| AN EFFECTIVE METHOD OF PERSONAL ORAL HYGIENE* |
DESCRIPTION OF THE METHOD
Above, attention has been directed to the essential local etiological conditions in caries and in periodontoclasia conditions without which lesions of these diseases do not originate, and existing lesions, with rare exceptions, do not advance further. With this information known and clearly understood it is evident that these conditions must be prevented or minimized to prevent the occurrence of the lesions and the advancement of existing lesions. Treatment of existing lesions is a matter for the judgment and experience of the dentist to decide. Some caries lesions require fillings; others may require trimming and smoothing of overhanging edges, perhaps enlarging the cavity, so it can be cleaned out well by the patient; still many others require nothing but watching.
It is necessary that all concretions (calculus) on the tooth within the periodontoclasia lesion be scaled off and the surface of the tooth be made as smooth as is practical. Masses and rough surfaces of calculus are very much in the way of. the patient's cleaning the tooth, especially within the crevice. It is very important that removal of the calculus include that in the deepest part of the pocket where the lesion is advancing. This calls for skill, patience and conscientious work.
There is no need or justification for the extensive mutilating gingivectomies sometimes done in this disease. Except in the case of some far advanced stage lesions and under special circumstances, thorough cleaning of the teeth by the dentist followed by the method of personal oral hygiene described below, results in rapid subsidence of inflammation. and of suppuration of the tissues involved. No further advancement of the lesion occurs.
Locations on the teeth which must be cleaned.-The important locations on the teeth which the patient must clean are occlusal depressions (pits and fissures); areas which are more or less protected from functional friction, such as the embrasures and interproximal surfaces; and the surfaces at the entrance to, and especially those within, the gingival crevices.
The material to be removed (cleaned off or out) consists of more or less food material, in various stages of decomposition, which has been retained since the previous cleaning, and of bacterial film material. which has grown there since the previous cleaning. All such material is soft and is easily dislodged by the right (proper) application of toothbrush bristles and of the filaments of dental floss. There is no other way by which they can be physically and effectively dislodged by the patient-no other way by which he can clean his teeth at these important locations.
Right kind of toothbrush and dental floss. - Effective cleaning of the teeth can be done only with a brush and floss, the bristles 'and filaments of which can be effectively applied to the areas to be cleaned. After having full information as to the functions to be performed and measurements of the spaces and places to be cleaned, and after much experimentation, I have ascertained what I believe are the optimum characteristics of brushes and of floss for the purpose. The exact details have been published,19,72 and the reasons for these specifications were given. In my opinion, based upon my own knowledge and experience, brushes or floss that deviate to any considerable extent from these exact specifications are inappropriate and less effective for the purpose, to whatever extent they so deviate.
Briefly, the specifications of the brush are:
1. Plain straight-handle design; overall length about 6 inches; width about 7/16 inch; 3 rows of bristles, 6 tufts to the row, evenly spaced.
2. High quality nylon bristles, about 80 per tuft, .007 inch diameter, straight trim, finished to 13/32 inch length.
3. Ends of bristles ground and finished to hemispherical shape or at least enough to eliminate all sharp points and rough edges.
4. A similar brush of reduced size for the use of young children should have an over-all length of about 5 inch, .005 inch bristles, finished in the same way to 11/32 inch length.
Briefly, the specifications of the floss are:
1. Material-high tenacity bright nylon yarn (Type 300), 2 denier per filament.
2. Construction-made by twisting together 5 threads Of 70 denier, 34 filament yarn.
3. Twist~S twist, steamset.
4. Size-350 total denier.
5. Manufacturer's technical desIgnation for this floss is: 70-34/5 'S 3, Nylon 300, steamset.
When teeth must be cleaned. Practically all caries activity occurs at night during rest and sleep. During the daytime movements and activity of the mouth, tongue, cheeks and lips result in frequent washing of the teeth and more or less changing of the saliva around the teeth including that at locations at which food material may be retained and decompose. Acids that may be produced are diluted and/or carried away, more or less, by such frequent changing of the surrounding saliva. Food material is also diluted or washed away, especially the easily dissolved parts of it.
Sugars and fermentable carbohydrates contained in particles of food material which is subject to frequent change of the surrounding fluid tend to leach out. Even food material retained within cavities gives up much of the sugar it may contain, from the frequent changing of the fluid with which it is constantly bathed.
All this activity and functions of the mouth by which fermentable carbohydrates and acid that may be produced are diluted or partially removed necessarily tends to reduce caries activity during the daytime. On the other hand, during sleep the flow of saliva is greatly reduced. The movements of the mouth by which the saliva surrounding decomposing food material at the caries locations is changed and the products of fermentation are washed away or diluted, are also greatly reduced. The most favorable conditions exist at this time for caries activity.
It has been found by several workers73·77 that caries incidence and activity are enormously increased in desalivated animals fed a cariogenic diet. Klapper and Volker78 found -that hamsters with only partial salivary gland impairment, when fed a suitable cariogenic diet, develop much more caries than controls. Apparently, the quantity of saliva is an important factor.
In xerostomia (dry mouth), in humans without exception,79 there is rapid decay of the teeth. This is believed to result from the lessened washing and bathing of the teeth by saliva. In cases in which caries is much in evidence on one sIde of the mouth only, the patients invariably80 have a preference for sleeping on the opposite side. This habit tends to dryness on the up-side which is where the greatest caries activity occurs.
It has been pointed out that the changing of fluid and washing of potential caries areas on the teeth which goes on, consciously or unconsciously, during the daytime is enormously decreased during rest and sleep. In addition, and what is even more important, flow of saliva is almost nil. Therefore, during sleep, the conditions are quite similar to those of desalivated animals or of humans' with xerostomia. Since conditions which permit and promote caries activity exist mainly at night during sleep, it is evident that to prevent such action at that time, the teeth must be cleaned effectively before retiring.
So far as caries activity is concerned, if. the teeth are thoroughly and properly cleaned at night before retiring, there follows a long period during which there is no acid production, because there is no fermentable carbohydrate food material present to produce it. This period coincides with the period during which caries activity otherwise occurs. The cleaning also dislodges Or removes much of the bacterial film material at the vulnerable areas. Not much growth of the remnants -stumps and stems-of such microorganisms occurs during the night, for lack of suitable substrate for their growth which food material, if present, would provide.
The time the teeth must be cleaned for prevention of periodontoclasia activity is indicated by somewhat similar considerations to those relative to caries activity. Usually food is taken into the mouth at several different times during the day. Remnants of food-solutions, microscopic particles, some larger-tend to lodge and be retained in protected areas at the entrance to the gingival crevices. Some may be forced into the crevice for short distances. In addition, larger tough particles may be retained 'between the teeth and press upon the interproximal gingiva, sometimes extending into the crevice. During the daytime the activities and functions of the mouth, and the abundant flow of saliva, result in washing away irritating materiaL If, however, it is retained over long periods of time during quiet and sleep, and minimum flow of saliva, it causes more or less continuous irritation of the tissues. Most favorable conditions exist for maximum growth of bacteria. If on the other hand the teeth are thoroughly cleaned at these locations, at night before retiring, there follows a long period during which there is no such irritation from decomposing food material, and there is little growth of bacterial film to advance into the crevice.
Thorough proper cleaning of the teeth by the necessary method described herein, not only removes retained food material and dislodges and removes bacterial film at and near the entrance to the gingival crevice, but the bacterial film on the tooth within the crevice all the way down to the very bottom of the lesion is mostly dislodged and removed. Little growth takes place during the night.
Removal of irritating material at the entrance to, and within, the gingival crevice permits rapid subsidence of inflammation and healing of the ulcerated crevicular gingival tissue of existing lesions. It is perfectly evident that for prevention of periodontoclasia and prevention of further advancement of existing lesions, the teeth must be cleaned at night before retiring.
Thorough cleaning of the teeth at night before retiring is essential for prevention of both caries and periodontoclasia. Notwithstanding the best job that can be done, there occurs more or less growth and accumulation of bacteria in the mouth at protected locations on the teeth and elsewhere during the night. It makes for somewhat more cleanliness and less decomposition of food in the mouth during the daytime if the teeth are brushed and vigorously rinsed in the morning before breakfast.
How to brush the teeth.-The most important areas to be cleaned with the toothbrush are (a) the occlusal pits and fissures, (b) the proximal surfaces in the sulci between the teeth as far as the bristles may go, (c) the surfaces of the teeth within the gingival crevices to the extent they are accessible to the application of the bristles of the brush. It is done by applying the ends of the bristles to the area with firm pressure and moving the brush back and forth ("vibratory motion") with short strokes, thereby dislodging soft material by the digging action of the ends of the bristles wherever they can be applied.
The bristles of the right kind of brush are smaller, therefore more flexible (easy to bend) than those of other brushes; they are all of the same length; the tufts are properly spaced for most effective use; (microscopically) each bristle is round or smooth on end. This brush was designed and the specifications for it were determined19 after first having accurate information as to the conditions to be met and the size and shape of the spaces to be cleaned with it.
All the surfaces of all the teeth to which the bristles of the brush can be applied, should be brushed. A good routine is to brush the buccal and labial surfaces of all the teeth first, then the occlusal and lingual surfaces of the grinders in all four quadrants, and finally the lingual surfaces of the anterior teeth.
In brushing the buccal, labial, and lingual surfaces the bristles should be forced directly into the gingival crevices and into the sulci between the teeth, at about a 45 degree angle to the long way of the teeth. With the bristles forced into the crevices as far as possible, short back and forth movements of the brush dislodge all soft material which they reach on the tooth within the crevice. At the same time the teeth are cleaned above the gum in the sulci and between the teeth, as far as the bristles may go.
At first there is more or less bleeding from the inflamed crevicular gingiva, but this rapidly ceases as the inflammation subsides and the tissues toughen up. Thereafter no reasonable amount of vigorous brushing with this brush causes bleeding, except for such periodontoclasia lesions as may not have healed yet.
A good way to brush the buccal and labial areas is to close the mouth with the teeth nearly together, then put the brush inside of the cheek and brush the lowers and uppers alternately, on one side of the mouth, moving forward and across the anteriors and changing to the other side, brushing the teeth there in the same way.
The occlusal surfaces of the grinders are to be brushed by applying the bristles to the surface, pressing down firmly and moving the brush back and forth with short strokes. This digs out any soft material that may be present in the occlusal pit and fissure depressions.
Usually at this same time the back teeth are brushed on the lingual side in the same way as on the buccal side. The bristles should be directed firmly, at about a 45 degree angle into the sulci between the teeth and especially into the gingival crevices.
This is the time to brush around the back teeth, the most unclean and most neglected place in the mouth. There is a certain relaxation of the jaw (a certain opening of the mouth) which each person must learn for himself, which permits the application of the bristles of the tip (or toe) of this brush to be applied into the space around the back tooth in a way that no other brush' could be applied. By the right pressure, application and brush movement one can learn to clean around his back teeth in a surprising and pleasing way. Soon one learns to brush simultaneously the occlusal surfaces, the lingual sides of the grinders, and around the back teeth, in each of the four quadrants.
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Finally the anterior teeth are brushed on the lingual side, by directing the bristles of the heel or of the side of the brush into the gingival crevices and the sulci between the teeth at about the same 45 degree angle as at all other places.
Although we have described the brushing in several different locations as if it were done in separate stages actually one proceeds without distinction or separate stages until the brush has been applied, as best it can be, to all areas which can be reached with the ends of the bristles. Anyone who knows how, can brush the teeth as well as is necessary in less than one minute. It is not a matter of how long to brush but to do it right by this method, which is quite different almost the opposite in important particulars- from methods generally advocated or followed. It consists essentially of forcing the ends of the bristles of a brush of appropriate specifications directly into the gingival crevices and into depressions where food material and bacterial film tend to accumulate, and by short stroke movements, dislodging and removing such material.
How to clean the teeth with dental floss. By the above method of brushing, the bristles of the brush have been stuck in between the teeth and into the gingival crevices as far as they will go, from the buccal or labial side and from the lingual side, but there will be a place along the middle between the teeth where the bristles have not met. The proximal surfaces not reached by the bristles, and those within the gingival crevices, have not been cleaned. The only way by which these important areas can be cleaned is by the proper use of the right kind of dental floss. The optimum characteristics of dental floss for this purpose have been determined,72 after first having accurate information as to the conditions to be met and the functions to be served by it.
This right kind of dental floss consists of a large number of microscopic nylon filaments, . not waxed, and not twisted except just enough to hold it together when in use. It is easy to understand that drawing (scraping) this bundle of microscopic filaments crosswise over a tooth surface would tend to cut off, dislodge and remove microscopic material that may be present there. The bacterial film and other material to be removed consists of microscopic particles.
Each person must be taught how to use dental floss right. Only a few people now know that the use of dental floss is necessary and those who do, in most instances, do not use it effectively for the purpose for which it is required.
For the purpose of cleaning the surface around the contact area, thereby preventing caries activity there, it is only necessary to pass the floss through the contact and back out. This cleans the proximal surfaces above the gum which have not been reached by the bristles of the brush.
For the purpose of preventing periodontoclasia, and preventing advancement of existing lesions, those tooth surfaces within the gingival crevices which cannot be cleaned with the brush, must be cleaned with dental floss. The foreign material on the tooth within the crevice, which causes and promotes the advancement of periodontoclasia, extends to the very bottom of the lesion. Therefore, to remove this material the floss must be carried to the bottom of the lesion.
The floss must be held firmly against the tooth and drawn outward (perhaps sometimes slightly endways also) so as to cut off and dislodge the bacterial and other microscopic material on the tooth within the crevice. The large number of separate nylon filaments of which the floss is composed, when drawn crosswise over the surface of the tooth from the bottom of the lesion outward, not only dislodge microscopic material but much of this is retained between the filaments and is removed with the string.
It does not matter what system is followed in cleaning the teeth with dental floss just so the floss is carried to the bottom of the crevice and then drawn firmly across the surface of the tooth from the bottom of the crevice outward. Different people develop their own technic and manipulations for cleaning their teeth with dental floss. They have to be taught by someone who knows how it should be done and why. The person must be shown that he has diseased gingival crevices, that the teeth are unclean within them, and that the floss must be carried to the bottom of the crevice in order to clean the tooth at this important location.
After considerable experience in presenting this method to a good many dentists and dental students, and in teaching other people how to clean their teeth with dental floss, this author has not found any change needed in the detailed directions he published several years ago 1, which are quoted verbatim as follows;
1. Cut off a piece of floss about 2 to 3 feet long.
2. Wrap one end with 2 or 3 turns around the first phalanx of the right index finger, for the purpose of anchoring or holding it.
3. Bring the floss over the end of the right thumb which is also held against the finger around which the floss is anchored.
4. Grasp the floss with the left hand and bring it over the end of the first finger of that hand. Thus a length of floss, about 1 inch long, is held between the thumb of the right hand and the first finger of the left hand. (Fig. 25-1.)
5. Now with the thumb inside of the cheek and the finger inside of mouth, the floss is carried to the very bottom of the gingival crevice back of the last right upper tooth, drawn slightly endways through the crevice and crossways outward across the distal surface so as to scrape off and dislodge the soft bacterial material on the tooth within the crevice and outwards.
6. Holding the floss in the same way, pass it into the next interproximal space. Carry it to the bottom of the posterior gingival crevice and clean the mesial surface of that tooth. Now, before withdrawing the floss from this interproximal space, clean the distal surface of the other tooth in the same way. Then withdraw the floss and move on to the next interproximal space, etc., until the proximal surfaces of all teeth have been cleaned.
7. In passing the floss between contacting teeth it is not forced directly in and out. It should be held over the contact and drawn gently and slightly back and forth endways. This allows the low twist, unwaxed floss to flatten and pass between the contacting teeth with the greatest ease.
8. After cleaning 2 or 3 teeth the part of the floss used is somewhat soiled and loaded with bacterial material. It is desirable to move along the string to a new place by taking another turn around the anchoring finger. This should be repeated from time to time as needed.
9. The floss is held and manipulated with the same fingers as indicated above until after the surfaces of the teeth in the interproximal space between the left central and lateral have been cleaned.
10. In cleaning the rest of the upper teeth, it will now be found more convenient and practical to hold the floss over the ends of the thumb of the right hand as before and over the thumb (instead of the index finger) of the left hand (Fig. 25-2).
11. All the lower teeth now should be cleaned in the same way. Most people will find that they can carry out the necessary manipulations most successfully with the floss held over the ends of the middle finger of each hand instead of the thumbs or the thumb and first finger as in cleaning the upper teeth. (Fig. 25-3)
12. After cleaning all the teeth with dental floss, the mouth should be thoroughly rinsed by forcing water vigorously back and forth between the teeth in order to remove material that has been loosened or dislodged but not removed by the floss. After a little experience one can clean all his teeth well with dental floss in from two to three minutes.
13; It gives a pleasurable sensation of cleanliness to hastily brush the teeth again after cleaning them with dental floss. But this is not essential.
Since practically all adults and many others have active periodontoclasia lesions of various extent around part or all of their teeth, there will be more or less bleeding of their inflamed gums when they first ,begin cleaning their teeth with dental floss. This soon ceases and the previously inflamed tissue rapidly heals. No bleeding or discomfort is experienced from any reasonable manipulations of the floss in the future. One soon realizes that his teeth are cleaner than they have ever been before.
DISCUSSION AND COMMENT
Although the method of personal oral hygiene herein described has been perfected and some of the information upon which it is based has been established or clarified during the past few years, actually the fundamental ideas as to the cause of these diseases of the teeth and gums, and quite similar effective means of preventing them, were known and taught almost one hundred and thirty-five years ago. If the method then known could have been available and followed generally since that time, countless millions of people would have avoided untold disease, impairment, and final loss of some or all of their teeth; and the resulting disfigurement, discomfort, and other unhappy consequences.
In the Charles Edmond Kells Collection in the Rudolph Matas Medical Library at Tulane University, there is a 200 page booklet81 entitled "A Practical Guide to the Management of the Teeth, Comprising a Discovery of the Origin of Caries or Decay of the Teeth with its Prevention and Cure," written by Levi Spear Parmly ("Dental Professor") and published in 1819. No doubt copies of this book can be found in other collections and in other libraries. Anyone claiming that our present conception of the cause and prevention of the diseases of the teeth - caries and periodontoclasia - is new, owes it to himself to read this treatise.
Parmly recognized and asserted, without reservation, that these diseases of the teeth and gums are caused entirely by local conditions of uncleanliness and that they can be prevented only by cleaning the teeth effectively. Up to this time most authorities considered that caries originated within the tooth and that gum disease was due to systemic conditions. If not the first, Parmly was certainly one of the first, to claim that local uncleanliness is the essential cause of decay of the teeth and to devise an effective method of cleaning them for prevention of the disease. He was enthusiastic about his "discovery" and asserted that "if the teeth and gums are regularly cleaned with the dentifric apparatus recommended by the author, no caries can possibly take place." "*** the interstices and irregularities of the teeth afford a lodgment for whatever is taken into the mouth, and no contrivance hitherto discovered can, from these parts, remove the accumulations."
Parmly came to New Orleans in 1824, taught his methods and gave several lectures on care of the teeth. He was from England where he was celebrated for his knowledge and methods. He also practiced and lectured in this country, in New York, Savannah, and Charleston, in addition to New Orleans. Copies of these lectures in our library present ideas and methods advocated by him at that time with which, with only slight improvement and modernization, our present information and methods entirely coincide. His "dentifric apparatus" consisted of three parts. Although there is no exact description of them, there is general information as to what they were and how they were to be used. "The first part to be used is the brush. It is made hollow in the middle to embrace every part of the teeth except the interstices; and thus, at one operation, the top (a part hitherto entirely neglected), the outer and inner surfaces are completely freed from all extraneous matter. The second part is the polisher for removing roughness, stains, etc., from the enamel and restoring the teeth to their natural smoothness and color." I do not find any description of the polisher.
"The third part is the waxed silken thread which, though simple, is the most important. It is to be passed through the interstices of the teeth, between their necks and the arches of the gums, to dislodge that irritating matter which no brush can remove, and which is the real source of disease. With this apparatus, thus regularly and daily used, the teeth and gums are preserved from disease."
In describing his method of cleaning the teeth with his "untwisted waxed silk" floss, he says "although the gums- may first become subject to slight bleeding, yet in a few days, by perseverance in the treatment recommended, this bleeding will soon cease." Persons subject to inflammation
of the gums "should clean them often with the waxed silk; when a new and healthy action will be communicated to the gums and they will be restored, in a short time, to their naturally firm and adhesive state."
Some of his other statements are especially interesting. "The first and most important object is cleanliness of the mouth, which is the only preventive of disease." "Where the teeth are kept clean and free from such objectionable matter." (relics of food undergoing putrefaction) "no disease will ever arise. This being the case, the means of prevention are clear and simple; and it is in the mode of cleaning them, that the whole secret of avoiding disease consists." This can be done only "in a proper manner, by using the dentifric apparatus described."
Disease of the teeth is "the effect of carelessness, inattention, or other want of cleanliness. It is in the power, therefore, of every individual to preserve the teeth and gums in perfect health." The advice relative to children's teeth, which he gave then, is quite applicable today. "In childhood the mouth should be cleaned every evening. The relics of food, which have been all the day accumulating, are thus prevented from committing their ravages during the night; and the habit of cleanliness will become fixed, from being so essentially connected with personal comfort." "When the permanent teeth begin to make their appearance, then is the time that the greatest attention to cleanliness is particularly necessary."
In the light of our present knowledge as to the essential etiological conditions in periodontoclasia, it is evident that no method of personal oral hygiene could be effective in preventing it, without the proper use of dental floss. Throughout the literature during the present century, many authors mention the use of floss silk or "flossing" as a part of the home care of the teeth. In most instances methods of using it suggested or implied could not be effective because they do not include cleaning the tooth within the gingival crevice. Joseph Head,82 in 1917, described his method of "floss-silking" the teeth which evidently did include application of the floss to some extent within the crevice. He says the silk should go "up well under the frenum of the gum ***across the gum and up into the opposite frenum." His statement that "the gums at first naturally bleed" further indicates that the method he advocated included carrying the floss into the crevice.
Proper use of dental floss is necessary for maintenance of both oral cleanliness and dental health. Whatever advocacy and promotion there may have been of this necessary part of personal oral hygiene, it remains a fact that, as yet, very few people use dental floss. Out of more than 900 people-mostly university personnel and dentists and dental students - whom I have examined during the past several years, less than half a dozen were using the available dental floss effectively and thereby maintaining a high degree of oral cleanliness and dental health. Some others used it irregularly and ineffectively.
During recent years there has been a wave of promotion of the idea that the teeth must 'be brushed soon after each meal. It is based upon the observation by Stephan and others83-87 that the application of sugar solutions to accumulated dental plaque material ("materia alba") is quickly followed by marked increase in acidity.
Fosdick88 and a group of cooperating investigators carried out a large clinical experiment to ascertain the effect upon caries incidence, of brushing the teeth within 10 minutes after each ingestion of food or sweets. The brushing was to be followed by thorough rinsing of the mouth. The controls followed their usual procedure which "generally consisted of brushing their teeth night and morning."
The results over a one or two year period indicate that the incidence of caries is reduced between 50 and 60 per cent by brushing (and/or rinsing) the teeth right after ingesting food or sweets. Both test subjects and controls had a considerable increment of caries lesions during the experimental period. The implication is that these were new lesions which were not present at the beginning. Any method of personal oral hygiene which allows the development of any new caries lesions, is inadequate.
It has long been well known that when fermentable carbohydrates are applied to a mass or accumulation of acidogenic bacteria, acids are produced quickly. If on the other hand, culture media containing the same fermentable carbohydrate is, inoculated with a relatively small number of such acidogenic bacteria, it requires hours of incubation and multiplication before significant amounts of acids are produced. This is common practice in bacteriology in testing acid and gas production of organisms.
In carrying out the experiments to test acid production of plaque material in situ, or to collect a sufficient amount for tests outside of the mouth, it is necessary for the subject to refrain from cleaning the teeth for some time, usually three or four days, to allow time for accumulation of sufficient suitable material for the purpose. How different these conditions are from those that exist when the teeth are properly cleaned of food and bacterial material with both toothbrush and dental floss every night before retiring! When this is done there is not time for harmful amounts to grow and accumulate during the following day before time to clean them the next night; or for sufficient amount for testing purposes either.
Advocating and promoting brushing the teeth after every ingestion of food, for the purpose of lessening caries incidence, encourages the misbelief that caries is the main disease of the teeth (periodontoclasia is the most important for adults), that the teeth can be effectively cleaned with the brush (which they cannot), and it tends to detract attention from the importance and application of the essential information that the teeth must be cleaned with both toothbrush and dental floss every night before retiring.
The oral hygiene (oral cleanliness) habits of different individuals vary greatly, as do the other habits of personal cleanliness. These are acquired in the home. During early childhood the child must learn by experience and the example of others that preparation for retiring at night must include thorough cleaning of the teeth. It should be an established practice in the home that no one may retire with an unclean mouth.
The young child cannot clean his teeth effectively; therefore, it must be done for him by the parent, who must know how to do it. During the first several years, use of the floss is not necessary. The teeth can be cleaned with the brush well enough to prevent caries, if it is done right. The most important part for the child is cleaning the occlusal surfaces of all the chewing teeth by firm application of the bristles to these locations, since almost all cavities in childhood originate on the occlusal surfaces of the grinders.
After a child is several years of age and the permanent teeth are in place, then it is important that the teeth should not only be cleaned with the brush, but that dental floss should be passed (in and out) between contacting permanent teeth, so as to insure against proximal caries activity. At some age, usually between 6 and 10, the child who has been well trained can take over his own oral hygiene procedure, at first under supervision and finally without.
At the present time most children have already sustained caries damage to some or several of their teeth, especially the grinders, by the time they are 12 to 15 years of age. This is entirely preventable and the parents have full responsibility for it. The responsibility cannot be placed upon the child or others. For a child to develop even one caries lesion is a reflection of neglect and deficient or uninformed guidance in this regard.
In general, as each person advances in age, there is a constantly increasing accumulation of dental disease and injury. Although such damage as has already occurred at any given time,cannot be prevented now, for all practical purposes, and except for some special circumstances, any' person can begin at any age and, by the right method of personal oral hygiene herein described, prevent the occurrence of any new caries or periodontoclasia lesion during the remainder of life. The oldest person the author has had under close observation is now 78. For years he has been able, by this method, to maintain the maximum degree of oral cleanliness and dental health.
People depend upon practicing dentists for information and advice relative to dental health. The knowledge, ideas, and methods of dentists are acquired largely through their training in the dental school. Up to the present time, the fundamental facts upon which this method of preventing the diseases of the teeth is based and the method itself, have been taught, and that in a restricted or limited way, in only two of the dental schools of the country, Loyola in New Orleans and University of Texas in Houston. Short course intensive postgraduate instruction has also been given to small numbers of dentists, who then return and enthusiastically teach this method to their patients. It should be understood that this is not just another method of personal oral hygiene to try on patients. The dentist who understands and knows of his own knowledge (not the opinions of others) the basic facts relative to the local etiological and pathological conditions in these diseases, already knows in advance that this method would be necessary to prevent them. He would be following the method himself. Until he does, he is not prepared to teach it to his patients.
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SUMMARY
Attention has been directed to the essential local etiological conditions in caries and in periodontoclasia. The lesions of these diseases are caused, and their advancement is promoted, by uncleanliness at vulnerable locations on the teeth which are not naturally kept clean. A limited number of illustrations have been included to visualize some of the ideas in the text. Reference is given to a larger number in the literature confirming the etiological conditions at the locations where the lesions of caries and periodontoclasia originate and advance.
Caries activity, and to a large extent, periodontoclasia' activity, occur at night during quiet and sleep. To prevent them the teeth must be thoroughly cleaned at night before retiring, thereby securing a long period during which there is no food material about the teeth to ferment Of decompose, and relatively little growth of harmful bacteria takes place. The teeth can be effectively cleaned at the important locations only by the proper application of the bristles of an appropriate toothbrush and the filaments of the right kind of dental floss. Details of the method are given. These differ from, and in some particulars are the opposite of, those usually followed. To maintain a high degree of oral cleanliness, and to prevent caries and periodontoclasia, the teeth must be cleaned right, with the right kind of both toothbrush and dental floss, every night before retiring.
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REFERENCES
1. Bass, C. C..: The necessary personal oral hygiene for prevention of caries and periodontoclasia, New Orleans M. & S. J., 101 :52, 1948.
2. Leber, T. and Rottenstein, J. B.: Investigations on Caries of the Teeth, Berlin, 1868. Translated by Chandler, T. H., Philadelphia, Lindsay and Blakiston, 1873.
3. Wedl, C.,.: The Pathology of the Teeth. .(Original German Edition, 1870) Translated by Boardman, W. E., Philadelphia, Lindsay and Blakiston, 1872.
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