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[S]INCE I READ THE PAPER OF Mr. J. Smith Turner on the Condition of the Teeth of School Children, communicated to the Hygienic Congress in London, I have realised the importance of the inquiry which he described and have sought further information bearing on it. . . . [I]t is surely startling to find that amongst 5249 children under twelve years of age, there were only 485 with normal perfect dentures—that is to say, made up of sound teeth requiring neither filling nor extraction, that only 26 percent of infants at five years of age have teeth free from caries and that every 1000 children at twelve years of age have amongst them 2543 teeth affected by caries. . . . The fact that 10 000 000 of artificial teeth are used in this country annually, although, of course, only a small proportion of the population can procure these articles of luxury, brings home to us the truth that dental mortality is heavy in these days and that the gaps in dental circles that require fillings must be big and numerous. . . .
I wish to confine what I have to say this afternoon to caries, the most ruinous of dental maladies, not only in childhood, but at every epoch of life. . . . [I]t can be scarcely necessary that I should rehearse to you the evidence that has been adduced to prove that it is now far more prevalent in this country than it has ever hitherto been and that its ravages are more widespread and serious, in the present than in any former generation, about the dental history of which we have records. . . . It is impossible to believe that the British Empire would have become what it is to-day if amongst those hardy Norsemen who pushed up their keels upon the shore at Ebbsfleet and entered upon the making of England there had been only one sound set of teeth in every ten, or if amongst our ancestors, who have extended our dominions by land and sea and won for us our civil and religious liberties by struggles in which personal vigour and endurance counted for more than they do in the highly scientific and explosive warfare of modern times, there had been all but universal rottenness of the teeth before adolescence. Depend upon it that in the England of the past the teeth were not as frail or troublesome as they are to-day. . . . I am not going to argue that sound teeth are the passports to power, or that biting and grinding capacity have determined the course of history, but this I will maintain, that no nation has ever climbed to pre-eminence on carious teeth, or can retain pre-eminence when its teeth are no more and that it behoves a conquering people jealously to look to its teeth and to keep them, not less than its weapons, bright and sharp. . . .
When we inquire into the cause of the greatly increased prevalence of dental caries in modern times we at once perceive that it is an instance of these imperfect adjustments which we often see in living beings in their passage from a natural to an artificial and from an artificial to a more artificial condition of existence. . . . The resources of civilization are more ample, nimble, and varied than those of dentition and so it has come about that the teeth have not been modified in accordance with the altered habits of life of modern times, and especially of the nineteenth century, and have not yet been adequately protected by specially devised safeguards. But in examining into the causes of the increase of dental decay which we see around us, we can go beyond a mere general statement of this kind and indicate, I believe, some of the specific conditions of modern life which are mainly responsible for it. . . .
In the first place, then, it seems to me that the greater prevalence of dental caries in these days is probably in some measure dependent on the softness and pulpiness of the food on which we for the most part feed. Hardness and toughness of food—and the food of savage and semi-civilised races is generally hard and tough—involve vigorous mastication and vigorous mastication involves a vigorous use of the teeth in their proper function and a copious flow of saliva and a copious flow of saliva involves cleansing of the teeth and gums, to which the active movements of the lips, tongue, and cheeks during mastication largely contribute. But the softness and pulpiness of food—and the food of all civilised races tends to become more and more soft and pulpy—means comparatively little mastication and use of the teeth and little mastication means a diminished flow of saliva, for the far-fetched condiments of refined cookery do not stimulate the salivary glands to anything like the same extent that ordinary sapid substances with energetic masticatory movements do and a diminished flow of saliva means diminished cleansing of the teeth which are at the same time imperfectly scrubbed by the feeble movement of the parts engaged in mastication, and so it comes about that when the food is soft and pulpy particles of it lodge in and about the teeth and gums, to an extent that is impossible where it is hard and tough and afford a nidus for those bacterial growths which alike by the decomposition they set up and their direct attacks are so inimical to the integrity of the teeth. . . .
In the second place, I would suggest to you as a specific cause of increase of dental caries a change that has taken place in a food stuff of a particular kind and of primary importance—I mean bread, the staff of life,—from which in the progress of civilisation the coarse elements—and the coarse elements consist of the outer husks of the grains of which it is composed—have been eliminated. In as far as our own country at any rate is concerned, this is essentially an age of white bread and fine flour and it is an age therefore in which we are no longer partaking to anything like the same amount that our ancestors did of the bran or husky parts of the wheat and so are deprived to a large degree of a chemical element which they contain—namely, fluorine. . . . Analysis has proved that the enamel of the teeth contains more fluorine, in the form of fluoride of calcium, than any other part of the body and fluorine might, indeed, be regarded as the characteristic chemical constituent of this structure, the hardest of all animal tissue. . . . If, in our dislike to grittiness, which has run parallel to our addiction to soft and succulent food and in our preference for the white and fine flour, we have cut out the main source of supply of fluorine to our systems, it is not difficult to understand how we may have thereby incurred comparatively feeble and unprotected teeth, with diminished power of resistance to adverse influences and peculiarly liable to decay. . . .
In the third place I would name to you, as a cause of increased dental decay in our population, the high nervous tension of our time and the impaired nutrition which that high tension frequently entails. . . . [T]here are now [also] vast numbers of human beings, the offspring of neurotic or neurasthenic parents, sent "into this breathing world," "deformed, unfinished," and "scarce half made up," whose teeth are delicate and destined to premature decay. The gastro-intestinal mucous membrane of the embryo from which the pulps and sacs of the teeth originate may in such cases be supposed to have been wanting in formative energy, or the trophic influence from nerve centres which is exerted, if not during papillary and follicular, certainly throughout the saccular and eruptive stages of dentition, may be presumed to have been defective. It is to be remembered that as early as the fourteenth week of embryonic life, when the membrane of the dental groove with its adherent follicles and their pulps are stripped off, there may be seen dental nerves running along under the follicles and distributing twigs to each of them; it is certain that from this time till the completion of dentition at the twentieth year the development of the teeth is more or less under nervous control. It is not to be expected, I think, that robust teeth will grow and come forth in due order in children who are kept in a state of nervous excitement or overstrain. While I am quite satisfied that inherited tendencies are more potent than personal experiences in inducing the dental debility which we encounter in nervous children, I still cannot acquit our modern system of education, with the over-pressure into which it so often runs, of some share in its causation, directly through interference with the growth and eruption of the teeth, as well as indirectly through interference with digestion and secretion and the consequent establishment in the mouth of conditions favourable to dental caries. . . .
In the fourth place, I would mention as a possible cause of the increased prevalence of dental caries amongst us the growing aggregation of our population in the large towns, for this aggregation entails for old and young higher nervous tension than country life, a greater liability to anemia and a low standard of health, and also to several zymotic and constitutional diseases, which not less than general reduction of health and nervous exhaustion leave their stamp on the teeth in impaired nutrition. But more than this, the conditions of town life conduce especially to those forms of dental failure which depend on bacterial onslaughts. Wherever human population is thick on the ground, the bacterial population is thick in the air, and in our crowded cities we have a crowded atmosphere contrasting unfavourably with the pure air of the country and conveying constantly into the mouths of men, women, and children volumes of parasites pathogenetic and non-pathogenetic. The mouth is indeed veritably a menagerie of tame and wild bacteria. . . .
Whether indigenous or of occasional and foreign intrusion, the bacteria which haunt the mouth find there conditions eminently suitable to their rapid multiplication. The mouth is indeed an incubating chamber specially prepared for bacterial cultivation. In it the proper temperature is steadily kept up and the proper degree of moisture and aeration is maintained, while proper nutriment is liberally supplied in particles of food which adhere to the teeth and gums, in the desquamating epithelium, in the sugar resulting from the transformation of starch by the action of ptyalin, and in the substance of the teeth themselves. . . . It is when the enamel is removed that bacterial inroads in the dentine become practicable and removal of the enamel is effected by lactic acid and the peptonising enzyme which other bacilli produce. Miller found in his experiments on artificial decay that as long as the enamel was entire acid had no power to injure the dentine beneath, but wherever the enamel was thin or imperfectly developed the dentine was soon softened by any acid that was present and the canaliculi were then speedily filled with bacteria, which gave rise to irregular corrosion. As a large majority of the bacteria which find their way into the mouth do produce acids, it is evident that conditions that increase the bacterial supply to the mouth must promote the destruction of enamel and the invasion of the dental tubules, so that the aggregation of our people in towns must tend to the diffusion of dental caries. . . .
[T]he principal causes of the increase of dental caries have, I believe, been summed up in what I have said to you this afternoon, and the practical question that now arises is what can be done to remove these causes or to counteract their effects, to banish from our country a blight that has invaded every household and to secure to our people the boon of sound and serviceable teeth.
I have said that the present state of matters is deplorable. I am sure you will agree with me that it is harrowing to reflect on the pain and sleeplessness and distress that are daily due to dental caries in this country. Beyond these immediate evils accruing from it there are remote consequences which are even more grievous. . . . The boy who can masticate has much better prospect of success and happiness in life than he who can merely munch, and the girl who dares to show her teeth will have more joy in her womanhood than she who has to veil them behind an imperturbable upper lip.
What, then, are the hygienic and prophylactic measures which should be resorted to for the prevention of dental caries and the preservation of sound teeth? The most important, the most hopeful of all of them, are those which you are met to discuss this afternoon, and which have reference to the care of teeth of children during the period of schooling. . . . [D]ental delinquency is only to be efficiently dealt with—on the large scale, at any rate—amongst those of tender years. I would, perhaps, not be going too far in alleging that if universal, continuous, and skilful supervision and management of the teeth during their development and eruption—that is, up till twenty years of age—could be secured, there would be practically nothing to do to the teeth afterwards. . . .
[I]t is the clear and pressing duty of Government or Parliament to provide that in all public institutions for maintenance or education of the young, whether under public control, as in the case of training ships, reformatories, industrial and workhouse schools, or under management of committees of subscribers, as in the case of orphanages, hospitals and homes the teeth of the children shall be periodically examined by a qualified dentist and everything that is needful done for their preservation. . . .
As regards Board Schools, there would certainly be greater difficulty in introducing compulsory dentistry. There would, no doubt, be resistance by ignorant and stupid parents, and perhaps by a pig-headed society, to any operative procedure enforced to ensure to children the inestimable blessing of sound teeth, just as there is opposition to compulsory vaccination and other beneficent measures of a kind; but, as far as I can see, there could be no objection to compulsory inspection of teeth and it is this, I respectfully submit to you that you ought to aim at and that, were it once fully introduced, would ultimately secure for us nearly all we want. . . . The very existence of such a system would create a public opinion in favour of sound teeth, it would bring home to the people a sense of the value of tooth culture and lead to widespread adoption of domestic precautions against dental caries, now too much neglected. In so doing it would have advantages beyond those merely relating to the teeth, for you may depend upon it, that the simple ceremonial observance of the morning and evening toothbrush, regularly preformed, exalts self-respect and so has a wholesome effect upon moral character.
A system of compulsory inspection of the teeth of school children and State-aided rectification of defects in them . . . would of course entail a large outlay of money, for I contemplate that the dentists employed in this public service would be adequately remunerated for their labours; but the money would be well spent and would yield a splendid return in the increased comfort, contentment, health and vigour of our people. . . . [S]ure I am that it would be for the ultimate welfare of the country (if so be that adequate tooth culture cannot be otherwise secured) even that the grand piano in some of our London Board Schools should give place for a time to the dentist’s chair. Admirable is the grand piano in its way; it is the high altar of popular aesthetics, but Chopin and Wagner ill accord with the groans of toothache. . . .
In conclusion, I would beg very cordially to wish you success in your efforts to secure the protection of the teeth of the young and I exhort you to steady perseverance in these efforts, undaunted by opposition, unruffled by ridicule and undiscouraged by failure, for your cause is a good and reasonable one and it must prevail. You are a wing, an useful and honoured wing, of the great army that is giving unceasing battle to the powers of darkness, disease and death.
Footnotes
Excerpted from "An address on tooth Culture" The Lancet. 1892;2:6–10.
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