From the Archives
Journal of the American Medical Association, June 9, 1928
Editor’s Note: This fascinating article, published in 1928, was almost certainly read by Dr. Price.
Dental caries may be properly considered as a disease of childhood, susceptibility at this age period being almost universal. In surveys of school children it is unusual to find a mouth free from caries. The average child will have seven or more affected teeth in various stages of destruction. The rate of progress of the carious process and the number of teeth involved varies with the individual. As the child approaches maturity, retardation of destruction becomes evident. In some instances active caries may become arrested spontaneously during childhood. The factors involved in the inactivation have not been understood, nor have many instances been recorded.
ETIOLOGY OF DENTAL CARIES
The etiology of dental caries is a subject of controversy. It is generally conceded that a break in the continuity of the enamel is a primary requisite. The exposed dentin thus becomes susceptible to attack by external agencies. Any factor leading to enamel defects will thus predispose a tooth to caries.
It is evident, however, that other factors also are involved, for it is not unusual to find in the middle aged all teeth abraded almost to the gingival margin, with the dentin widely exposed, yet no evidence of active caries. Various strains of bacteria have been described as causative agents. It is obvious that the carious process involves a bacterial factor, but it is questionable whether this is due to any specific organism or is a secondary invasion of dentin which has previously been injured in such a way that it cannot withstand the many organisms found in the normal mouth. Strict oral hygiene is not necessarily a preventive of caries, and many adult mouths which do not receive care and have exposed dentin show little carious activity. That some other factor is involved from those mentioned is made presumptive by the observations which form the basis of this study.
UNUSUAL ARREST OF CARIES
The present report was prompted by some unusual observations made in the course of repeated routine examination of patients in the dental division of this clinic. The examinations disclosed numerous instances of definite arrest of caries in children. Teeth containing large cavities, which ordinarily would have an area of softened dentin surrounding the zone of destruction, were found instead to be very dense. In these mouths in which there was evidence of rapid and extensive involvement of many teeth, further invasion was shown by subsequent examinations to be checked, and open cavities did not show any signs of progress months after they had first been described. Moreover, the occurrence of salivary calculous deposits on these teeth was almost universal, and it recurred rapidly after its thorough removal. Salivary calculus, though not uncommon in the adult, is very unusual in the child. Otherwise, these patients did not show anything noteworthy from a dental standpoint. Shedding and eruption were about normal in most cases. The degree of oral hygiene varied as greatly as in any unselected group of similar size. Some teeth showing unquestionable arrest of caries were found in the most poorly kept mouths.
When these dental observations were correlated with the medical histories of the patients, it was found that without exception the children with arrested caries were all diabetic patients who had been under careful management for six months or more.
The diabetes itself does not offer an explanation of the arrest of caries. A review of the earlier examinations of many of these patients at the time that they first came to the hospital showed the caries to have been definitely active. Furthermore, it is known that in diabetes not under control and in ketosis there is a negative mineral balance which of necessity must lead to decalcification of teeth.
Since arrest of caries was not noted in children with any other disease or condition and since it is not dependent on diabetes, it appears that it must depend on some factor in diabetic management. A further study of other diabetic patients revealed a parallelism between the establishment of diabetic control and the quiescence of the caries.
RELATIONSHIP OF DIABETES MANAGEMENT AND DENTAL CARIES
The principle of diabetic management in this clinic represents an attempt to approximate normal metabolism. Insulin is prescribed in amounts sufficient to keep the blood sugar as nearly within normal limits as possible. The diet is designed to meet the requirements of a normal child for growth, activity, and health. It differs from the usual concept of an ideal diet for a normal child in that fat, rather than carbohydrate, is used as the chief source of energy, the fatty acid: dextrose ratio being 1.5:1. All these children were on the same ratio of protein: carbohydrate: fat, namely, 7:9:21. The total amounts prescribed varied according to each child’s degree of development.
In general, the same foodstuffs were used for all. To a large extent these consisted of milk, cream, butter, eggs, meat, cod liver oil, bulky vegetables and fruits. The menu was designed to include approximately a quart of milk and cream daily. The fat was furnished principally as cream, butter, and egg-yolk. Each child received calories sufficient for full activity; the energy value was higher than is frequently employed in diabetic diets. Adequacy of insulin dosage was verified by frequent blood sugar estimations. These values closely approximated normal concentrations. Glycosuria [excretion of glucose into the urine] was different.
When diabetes is well under control we are inclined to look on diabetic children as essentially normal and as not differing from other children in any definite manner. It seems reasonable to us to suppose that the insulin given has done nothing more than to assist in the maintenance of normal sugar metabolism. If these premises are granted, the only factor in the arrest of caries remaining to be considered is the character of the diet. The arrest of caries in these children was coincident with strict dietary regulation, and it seems probable that the diet was the essential factor leading to its arrest.
The menus which these patients received furnished the essentials of a complete diet, so far as our present knowledge can determine. The use of an abundance of dairy products, fruits and vegetables, supplemented with cod liver oil, insured a considerable supply of mineral salts and vitamins. It is probably of significance that the ash of the diet was predominantly basic. This, together with an adequate and balanced ration, is the essential difference between the diet of these children with arrested caries and that of the child whose caries are progressive. The average child is generally allowed to use his appetite as an index of his food needs. His menu is determined by the choice of food offered him. Menus employed in the home are often far from complete in accessory food substances and minerals. It may be safely said that these diabetic children ate regularly a diet more in accordance with the needs of a normal child than the average child receives.
The high incidence of caries during childhood, its activation in adults by pregnancy and lactation, and its frequent association with deficiency diseases give evidence of its dependence on metabolic disturbances. Such disturbances may depend in part or wholly on the character of the food intake. Howe, Grieves and Marshall have demonstrated the development of caries in laboratory animals receiving diets inadequate either in vitamins or in minerals. These dietary deficiencies result in disturbances of the mineral balance. Such disturbances can manifest their effects within a surprisingly short time. Demonstrable changes in tooth structure have been noted within a few hours after the ingestion of various substances which affect the mineral metabolism of the body as whole. It is well known that calcium is readily mobilized from the bones and teeth when needed for the regulation of mineral metabolism. Chemical analysis of carious teeth shows reduction of the calcium and phosphorous. Associated with the development of tooth decay, the adjacent dentin becomes softened. These changes, by lowering the physiologic integrity of the dentin, permit bacterial invasion to occur.
It would seem reasonable to suppose that, with a correction of conditions leading to metabolic disturbances, the teeth should develop resistance to caries. The spontaneous arrest which is not uncommon in the adult may be credited in part to the relief from metabolic strain associated with growth. With an approximation of ideal conditions in childhood, arrest of caries should result.
AVERAGE AMERICAN DIET LACKING
To correlate these observations with the problem of caries in the child who does not exhibit a manifest form or recognized metabolic deficiency, we must consider the borderline states of nutritional disease conditions and study them in relation to the type of diet which is commonly employed by the average American family. Analysis of these diets from the standpoint of vitamin and mineral adequacy shows them to fall below the optimum values, sometimes to a marked degree. While their defective character might not reveal itself in the case of the adult who is free from undue metabolic strain, the same would not be true of the child, whose requirements of growth and development keep him continuously near the danger zone of metabolic imbalance.
In the case of these diabetic children, with their condition kept quite well under control by dietary and insulin management, we believe that because of the intake of a supposedly adequate supply of vitamins and minerals the caries has become arrested. The employment of similarly adequate diets by the average healthy child should be equally effective in the prevention and arrest of tooth decay.
This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly magazine of the Weston A. Price Foundation, Fall 2012.
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