CHAPTER 2.

MOUTH HYGIENE

The late Dr. Osler, one of the great physicians of the present age, in an address delivered before the students of the Royal Dental Hospital of London, said:

“You have just one gospel to preach, and you have got to preach it early, and you have got to preach it late, in season and out of season. It is the gospel of the cleanliness of the mouth; cleanliness of the teeth; cleanliness of the throat. These three things must be your text through life.”

“Oral hygiene--the hygiene of the mouth--there is not one single thing more important to the public in the whole range of hygiene; and it is with that which you, as practitioners, will have to deal.”

The emphatic statement of this great teacher and physician to a class of dental students is repeated here because it clearly emphasizes the supreme importance of oral hygiene--mouth cleanliness.

Unfortunately, it is not widely recognized how close is the relationship between an unhealthy and unclean mouth and many serious general diseases of the body, both of the infectious and non-infectious types.

Of the former, children, in particular are highly susceptible, because of their common practice of carelessly putting into the mouth objects without much regard to their nature, or possible germ-carrying properties. As a result, germs are conveyed to the mouth, where, if the utmost cleanliness does not prevail, they find a favorable field for incubation, and only too often visiting disease upon the child.

A knowledge of the principle of hygiene, which is acquired by children who are taught to keep their mouth clean and wholesome, makes them more careful not to put casual objects into the mouth.

RESULTS OF ORAL HYGIENE

By many it may seem trite to stress the importance of oral cleanliness, when mouth hygiene is now considered a routine matter in the daily lives of millions of people. But, strange as it may seem, there are more millions by far in this country who are strangers to the tooth brush than there are patrons of this agency of cleanliness.

A statistician some time ago estimated that less than twenty-five million people in America are habitual users of the tooth brush. Simple arithmetic tells us, therefore, that over eighty-five millions of Americans are still to be converted to the merits of elementary mouth hygiene.

Dr. Alfred C. Fones, a pioneer in oral hygiene, initiated a system of mouth hygiene in the public schools of Bridgeport, Conn., in 1914, from which was traced a marked decrease not only in dental diseases, but in the contagious diseases common to childhood.

Dental hygienists were placed in the various schools, and their number was increased until, in 1919, twenty-six were appointed. These women, who received intensive training, both scientific and practical, in a special school for dental hygienists, supervised the care of the mouths of nearly twenty thousand children.

All possible emphasis was laid on cleanliness, and the _prevention_ of dental decay. After decay has once set in, all work is of necessity palliative, and has to be more or less continuous, with results that cannot be foreseen.

Dr. Fones began the first year with the first and second grades. A careful system of four distinct parts was arranged. First, the hygienist would clean the teeth of every child in the school.

Secondly, tooth brush drills were practiced to teach a method of brushing the teeth at home.

Thirdly, class-room talks relating to food and cleanliness were given, supplemented by stereopticon pictures.

Fourthly, the parents’ interest and co-operation were obtained through special educational literature.

As a result of this systematic work, in 1921, the reduction in dental decay in thirty schools where the children were under treatment averaged 69.3 per cent. One of the remarkable results was that out of 1,161 children in the fifth grade, only 65 had cavities in their permanent teeth.

Furthermore, the reduction in decay was accompanied by a reduction in the percentage of retarded pupils, from an average of forty to twenty.

Communicable diseases as we have already observed, are highly prevalent among children with unhygienic mouths. The greatest harm is often done before the child starts to school because of the neglect on the part of the parents in caring for their children’s mouths.

After the mouth hygiene system had been in effect in Bridgeport for four years, there was a marked decline in the death rate of three common diseases among children. The following figures give the death rate per 100,000 population in 1914, before introducing the system, and four years later:

1914 1918 Diphtheria 36.6 18.7 Measles 20. 4.1 Scarlet fever 14.1 0.5

This represents a reduction in these three diseases from 24.6 to 7.8 per 100,000 population.

Of course, it is impossible to prove that the entire results were due to the mouth hygiene campaign. Perhaps other factors entered into the situation. But there is no doubt in the minds of those who witnessed and studied the remarkable accomplishments in Bridgeport, that by far the greatest single factor in reducing diseases among children was oral hygiene--a well-taught lesson in cleanliness.

HOW TO CLEAN THE TEETH

Every one should be on intimate terms with a tooth brush and a good dentifrice (powder or paste) recommended by a dentist. It is desirable that the teeth be carefully brushed after each meal. While the brush is looked upon by some members of the dental profession as a bacteria carrier, nevertheless, with proper care of the brush by the user, and until some more hygienic agency is devised, we must continue our allegiance to the tooth brush.

Some authorities advocate the rotary or circular movement of the brush upon the teeth and gums, while others prefer the rolling of the brush from the neck of the gum toward the biting edges of the teeth.

The former claim that when the gums are not in a healthy state, injury from the bristles of the brush might result and cause irritations, opening up avenues of infection. The latter maintain that no harm can result from such procedure.

A middle course may be suggested. First, ascertain whether the gums are firm and in a perfectly healthy state. If so, carefully brush the teeth with a suitable powder or paste, in front and in the back. Care must be taken that the brush reaches surfaces of the grooves of the posterior teeth, where particles of food are apt to lodge.

The gums should be brushed when cleaning the teeth, but with the utmost care and without using pressure on the brush.

Of the three grades in which tooth brushes are usually made--“soft”, “medium” and “hard”, the “medium” brush is to be recommended for general use. The soft brush is usually too soft to be effective in removing particles of food from crevices and spaces between the teeth; while the “hard” brush, because of the stiff, wiry bristles, may injure the delicate gum tissue.

Some authorities contend that when the gums are irritated constantly in this way and made to bleed, the abrasions invite infection, and is often the cause of acute stomatitis, and is also conducive to pyorrhea. On the other hand, Dr. Paul R. Stillman, in a recent article on the care of the gums, said one of the chief problems in managing cases of gum tissue with a low tone is to arouse the regenerative forces of nature and maintain a constantly high tone in the gum tissue. To realize this end, stimulation and massaging of the gums by careful brushing is advocated, and an occasional bleeding is not considered injurious.

It is evident, from the foregoing statements, that until there is more unanimity of opinion, a moderate course and the avoidance of extremes are advisable.

The tooth brush alone should not be depended upon, and no cleansing outfit is complete without a spool of silk dental floss. Food debris will stick between the teeth, and the danger resulting from such germ incubators as tend to propagate dental decay is best removed with silk floss drawn between the teeth. Care must be taken that the gums are not irritated by this procedure.

A little lime-water is excellent to rinse out the mouth after cleaning. While the lime-water is in the mouth, force it back and forth between the teeth with the tongue and cheeks. Continue this until the water foams, which indicates that it has been in the mouth long enough to have had a beneficial action on the teeth.

Lime-water has a very pronounced influence in preventing the decay of the teeth, and when used in conjunction with a general regimen of mouth hygiene, it is a valuable supplementary agent.

Milk of magnesia may be used as a mouth wash for children, particularly in case of over acidity, such as when the teeth are sensitive and set on edge when eating grape-fruit, grapes, lemons, etc.

When tooth picks are used--although it would be better to use silk floss instead at all times--great care should be taken to avoid injuring the gums. Wooden tooth picks are unsafe for this purpose, as they are too thick and clumsy to enter the dental interspaces. They have been known to break and leave slivers in the gums, causing inflammation, suppuration and sometimes sepsis.

The only tooth picks to be recommended are thin, sterilized quills. These can be used without injury to the tissue, and, when scraped thin, will easily pass between the teeth. At the same time they are sufficiently rigid to remove the ordinary fibrous food debris that becomes lodged between the teeth.

The tooth brush should be kept in a sterile condition, so as to avoid danger from infection. This can readily be accomplished. The brush should be carefully washed with clean water each time after using, and preferably immersed in ethyl alcohol. A glass holder, fitted with a screw top, makes an ideal container for the brush.

THE TONGUE

As it is impossible to keep the mouth in an hygienic condition if the tongue is unsanitary, this organ often requires special attention. The upper surface of the tongue is equipped with numerous tiny _papillae_ and minute grooves or depressions surrounding them.

This uneven surface offers an attractive breeding ground for objectionable micro-organisms. To have an hygienic mouth, the dorsum--upper surface--of the tongue should, therefore, be cleaned every morning. A simple instrument, known as a tongue-scraper, made of ivory, celluloid, or bone, may be obtained for this purpose. It is a bow or loop-shaped device, with a handle about six inches long. A home devised substitute in the form of a silver butterknife, may be set aside and used for this purpose.

In using this appliance, it should be placed well back in the mouth, to the root of the tongue, and then drawn forward upon the surface to the tip of the organ. This should be repeated a few times.

It is said that the Japanese include a tongue-scraper with every tooth brush sold. In this respect, we Occidentals might well take pattern after the scrupulously clean Japanese. In the absence of a tongue-scraper, the tooth brush may be used for the purpose--drawing it over the surface of the tongue--but it is not so comfortable or well adapted.

MOUTH WASHES

Mouth washes, it should be understood, are not by any means a substitute for thorough and regular brushing of the teeth. Real mouth cleanliness can be obtained only by mechanical means. Washing the mouth out with fluids will not remove food deposits left on the teeth, particularly those lodged in crevices.

However, washes have their place, as an auxiliary measure, in the regimen of mouth hygiene. They are especially useful in helping temporarily to overcome an offensive breath--in connection with other necessary treatment; in removing a “bad taste”; as a cooling agency, and to allay an inflammatory condition of the mouth as a result of disease or other cause.

There are mouth washes based upon both alkaline and mildly acid principles. As most of the destructive germs of the mouth flourish in an acid reaction, the alkaline solution neutralizes the acidity, thus making the condition of the mouth less favorable for the propagation of germs.

Of the alkaline group, the most readily available and one of the most efficacious, is salt and water--a mixture of a teaspoonful of ordinary table salt to a glass of water. If more salt is used, however, it will do no harm. Soda bicarbonate, or common baking soda, in the proportion of a teaspoonful to a glass of water, is also excellent.

Milk of magnesia, already referred to, is considered by some authorities to be very good. When worked about the mouth and between the teeth, it not only neutralizes the acidity, but protects the teeth by leaving a coat of magnesia over their surface.

Of the mildly acid mouth washes, hydrogen peroxide, mixed one part to two of water, is germicidal. The regular use of this preparation, however, has a tendency to produce an unpleasant irritation and “set the teeth on edge.” In fact, any acid element has this effect, more or less.

Listerine, properly diluted, is a pleasant, mildly acid mouth wash with antiseptic properties.

Dakin’s solution is another powerful antiseptic mouth wash, the product of Dr. H. D. Dakin. It was widely and effectively used for treating wounds in the World War, having been sponsored by Dr. Alexis Carrel, the famous surgeon.

Dr. W. H. Dixler, in a paper read before the Pittsburgh Adontological Society, described its action most interestingly as follows:

“The action of Dakin’s solution is an intensely germicidal one, having a store of chemically combined chlorine in a form which is non-irritating and non-toxic. When brought into contact with proteins and blood serum micro-organisms and pus, it readily parts with its chlorine to the basic substance, immediately exerting its antiseptic and germicidal action.”

“We found that it performs this chemical action without irritation, and that it does not coagulate albumen, nor does it interfere with the digestive action of trypsin of protein, but it does actively disintegrate protein, and influence a flow of lymph, thereby cleansing the wounds, which is one of the most important features in wound sterilization. We are inclined to believe that necrosed tissue is dissolved and liquified, so that it may be carried away by drainage or absorption, and in this way the germs on the clean surface of the living tissue readily are exposed to its germicidal action.”

Dakin’s solution is also efficacious in combating pus formation in pyorrhea. In fact, it is valuable in overcoming pus formation under any conditions, and on this account proved itself so useful in treating the suppurating wounds of soldiers during the World War. The remarkable strength, combined with its non-toxicity, is attested, when we realize that a one in one-thousandth solution of this germicide is more effective than a five per cent solution of carbolic acid.

As a mouth wash, it is used in one-half to one per cent strength, morning and night, or when needed. The mouth should be rinsed thoroughly, retaining the solution for a minute or two in order to have the antiseptic liquid act upon the germs.

BLEEDING GUMS.

Persons troubled with bleeding or sore gums should consult a dentist, as this may prove to be a symptom of approaching pyorrhea, or other deep-seated disorder. However, if home treatment is imperative, Dakin’s solution may be recommended for temporary use; also sodium perborate (Merk’s)--one teaspoonful to half a glass of water, used as a mouth wash every two hours.

_Stomatitis_, or inflammation of the mouth, which generally takes on the form of blisters or ulcers, is a very distressing complaint. Attention should be given to diet, as well as to the most thorough-going hygiene of the mouth, and a physician might well be consulted to see if there is any general symptomatic trouble, or if the inflammation is a symptom of any other more serious disease.