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Dental Health in the Army
DENTAL BULLETIN SUPPLEMENT TO THE ARMY MEDICAL BULLETIN
VOLUME 5, NO. 3 (JULY 1934)
DENTAL HEALTH IN THE ARMY
Major W. D. Vail, D.C.
General consideration.—There are many factors to be considered in a discussion of dental health. Health is known as a normal condition of body and mind. From a dental health viewpoint, adult health implies 32 normal teeth in normal occlusion with normal gingival and sub-gingival tissues, all contained in a normal cavity. Such a development is the result of normal biological processes and there is every reason to expect such a result when the essential elements of biological forces are present, viz.: nutrition and functional activity. Growth and health are impossible without nutrition and the maintenance of health is impossible without functional activity; they are indispensable, and it is the frequent lack of these two elements that accounts for the infrequent development and maintenance of normal dental health.
Nutrition.—There is much to be said on the matter of nutrition. Nutrition is primarily dependent on normal physiological processes and proper constituency of the diet. The diet must contain constituents of the several tissues of the body if metabolic balance is to be maintained.
Eighty-five per cent of the body weight is water and only fifteen per cent is solid matter. It is surprising to learn that of the latter fifty-eight per cent is calcium phosphate.1
American diet is notably deficient in calcium content and investigators believe that calcium in human nutrition is of greater importance than is generally realized. There is a basis for the belief that “general health is improved and recovery from disease aided when the optimum calcium supply and utilization
is assured.”2 From its general bolstering influence it appears that calcium therapy may deserve serious consideration in Army health problems. It is from this standpoint the calcium diet offers the greatest possibility as a factor in dental health of the Army. Its role as a factor in the control of dental caries after the development of tooth structure has occurred, has not been conclusively demonstrated.3
Dr. Bunting is inclined to believe that diet is a factor in producing oral conditions that favor or retard the growth of the bacillus acidophilis, which he regards as the specific cause of caries.4
The constituency of diets is undoubtedly an important factor in health, general and dental. There is, however, a wide gap between the intake and utilization of diets. In the Army a diversified, well prepared diet is provided. Its utilization is promoted by military activities and environment. Until more definite conclusions are reached, dietary recommendations, except for a continuous study of the subject, do not seem appropriate in the Army.
Functional activity.—It has been said that nothing succeeds like success. It may also be said, with equal truth, that nothing promotes function like normal function.
Modern diets do not require full masticating function for deglutition, hence masticatory function has fallen into disuse. One is not required to actually incise food to obtain a morsel, nor compelled to prepare that morsel for further reception in the digestive tract by thorough mastication. On the other hand, food content has not changed materially and the requirements for oral digestion are as vital as ever. Inefficient mixing of food with saliva in the mouth endangers digestion; the lack of masticating function lowers local resistance. Therefore the maintenance of an efficient masticating function is an important health measure; it promotes nutrition at its inception and has a stimulating effect on the teeth and their investing tissues. The opinion is held that inefficient masticating function is a leading contributary [sic] cause of sub-normal dental health.
Loss of natural teeth impairs masticatory function and artificial teeth are inefficient substitutes for natural teeth. The importance of the conservation of normal masticating function
merits consideration of the measures that may be provided for the preservation of healthy natural teeth.
Loss of Teeth in the Army.
Officers.—The loss of teeth incurred by officers of the Army was determined by a study based on the record of annual physical examination of 6,000 officers made in 1933. The data was divided into five-year age groups, beginning at 20 - 24 and ending 60 - 64. The following are pertinent results of that study.5
(1) Officers having all natural teeth (excluding 3rd molars).
20-24 year group
615 per 1,000 or 61.5% of officers.
60-64 year group
71 per 1,000 or 7.1% of officers.
282 per 1,000 or 28.2% of officers.
(2) Officers having no natural teeth remaining (edentulous).
35-39 year group
6 per 1,000 or 1 in every 167 officers.
60-64 year group
115 per 1,000 or 1 in every 9 officers.
22 per 1,000 or 1 in every 45 officers.
(3) Officers having either upper or lower jaw edentulous, part or all natural teeth remaining in opposite jaw.
30-34 year group
2 per 1,000 or 1 in every 500 officers.
60-64 year group.
53 per 1,000 or. 1 in every 19 officers.
27 per 1,00.0 or 1 in every 37 officers.
(4) Rate of loss of teeth (3rd molars not included in computation of rate).
609 per 1,000 or .6 per tooth per officer.
8,835 per 1,000 or 8.8 teeth per officer.
3,841 per 1,1000 or 3.8 teeth per officer.
The rate of loss of teeth increases with the advance of years. The increase from 20-24 to the 55-59 year group is 235 per 1,000 per year. In the 60-64 year group there is a slight loss due, no doubt, to the fact that separations from the Army at the age of 60 or thereafter remove many officers from the active list who have large numbers of teeth missing.
The extent of loss of teeth by officers is emphasized by the following fact: 1 in every 20 is endentulous in one or both jaws. In other words, they wear full dentures, either upper, or lower, or both.
Whole Army.—The records show that the rate of extraction of teeth (including third molars) during the year 1932 was 369 per 1,000 per annum.6 The significance of this rate is that it represents the loss of one tooth by each individual in the Army every two years and ten months.
Comparison with similar data.—The above data would have more value if it were comparable with other similar data. Unfortunately such comparisons are limited. It is doubtful if any similar civilian groups live under conditions comparable with the military service. The standard of dental practice in the United States is considered higher than that in foreign countries, therefore comparison with foreign armies is not equitable.
The dental service of the United States Navy is not entirely comparable with the Army dental service. There are more dental officers per 1,000 military personnel in the Navy than in the Army. The requirements for enlistment in the Navy are more rigid, the requirements being twenty vital teeth, whereas in the Army twelve teeth are accepted, vital or non-vital. In the Navy, dental service is not extended to dependents of Navy personnel; in the Army considerable service is rendered for them.
Causes of Loss of Teeth.
General.—Approximately 80 % of common diseases have their self-limitations, or their downward, or incurable trend, slow or rapid, as the case may be.7 Caries and pyorrhea are the causes of the greatest losses of teeth. These diseases are not
self-limiting; once initiated, they progress on their downward trend unless corrective procedures intervene.
There is no immunity nor may it be acquired. Preventive inoculation is not applicable. Even advocates of calcium diets hold that local preventive measures both by the' patient and the dentist are required for successful results.8
In the Army.—Dental diseases per se are not causes for rejection in the military service; consequently they are common to all military personnel. Under such conditions health measures become corrective rather than preventive and, therefore, the burden of such effort rests on the dental service in so far as it has the capacity to serve. The capacity of the dental service depends upon (1) the standard of dental requirements, for commission or enlistment, (2) the quota of dental service personnel, (3) the cooperation of military personnel in a dental health training program, and (4) the extension of the dental service.
(1) The higher the dental standard for enlistment and adherence to its requirements are, the more easily a given number of dentists can maintain a satisfactory state of dental health., When 731 per 1,000 of recruits are in need of dental attendance, 256 of whom need emergency treatment,9 it is reasonable to believe that many possess unserviceable teeth that require extraction for the relief of pain, if for no other reason. The minimum enlistment qualifications require 12 serviceable teeth, but do not cover other conditions such as, for example, the presence of six or seven carious roots and teeth that are a potential menace to health. Dr. Black's report, based on a study of an unselected group of 600 individuals, showed that 57% of persons between the ages of 20-24 years had chronic infections about their teeth.10 Although it is believed that group of individuals possessed a higher standard of dental health than the average group of recruits, the report is indicative of the dental conditions that are commonly found in recruits and shows a need for the adoption and enforcement of higher entrance requirements. There are times when it may be necessary to waive higher requirements to obtain sufficient recruitment, but it would seem to be economical to apply higher requirements when it is possible.
(2) There is a maximum effort a given number of dental officers can make under given conditions. Such an effort may be
said to be adequate when their services are characterized by high rates of preventive measures, and relatively low extraction rates. The fact that 57% of cases treated report for emergency treatment (relief of pain and other intolerable conditions) is evidence that preventive measures are not effective.11 The time necessarily devoted to emergency attendance interferes with the application of effective corrective measures; dental infections involve the deeper tissues, become a menace to general health and finally result in the extractions of many teeth done in conjunction with medical attendance. Thus masticating efficiency is partially or wholly sacrificed as a health measure when, if the necessary dental attendance were available, both health and masticating efficiency would be conserved. It is reasonable to expect the maintenance of satisfactory natural masticating efficiency if an adequate number of dental officers is provided.
The capacity of a dental officer may be increased by providing him with trained enlisted assistants. Dental operations require close physical application and any relief that may be furnished a dental officer has an important bearing on the quality and quantity of his service. Many of the details in connection with dental service may, with proper supervision, be delegated to others. For example : The underlying causes of pyorrhea are long continued mild irritations of the gum margins, and deviations from the normal in lines of occlusial stresss.12 The removal of these irritations may be done by trained enlisted men and, depending on their experience and adeptness, their services may be extended to the treatment of simple gingival lesions. This would provide great relief to the dental officer, and excellent benefits to the command. The mechanics involved in the construction of dental prostheses may be entrusted to enlisted men. An efficient organization of the dental service of a command approximating 1,000 where one dental officer is on duty would be: 1 enlisted man as chair assistant, 1 as a hygienist, 1 as a dental mechanic and 1 as a record and supply clerk who would have supervision over office management. Such an organization would increase greatly the capacity of the dental service and would permit some organization for a dental health training program.
(3) A dental health training program should be a component of every dental service because the responsibility for dental
health is divided between the individual and the dentist. Full cooperation between the two is required for satisfactory results. A dental health program should embrace instructions in a uniform method of hygiene for the teeth and their investing tissues (including masticating functions) by lectures and demonstrations; follow-up procedures to ascertain that the instructions are understood and followed; the provision of sufficient dental service to provide for periodical examination and treatment of incipient lesions, and the institution of dietary measures if and when indicated.
In the Army a dental health training program offers great possibilities, provided it is properly planned and executed and there is sufficient dental personnel available to furnish the necessary cooperation with individual effort to make the program effective. Unfortunately individual effort is only partially successful, unless supplemented by appropriate dental examination and treatment.
Dental health measures should be prescribed, the necessary instruction provided, and regulations requiring reasonable compliance enforced. Dental attendance regulations should embrace the required cooperative effort of an adequate dental service. Such a program is the only practical means of applying preventive principles to dental health; otherwise, only corrective measures are applicable and these have proven ineffectual.
(4) The extension of dental service to dependents of military personnel is in conformity with Army Regulations. A strict compliance with the latter prevents dental attendance to “dependents” where it interferes with treatment for military personnel. However, human suffering must be relieved and in dental attendance the mere relief of pain is often the worst form of temporizing, and justice to humanity demands some definitive treatment. Inasmuch as Army Regulations provide for this character of treatment, it should be understood that the inadequacy of dental personnel is increased to that extent.
The loss of teeth at the rate of 1 tooth per individual every 2 years and 10 months is excessive.
Dental diseases are not amenable to specific preventive measures such as innoculation [sic]; there is no immunity, actual or acquired.
The means for the control of dental diseases are rigid individual hygiene requirements, supplemented by periodical professional care.
The wide prevalence of dental diseases in the Army is indicative that control measures have not been successfully .employed.
The rates of extraction may be lowered and masticating function preserved with mutual benefits to health by (1) higher standards of dental requirements for admission into the Army, (2) the institution of an effective oral health training program, and (3) a suitable increase in dental service personnel.
1 Domb, David B.: Nutrition: The Chemistry of Life, Pac. Dent. Gaz. and Jr. 41:843 (Oct.) 1933.
2 Bernheim, Alice R.: Calcium Need and Calcium Utilization, J. A. M. A. 100: 1001 (April 1,) 1933.
3 Johnson, C. N.: Control of Dental Caries, Dent. Items of Int. March 1933.
4 Bunting, R. W.: Recent Developments in The Study of Dental Caries, Science 78: 419 (Nov. 10,) 1933.
5 Dental Bulletin, Supplmt. Army Med. Bul. 4: 103 (July) 1933.
6. Report of Surg. Gen., U.S. Army, 1933, p. 176.
7 Mayo, Chas. H.: A Transitional Age in Medicine, Int. Clinics 4: 1 (1932 Series).
8 Apperman, I.: Calcium 'Metabolism and Dental Caries, Dent. Cos. Sept. 1932, p. 841.
9 Dental Bulletin, Supplmt. Army Med. Bul. 4: 36 (Jan.). 1933.
10 Black, A.D.: Roentgenographic Studies of Tissues Involved in Chronic Mouth Infections: J. A. M. A. 71: 1279 (Oct. 19) 1918.
11 Dental Bulletin, Supplmt. Army Med. Bul. 4: 20 (Jan.) 1933.
12 Crane, A. B. and Kaplan, Harry,: Recognition of Pyorrhea Alveolaris and What Constitutes a Cure, Dent. Items of Interest, Sept. 1932.