTIFICIAL METHODS
one. And on the other hand, what statistics we have
seem to show but little reliance can be put on artificial
procedures. Thus in the better-class schools where
the toothbrush is at least sometimes used, there is no
evidence that the teeth are better than in schools
where the toothbrush is not useds—indeed, it is noted
that “the better the school the worse the teeth.”29
Men and boys, who use artificial methods less than
women and girls, seem also to have less caries. Indeed,
while having no doubt that artificial methods properly
practised do some good in preventing the disease, we
must admit that there is as yet no satisfactory statis-
tical evidence to show that the artificial procedures—
as commonly executed—prevent dental caries.
It would appear that we should regard and advocate
the brushing of the teeth rather in the light of a cos-
metic than as of any particular value in preventing
caries. This view has been expressed in a leading
article in the British Journal of Dental Science, which
says:—
“We have all observed mouths free from caries
where no efforts at ‘oral hygiene' have ever been made,
and we are all familiar with mouths requiring constant
dental attention, the owners of which are zealous
in the use of the toothbrush and dentifrices. In fact,
with respect to the toothbrush, we are of opinion
that its use is more of a cosmetic than of a prophylactic
nature, though we by no means condemn its use as a
means to prevent caries.”19
The only artificial procedures which have a marked
and undoubtedly beneficial effect are the various
dental operations commonly resorted to, which restore
the teeth to functional activity, or remove the diseased
conditions which prevent functional activity and
consequently the normal self-cleansing processes.
CHAPTER VI
ON THE MEANS OF DISSEMINATING
KNOWLEDGE NECESSARY FOR THE
PREVENTION OF DENTAL CARIES
FROM what has already been said it is obvious that
the cleansing power of true or effectual mastication
is better almost beyond comparison than artificial
cleaning. Efficient mastication not only keeps the
teeth clean and free from injurious plaques of bacteria,
but the gums are kept clean, healthy, firm and so finely
applied to the necks of the teeth as almost to defy the
lodgment of all appropriate kinds of foods. The
peridental membrane and alveolar processes are kept
strong and healthy, and no doubt the gingival organ
is likewise benefited. The bones of the jaws also are
stimulated in their development, and the teeth are
more perfectly implanted and regular than when mas-
tication has been insufficient, and artificial cleansing
has been solely relied upon for their welfare. More-
over, digestion and the general health are both directly
and indirectly benefited. It is, therefore, the obvious
duty of every dental practitioner to instil into his
patients the value of efficient mastication, and to get
them to understand that no amount of artificial cleansing
will make up for the continual transgression of the
dictates of physiology, and that this is doubly important
with regard to growing children whose habits have yet
to be formed. It is hardly necessary to say that the
attempt to teach the art of vigorous mastication is
63
64 DISSEMINATING KNOWLEDGE
perfectly futile unless the food is of such a consistency
as will stimulate or require it. From Dr. Black’s
Phago-dynamometric records we observe that the
vigour of mastication is and must be proportional to
the consistency of the food consumed, if the food is
masticated at all. Here, however, we are met with a
difficulty, for if medical practitioners advocate soft
food for children, as in actual practice they very
generally do, and the dentist advocates its discon-
tinuance, then the diffusion of the required knowledge
is greatly impeded. As the general medical practi.
tioner comes in contact with children at a much earlier
age than the dentist does, great havoc may be wrought
in children’s mouths and teeth before the advice of a
dentist may even be thought of. It is, therefore,
obvious that medical men must learn or be taught how
the mouth may be most effectually kept clean. There
are few indeed, who realize that the mouth is, or at
least ought to be, much cleaner after a meal which
really requires mastication than at any other time.
The detergent effects of the foodstuffs have admittedly
been overlooked. It is not so very long since the idea
that a meal invariably left the mouth dirty was
generally believed even by dentists, so that we can
hardly expect the public to be converted at once to the
idea that the meals themselves should be cleansing
to the mouth and teeth. It is not too much to say that,
notwithstanding its immense importance from the
point of view of general health, the natural hygiene
of the mouth has in the past to all intents and purposes
been entirely overlooked. It is true that artificial
cleansing of the mouth has been insisted on, but that
some foods leave the mouth physiologically clean,
while others leave it dirty, seems never in any text-
book of dietetics to have been so much as mentioned.
Foods which lodge about the teeth and do not clean
the mouth, have been recommended without the
slightest concern as to whether they kept the mouth,
and indirectly the alimentary canal, free from chronic
DISSEMINATING KNOWLEDGE 65
fermentation, so long as they were known to be easily
digestible and to supply the requisite amount of
proteid, carbohydrate, etc. In fact, the viewing of
food from its nutritional and not its hygienic value is
still a matter for serious regret among those who under-
stand the value of oral and indirectly alimentary
hygiene. Thus in reviewing an important medical
book18 recently published, the British Dental Journal
said, “We are at the outset pained to find that wherever
a dietary is given in detail in this work, as being
specially adapted for school children, no thought
apparently has been given to the fact that human
teeth are primarily intended for mastication, and
that upon the functional activity of the teeth depends
the proper development of the jaws; again, we would
point out that a diet should be so arranged as to pro-
vide a natural toothbrush, and not be composed of
those very ingredients which on fermentation lead to
the production of lactic acid and consequent decalci-
fication of the dental enamel.”33 It is obvious that
the first thing required for the diffusion of the requisite
knowledge is to have it clearly taught in text-books
for dentists and medical practitioners. We may
say that as far as dental text-books are concerned this
has just recently been done,9 and is further about to be
done in a forthcoming text-book,2 and from what we can
gather, what is being done in England to-day will,
in the course of time, be done in other countries.
With regard to medical text-books, unfortunately, the
importance of the subject has not yet been fully
realized by all the writers. Some, however, have
recognized the more modern teaching of dentists,
and further have advocated an abandonment of the
current practice of pap feeding for children,6 not only
On account of the teeth, but because of harmfulness
with regard to the alimentary canal56 and body
generally.98 Notwithstanding this, however, it would
seem desirable that more attention should be paid
to the hygiene of the mouth by medical practitioners,
66 DISSEMINATING KNOWLEDGE
and only good would result from requiring from
medical students an elementary knowledge of the
principles of oral hygiene. Moreover, fuller recognition
of dentistry as a branch of medicine at the universities
where medical degrees are granted should be demanded.
All this is important because the subject of oral hygiene
is necessarily associated with questions of dietetics,
and consequently in this matter it is to the medical
profession that the public look largely for guidance.
As regards the dental branch of the profession, it has
been and is doing excellent work so far as that is possible
under existing circumstances. The British Dental
Association and the School Dentists Society, have
made statistical investigations which have done much
to awaken both the medical profession and the public
to the great importance of the subject. Here it is
hardly necessary to say that the treatment of school
children’s teeth should always be accompanied by
instructions as to the prevention of the disease which
will be effectual. Otherwise the chronic irritation
of increasing rates, and the almost certain recurrence
of the disease within a few years will most assuredly
give rise to the suggestion that such treatment is not
initiated by the highest motives. This would be
a great misfortune, because the treatment of school
children’s teeth is itself of importance in preventing
further caries. It makes the children able to eat food
suitable for the hygiene of the mouth and alimentary
canal, together with all its concomitant and conse-
quent advantages. From what we have just said it
may be observed that the best means of educating
the public is through what may be called the recognized
channels; that is to say, those with special knowledge
must expound the subject in such a way that the
leaders of medical thought and writers of text-books
shall become acquainted with the truths, and when
this is done there is but little fear but that the truths
will gradually become generally known. The public
have always looked to the medical profession for
DISSEMINATING KNOWLEDGE 67
guidance, and there is no higher authority to whom
they are able to appeal, and therefore no efforts should
be relaxed, either in regard to perfecting the knowledge
of the medical practitioner in this special branch of
learning, or in bringing before his notice the reasons
for considering the hygiene of the mouth as the most
important part of preventive medicine.
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IO.
BIBLIOGRAPHY”
Badcock, J. H.-The Need for the Correction of the Malpositions
of the Teeth. British Medical Journal, Sep. 17th, 1910, p. 772.
Bennett, N.G.-A System of Dental Surgery. Section, Etiol-
ogy of Dental caries, by J. Sim Wallace.
Black, G. V.t—Operative Dentistry. Vol. I., p. 165.
Black, G. V.-Report of the Committee on Scientific Research.
Dental Cosmos, Igo3, p. I424.
Black, G. V.-The Physical Characters of the Teeth. Dental
Cosmos, I895, p. 367, etc. - -
Black, G. V.-Susceptibility and Immunity to Dental Caries.
Sept., 1899, p. 829. -
Bogue, E. A.—Infant Diet a Factor in Dental Irregularities
and Decay. Journal of the Allied Sciences. March, IoIO.
Campbell, H.—Observations on Mastication. Lancet, July
IIth, 18th, 25th, and Aug. 8th, Igo3.
Colyer, J. F.—Dental Surgery and Pathology. Section (I)
Etiology of Caries, pp. 606–612, and (2) Prophylaxis, p. 617;
(3) Chronic General Periodontitis, p. 624. -
Colyer, J. F.—Proc. Royal Soc. Med., Odonto. Section, Nov.
23rd, 1908, p. 9 (Adenoids and the feeding of infants in
relation to the growth of the jaws).
Colyer, J. F.—Recent Views of Heredity. Dental Record,
Jan., I908, p. I. -
II.
I2.
I 3.
I4.
Dental Annual, Igo.4, p. 55.
De Schweinitz and Randall.—Diseases of the Eye, Ear, Nose
and Throat, Vol. II., p. 947 and p. 939.
Editorial. British Journal of Dental Science. Nov. Ist., 1905.
Goadby, K. W.-The Buccal Secretions and Dental Caries.
British Medical Journal, Sept. 17th, 1910, p. 770.
* Quotations from the essayist's own writings are not notified.
t The investigations of the late Dr. W. D. Miller with regard to
the micro-organisms of the mouth and correlated subjects, together
with Dr. G. V. Black's bacteriological, gnathodynamometric and
chemical and physical investigations, are of quite exceptional
importance in having provided data for the elucidation of the
causation and prevention of dental caries.
68
BIBLIOGBAPHY , 69
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Goadby, K. W.—Mycology of the Mouth, p. 90.
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Head J.-Miller's Obervations on the Wasting of Tooth Tissue.
Dental Cosmos, IQO7, p. 807.
Kelynack, T. N.—Medical Inspection of Schools and Scholars.
Leading Article, British Journal of Dental Science, Nov. Ist,
I905 - -
Leading Article, Lancet, Oct. 2 Ist, I go 5.
Mackenzie, Dan.—The Relations of Dentistry and Otolaryn-
gology. Dental Record, Dec., Igo7.
Miller, W. D.—Study of Immunity to the Diseases of the
Mouth and Teeth, Dental Cosmos, Feb., Igo3, p. 85.
Miller, W. D.—Micro-organisms of the Human Mouth. P. 44.
23a, p. 72. 23b, p. 208. **
Miller, W. D.—Study of Certain Questions Relating to the
Pathology of the Teeth. Dental Cosmos, Dec., 1904, p. 983.
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Pathology of the Teeth. Dental Cosmos, Jan., 1905, pp. 18
and 23. -
Mouth Disinfection. Lancet, Nov. 20th, 1909, p. 1512.
Mouth Washes. British Medical Journal, Oct. 30th, 1909,
p. I 3OO. -
Mummery, Stanley P.-Heredity and Dental Diseases. Pro-
ceedings of the Royal Society of Medicine. Odontological
Section, 1908, p. Io9. -
Oliver, Sir Thomas.-Address to the Section of Industrial
and School Hygiene. Journal of the Royal Institute of
Public Health, 1910, p. 645.
Peters, E. A.—Kelynack's Tuberculosis in Infancy and Child-
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Paulow and Thompson.—The Work of the Digestive Glands.
pp. I 5 T-I52.
Pedley, R. D.—The Hygiene of the Mouth. p. 18.
Review of Books. British Dental Journal, Sept. Ist, 191o,
p. 863.
Schutzenberger.—Fermentation, p. 292.
Spokes, Sydney.—Notes on Hypoplasia of the Enamel.
Journal of the British Dental Association, 1897, p. 31.
37.
38.
Sutherland, G. A.—Treatment of Children's Diseases p. IIo;
36a, p. I3.
Tomes, J. & C. S.—A System of Dental Surgery, p. 16.
Variot, G. et Lassabliere, P.-Troubles nutritifs produits par
la panade dans les jeunes organismes. Comptes Rendus,
Soc. Biologie, Io juillet, 1908.
70 BIBLIOGRAPHY
39. Wallace, J. Sim.—The Addendum Prandii and Professional
- Education. British Dental Journal, Oct. Ist. 1909.
40. Wallace, J. Sim.—Oral Bacteria and Acquired Immunity.
Medical Press and Circular, 1910, p. 424.
41. Wallace, J. Sim —Open Windows and Adenoids. Medical
| Press and Circular, 1908, p. 373.
424 Wallace, J. Sim.—Experiments and Observations on Bread.
Proceedings of the Royal Society of Medicine, June, 1911.
43. Wallace, J. Sim.—The Irregularities of the Teeth. 43a, p. 79.
44. Wallace, J. Sim.—The Cause and Prevention of Decay in
Teeth, p. 7.
45. Wallace, J. Sim.—Supplementary Essays on Dental Caries,
Caps. II., III., IV. C. p. 77.
46. Wallace, J. Sim.—The Rôle of Modern Dietetics in the Causa-
tion of Disease.
47. Wallace, J. Sim.—Transactions of the British Society for the
Study of Orthodontics, Vol. I.
APPENDIX
*E===ºssºmºsºmº
Foodstuffs and Dental Caries
NOT CLEANSING AND
IIABLE TO INDUCE
I) ENTAL CARIES.
Farina c e o us and
sugary food in general
without fibrous element.
Examples: Sweet bis-
cuits and cake ; bread
and marmalade ; bread
and jam ; new bread
without crust ; bread
soaked in milk; milk
puddings; porridge and
milk ; preserved fruit ;
chocolate and sweets of
all kinds; honey.
Liquids : Cocoa and
chocolate.
The above foods
Should not be eaten
eaccept when followed by
foods of the cleansing
kind.
CLEANSING AND PRE-
VENTIVE OF DENTAL
CARIES.
Fibrous foods generally.
Examples: Fish, meat,
bacon, poultry. Uncook-
ed vegetables, lettuce,
cress, radish, celery.
Cooked vegetables are
as a rule cleansing, but
in a less degree than
uncooked vegetables.
Stale bread with crust;
toasted bread of all
kinds; twice baked bread;
pulled bread and cheese.
Savouries. Fresh fruits,
especially those requiring
mastication, e.g., apples.
Fatty foods, e.g., butter
and margerine. Liquids:
Tea, coffee, water, also
soups and beef tea.
71
Works by J. Sim
“The Cause and Prevention of Decay in Teeth.”
2nd Edition. I902. Price 5s.
“We believe the conclusions are fair, and the day is not far distant
when the dental world will come to believe them as he believes
them.”—Dental Headlight, U.S.A.
“Mr. Wallace ably champions his own views, and the work has
many points to stimulate thought.”—Dental Record.
“If not absolutely convincing, is none the less of great importance
in Calling attention to the dental dangers arising from our civilized
methods of preparing food.”—Journal of the British Dental Associa-
tion.
Wallace, D.Sc., M.D., L.D.S.
SUPPLEMENTARY ESSAYS ON
“The Cause and Prevention of Dental Caries.”
Igoé. Price 2s. 6d.
“The main contentions which have been made now for some years
by the writer have been corroborated by laboratory tests. The
question of food selection is treated with a broad outlook, and is one
of the most interesting problems considered.”—Medical Record.
“Dr. Wallace argues his point well and his conclusions, though
evidently not those of the dental world in general, seem thoroughly
plausible.”—Practitioner.
“The Rôle of Modern Dietetics in the Causation of Disease.”
I905. Price 3s. 6d. nett.
“We agree that there should be a return to a more natural plan
in the feeding of children.”—British Medical Journal.
“There has been a dearth of new publications during the year
and of those issued perhaps the most suggestive and valuable has
been Dr. J. Sim Wallace’s book on ‘Modern Dietetics in the Causa-
tion of Disease.’”—Lancet (Annus Medicus).
“Most suggestive and eminently practical.”—Medical Press.
“An uncompromising attack upon our choice of food, especially
that for children. . . . . The author's views are well worthy of
careful consideration.”—Edinburgh Medical Journal.
“The Årregularities of the Teeth.”
I904 Price 5s. nett.
“He also takes occasion to emphasize his well-known theory on
the prevention of irregularity. Dr. Wallace writes very convinc-
ingly on this topic and his conclusions are well worth studying.”—
The Dental Review.
“Adenoids, irregularities and caries of the teeth and ‘indigestion,”
are so common that we are apt to accept them as a matter of course ;
but when one realizes the amount of suffering and of financial loss
that they entail on the community, one recognizes the urgent
necessity of finding a means of prevention, and it is because we
believe that Dr. Wallace has pointed out the means of very largely,
if not entirely, preventing these evils, that we heartily commend
the book to the attention of the profession.”—Scottish Medical
Jow?'nal.
JUN 20 1921


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