The Dental Disabilities of School Children
The Psychological Clinic Copyright, 1909, by Lightner Witmer, Editor. Vol. III. No. 8. January 15, 1910. :Author: Edward C. Kirk, D.D.S., Sc.D.,
Dean of the Dental School, University of Pennsylvania.
I esteem it a special privilege to be given the opportunity to address an audience of teachers upon a phase of hygiene which is growing daily in importance and which has a direct bearing upon the character and progress of educational work.
Perhaps no aspect of modern educational activity is more characteristic than that which is concerned with the interrelationship of bodily and mental health. A generation ago, serious consideration of the health factor was regarded as outside the sphere of educational discussion, even a decade ago the hygiene of school children was only of incidental interest, whereas to-day it is commanding the attention of educators the world over as a problem of paramount importance fundamental to the work of education. So actively has the conception of interdependence of bodily health and mental efficiency been developed, that the old dictum of Juvenal, mens sana in corpore sano, in the light of modern investigation has attained to the dignity of a scientific axiom. To-day no one of intelligence questions the essential importance of the health of school children as a prerequisite to efficient school work, and the health problem is becoming a more and more important consideration in its educational relations. While the hygienic aspect of the educational problem is distinctly modern in its development, the underlying principle of the interdependence of mental and bodily activity awakened interest much earlier as an educational question.
In a remarkable paper by Dr Edward Seguin, of New York, entitled, “New Facts and Remarks Concerning Idiocy,”2 the ‘An address delivered before the Teachers’ Institute of the Reading District at Reading, Pa., October 30, 1909.
aA lecture delivered before tbe New York Medical Journal Association, October, 18G9. author points out the mutual dependence of the great nervou9 centers and the peripheral nerve endings, and the. greater possibility of acting upon the centers through the periphery than on the periphery through the centers, at least during the period of growth. He was led to this important deduction as the result of his experience in the successful education of imbeciles by a system of training based upon the stimulation of the sensorium through the tactile and visual perceptive faculties, as a result of which he was enabled to enunciate the physiological principle afterwards successfully utilized in the manual training idea, i. e. the education of the brain through the perceptive faculties as a whole rather than through those of the ear and eye exclusively. Reference is made to this pioneer work because it so clearly involves a recognition of the important part played by the nervous mechanism of the body in the educational process, and thus affords an easy step to the logical deduction that whatever interferes with the integrity of the nervous mechanism as such or with its normal functioning, constitutes in greater or less degree an obstacle to the education of the mind.
In the consideration of physical defects as related to individual educational progress, those deficiencies which obviously interfere with the child’s ability to study were naturally the first to attract attention. Hence defects of vision and of hearing, being direct obstacles to study, have commanded greater and more sympathetic consideration upon the part of school authorities than a much larger and equally potent, though less obvious, group of disabilities which are only now beginning to excite the interest which their importance warrants. In this latter class may be included the whole range of disorders, local and constitutional, which have their origin in abnormal conditions of the mouth and its contained dental organs. Time will permit of only a general and hasty reference to the main features of this phase of the subject. Apart from its relation to articulate speech and respiration, the mouth is the portal of the digestive tract; it is the laboratory in which the food is prepared for digestion, and in which the initial stage of digestion takes place. In order that the preparation and predigestion of foods shall proceed normally, it is essential that the dental apparatus shall be normally developed, the teeth correctly arranged with reference to their relative positions and that they be sound and clean, and that the saliva which is the digestive juice of the oral cavity shall be normal in composition and sufficient in quantity. Imperfections in these requisites entail disturbance not only of the process of food preparation and its normal predigestion in tlie mouth, but wliere these processes are continuously interfered with, derangement of the entire digestive and assimilative mechanism ensues, giving rise to a long category of disease conditions. Such being the case, the care of the mouth and teeth becomes an important and necessary department of hygiene, requiring the same careful study and intelligent application of health rules and their enforcement which we recognize as essential to the protection of bodily health against other sources of disease causation.
The most potent and general cause of dental disability and consequent disease is uncleanliness of the mouth and teeth. In the past twenty-five years the scientific investigations which have been made of the causes of dental disease have demonstrated beyond question that the human mouth presents conditions favorable to the growth and development of a large variety of bacterial organisms, very many of them being the known causes of a large number of local or bodily diseases. In the human mouth the conditions of temperature, moisture, oxygen and food supply required for the development of bacteria are found in an ideal relation so that the mouth becomes as it were an incubator in which these disease-producing organisms multiply with astonishing rapidity. In an habitually unclean mouth certain of these germs bring about fermentation of starchy foods and sugars, generating an acid which dissolves the mineral salts from the hard structures of the teeth, exposing the cartilaginous matrix or basis of the dentine; this in its turn becomes infected by germs of putrefaction which liquefy and destroy it, producing the disease known as dental caries or tooth decay. Beside the germs of dental caries, pus germs or those which are the exciting cause of suppurative inflammation are found abundantly in all unclean mouths as well as the germs which are the exciters of pneumonia, tuberculosis and a host of other wellknown diseases. Where ordinary care is given to brushing and cleansing the teeth, the total number of these disease-producing germs does not reach a point beyond the power of the defensive forces of the healthy body to take care of, but in neglected mouths not only are disease processes set up in and about the teeth themselves, but the constant swallowing of disease-producing germs and their excretions along with the food infected by contact with the germ-laden teeth and soft tissues of the mouth, sets up infections of the whole digestive tract. This in time becomes a manufactory of poisonous substances which are absorbed into the general circulation, causing a chronic blood poisoning and general interference with the whole bodily nutrition. It will thus be seen that an unclean mouth is the originator not only of local dental disturbances, but it is a source of infection to the whole body. The chronic poisoning of the blood stream in this manner may and often does, in the course of time, so interfere with the processes of nutrition as to depress the vital resistance of the body to a plane where it is unable to prevent infection from specific disease germs and the unfortunate sufferer may thus be carried off by an attack of acute disease, having its unsuspected predisposing cause in a chronically filthy mouth. Another result of tooth decay is important to note. When caries has destroyed the hard tissues which protect the central organ of the tooth, the dental pulp, its infection and death quickly follow, the process usually being signalized by an attack of acute toothache. Death and loss of the pulp leaves an open passageway through the tooth root for the entrance of disease-producing germs, affording them direct access to the bony structures in which the tooth roots are embedded.
The production of a dental abscess resulting in a so-called “gum boil” is a common expression of this type of infection. But pusproducing germs are not the only disease producers that find entrance to the circulation through this channel. It has been found as the result of careful, clinical and scientific study, that the germ of tuberculosis is among the invaders that gain frequent access to the body through the avenue of the empty tooth pulp chamber giving rise to tuberculous abscesses so commonly observed in or about the lymphatic glands of the neck or giving rise to tubercular inflammation of the bones of the jaws and those of their related regions.
The local and general diseases whose origin has been unquestionably traced to infections arising from filthy mouths are numerous and convincing, but time will not permit even a short enumeration of them here. I have merely endeavored to point out and briefly illustrate the general fact.
Apart from the damage to health and the consequent physical disability arising from oral uncleanliness, neglect of mouth hygiene leads to loss of the teeth, a loss which has never been taken as seriously by the uninformed as its importance warrants. The loss of even a single tooth should be looked upon as a calamity, for the reason that it means always the loss of function of two teeth, the one actually lost and its opposing tooth, for a tooth without its normal antagonist is functionally useless. But even if this should constitute the total loss there soon follows a disarrangement of the whole denture, the teeth assuming abnormal and irregular positions because of the loss of mutual support which the individual teeth exert upon each other in a normally arranged denture. This entails a disturbance of the proper relations of the food-grinding mechanism and interferes with the function of mastication. The evils of imperfect mastication need scarcely be dilated upon. To put upon the stomach the burden of digesting food imperfectly masticated, is to invite disease of the entire nutritional apparatus. The study of this phase of the nutritional question and the results obtained from the experiments made by Prof. Chittenden, of Yale, in collaboration with Mr. Horace Fletcher are sufficiently convincing and are doubtless familiar to all of you. The relation of this broad subject to the health of school children and to their mental efficiency is just now attracting worldwide attention. America, the land of dentistry and dentists, has, strange to say, been rather tardy in giving it serious and practical consideration. Germany and Austria, Russia, France, Switzerland, Sweden, England, and Australia have been making careful studies of dental and oral hygiene in relation to school children for a number of years. The institution of systematic dental inspection of school children and the creation of free dental clinics may, generally speaking, be said to be accomplished facts in the countries I have named. Statistics show that from 90 to 98 per cent of the school children in all countries suffer from some form of preventable dental disease, and what concerns us more directly is that the greater proportion of backward children, those unable to keep up with the average work of the class, are found to be sufferers from some form of dental disorder, arising mainly from neglect of the simplest and most obvious rules of mouth hygiene. Among upwards of fifteen thousand patients annually treated at the dental clinic of the University of Pennsylvania, a large proportion are school children between the ages of six and fifteen years. Examination of their mouths rarely discovers one that is maintained in a fair state of cleanliness, few own or use a tooth brush, and all require more or less professional attention. In studying the causes of mental inefficiency in backward school children, Prof. Lightner Witmer of the department of psychology at the University of Pennsylvania has been focussing attention upon the mouth conditions of these children. Many of them are referred by Dr Witmer’s department to our dental clinic, they are invariably “dental cripples” as some one has aptly termed them, they present infected mouths, decaying teeth, damaged grinding mechanism from loss of teeth or from irregularities, all of which are manifestly interferences with bodily health and therefore of mental efficiency. It has been discovered that one-third of the 148,000 pupils in the public schools of Philadelphia are over age for their grade. Records show that 483 children have been thirty months or more in the same grade, while 9486 pupils have been recorded as beginning for the third time in the same lessons, and from these facts it is contended that many children are mentally incapable of pursuing their studies.
It is not my purpose to discuss in detail the relations which each of these dental disorders bears to the efficiency of the child as a student at school; from whatever angle the subject is investigated the logical conclusion arrived at is the same, viz., that all these disorders are sources of ill health and that ill health is a direct handicap to the effective working of the nervous mechanism, upon the normal functioning of which intellectual progress depends. The practical question which is the necessary outcome of our acceptance of this general major premise is, what can be done about it? My own observation leads me to conclude that three things are necessary:
First, education of children and parents as to the essential facts concerning mouth hygiene to an extent that will force the conviction that cleanliness of the mouth and teeth is essential to health and is the best safeguard against disease. Secondly, systematic and regular inspection of the mouth of school children by expert dentists.
Thirdly, the organization of dental dispensaries where the needy may obtain proper dental treatment free of charge. It is with considerable hesitation that I suggest an addition to the work of teachers already overburdened with the duties imposed by a curriculum which is said even now to be overcrowded; nevertheless the importance of a knowledge of the principles of hygiene in general, and of dental hygiene in particular, is so evident and so fundamental in its educational relations that it would seem to be the part of wisdom and common sense to embody a reasonable amount of instruction in dental hygiene in the curriculum of study even to the neglect of some relatively less important topic now required as a part of the educational scheme. I think we would be justified in taking such ground quite apart from the humanitarian features of the case, when we consider that all of the evidence goes to establish the fact that lack of knowledge of dental and oral hygiene is the fruitful cause of health disorders which directly inhibit the capacity of the child for study, and, therefore, from the educational standpoint alone as a means of improving the mental efficiency of school children, the introduction of a fair amount of instruction in the elementary phases of dental and oral hygiene would be more than justified. No amount of instruction in this subject can be productive of practical results without efficient means for putting into effect the principles taught. This will require among other things inspection of the mouths of public school children by experts qualified for that work. It is a work which should not be entrusted to medical inspectors ; the curriculum of medical study does not furnish the training requisite for the intelligent and skillful performance of that class of work. Under present conditions, those best qualified for the study of mouth inspection are dental specialists who by training and experience have been properly educated for that work; and, finally, in connection with school education in dental hygiene and efficient dental inspection of school children, there must be provided the means for the treatment of dental disorders where the needy can receive the required attention free of expense. This will necessitate the creation of a large number of free dental dispensaries organized in principle upon the same efficient lines that characterize the free dispensary which has been established in your own city of Reading.
In order to secure an efficient organization of these three fundamental factors, education, inspection and treatment, a collaboration of school boards, of municipal authorities and of the organized dental profession must be brought into harmonious relationship. In closing, I cannot suggest to you a better expression of the great truth which is at the basis of this now general movement than to quote to you a statement made by Dr Elliott, of London, in a report upon the subject made to the School Dentists’ Society of England in 1904. Dr Elliott said, “The child’s health, mental and physical, is a national asset which it is the duty of the state to preserve and foster by every possible means.”
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