EFFECT OF DIET ON CARIES IN CHILDREN.

r
THE BRITI!B
lfEDICJL J 01JBNU.
p.erious energy through the phrenic will diminish and lead
to movements of the vocal cord in which the excursions will
be equal to, and not greater than, those of the vocal cord
on the opposite or normal side?
Another question also requires an answer : When the vocal
cord is moving normally through nervous impulses conveyed
to it through the phrenic, will the patient be able to
phonate? This is the question asked by Sir Frederick
Mott. The answer can hardly be decided by experiment on
the monkey: operation on man will give the reply. This
will be the decisive experiment.
The conclusion, therefore, appears to be, that for the cure
of recurrent laryngeal palsy and th8 attainment of normal
moYement of the vocal cord in tranquil respiration,
anastomosis with the vagus or the descendens noni must be
rejected, and wme form of anastomosis should be carried out
with the trunk or with one of the roots of the phrenic nerve.
The Medical Research Council has defrayed the expenses cf this
research, and given me every possible assistance at the National
Research Institute.
THE EFFECT OF DIET ON THE
AND EXTENSION OF CARIES IN THE
TEETH OF CHILDREN.*
(Preliminary N ate.)
BY
MAY C. LEE PATTISON, M.B., B.S.LoxD.,
AND J. w. PROUD, L.D.S.,
SHEFFIELD.
INTRODUCTION.
IT has been found by May Mellanby
1
in her experimental
work on puppies, first published in 1918, that the structure
of the teeth and their arrangement in the jaws are con-
trolled by the diet and environment to which the animals
are subjected during the period of development of their
teeth. Some dietetic factors tend to help, and others to
hinder, the formation of well calcified, evenly arranged
teeth. In the former group are to be found substances
rich in a vitamin closely allied, both as regards distribu-
tion and properties, to vitamin A. This group of sub-
atances includes cod-liver oil, animal fats (except lard),
milk, and yolk of egg. Among those foods which lead to
the development of badly fotmed teeth, cereals, and particu-
larly oatmeal, occupy a prominent position. Thus the total
influence of a mixed diet on the structure and the arrange-
ment of the teeth in the jaws of puppies is the outcome of
a battle between different dietetic influences.
In addition to the influence of diet, May Mellanby
2
has
also shown that exposure of the animal to either sunlight
or other sources of ultra-violet radiation has, under some
oonditions, an important influence on tooth formation. It
is probable that the effect of these radiations is to make
active the calcifying vitamin stored in the body. In fact,
the interaction of the dietetic and environmental influences
on tooth formation is certainly very close. .
Two questions arise from the experimental work on the
factors influencing the formation of puppies' teeth: first,
Do the same factors control the formation of the teeth of
human beings? and secondly, What relation ha Ye these facts
to dental caries in man?
With regard to the first question, it is not yet possible
to state that the results are applicable to man, in spite of
the fact that the experimental work was published some
years ago. There seems, however, some justification for
believing that they are. It may be said also that if the
results of this experimental work can be extended to man,
a partial answer to the second question is supplied, for if
teeth perfectly formed and well arranged in the jaws can
be produced in children by feeding them along the lines
suggested by the animal experiments, then such teeth
will be less liable to caries than if they were imperfectly
formed.
.Although such a relationship is obvious to some, yet the
Jdea is not generally accepted by dental authorities, because
of the supposed fact that children's teeth are in general
" The expenses of this research were defrayed in part by a grant from
the liledical Research Council and the Dental Board of the United
J[lngdom, to whom our thanks are due.
well formed and yet very liable to become carious. May
Mellanby,
3
however, found, when examining a large number
of children's teeth under the microscope, that on the whole
the more perfectly formed teeth, as evidenced by micro-
scopical examination, were the least carious. There were,:
however, exceptions to this rule, for out of 302 teeth
examined microscopically 11 were carious and yet well
formed, while 13 were free from caries although of defective
structure. Closer examination revealed that when teeth
were well formed and carious any secondary dentine present
was usually poorly calcified; and, on the contrary, badly
formed teeth free from caries, or in which caries had been
arrested, generally had some well formed secondary dentine.
It appeared, in fact, that although the formation of the
original enamel and dentine was as a rule a good indication
of the susceptibility of a. tooth to caries, the presence and
structure of secondary dentine indicated a second line of
defence dependent on resistance set up in the body and
particularly in the tooth itself.
These data, obtained by examination of deciduous teeth
of children, were further correlated with some experimental
results which showed in a few cases . that good secondary
dentine was formed in puppies' teeth on a. " good " diet,,
and imperfect secondary dentine when they were on
" defective " diet. Thus it appeared probable that in
children also " good " diets might contribute to the arrest
of decay. On the contrary, diets compatible with the
formation of bad enamel and dentine might be expected tO
offer less resistance to the initiation and spread of caries.-
It may be noted here that the resistance of the puppies to
infective processes generally was found to be closely depen-
dent on their diet--a " good " diet affording them great
resistance, and a " defective " diet rendering them more
susceptible. Reference must also be made to the claim of
1\IcCollum, Simmonds, Kinney, and Grieves and Howe
that " caries-like " lesions can be produced in rats and
guinea-pigs by diets defective in certain respects.
OBJECT AXD CoNDITIONS OF INVESTIGATION.
It is evident that the previous experimental work
gested most strongly that dental caries in human beings
would be influenced by the small but specific differences in
diet above mentioned. It appeared necessary, therefore,
to investigate this matter, because corroboration of the
animal results and their extension in man to the problem
of caries would, if forthcoming, raise this subject from
a position of academic interest to one of immediate human
utility.
The children under observatio=t were in an institution
during the period of the investigation, and their diet and
environment generally were under the close supervision
of one of us (C. L. P.), by whom the improvement in the
health of the children was carefully watched.
Three groups of children were taken. One set (nine in
number) were placed on diet (diet A) which included cod-
liver oil, milk, and eggs, but no oatmeal. On the basis of
the investigations referred to above, this diet, which has
a potent effect in bringing about calcification, might be
expected to increase the resistance of the body, and especially
the teeth, to bacterial infection. The next group oon
sisted of ten patients
1
who received a diet (diet B) similal'
on the whole to diet A-the chief differences being that it
included oatmeal, very little egg, and less milk thati diet A,
and no cod-liver oil. The third group consisted of thirteen
children chosen from patients on the ordinary hospital diet
(diet C). They were selected so as to be comparable with
the first two groups in age, duration of institutional
treatment, etc.
The diets eaten by the three groups are indicated below,
but naturally the quantities varied to some extent with the
age of the child.
It will be noticed that diet B, which contains more cerealt.
including oatmeal, and less calcium and vitamin A, b
otherwise not very different from the ordinary hospitai
diet (diet C), which holds an intermediate position-so far
as power to stimulate calcification in puppies is concerned
-between diets Band A. ',
The eHect of the three diets on the patients was very
carefully watched, and as far as could be observed there
was no difference in the improvement of the general health;
EF.FECT OF DIE'l' ON CARIES IN CHILDREN.
TABLE !.-Daily Diet.
Diet. A. B.
0.
(Hospital Diet.)
1\Iilk ... ... ... 2 to pints i pint H pints
Bread ... . .. 2 to! oz. 5 oz . .4d lib.
Fat ... ... ... 1 oz. (butter) 1 oz. (margarine 1 oz. (margarine
except towards except towards
Sugar (including
end) end).
oz. 3oz. H oz. and jam,
cooking) etc.
Oatmeal, groats
- 2 to 4 oz. Occasionally.
or gruel
Rice, tapioca, etc. no,.
Meat (cooked) ... oz . Hoz. 2!oz.
Potatoes ... . .. 2 oz . 4 oz. 4oz.
Other vegetahleR 2 oz. ! oz.
Cocca ... . .. Made with Made with Made with
milk water milk.
...
... . .. 1 Very little Sometimes.
Fruit, etc .... ... 1 orange, or As in Diet A As in Diet A.
or
swede juice,
Cod-liver oil
. 1 or 2 dr,
... 3 to 6 dr. -
2 to 3 dr.
in the three groups. The condition of the mouth and
of each child was charted at the beginning of the
dietary and also after some months, the period varying
slightly m differei1t cases. The difficulties of correctly
reeording all the findings are obvious, but we have tried
to retain the same criteria throughout.
Hypoplasia.-The general condition of the teeth as
regards hypoplasia obvious to the naked eye was noted.
A speeial standard (based on the observations mentioned
above) was adopted, and as far as possible used, throughout
the investigations.
Cmies.-An attempt was made to record the position,
extent, and deg1ee of softness and hardness of each carious
point in the individual teeth. After periods which varied
in the three groups from an avera"G of seven and a
half to eight months the teeth were examined and
the results charted. The number of teeth in which new
carious. areas had occurred since the first inspection and the
number of teeth previously carious in which the caries had
increased were noted. In addition, an attempt was made to
record the of hardening or softening of the carious
areas. Rad1ograms were taken at intervals, for it was
possible that there might be some alterations in
the structure and development of the bone surrounding
the teeth, of a similar nature to that observed by May
Mellanby in puppies.
Histology.-In most cases at the beginning and also after
some months of the dietary one or more carious teeth were
extracted, mounted in balsam, and ground down so that a
microscopic examination could be made. By this means the
W:tailed structure of some o.f the teeth can be compared
wtth that observed macroscopically. It w<ts hoped also from
these sections to get an indication as to whether the diet
had had any action on the carious process-such for
instance, as arresting it. This question will be dealt' with
when the investigation is more complete,
Ultra-violet Light: Saliva.-The action of ultra-violet
light together with the_ different diets is being investi-
gated, but the results wtll not be referred to in this pre-
liminary paper. C. Lee Pattison is estimating the calcium
content and hydrogen-ion concentration of the saliva of
these patients. '!'his will also be discussed in a separate
publication.
RESULTS.
Before recording the results obtained the following
points should be noted:
1. were select!ld for the three groups so that their
home environment. and d1ets _from birth to admission to hospital
werE\ as alike as. poss1ble-for example, particulars of the
prevwus diet were from the parents, and, although the
value of these data ts not great, efforts were made to have the
groups as possible in this respect. In most cases
the of the homes were known from the personal
observations of one of us (C. L. P.).
2. The_ a\erage l!"ngth .of time during which patients were on
the ordmar_y h<.>sp1tal dtet, before the first inspection of their
teeth, was, m months : Group A, 7.5; Group B, 8.5; Group C, 8.5.
3. The average age of the patients at the beginning of the
experiment was, in years: Group A, 7.5; Group B, 7.5; Group
c, 7.1.
4. The average period covered by the investigations was, in
months: Group A, 7.5; Grouf B, 7.5; Group C, 8.
5. The average amount o dental hypoplasia observed by the
naked eye was practically the same in the three groups A, B,
and C.
6. The average number of carious teeth in each child before
commencing the diets was : Group A, 6.25; Group B, 6.125;
Group C, 7.
TABLE H.-Summary of Investi,!Jation and Results.
A. B. c.
--------------1------
Number of patients in each group
A time between admission and first in-
spection (months)
Average age at which diet started (years)
9
7.5
7.5
10
8.5
7.5
13
8.5
7.08
Average period covered by the investigation 7.5 7.5 8.0
(months)
Average number of erupted teeth per child at 18.75 19.25 21.0
first inspection
Average number of carious teeth per child at 6.5 6.125; 7.0
first inspection
Exttttsion o/ Caries .
Average number of entpted teeth per child at
last inspection
Actual number of new teeth becoming carious
between inspections
Average number of new teeth per child becoming
carious
Number of teeth already carious in which caries
increased
Average number of teeth per child in which
caries increased
Total number of teeth showing new or increased
caries
Average number of teeth per child with new or
increased caries
Total number of carious teeth in which harden-
ing has occurred
Softening has occurred in
17.75
6.0
0.65
7.0
0.75
13.0
1.4
14.0
0
18.0
28.0
2.8
23.0
2.3
51.0
5.1
7.0
4.0
20.5
20.0
1.54
18.0
1.4
38.0
2.9
13.0
1.0
It will be noted that the average age of the child, the
period of investigation, and the dental condition before
the first inspection were practically identical-in fact, the
only obvious variation in the three groups was in the diet
the children received. It is therefore this factor which
is probably responsible for the differences observed in the
dental changes.
TABLE number of t<'eth per. child showing a spread of
canes prevwusly present and new cartous areas, together with the
main differences in the thl'ee diets.
Diet. Main Difference in Diet.
-----;:-1 Abundant calcifying vitamin and calcium; small I
amount of carbohydrate, not including oatmeal
Less calcifying vitamin and calcium; much carbo- I
hydrates, including oatmeal
Intermediate amount of vitamin A, calcium, I
carbohydrates ; some oatmeal
Average No.
of Teeth per
Child in which
Caries has
Spread.
1.4
-----
5.1
2.9
In other words, the tendency for caries to spread was
greatest in children receiving diet B, least in those receiv-
ing diet A, and intermediate in those receiving diet C.
SUMMARY.
It has been found that when children are fed on a diet
which has been shown (by May Mellanby) in the case of
puppies to result in the formation of well calcified teeth
then the initiation and spread of caries takes place at
slower rate than in the case of similar children fed on diets
not having such calcif):ing activity. The diet giving
the best be.stdes hav.mg ordinary qualities of
a_ dtet, 1s both m and the calcifying
Vttamm, and contams comparattve,y little cereal none o{
which is in the form of oatmeal. '
REFERENCES.
'May Mellanby: Lancet, 1918; Dental Record 1920 British Dental
Journal, 1923, etc. '
2 The ame: British Dental Journal, May, 1824.
19
;lhe same: lbtd., January, 1923; P.-oc. Roy. Soc. !.led., vol. xvi,
N. Simmonds, E. M. Kinney C J Grieves Bull Johna
lfo[Jkins Hospital. No. 382, 1922, p. 202. '
5 Howe : Dental Cosmos, 1920, lxii.
BRITISH MEDICAL
JOURNAL
LONDON SATURDAY JANUARY 13 1951
A FURTHER STUDY OF THE TEETH OF 5-YEAR-OLD CHILDREN IN
RESIDENTIAL HOMES AND . D.(Y SCHOOLS
BY
MAY MELLANBY
AND
. HELEN MELLANBT, M.D., Ph.D.
witlt the Assistance of J9AN JOYNER, B.Sc., and MARION KELLEY
!t was brought home to one of us in 1929, when examin-
mg the teeth of some 5-year-old children in London
County Council schools, that there was a great differ-
condition of their teeth and those of
children hvmg .m orphanages 'in the Midlands. Among
the.L.C.C. pupds at this time there were only 4.7% *with
canes-free or almost caries-free deciduous dentitions
whereas it was obvious at a glance that the number of
children with caries-free teeth was much
htgher. In 1943 the chance arose of making a limited
of inspections of the teeth of children
hvmg under dtfferent conditions. It was decided, in the
first place, to see whether any changes had occurred in
!he teeth of L.C.C. pupils between 1929 and 1943. The
was so great (the 4.7% of 1929 had
mcreased to 24.2% in 1943) that similar inspections were
made in 1945, 1947, and 1949 (MellanbyandCoumoulos
1944, 1946 ; Mellanby and Mellanby, 1948, 1950). '
was not until 1945 that an opportunity arose of
seemg whether there was any real connexion between
living and dental health in orphanage and
L.C.C. chddren. . Concurrently, a similar inquiry was
made pupds attending private (fee-paying) day
schools ; hke the L.C.C. children, they lived with their
own families. Meanwhile various workers had observed
a tendency for children brought up in orphanages to
suffer little from caries; while others, including Collett
(1935) and (1939) in Norway; and Anderson
et (1934), .m Toronto, had published a few figures
relatmg to m1xed age groups indicating that there was
less caries among such children than among the general
population. The threefold survey of 1945 (Coumoulos
and Mellanby, 1947) showed that children living in
homes had the worst dental structure, suggesting poor
calcifying diets daring tooth development, and .yet had
the least caries-less than the children of comparatively
well-to-do families and much less than the L.C.C. group.
It would have beeri instructive had we been able to
parallel every survey in L.C.C. schools with similar
inspections among residential homes and private-school
children, but this was not possible. Early in 1950,
however, the two groups in question were reinvestigated.
This seemed especially urgent, since the present policy
of boarding-out and adoption is removing nearly all
5-year-olds from homes.
In this paper we are using the term "home" or " resi-
dential home " to cover residential nurseries and schools
a?ministered by the State or by voluntary bodies ; pre-
viOusly we called them institutions. These are maintained
. *This figure of 4}% include,d, chil<!ren with up to three teeth
w1th very slight canes (C, cavities) smce the number of caries-
free individuals was negligible.
for children deprived of a normal home life for a variety
of reasons, such as the death, prolonged illness, or prison
of one or both parents, illegitimacy, or lack
of smtable housing facilities. Formerly such children
were accommodated in orphanages or institutions of
various types, including
Clinical Material and Methods
So far as possible the same homes and schools were
included in the 1950 survey as previously, but others
from near-by districts were added to increase the size
of the sample. In all, 55 homes (mainly situated in
and the surrounding country, with a few in the
Mtdlands) and 32 private and independent schools (in
London and adjacent counties) were visited, the total
numbers of children dentally inspected being 542 in the
former and 560 in the latter group. In 1950, as in 1945,
the average age of both groups of children was approxi-
mately 5t years.
The adopted for hypoplasia caries in
the clinical examination, and the methods used in cal-
culating the results, were the same as those employed
on many previous occasions. The degree of hypoplasia
was estimated with a right-angled probe : and the
rougher the labio-buccal surfaces the greater the degree
of M-hypoplasia. For diagnosing caries an illuminated
mirror and sharp rat-tailed dental explorer of standard
size were used. The teeth were neither dried nor
x-rayed, since, although these aids to detection would
have resulted in more caries being seen, the findings
would not have been comparable with those of past
surveys ; moreover, the diagnosis of the presence and
extent of caries by any known method often comes in for
criticism. For this type of work the important thing is
to have agreement on the standards to be adopted, fol-
lowed by adherence to these standards on the part of
the investigators, who must work in close collaboration.
The method of presenting the findings, especially those
relating to caries, is also open to criticism. We have
considered the arguments for and against our system
and the schemes adopted by some other workers, but
for various reasons we prefer to retain our own. Most
dental research workers concentrate mainly on the
incidence of disease, including evidence of past decay, in
recording the dental status of any given group of the
population. They often ignore the structure of the
teeth, apart from the grosser forms of defect, and its
bearing on the liability to caries. We, however, feel
strongly that both should be considered, and that, in
accordance with the precepts of preventive medicine, the
emphasis should be on the well-calcified and the caries-
4697
52 JAN. 13, 1951
TEETH OF 5-YEAR-OLD CHILDREN
BIUTISH
MEDICAL JOURNAL
free teeth rather than merely on the incidence of defect
or disease. In giving the results of the surveys, there-
fore, we mention first the more ideal state which it
is hoped more children will ultimately attain:
In assessing the quality of the teeth, division was made
into those which were externally smooth (no hypoplasia)
and those with varying degrees of roughness of the labial
or buccal surfaces. M-hypoplasia (King, 1940) was
graded M-Hy
1
to M-Hy
3
, according to the ;ncreasing
severity of the defects, while teeth with certain well-
defin_ed types of surface irregularity were, as before,
classified separately as gross or " textbook, hypoplasia.
The. numbers of teeth in the various categories of hypo-
plasia are expressed in the tables as percentages of the
total number of teeth examined. Any teeth which were
so carious or had such heavy deposits of tartar that the
surface structure could not be gauged were omitted from
this classification, and thus from the tables dealing \\ ith
structure. The average extent of surface texture defects
of the M-type is represented by the average hypoplasia
figure (A.H.F.) ; this, in conjunction with the percen-
tages of hypoplastic teeth, is, we believe, useful in
assessing the improvement or otherwise in the dental
structure of wccessive samples of children-for
example, 5-year-old L.C.C. pupils examined between
1943 and 1949.
Caries is expressed both as incidence and as extent for
each type of tooth, and for the sum of all types, in
each group of children. The incidence of decay by
itself, whether given as a percentage or as the D.M.F.
(decayed, missing, and filled) figure, can be misleading,_
since a group of individuals with small cavities woUld
appear in the table to have the same amount of caries
as a group in which the cavities were large. For this
reason the extent of caries in each decayed tooth is
described as being of grade 1, 2, or 3, according to the
estimated size of the cavity in relation to th.e 'size of the
tooth. The average caries figure (A.C.F.), like the
A.H.F., is some fraction of 3, and measures the esti-
mated average extent of caries in the teeth. In our
opinion the advantage of this method as against those
involving tooth surfaces is its relative simplicity ; also
the results so expressed are comparable with those
previously given in this series of reports and those pub-
lished by others using the same method (Deverall, 1936;
Davies, 1939; King, 1940; Coumoulos, 1946; Stones
et al., 1949).
In all the surveys made since 1943 it has been possible
to calculate from the published figures the D.M.F.
values. For instance, the percentage of carious teeth.
as expressed in Table IV and in earlier papers, is equi-
valent to the D.M.F. per lOO deciduous teeth, while the
total number of carious teeth divided by the number
of children and then multiplied by 100 gives the D.M.F.
per 100 children. Since the deciduous incisors are in
process of being shed between the ages of 5 and 6 years,
the missing ones are considered, in all our surveys, to
have been lost naturally, and are therefore omitted from
the tables. On the other haQ.d, any absent canines and
molars would almost certainly have been extracted for
caries at this period ; they are therefore included in the
caries totals (grade C
3
). It will be seen from Table I
that the majority of missing incisors in this age group
are lower centrals, in which there is very seldom any
decay, so that the total number of decayed teeth which
might have been present in those counted as " shed
must be small. It is obviously more difficult to analyse
caries figures for children of mixed age groups, espe-
TABLE I.-Percentages of Teeth Present at Time of Inspection
Homes
Private Schools
Type of Tooth
1945 1950 1945 1950
Uppet:
Centrals 940 933 935 949
Laterals 978 986 992 987
Canines 998 999 1000 1000
1st molars 995 994 982 981
2nd molars 998 994 995 992
Lower:
Centrals 857 815 760 763
Laterals 985 989 974 977
Canines 1000 1000 99-S 1000
1st molars 986 989 954 955
2nd molars 992 986 984 982
All types
I
973 968 958 959
cially those between 7 and 12 years, because the times
of eruption and shedding vary widely. For the
5-year-old children the task is relatively simple. From
Table I it is also seen that nearly all the teeth are still
in situ, with the exception of the lower central incisors,
which are normally shed relatively early.
Results
Table II shows the percentages of children in the
two groups who were caries-free and those who were
nearly so, together with the numbers of D.M.F. teeth
per 100 children.
TABLE !f.--Children Caries-free or Almost So, a11d the D.M.F.
Values Per lOO Children in. Residential Homes (R.H.) and
Private Schools (P.S.)
V
No. of
%Caries- %Almost
%Caries-
JlD.M.F.
Group Children
free+Those
per 100
Investi- Examined
free Caries-free Almost
Children
gated
Caries-free

-
1945 1950 1945 1950 1945 1950 1945 1950 1945 1958
R.H. 325
5421
572 587 89 149 661 736 204 139
P.S ... 371 560 504 400 43 180 547 580 275 246
Although the figures for caries-free children are given
here to conform with the reports of all the earlier sur-
veys of the series, it has throughout been realized that
where the differences between the various groups under
review are not spectacular a better picture is gained by
considering teeth rather than dentitions. Thus some
10% more private-school children had dental decay in
1950, yet the total percentage of caries-free teeth (C
0
) was
actually greater than in 1945. In other words, the
disease was more widespread at the time of the later
survey, but was of a milder form (see Tables II and IV).
The findings relating to the teeth as opposed to the
whole 4entitions of the children are given in Tables Ill
to VI. In considering them, a comparison will first be
made between the 1950 and the 1945 results for each
of the two groups of children separately. Then the
results for the residential homes and the private-school
groups will be compared. Passing references to the
finding> in L.C.C. schools in 1949 and 1945 will also be
made, although 'the interval between examination was
six months less for them than for the other groups.
Surface Structure of the Teeth
Residential Homes in 1950 and 1945.-lt will be seen
from Table Ill (column 4) that 42.0% of all the teeth
were perfect or nearly perfect in structure--that is,
hypoplasia-free-in 1950 as compared with 32.3% in
1945. This improvement was found in all types except
the upper first molars, which remained the same as
before, and the upper second molars, where the
JAN. 13, 1951 TEETH OF 5-YEAR-OLD CHILDREN
--- ----------------------------
percentage decreased. (It is realized that tartar deposits
found on a proportion of upper molars, espec:ally
second molars, may mask the actual surface texture,
thus making it difficult to assess the structure and there-
fore any change. This applies to all our surveys.) There
was very little M-hypoplasia of the most severe grade
(M-Hy
3
) in any type of tooth in 1950, less than 1% of
all the teeth examined falling into this category, as
compared with the slightly higher figure of 1.7% in 1945.
The A.H.F. had decreased for every type of tooth
except apparently the upper second molars, the total
having fallen from 0.92 to 0.76. Gross hypoplasia,
though relatively low in both series, was lower in
1950 than previously, 1.7% of all teeth, as compared
with 4.8% in 1945, being affected by this form of
defect.
Private Schools in 1950 and 1945.--Among these
children the dental structure was substantially the same
in 1950 as in the earlier survey. There were 52.3% of
the total teeth free from hypoplasia as compared with
54.0% previously (Table Ill, column 4). Some, such as
the upper incisors and canines, showed improvement in
the five-year-period, while others, notably the
were not as good as formerly.
As in the case of the residential homes, very few
_ teetli had re:tlly severe structural defects (M-Hy
3
), the
TABLE 111.-Comparison of Tooth Structure in Residential Homes (R.H.) Private Schools (P.S.)
(l) Total No. of (4) Good (S) Slightly (6) Defective
(7) Very
(8) Gross
Teeth Examined Structure Dofective Struc Structure
Defective
Hypoplasia (9) A.H.F.*
(2)
Structure
(I) Type of Tooth
Group
for Structure (Hy,) tore (M-Hy1) (M-Hy,)
(M-Hy,)
(G-Hy)
1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 1950
Upper:
% % % % % % % %
0/
% /o
Central incisors R.H. 609 1,001 322 517 392 345 205 116 16 02 62 20 091 059
P.S. 689 1,053 518 635 309 303 142 54 06 00 25 08 063 041
Lateral incisors R.H. 635 1,062 329 433 535 466 83 81 05 02 46 18 075 065
P.S. 722 1,096 644 650 263 321 65 24 06 00 1-8 05 042 037
Canines .. R.H. 647 1,079 300 493 572 448 91 44 05 00 14 14 079 054
P.S. 735 1,113 638 75-7 312 2H 3-3 07 03 00 10 03 039 025
1st molars .. R.H. 639 1,070 77 76 369 490 466 403 27 08 61 23 147 135
P.S. 725 1,095 248 125 472 600 232 272 29 01 19 02 104 1-15
2nd molars .. R.H. 644 1,070 62 30 326 365 517 533 S4 51 40 21 159 162
P.S. 736 1,105 198 72 514 498 249 424 28 "05 1-1 00 I'll 136
Lower:
Central incisors R.H. 552 869 781 933 205 64 04 02 00 00 11 00 021 007
P.S. 559 845 925 973 7-1 27 02 00 00 00 02 00 008 003
Lateral incisors R.H. 636 1,064 668 765 313 224 08 07 00 00 H 05 033 024
P.S. 718 1,088 879 863 111 13-S 04 00 00 00 04 02 012 014
Canines .. R.H. 647 1,079 501 641 402 323 22 13 00 00 23 08 048 036
P.S. 736 1,118 81-8 810 137 179 16 02 00 00 07 04 018 018
1st molars .. R.H. 631 1,068 166 210 404 481 307 275 19 04 103 30 120 108
P.S. 698 1,067 370_ 210 415 626 181 162 21 00 1-1 02 085 095
2nd molars .. R.H. 637 1,064 88 204 400 561 364 195 42 08 105 31 140 101
P.S. 718 1,094 242 22-8 446 623 267 142 28 06 17 01 108 093
Totals .. R.H. 6,277 10,426 323 420 395 383
I
209 169 17 08 48 17 092 076
P.S. 7,036 10,674 540 523 310 361 121 IH 12 01 13 03 060 059
A.H.F. (average hypoplasia figure)= Total hypoplasia figure
Total No. of teeth examined for structure (excluding those with G-hypoplasia or unclassified hypoplasia)
A few of the teeth included in column 3 co:.ld not be classified into any of the grades shown in this table. Therefore the porcentages rlo not add up to
1110 in all instance.
TABLE 1V.-Caries Incidence and Extent in Residential Homes (R.H.) and Private Schools (P.S.)
(8) Total
(3) Total No. (4) No Caries (5) Slight (6) Moderate (7) Severe Carious Teeth
(9) A.C.F.*
(I) Typ> of To:>th
(2) of Teeth (Co) Caries (C1) Caries (C,) Caries (CJ (i.e. D.M.F.
Group
per 100 Teeth)
1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 1950
Upper:
% %
0/
% % % % % % % /o
014
Central incisors R.H. 611 1,011 897 903 23 59 62 33 18 OS 103 97 020
P.S. 694 1,063 888 906 30 3-9 65 49 17 07 112 94 021 016
Lateral incisors. R.H. 636 1,069 950 964 13 22 35 13 03 01 50 36 009 005
P.S. 736 1,105 942 967 24 H 27 1-6 07 05 58 33 010 006
Canines .. R.H . 650 1,084 97-1 992 03 04 23 03 03 02 2-9 08 006 001
P.S.
742 1,120 958 978 16 01 19. 20 07 02 42 22 007 005
1st molan .. R.H .
650 1,084 863 935 57 18 55 H 25 14 137 65 024 013
P.S.
742 1,120 798 845 47 41 97 88 s-s 27 201 155 042 030
2nd molars .. R.H .
650 1,084 746 881 132 64 102 46 20 09 254 119 040 018
P.S.
742 1,120 724 763 93 11-8 142 104 4-1 15 276 23-8 050 037
Lower:
883 989 997 04 01 03 002 001
Central incisor. R.H.
557 07 00 00 02 H
P.S.
564 855 989 995 05 00 05 02 00 02 H 05 002 001
Lateral R.H ..
640 1,072 992 994 05 03 03 00 00 03 08 06 001 001
P.S.
723 1,094 994 996 01 01 04 02 00 0 I 06 04 001 001
Canines .. R.H .
650 1,084 989 991 03 06 06 04 02 00 H 09 002 001
P.S.
742 1,120 973 988 03 03 22 08 02 01 27 12 005 002
1st molars .. R.H .
650 1,084 835 862 42 52 72 65 5-l 2-1 165 13-8 034 025
P.S.
742 1,120 699 71-4 45 75 146 143 1H 68 301 286 067 056
2nd molars .. R.H .
650 1,084 7J7 779 102 IH 92 59 70 H 263 22-1 049 034
P.S.
742 1,120 6H 611 115 186 143 154 91 s-o 349 389 068 064
All typ:s
.. R.H.
6,344 10,539
I
895 928 3-9 36 46 26 19 09 105 72 019 012
P.S.
7,169 10,837 858 873 3-9 49 69 60 3-S 18 127 028 022
A.C.F. (average caries figure)=
Total caries figure
Total No. of teeth
54 JAN. 13, 1951
TEETH OF 5-YEAROLD CHILDREN BluTISB
MEDICAL JOURNAL
proportion being 0.1% of all the teeth examined, as com-
pared with 1.2% in 1945. The only teeth coming within
this grade in the more recent survey were the molars.
There was very little variation in the A.H.F. for the
different types, and the figures for all types together were
the same. Gross hypoplasia was again very uncommon
in either year, the total amount in 1950 being 0.3% of all
teethexamined-1% less than in 1945.
Comparison of Homes and Private Schools.-lt will
be seen from Table Ill that the children in the residential
homes in 1950 still had worse dental structure than those
in the private schools, 58.0% of all teeth as
with 47.7% showing some degree of hypoplasia (A.H.F.
0.76 as against 0.59). Since, however, in the former
group there had been an improvement during the past
five years-that is, the percentage of hypoplastic teeth
had fallen from 67.7 to 58.0, a 14% reduction-whereas
in the latter group there had been none, the disparity
was less.
L.C.C. Schools.-Among the L.C.C. group examined
in 1949, although the percentage of hypoplastic teeth
had increased somewhat since 1945, being 68.0% as com-
pared with 62.0%, the A.H.F.was much the same, 0.88
compared with 0.91.
As regards dental structure, therefore, these observa-
tions indicate a general improvement among the residen-
tial homes population since 1945, but little change among
private schoo!s or the L.C.C. group. The private-school
children had on each occasion the best-formed teeth,
while the positions of the other two groups were reversed
at the time of the second inspection, the residential
homes group having better calcified teeth than the L.C.C.
group, though not reaching the standard of the private-
school children.
Caries of the Teeth
Residential Homes in 1950 and 1945.-Table IV
(column 4) shows that, in spite of the fact that a large
percentage of the teeth were caries-free in 1945, there
was an improvement during the five years between in-
spections, the respective figures being 89.5% and 92.8%
of the total number examined. This improvement was
reflected in each type of tooth, but especially in the
molars, and in particular in the upper molars. With
regard to disease incidence, there were very few carious
teeth in these residential-home children in 1950, c,mly
7.2% of the total number being affected, as compared
with the previous figure of 10.5%, which was in any
case very low. In passing, it may be noted how small
w::ts the proportion of carious teeth graded C" remem-
bering that this category includes extractions. The extent
of caries, as expressed by the A.C.F., fell iFl 1950 for
every individual type of tooth, the figure for all types
together being 0.12, as compared with 0.19 in 1945.
Private Schools in 1950 and 1945.-The private-school
children showed a slight improvement in the five-year
interval. The total percentage of caries-free teeth rose
from 85.8 to 87.3, and each type, with the exception of
the lower second molars, showed improvement. The
percentages of carious teeth at the two inspections were
thus 14.2 in 1945 and 12.7 in 1950. The A.C.F. for
each type of tooth in 1950 was the same. as or lower
than before, so that the total A.C.F. showed a slight
reduction (0.28 to 0.22).
Comparison of Homes and Private Schools.-The
figures given in Table IV indicate that, as in 1945,
the teeth of the residential-home children examined in
1950 still had less disease than those of the private-
TABLE V.-lncidence of Caries in Teeth with Varying Grades of Structure

(3) J ncisors (4) Canines (5\ Molars (6) All Types
(I) Grade of (2) Total No.
%
Total No.
%
Total No
"/
Total No.
%
Structure Group Examined Carious Carious Examined Examined Carious
1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 195()

Good(Hy,) .. R.H. 1,261 7,603 05 09 518 1,224 00 03 250 554 04 81 2.029 4,381 03 17
PS. 1,970 3,142 08 14 1,071 1,749 08 06 758 690 30 170 3,799 5,581 Jo3 31
Slightly defective R.H. 891 1,134 27 57 630 831 21 1-4 956 2,026 86 133 2,477 \991 48 87
(MHy,) P.S. 523 841 88 87 330 457 64 35 1,330' 2,557 206 226 2,183 3,855 156 173
Defective (M-Hy,) R.H. 185 211 21-6 147 73 61 [137] [OOj 1,057 1,503 298 127 1,315 1,775 278 125
P.S. 149 83 [302) (9-6] 36 10 [389) (400) 669 1,095 568 347 854 1,188 514 330
Very defective RH. 13 4
f385)
[250] 3 0 fOO) - 91 77 [582) [182) 107 81 542 [185]
(M-Hy,) P.S. 8 0 75-U)
- 2 0 (00] - 77 14 [896) [42-9] 87 14 [862) [429]
Gross (G-Hy) ..
I RH.
80 44 [388]
[227] I
24 24 [00] [00) 197 112 198 125 301 180 233 133
P.S. 34 16 [382) [250) 12 8 [00] (00) 42 5 [381] [600) 88 29 (330) [2411
----
NotP.-For some grados of structure the numbers of teeth were relatively small. The percentages based on these probably have little significance, and are
therefore given in brackets. .
TABLE VI.-Extent of Caries in Teeth with Varying Grades of Structure
--
I
( 3) Incisors (4) Canines (5) Molars (6) All Types
(I) Grade of (2) Total No.
A.C.F.
Total No.
A.C.F.
Total No.
A.C.F.
Total No.
A.C.F.
Struuure Group Examined Examined Examined Examined
1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 1950 1945 1950
Good (Hy,) .. RH. 1,261 2,603 001 001 518 1,224 000 0004 250 554 0004 011 2,029 4,381 0004 002
P.S. 1,970 3,142 001 002 1,071 1,749 002 001 758 690 004 024 3,799 5,581 002 004
Slightly dofective R.H. 891 1,134 004 008 630 831 004 002 956 2,026 012 021 2,477 3,991 007 013
(M-Hy,) .. P.S. 523 841 015 016 330 457 011 007 1,333 2,557 036 036 2,183 3,855 027 028
Defective (M-Hy,) R.H. 185 211 042 023 73 61 [025] [000] 1,057 1,503 051 020 1,315 1,775 049 019
P.S. 149 83 [020) 36 10 [075) [090] 669 1,095 111 059 854 1,188 100 057
Very defective
I R.H.
13 4 [069) [025] 3 0 [000] 000 91 77 [109] [031] 107 81 101
t031]
(M-Hy1) .. P.S. 8 0 [163] 000 2 0 [000] 000 77 14 [217] [093] 87 14 [207] 093]
I
Gross (G-Hy) ..
I R.H.
so 44 [081] [030] 24 24 [000]
[000] I
197 112 039 018 i 301 180 047 018
P.S. 34 16 [076] [0501 12 8 [000] (000] 42 5 [086] [120) /1 88 29 [070] (048]
Note.-For some grades of structure the numbers of teeth were relatively small. The A.C.F. based on these probably have little significance and are
therefore given in brackets.
JAN. 13, 1951 TEETH OF 5-YEAR-OLD CHILDREN
school children, 7.2% in the former group compared
with 12.7% in the latter being carious. Though in both
cases there had been an improvement in the five years,
this was proportionately greater in the former (a drop
from 10.5% to 7.2% of carious teeth-a reduction of
32.0%-compared with a drop from 14.2% to 12.7%
in the private-school group-a reduction of 10.5%), so
that the gap between the groups had widened slightly.
L.C.C. Schools.-In contrast to the slight improvement
in the above-mentioned groups, the 1949 survey of
L.C.C. school-children showed no improvement in the
caries position as compared with 1945 .. The proportions
of carious teeth in the two years were 26.5% in 1945
and 26.7% in 1949, while the corresponding average
caries figures were 0.55 and 0.54.
So far as caries is concerned, then, the children of
the residential homes had fewer diseased teeth than those
of private schools and many fewer than those of
the L.C.C. schools at both inspections. It must be
emphasized again that the caries incidence and extent
both in residential homes and in private schools are so
low that improvements are inevitably small.
Relation between Structure of Teeth and their
Susceptibility to Caries in 1950
It was found in the latest survey, as in 1945 and all
other surveys of this series, that within each of the
groups of children the better-formed teeth-that is,
those with no hypoplasia-were less liable to caries than
the M-hypoplastic ones, and that the more severe the
defect the greater the liability to the disease (see Tables V
and VI). This is true for individual types (incisors,
canines, and molars) as well as for all teeth taken
together. To demonstrate this point figures are given
for three grades of structure in Table VII.

TABLE VII
of Teeth Caries-
free (C,)
R.H. P.S.
Slightly defective (M-Hy,) . . 913
Oood (Hy,) . . . . . ., 986
Defective (M-Hy,) . . . . 875
969
827
670
%of Teeth with Con-
siderable Caries
(C,+C,)
R.H. P.S.
06
3-9
59
13
100
208
There were insufficient numbers oi"M-Hy,, teeth to give a statistical result
for this group.
In all cases it will be seen that for a given grade of
structure there was less caries among the children
from residential homes than among those in the private
schools. Further reference to this point is made in the
discussion.
Filling and Extraction of Carious Teetll
Table VIII shows the considerable increase in
treatment for both residential homes and private-school
children over the past five years, especially as regards
fillings. Much more treatment was recorded in both
surveys among the private-schools group than among
the children in the homes, approximately three times the
TABLE Vlll.-Percentages of Carious Teeth Extracted and Filled
No. Carious
%
I
%Total
Teeth (Including %Filled
GroUI' Extractiorf)
Extractions Treated
1945 1950 1945 1950 1945 1950 1945 1950
R.H ... 664 754 29 56 47 118 76 174
P.S . .. 1,019 1,378 63 73 185 297 248 370
Note.-The few teeth treated With silver nitrate are omitted from this table.
number of fillings being present. It must be pointed
out, however, that slightly over 50% of the carious
cavities in the residential homes were very small (C,
grading), while fewer (38%) of the private-school cavities
were graded as cl.
Staining of the Surface Enamel
The superficial staining of deciduous teeth, which is
often confined to the gingival margin and molar fissures,
has been commented on _by several workers. In past
surveys a note was made of this condition and it was
found that those children with definite black or brown
staining on few or many teeth had less caries than
children with none, or children whose teeth showed defi-
nite green staining. In this most recent survey there
was very little difference between the caries susceptibility
TABLE IX.-Amount of Caries in Relation to Superficial Staining
of Teeth
-
I
Group I
No. ofChildien
%Carious
A.C.F.
Type of Teeth
Stain
1945 1950 1945 1950 1945 1950
No stain R.H. 106 (32-6%) 294 (542%) 115 67 021 011
P.S. 246 (663%) 458 (81-8%) 129 129 025 023
Black and R.H. 109 (335%) 179 (330%) 57 58 011 009
brown P.S. 25 (67%) 27 '(4-8%) 29 107 005 019
stain
Green R.H. 32 (98%) 20 202 144 039 022
stain P.S. 64 28 (50%) 225 187 046 033
---
of mouths with black and brown stain and those with
none (Table IX) ; but in this connexion it must be
remembered that there is very little caries anywhere.
Mouths with green stain appear more susceptible, but
the numbers of children with this stain are small. Indeter-
minate varieties of colour were omitted from the calcu-
lations. An interesting point was the large proportion
of residential-home children-about 33% at each inspec-
tion-who showed brown or black stains, as compared
with less than 7% of private-school children.
Arrest of the Carious Process
There was an apparent decrease in arrested caries
among both groups compared with 1945, but this may
have been due p1rtly to the personal factor in examina-
tion. Arrest is a gradual process, and it is not always
easy to agree on a specific standard and maintain it
from year to year: The difference between the two
groups, on the other hand, is real, the children in the
residential homes showing more teeth with arrested
caries, 13.5% of all the untreated carious teeth, com-
pared with only 2.9% in the private-school group. So
far as they go, therefore, these figures also indicate
greater resistance to the carious process in the residential-
home children.
Discussion
The object of the 1950 survey among children in resi-
dential homes and private schools was twofold: (1) to
find out if the differences observed in 1945 between the
two groups were still evident ; and (2) to see whether
there had been any change in dental status in either
of the groups over five years.
In both 1945 and 1950 the structure of the deciduous
teeth of the residential-home children was not as good
as that of the private-schools group, while their caries
incidence was lower. Since 1945 there had been improve-
ment in their dental structure (42.0% of the teeth were
perfect in structure, compared with 32.3% in 1945-an
improvement of nearly .one-quarter) and decrease in
56 JAN. 13, 1951 TEETH OF 5-YEAR-OLD CHILDREN
BRITISH
MEDicAL JouRNAL
caries (from 10.5% to 7.2% carious teeth), in spite of
the fact that at the time of the earlier survey the total
incidence and extent of the disease were already very
low. The private-schools group, on the other hand,
which had comparatively good tooth structure in 1945,
showed no improvement, while the decrease in caries
in 1950 was very small (14.2% of the teeth were carious
m 1945 and 12.7% in 1950). Thus the number of carious
teeth found in homes children was reduced by nearly
one-third, that in private schools by only one-tenth.
Whether the results given in this report are merely
periodic fluctuations cannot be stated. No examinations
of these two groups were made in 1947, which was the
peak year for caries-free teeth in L.C.C. school-children ;
it is possible, although unlikely, in view of the .already
small incidence of the disease, that the findings might
have been still better then.
What are the reasons for these differences ? A com-
parison between the two surveys does not suggest that
the reduction in decay is due to any variation in the
sugar content of the diets or to the amount of dental
treatment given. The strict rationing of sweets and sugar
during the war ensured little difference in this respect
throughout the post-eruptive period for the two groups
examined in 1945, and those inspected in 1950 would
have had, if anything, more sugar and sweets in their
diet. Again, there was more treatment in both the
groups seen in 1950 than in 1945, but for both years
the percentage of carious teeth treated was much greater
in private-school children than it was in the homes
children.
There may be many contributory factors, but in dis-
cussing the differences between the two groups examined
in 1945 it was suggested on the basis of experimental
and clinical investigations previously made (Mellanby,
1923, 1934) that .. the calcifying properties of the respec-
tive diets at different periods, both pre-eruptive and
post-eruptive, are an important key to the situation."
It was pointed out that, as a whole, the relatively well-to-
do mothers were more likely (from financial and other
considerations) to follow medical advice, then becoming
commoner, to take plenty of milk and some source
of vitamin D during pregnancy and lactation, than were
the poorer mothers of the children who later entered
the homes.-
It also seemed likely that the mothers in better cir-
cumstances would continue to give their children such
foods in the months immediately after weaning. Dur-
ing both of these periods the deciduous dentition would
be developing and erupting. In the post-eruptive stage,
however, there would often be a change in the respec-
tive positions of the children from this point of view.
Dietary discipline would tend to be relaxed in the case
of children living in their own homes, especially where
likes and dislikes of such things as eggs, milk, and cod-
liver oil were concerned. In the communal life of the
residential homes, on the other hand, fads and fancies
would be much less in evidence and regular meals of
high nutritional and calcifying quality, including an
ample allowance of milk and a daily dose of cod-liver
oil, were the routine, as was ascertained in the course
of the survey.
Thus it seemed probable that the post-eruptive diet
of the relatively well-to-do child might not be as good
for the teeth as the pre-eruptive diet, whereas the later
diet of the residential-homes child would in all prob-
ability be much better than that given during the period
of tooth development ; in this way the resistance to
caries of the teeth of the private-schools group would
tend to be weakened, and that of the homes group
strengthened.
In general these same relative conditions would, in
our opinion, be likely to obtain in respect of the children
examined in 1950 ; but whereas the pre-eruptive and
post-eruptive diets of the private-school children had
probably remained on much the same level in the interim
(thus resulting in a rather similar dental condition), there
had been certain important modifications, especially in
the pre-eruptive period, in the dietary of the homes
children. The uncertain quality of diets taken by expec-
tant and nursing mothers and weaned infants in 1938-41
(affecting the structure of the teeth of children seen in
1945) had given place to the rationing of important
foods, plus a system of special food priorities for these
vulnerable groups, by 1943-6 (when the teeth of the
children examined in the later survey were developing
and erupting). This priority scheme should have been
of especial benefit to the poorer mothers, the section
of the population from which the majority of residential
homes children are derived. These priorities were avail-
able on ration books, and would in many cases be takef\
as a matter of routine, especially as the milk could be
obtained at a reduced price, or even free, and the cod-
liver oil and vitamin tablets were issued free to all.
In addition, more was being done than formerly
through maternity and child-welfare services to dis-
seminate knowledge of better nutrition. Some of the
children entered the homes at the age of a few weeks
or months, and in these cases there would be time for the
excellent infant and weaning diets given there to exert
their effect on calcification, especially of the deciduous
molars. In such homes feeding had become even better
than in the early war period, owing to stricter planning
and supervision, thus increasing, if anything, the favour-
able post-eruptive influences of such diets.
The work of Schiotz (1939) and Collett (1935), and a
small investigation by King (1946), suggested that the
earlier in life the children were admitted to the orphan-
ages and the longer the period of residence, the less the
incidence of decay. There was evidence of this nature
in the data obtained in the 1945 survey, though it was
not published; the results Qbtained in 1950 are now
being analysed from this point of view.
The improved dental structure observed in the resi-
dential-home children in 1950 can therefore largely be
attributed to the better nutritional status in the period
of early tooth development as compared with the similar
period for the 1945 group. This would of itself tend to
result in a reduced caries incidence ; but in regard also
to the post-eruptive diet these children leading a com-
munal life would appear to benefit greatly. Not only
are the diets in residential nurseries and homes well
planned, but under the British rationing scheme there is,
and has been since 1942 (Ministry of Food, 1947), actu-
ally more of the, important foods available per child
in these homes than can be obtained for children living
with their families. Moreover, in the latter case any
~ p e c i a l allocation for the children may be all too often
pooled with the food for the rest of the household.
Furthermore, these children have far more say than
those in the homes in regard to what they will or will
not eat, and in many instances they are able to spoil
their appetite by eating food of low nutritional value
between meals.
In our opinion, few families in Britain, whatever their
economic status, provide for their children diets which
JAN. 13, 1951 TEETH OF 5-YEAR-OLD CHILDREN
are as good in their calcifying properties as those served
in children's residential homes to-day, and in few is the
intake of cod-liver oil and even milk likely to be nearly
so regular or so long maintained. It seems to us, there-
fore, that the excellent diet given in these homes is
responsible for their low caries incidence. The reduc-
tion noted since the previous survey five years ago is no
doubt partially the result of improvement in dental struc-
ture, but it may have been enhanced by the even better
diets provided for these children in recent years.
It is a challenging thought that, on the whole, children
brought up in orphanages and other public institutions
have a better chance of remaining free from caries
(at least up to the age of 5 years) than children of the
same age brought up in private families.
Summary
The new results given in this paper are compiled from the
individual dental charts of a survey in 1950 of 542 children
aged 5 years living in homes (orphanages and institutions)
and 560 children of the same age attending independent and
private day schools, mainly in London and surrounding
counties.
These two groups of children are compared with similar
groups examined in 1945 and with each other, as regards
both dental structure (according to the standards originally
set up by May Mellanby) and caries incidence and extent.
Reference is also made to surveys among L.C.C. school-
children in 1945 and 1949.
Among the children in the homes, tooth structure was
found to have improved since 1945, there now being 42.0%
of the teeth free from both gross and M-hypoplasia as
compared with 32.3% previously. Concurrently there was
also a reduction in caries incidence from 10.5% to 7.2%.
The private-school group showed much the same average
structure in 1950 as before, while the caries incidence had
declined only slightly, 12.7% of all teeth being carious as
compared with 14.2% previously.
The average dental structure of the residential-home
group still lagged behind that of the private-school children,
the difference between the two groups was not as great
as before.
In spite of worse dental structure, the children in the
residential homes had a lower caries incidence and extent.
The relationship between dental structure and caries in
both groups in 1945 and 1950 was such that the greater the
degree of M-hypoplasia the greater was the liability of the
teeth to caries, but for each grade of structure the residential-
home children had less decay than the others. This relation
between structure of the teeth and liability to decay has
been observed in all similar surveys where the same standards
have been adopted.
In each group of children there was an increase in the
amount of dental treatment, both fillings and extractions.
but particularly the former. At each inspection the percen-
tage of fill!;d teeth among the private-school group greatly
exceeded that among the residential-home children.
.j\pproximately 33% of the children from residential
homes showed black or brown staining on their teeth in both
years, as compared with only 6.7% and 4.8% in the two
groups of the private-school children.
Suggestions are made to account for the differences found
in both structure and caries incidence between residential
homes and private schools, and for the change occurrig
between 1945 and 1950.
We would like to put on record our grateful thanks to the
many people who have so generously assisted us, and without
whose help this survey would not have been possible. Particularly
we acknowledge our indebtedness to the medical officers and
governing bodies for permission to examine the 5-year-olds in
children's homes, and to the superintendents, matrons, and
teachers who helped with the actual inspections. In the case of
the private-school children we thank sincerely all the principals
and teachers who so willingly gave us time and assistance to
further our researches. We also much appreciated the help given
by Miss Irene Alien, of the Medical Research Council's Statistical
Department.
REFERENCES
Anderson, P. G., Williams, C. H. M., Halderson, H., Summer-
feldt, C., and Agnew, R. G. (1934). J. Amer. dent. Ass., :zt,
1349. .
Collett, A. (1935). Tidsskr. norske Laegeforen., No. 22.
Coumoulos, H. (1946). Nature, Lond., 158, 559.
-- and Mellanby, M. (1947). British Medical Journal, 1, 751.
Davies, J. H. (1939). Brit. dent. J., 67, 66.
Deverall, A. (1936). Spec. Rep. Ser. med. Res. Coun., Lond.,
No. 211.
King, J. D .. (1940). Ibid., No. 241.
-- (1946). Lancet, 1. 646.
Mellanby, M. (1923). Brit. dent. J., 44, I.
-- (1934). Spec. Rep. Ser. med. Res. Coun., Lond., No. 191.
-- and Coumoulos, H. (1944). British Medical Journal, 1, 837.
--(1946). Ibid., 2, 565.
-- and Mellanby, H. (1948). Ibid., 2, 409.
Mellanby, H., and Mellanby, M. (1950). Ibid., 1, 1341.
Ministry of Food (1947). Our Food To-day, No. 3.
Schiotz, E. H. (1939). Brit. dent. J., 66, 57.
Stones, H. H., Lawton, F. E., Bransby, E. R., and Hartley, H. 0.
(1949). lbid.' 86, 263.
POSTERIOR GASTRO-ENTEROSTOMY
IN PEPTIC ULCER: LONG-TERM
RESULTS
BY
DOUGLAS H. CLARK, Ch.M., F.R.C.S.Ed.,
(From the Peptic Ulcer Clinic, Western Infirmary, Glasgow)
Gastro-enterostomy in the treatment of peptic ulcer has
been the subject of many reports, often conflicting and
in recent years seldom favourable. Although to-day
abandoned by many, there are still some wh9 champion
its cause. In this country Sir James Walton (1950),
on careful and complete follow-up of a large series of
cases, has found a constant incidence of stomal ulcer of
only 2%, but most other workers put the figure much
higher, even as high as 40%. The results obtained by
Heuer (1944) agree with the experience of the majority
of recent writers. In his series of 159 cases followed
for periods of 3 moitths to 10 years (85 followed from
5-10 years) 21.4% developed recurrent symptoms.
In comp:uing the end-results of gastro-enterostomy
and gastrectomy, Heuer found on both short-term and
long-term follow-up that the outcome was 10% in
favour of gastrectomy ; but, as he pointed out, this
advantage is reduced by the lesser immediate mortality
of gastro-enterostomy. To the debit side of the gastrec-
tomy will have to be added a still undetermined but
probably considerable percentage of unsatisfactory results
in the form of " small-stomach " syndromes. It is also
probably fair criticism of the more extensive procedure
that when medical men, and especially surgeons, con-
template operation as a personal issue gastro-enterostomy
is given more than fleeting consideration.
With such thoughts in mind, it was felt that a further
report on the results of gastro-enterostomy, stressing the
long-term results, would be of interest.
Clinical Material
The material in this review consists of 330 patients
subjected to gastro-enterostomy for peptic ulceration
during the 14 years between January 1, 1924, and
December 31, 1937. All cases were under the care of
one surgical unit in the Western Infirmary, Glasgow.
'MARCH 20, 1926) DIET AND DISEAsE.
). tbital )ssodatian Jt.dnrt
011'
DIET AND DISEASE,
WITH SPECIAL REFERENCE TO' THETli1ETH, LUNGS,
AND PRE-NA1'AL FEEDING.
BY
- EDW ARD MELLANBY, M.D.CANTAB., F.}t.S.,
HO:&'OIURY PHYSICIAN, ROYAL J:liiFIR:U:ARY, SHEFFIELD; PROFESSOR 01'
PHARMACOLOGY, UNIVER3ITY OF. SHEFFIELD.
(With SpeciaZ Plate.)
EIGHTEEN months ago I delivered a British Medical Asso-
ciation Lecture at Bradfordla in which I discussed the
subject I was actively i-nvestigating at the time-namely,
the part played by modern dietary in the production . of
disease as found in this country. I should not have chosen
the same subject for this evening's discourse were it not
that it is still being intensively investigated all over the
world, with results that only emphasize its importance.
Modern experimental work on animals, backed up by
clinical observation, ha,s brought tp light the fact that the
.(lietary of the people of this country is defective in two
important respects: (1) that it includes too little of the
substances which contain fat-soluble vitamins, and (2) that
it contains relatively too much cereal. Each of these
dietetic mistakes tends, among other things, to bring about
a certain pathological defect of. structure and function
in the body, so that their combined influence in this respect
is very great and produces widespread disability ,la, b, c
For instance, one of the fundamental effects of a fat-soluble
vitamin is to stimulate calcification of bones and teeth,
while, on the other hand, excess of cereal in the diet inter-
feres with the calcification of these organs. It can be
imagined, therefore, how potent must be. the destructive
action on developing bones and teeth of a diet deficient in
calcifying vitamin and containing an excess of cereal.
The meagreness of the sunshine in this country and its
poor quality so far as ultra-violet radiations are concerned
only serve to make matters worse; for, arising from the
observations of Huldsch.insky2 on the effect of ultra-violet
radiations on the calcification of bones of rachitic children,
we now know that deficiency of antirachitic vitamin in the
diet can be made up to some extent by exposure of the
body to ultra-violet light, while I have shown elsewhere
that excess of cereal in the diet, which interferes with
bone calcification, can also be antagonized by exposure to
these rays.l
To-night I propose to return once more to the same
subject, and, by other illustrations of the action of these
dietetic factors on the body, try to drive home, not only
how widespread are the diseases for which these specific
dietetic defects are responsible, but also show that it is
only by feeding in such a way as to avoid these defects
that success can be obtained in the control and elimination
of much illness.
. TEETH.
I propose, first of all, to deal with the subject of the
teeth, and to provide some evidence obtained by May
Mellanby3a-B which suggests strongly that much of the
dental defect of this country is due to the dietetic mis-
:l;akes mentioned above. Incidentally the results also
indicate the means for combating this serious state of
affairs.
It will be clear that if the. fundamental cause of dental
defect is due to the fact that the dietary of the people
in this country is exceptionally low in calcifying properties,
then the teeth ought to he badly formed. The test can be
made at once. Befoi:e, howe.ver, dealing with the point, it
may be welt to state that the ordinary accepted teaching
by dental authorities. of the structure of, for instance,
children's teeth in this country is that, on the whole, they
ar!l well formed, only something of the order of 2 to 3 per
:Cent. being recognized as defective in structure. This, if
true, would at once disprove the suggestion made above as
.io .cause. of dental defect. But is it true P .The 2 to
*Delivered to the MidCheshire Division, November 12th, 1925.
3 per cent. of defect observed in the deciduous teeth of
children are cases of gross hypoplasia of the enamel,
smaller abnormalities being passed as normal. It was -only
when teeth were examined microscopically after being
ground down to thin sections that the real structure of the
teeth was appreciated and correlated with the naked-eye
appearance of the enamel. When this was done it was at
once evident that a large proportion of human deciduous
teeth -were badly formed-not the 3 per cent. suggested,
but something like 80 to 90 per cent.3b The following
table sums up the results as to the structure of children's
temporary teeth after being ground down and examined
microscopically.
TABLE I.-Relation between Structure and Caries in tl!e Teeth
of Children.
Good Structure. Defective Structure.
Type of Number
Tooth. Ex&mined.
I
No Caries. Caries. No Caries. Caries.
Incisors ... 100 58 11 1 30
Canines ... 70 5 0 25 40
Molars ... <166 2 11 2 451
Total ... 636 65
I
22 28 521
The different ratios of abnormal to normal teeth in th9
types is interesting. In the case of the molars, for
instance, only 13 out of 466 teeth examined were well
formed, while in the case of the incisors no less than
69 per cent. were of good structure. It will be also noticed
that there was some correlation between the structure of
the teeth and caries, for out of the 636 teeth examined
521 were of defective structure and carious, while 65 were
of sound structure and non-carious. That is to say, 586
of these 636 teeth, or 92.14 per cent., were in agreement
with the hypothesis that a sound tooth is less liable to
caries and an imperfectly formed tooth more likely to be
carious. Of the 636 teeth, 50, or 7.86 per cent., were in
a condition oppose\l to this generalization. This subject
has .been .discussed by May :Mellanby elsewhere,3d and it
was pointed out that the exceptions could be explained by
the fact, which can also be demonstrated experimentally,
that even after eruption the reaction of the teeth to
harmful stimuli can be varied by the same dietetic influ
enees which control the formation of the teeth. Thus
badly formed tooth can be. made to resist more potently if
the diet is made good, wh.ereas the resistance of a well
formed tooth is lowered by a defective diet.
The point I wish to make now, however, is that a very
large percentage of human deciduous teeth are badly
formed, and not the 2 or 3 per cent. as usually stated. In
Figs. 1 and 2 can be seen cross-sections of two molars of
children : Fig. 1 is a photograph of a perfectly formed
molar tooth-a rarity nowadays in this country; the struc-
ture of the tooth in Fig. 2 is obviously very imperfect, and
a small spot of caries is evident, yet this tooth was
described by a dental surgeon as well formed judging by
its external macroscopic appearance.
It is clear that children's deciduous teeth in this country
are not only very susceptible to caries, but that they aro
very defective in structure.
The question now arises, Can the structure of teeth be
controlled experimentally by diet during development, and,
if so, are the dietetic factors controlling the formation
of teeth of the same nature in children as in experimental
animals? It is tiow possible, according to the experimental
work of May Mellanby, to produce any degree of perfection
or imperfection in the structure of the teeth of dogs by
means of the diet eaten during the development of the
teeth. The most important variables of the diet that are
altered to bring about these differences include (1) the
.amount of fat-soluble vitamin,3a (2) the variation in the
amount and type of cereal eaten,3c and (3) exposure of the
ai1imal, or in some cases the food, to a .source of ultra
violet radiation.3e The more deficient the diet is in the
calcifying vitamin, the more it . cons.ists ?f cereal,
especially and the less the ammal 1s exposed
[3403J
516 1\:IABCK 201 1.926] DIET AND DISEASE.
tu. ultra-violet radiations, the worse formed will be the
tPdh. On the other hand, the more :the fat--soluble vitamin,
and the less the cereal eaten, and the greater the exposure
uf tho animal to ultra-violet radiations, the better formeq
will be the teeth. These facts are demonstrated in the
(Figs. 3, 4, and 5), which are a few examples
Hg the effect of these dietetic and environmental
factc rs in dental structure. For instance, the difference
between the teeth and jaws in Fig. 3 is simply due to the
fact that the diet of A contained some cod-liver oil, which
is a rich source of calcifying vitamin, the diet of B con-
tained a corresponding quantity of butter with a smaller
vitamin content, whereas the diet of C was very deficient
in this vitamin, as linseed oil formed the fat content of
its diet. Except for these differences everything in the
diet and environment of these three puppies, who were
members of the same litter, was constant.
The destructive effect of cereals on teeth formation, and
t'specially that of oatmeal, is seen in Fig. 4. Except in the
ease of A, the diets of these animals, though deficient in
fat-soluble vitamins, were constant in this respect, and the
variable tested was the cereal. It will be seen that when
oatmeal was the cereal eaten (Fig. 4, B) the teeth were
Yet'Y badly formed. The abnormality was least when white
ffour was eaten (:!fig. 4, C), and rather worse when wheat
germ waS substituted for 10 per cent. of the white flour
(.l!'ig. 4, D). Even the potent of oatmeal, however,
was completely antagonized by 19 c:cm. of cod-liveroil eaten
daily by the dog whose jaw is represented in Fig. 4, A.
The diets of the animals whose teeth are 1epresented hi
Fig. 4, A and B, both contained oatmeal and were iden-
tical in other respects except that 10 c.cm. of cod-liver oil
daily was eaten by A, and 10 c.cm. of olive oil by B. The
tooth illustrated in Fig. 4, A, is perfect in structure.
Tl1e effect on the structure of the teeth of exposing an
animal to a source of ultra-violet radiations can be seen
in Fig. 5 (A and B). Both of the animals whose jaws are
represented in Fig. 5 were brought up on identical diets
deficient in the calcifying vitamin, and lived under the
same conditions, the only difference being that one
(Fig. 5, B) was exposed thrice weekly for twenty minutes
to the rays of a mercury vapour lamp. The improvement
il1 the calcification of the teeth produced thereby is
obvious.
I have now shown you some evidence which indicates
(1) that the deciduous teeth of children are for the most
]>art badly formed, and (2) that the structure of dogs'
teeth can bo controlled at will by varying certain specific
factors of diet and environment. The question How
do tlwse facts bear upon the widespread scourge of caries
in the teeth of children P One method of answering the
IJUestion would be to feed children from birth along the
lines which animt\1 experiments have indicated as resulting
in perfect tooth formation, determining the amount of
caries in the temporary dentition, and after the shedding
of these teeth from the sixth year onwards grinding them
<lown and examining microscopically. A number of children
are being brought up on a diet which, from birth onwards,
includes milk, egg-yolk, and cod-liver oil, and up to the
J>l'esent, so far a!! is known, caries has not appeared in the
t<'eth of these children, but the oldest is now only 5-! years
of ago, so the test is still in its early stages.
In order to attack the point in a direct fashion with the
idea of seeing whether the results obtained with animals
oould have any bearing on the teeth of children after erup-
tion and after being fully formed, :the following preliminary
investigation was made by May Mellanby, C .. Lee Pattison,
and J. W. Proud.4 A number of children in an institution
were placed on diets which, according to animal experiments,
varied in their effect on calcification. Group A were given
a diet which contained much milk and sqme cod-liver oil,
less cereal (none of it oatmeal), in addition to other food-
stuffs. The diet of Group B contained less milk, more
ccteal (including oatmeal); while in the case of Group C
an intermediate diet from the point of view of calcifica-
tion, and one which was usually the standard diet of the
institution,. was The children were arranged in
groups so that the average age of each group was about
the same. Before the diets were started the mouth of each
was carefully charted, the amonnt and type of hypo-
plasia, the carious points, their extent and degree of
ness, the missing teeth, etc., being noted. After seven and
a half to eight and a half months of the diets the condition
of the teeth was again charted, and the followin& result.
were obtained.
TABLE 11.-E.ffece of Dieu .A, B, and a on the Inieia,ion and Sprearl.
of Caries in Children.
New No. of
Avera.ge
New Carious
Diet. M:a.in Dietetic Difference. Points of Children
Points per
Caries. in GrouP.
Child.
A Abundant calcifying
and calcium
vitamin 13 9 1.4
B Poor in calcifying vitamin ; less 51 10 5.1
calcium, more cereal, espe-
cially oa.tmeal .
2.9 0 In,ermediate between A and B 38 13
It will be noticed that there was nearly four times as
much new caries per child on Diet B as in the Diet A
group. all other oonditions of hygiene and :Jl!ode of
living were constant; it is probable that the differences in
diet were for the changes in the teeth of the
children. If this be true, then the results observed experi-
'imentally on the teeth of dogs can be applied to children.
The numbers of children obseryed in this investigation
were small; a bigger investigation of a similar nature is
necessary before the results can be regarded as definitely
established. On. the other band, the amount of difference
of developing caries in the various groups seems too pig
to be explained by inaccuracies of observation and
To sum up, the experimental work d,emonstrating . the
conditions of diet which bring about the production of
perfect and. imperfect teeth in taken in conjunction
with the investigation on children outlined above,
it almost .
(1) that the widespread development of caries in
children's teeth is primarily a problem of defecti'Ve
feeding which results in imperfect formation of theh
teeth;
(2) that the dietetic factors which result in good
and bad formation of teeth also confer upon or take
away from the erupted teeth qf children the power of
1esistance to the carious process;
(3) that foods containing fat-soluble vitamins, such
as milk, egg-yolk, butter, animal and fish fats, and
especially cod-liver oil, bring about the formation of
good teeth, while cereals, and especially oatmeal, in the
absence of calcifying vitamin
1
bring about the formation
of defectively calcified teeth.
THE INFLUENCE OF THE MATERNAL DIET DURING PREGNANCY
ON THE SUSCEPTIBILITY OF THE OFFSPRING TO DISEASE.
It would bo a generally accepted proposition that the
feeding and nutritional condition of a mother during preg-
nancy modifies the metabolic changes and consequently the
well-being of the offspring. If it were only a question of
insufficient nourishment supplied to the mother, evidence
on this point would be difficult to obtain, for the ability
possessed by the maternal organism. of sacrificing her
tissues for the supply of the fundamental nutriment of .the
developing foetus is certainly very great. There is, how-
ever, better evidence that the malnourished as opposed
the starved maternal organism transmits undesirable weak-
ness and tendencies to pathological change to its offspring.
In the case of rickets, for instance, the maternal factor
has appeared so important to sonie that heredity has even
been advocated as the prime cause of this disease. This
view has not, however, received much support. The con-
genital influence which has been stressed by Kassovitz is
supported by such facts as the special tendency of pre-
mature babies and of twins to develop rickets. It is true,
as Schmorlli pointed out, that newborn infants do not show
rachitic changes of bone, but it is not improbable that the
osteoporotic condition as evident in the craniotabes seen
in infants soon after birth is a closely related state and
may be due to malnourishment of the mother.
Experimentally Korenchevsky and Carr't showed that, in
the case of rats, rachitic changes of the bones could be
MAR OH 20. DIET AND DISEASE. [ !'IDI - 517
'.# v.f llBDIC.u.Jou .. ..,

produced more rapidly, and more certainly, if the _mother
during pregnancy, as as the offspring, were fed on
diets deficient in antirachitic vitamin and calcium. Hess
and Weinstock5 h-ave also studied this problem and found
that, although improving the diet of mothers during
nancy and lactation mitigated tlie development of rickets
n infants, it did not prevent it.
In the experiments now to be described the mothers
during pregnancy were certainly no.t insufficiently fed.
the point of view of energy-bearing dietetic con:
stituents the diets were not greatly dissimilar. Even as
regards many of the actual foods comprising the respective
diets they were identical in kind and in amount eaten.
On _the other hand, specific differences were introduced of
such a na:ture that one bitch (A) received a diet which,
from work, would be expected to result in good
while the second (B) received a diet which ex-
penence had taught would lead to malnutrition. The
diets were as follows :
Bitch 4. Bitch B.
Jlread (white 1lour), 150 to 200 grams. Oatmeal, lOO to 150 grams.
Cod-liver oil, 10 20 c. cm. Olive oil, 10 to 20 c.cm.
Separated milk, 400 reduced to Separated milk, 400 reduced
lOO c.cm. to lOO c.cm.
Me&t, loo gr&ms. 1\fe&t, 30 to lOO grams.
Yeast, 15 grams. Yeast, 15 grams.
These animals lived throughout the experimental period
under identical conditions and became pregnant at
approximately the same time, the father being the same
n each case. The diets were started in February 1923
and continued throughout pregnancy, which ended
6th and 11th respectively, and during the period of !acta.;
tion, which lasted until July 23rd and 28th, when the
progeny in each case were removed from the mothers and
lived separately.
After weaning, the diets were so arranged that two
puppies (one puppy from each litter) were given the same
food. The following table illustrates the conditions of the
experiments. All puppies received the same amount of
lean meat! separated. milk, orange juice, salt, yeast,
together with the special substances indicated in the table
for each puppy.
TABLE Ill.
No. of I
Puppy.
Diet Vari&bles. Mother. Father. Z-Ray ResuU.
698}
709
699}
706
700)
7041
701}
708
Oatmeal. linseed oil, and
0.5 gram calcium car-
bonate
Oatmeal and linseed oil
Oatmeal and cod-liver oil
White 1lour and cod-liver oil
703} Oatmeal and cod-liver oil,
heated and oxygenated
707 72 hours
A
B
A
B
A
B
A
B
A
B
R Nearly normal.
R Moderately bad
rickets.
R Slight rickets
R
(Fig. 6, A).
Very b&d rickets
(Fig. 6, B).
R Normal bones.
R Normal bones.
R Normal bones.
R Normal bones.
R Slight rickets
(Fig. 7, 1).
R Bad rickets
(Fig.7,B).
The only results that need be referred to here are those
of the dogs on diets which would be expected to interfere
most severely with bone calcification. 'l'hese are 698 and
709 (oatmeal, linseed oil, and calcium carbonate), 699 and
706 (oatmeal and linseed oil), and 703 and 707 (oatmeal and
cod-liver oil, heated and oxygenated seventy-two hours).
Since there is little or no calcifying vitamin in linseed oil,
and that present in cod-liver oii is destroyed by seventy-
two hours' heating and oxygenation, none of these diets
contained the necessary amount of vitamin. The results
obtained in the case of 699 and 706 (oatmeal and linseed
oil) can be seen in Fig. 6 (A and B), where the radio-
graphs after ten weeks of the diet are shown. It will be
seen that 706 (defectively fed mother-,--Fig. 6, B) has
advanced rickets in the radiograph, whereas the radio-
gr.aph o! 699 (well. mothe_r-Fig. 6, A) shows only
at th1s t1me. Smce the. only difference in
the hfe-history of these two dogs is that the mother of
was defectively fed during pregnancy and lacta.-
wh_Ile J?-lother of 699 had a. good, strongly calci-
fymg diet, It IS probable that this is responsible for
the increased susceptibility of 706 to develop rickets aa
compared with 699.
A similar result was obtained with 703 and 707, where
heated and oxygenated cod-liver oil was the fat eaten by
both. It will be obvious in Fig. 7, A and B, that 7Cfl
(defectively fed mother-Fig. 7, B) has developed more
severe rickets than 703 (well fed mother-Fig. 7, A), and
the reason for this is probably the same as in the case of
the preceding pair. Animals 698 and 709 (radiographs
not shown) reacted_ in the same way: 709, having the
defectively fed mother, developed much more severe
rickets than 698 (well fed mother).
It was a matter of interest to know how long the
influence of the defective diet of the mother would be
evident in the offspring, and more information was
obtained from other puppies in these litters in the follow-
ing way. Animals 701 (well fed mother) and 708 (badly fed
mother), after weaning, were given a good d_iet containing
an abundance of antirachitic vitamin. This contiimed for
four months, and by this time the puppies were in ex-
cellent condition and about 6 months old. The diet of
each was then changed to a defective one by the
tion of oatmeal for white flour jlnd olive oil for cod-liver
oil. After six weeks of this defective diet it will be seen
that the bones of 708 (defectively fed mother-Fig. 8, B)
and of 701 (well fed mother-Fig. 8, A) were still practi-
cally normal. These animals were now 7! months old and
well grown dogs. However, after three months more of
these defective diets, when they were 10! months old,
there was a great pifference between these two animals,
which is obvious in the radiographs and photographs of
these dogs (Fig. 8, C and D, and Fig. 9, E ai1d F). It will
be seen that 708 (Fig. 8, D, and Fig. 9, F) is very rachitio
in appearance as compared with 701 (Fig. 8, C, and Rig. 9, E).
The rachitic in 708 (Fig. 8, D, and Fig. 9, F) are
comparable to those of late rickets seen occasionally in
adolescents.
The greater resistance of 701 to the development of
late rickets and the susceptibility of 708 to this disorder
must have been due to the difference of the maternal feed-
ing' during pregnancy and lactation; for, since weaning at
the age of 6 weeks, the diets of each and all the other
conditions of life have been identical. It seems clear, then,
that the influence of a defective diet given during preg-
nancy and lactation is not only evident in the offspring
during early life, but that, even after a prolonged period
of perfect feeding, the tendency to the development of
defect is still obvious in the case of dogs whose mothers
have a bad diet. It is surprising that the defective diet
effect should be so lasting, and that it should be so diffi-
cult to overcome by a _period of excellent treatment of the
puppy.
Summary.
If bitches are fed during pregnancy on diets which, in
the case of puppies, will lead to rickets, then the offspring
have a greater tendency to develop this disease. This
tendency in the young is not removed by a period of good
diet, but may become evident again at a later period of
defective feeding.
THE RELATION OF DIET TO SusCEPTIBILITY TO INFECTIONS
OF THE RESPIRATORY TRACT.
Attention has been drawn by many recent workers on
dietetics to the increased susceptibility of animals to in-
fection as the result of diets which, while good as regards
their protein, fat, carbohydrate, and energy content, are
defective in quality. McCarrison,B for instance, has
described the frequency of a catarrhal condition of the
intestine, especially in the form of colitis, in animals
whose diet was deficient in vitamin B. In t.he course of
my own work I commented on the readiness with which dogs
succumb to distemper and the great intensity of mange
when these diseases appear in animals whOISe diets are
deficient in vitamin A.lb Drummond9 has described a lower-
ing of resistance of adult rats to bacterial infection, ma!1i-
festing itself sometimes in the form of an i lflammatory
518 MARCH 20, 1926] DIET AND DISEASE.
condition of the lungs, when they were fed on diets defi-
dent in vitamin A. Cramer and KingsburylO have also
called attention to the mortality of rats from broncho-
pneumonia when these animals are kept sufficiently long
on diets free- from. vitamin A. They conside1 that the
atrophy of mucus-secreting cells in the mucous membrane
of the trachea and larynx, observed by Mori,ll and in the
intestine, obsened by themselves, allows the local bacterial
infection of these tissues when the diet is deficient in
vitamin A. These are a few of the instances in which
attention has been called to this important problem. Any
information on the question of the relation of diet to
resistance to infection, especially as it concerns the respira-
h>ry tract, seems to me to be of sucli great tnactical
importance that I think it necessary to give my own
experience on the subject.
At one period in the course of my experimental investi-
gations on dogs, the work was greatly hampered by the
development of an inflammatory condition of the lungs.
Another condition of the lungs found post mortem in some
of the dogs was that of local collapse, especially along the
margins of the upper lobes of the lungs. This was often
associated with patches of emphysema in other parts of the
lungs. This condition, as a general rule, was not accom-
panied by congestion. It was usually found in dogs 'Yhich,
on account of their diet, had become eithe1: very lethargic
or had developed mnscular weakness or both.
l-Iany of the experiments have been mariP with the object
of elucidating the effect of diet on bone formation, so that
the numher of animals developing bone defect has been
large. This, no doubt, accounts for the fret1uency with
which muscular weakness and the accompanying condition
of local hmg collapse. or atelectasis occur in these dogs.
Lately I hare examined microscopically many of the
lungs seen to be abnormal at the post-mortem examination
made at the end of each experiment, and found the in-
flammatory conditions in all cases represented varying
degrees of bronchopneumonia. It then seemed worth while
to analyse the results and see in what way, if any, the
incidence of the bronchopneunionia was related to tl1e diet.
I will briefly tabulate these results and then discuss them.
TABLE IV.-Lwru CouditiOiafound at Post-mortem Examination
. of a Series of 330 Dogs in Relation to Diet.
Diets as regards Vitamin A Content.
Condition of
Vegetable Butter,
Cod-liver
Lungs.
Fat,
Butter
Vitamin A
Cod-liver Oil,
Vitamin A
+ Vit&r
Destroyed
Oil+ Vitamin A
Deficient.
ntin A.
by Heat.
Vitamin A. Destroyed
by Heat.
-------------
Normal ... ... 155 55 11 24 3
Bl'Oncho- 43 0
pneumonia.
4 0 1
Local collapse ... 23 9 2. 0 G
Total ... ... 221
r-;-
17
I
24 4
These results indicate a close relationship between the fat-
soluble vitamin content of the diet and the susceptibility of
the animal to develop an inflammatory condition of the
lungs. All the cases of bronchopneumonia were found in
dogs whose diets were deficient in fat-soluble vitamin, and
no bronchopneumonia developed when the diet contained
either butter or cod-liver oil. Except for the variable
amount of fat-soluble vitamin, the diets of these animals
would formerly have been considered good-that is to say,
they contained an abundance of protein, fat, carbohydrate,
and energy. In some cases the calcium intake was only
sufficient on the assumption that the diet contained a large
amount of calcifying vitamin. For instance, if diets of
this nature contained cod-liver oil as the fat entity, and
therefore an abundance of calcifying vitamin, the calcium
intake was sufficiently high to result in perfectly formed
teeth and bones. In fact, it is to be doubted whether any
ordinary diet can be so low in calcium content as to lead
to defective calcification of the body tissues if' cod-liver
oil.is also ingested at the same time. On the other hand,
when butter is the source of fat-soluble vitamin in the diet
it is essential, in order to produce well formed teeth and
lx,nes, strongly contracting musdes, and good general
activity, that the diet should also be richer in ealcium.
The reason for this is probably that bu.tter contains a
much smaller amount of antirachitic vitamin than cod-liver
oil, so that the butter effect on calcification is best seen when
there is plenty of calcium.in the diet. In .the above table it
will be seen that local collapse of lung tissue was found in
nine cases in which butter was the fat eaten. -If the calcium
of the diets in these particular eases had. been higher, the
musculature of the animals would have been strqngC'r, the
animals would have been more vigorous, and local collapse
of lungs would have developed. Yet none of these animals
eating butter, although some were abnormal in other ways,
even as regards the lungs, developed bronchopneumonia.
Although, therefore, it is certain that there is an intimate
relation between fat-soluble vitamin in the diet and calcium,
especially as regards the &tructure and function of bones,
teeth, and muscle, it seems possible to. deduce1 on the basis
of the above statistics, that this vitamin alone confers an
increased power of resistance to lung infection even under
conditions when bone and muscle structure is defeetivC'.
It is necessary, in discussing this question as to the
relationship of diet and the c;:!f _j;he body to
inflammatory conditions of the respiratory tract; to empha-
size that, whatever truth there may be in the suggestion
that fat-soluble vitamin aids in the defensive mechanism,
it is only mie point 'of a more complicafed story. Whether
thC're was aliy _'special organism which 'invaded the lungs
of these dogs 1.s 1iot yet known, as, tip tO the present, the
subject has not -been 'studied in detail. There. certainly
other points 'Of crucial importance in tlie ettology of
bronehoJincl.tinoiJi'a, but what these are, cannot bd stated
definitely: In some cases,: at least, the bronchopneumonia.
developed in 'aninials \\:hich not only had 'the diet defect
deseribed above, but also had been taken out of their
indoor kennels into the open air, wl1ere it was usually cold
and windy and often wet, in order that their running
pqwers should be determined. The opportunity, in fact,
was presented to them of catching_a " chill." . Th_e dogs on
the diets containing vitamin A were also placed under the
same conditions, but their resistance was apparently suffi-
cient to make the low temperature of the external condi-
tions of no account. It is impossible to state that this
cl1ange of environment, which lasted only a few minutes,
was always a factor in the development of the inflammatory
condition of the rt>spiratory tract, but it may have been
a causative agent in many cases.
Another condition which commonly develops in
when feeding on diets containing excess of cereal and a
deficiency of fat-soluble vitamin is diarrhoea. In animals
which feed on such a diet for a long enough period diarrh'oea
generally develops, but this may only happen after severe
defed of bone formation is present. On the other hand,
diarrhoea may appear soon after the diet begins and before
there is obvious bone deformity. It has seemed, although
not proved, that the better the puppies are fed during the
pre-expPrimental period, the longer time will elapse before
the defective diets are accompanied by diarrhoea. This
statement is definitely true of rickets both as the
pre-natal and post-i1atal feeding of the mother, and it
probably applies equally to the development of catarrhal
conditions of the alimentary tract. It may also explain the
variable susceptibility . of young animals to catarrhal and
inflammatory conditions of the respiratory
THE POSSIBLE BEARING OF THE ABOVE RESULTS ON
THE " CATARRHAL" CHILD.
The observations described above, dealing with the
effect of feeding the maternal organism during preg-
nancy and lactation on the susceptibility of the young. to
develop rickets, together with the results showing the
altered resistance under similar dietetic conditions to
inflammation of the respiratory passage, have impressed
upon me the possibility that the so-called " catarrhal "
cl1ild is probably a product of defective feeding of the
mother during pregnancy and lactation.. There is general
. agreement among clinical workers that there is some
common factor in the etiology of the diseases which result
l in the " catarrhal " child, the rachitic child, and the child.
with enlarged tonsils... So far as my own animal experi-
MARCH 20, 1926 j E. MELLANBY: DIET AND DISEASE.
FIG. !.-Photomicrograph of ground section of a perfectly formed
human deciduous molar. Rarely found. (May Mellanby.)
FIG. 3 (A, B, and C).-The eftect of the calcifying vitamin. The jaws
of three pupJ.>ies of the same litter brought up on the same diets except
that A contamed 10 c.cm. of linseed oil daily, B contained 10 grams of
butter daily, and C contained 10 c.cm. of codliver oil daily. Note the
perfect formation of the teeth of C and the imperfectly formed teeth
m A. (May Mellanby.)
.
A
c
FIG. 2.-Photomicrograph of human deciduous molar: Note defect ia
structure of dentine. A typical specime!l as ordinarily found in this
country. (May Mellanby.)
FIG. 5 (A and B).'-The eftect of ultraviolet radiations. Photograph!>
of the lower jaws of. two puppies brought up on the same 'diet deficient
in calcifying vitamin and living under the same conditione, Puppy A
only was exposed thrice weekly 1or twenty minutes to the :radiation ef
a mercury vapour lamp. Note the better formed teetli 'of :A'tas comparetl
with B .. (May Mellanby.)
B
D
FIG. 4 (A, B, C, and D).-The eftect of difterent cereals. Photomicrograph of ground sections of molar teeth of four puppies of the same litter.
The diets of B, C, and D were deficient in antirachitic 'Vitamin and were identical except that B contained oatmeal as cereal, C contained white
flour as cereal, and D contained white flour and wheat ' germ (10. per cent.) as cereal. The diet of A was identical with that of B:.....that is, it
contained oatmeal as cereal, but olive oil in Diet B was replaced by 10 c.cm. of codliver oil, which completely antagonized the bad eftect of the
oatmeal. Note how defective is the dentine in B (oatmeal), also that wheat germ has made the teeth of D worse than C (white flour). (May Mellanby.)
MARCH 20, 19:.6) E. MELLANBY: DIET AND DISEASE.
A
FIG. 6 (A and B).-Radiographs of wrists of puppies (699 and 706)
taken after ten weeks of the same experimental diet. A, durinll' pregnancy
and lactation the mother of 699 had been well fed-that IS, received
abundant antirachitic vitamin. B, durinjr presnancy and lactation the
mother of 706 had been fed on defect ve diet-that is, deficient in
antirachitic vitamin.
A
B
FIG. 7 (A and B).-Radiographs of wrists of puppies (703 and 7111)
taken after ten weeks of the same experimental diet. The mother of
A (703) had been on a diet deficient in antirachitic vitamin during
pregnancy and lactation, while the mother of B (7fYT) had had a diet
good in this and other respects during the same period.
c
FIG. 8 (A, B, C, and D).- Radiographs of wr\sts of two puppies (701 a.nd 708). of. 701 C) '!'as fed during pregnancy
and lactation The mother of 708 (B and D) durmg pregnancy and lactatiOn had a d1et deficient ID antrach1tlc v1tamm, and containing, among
other things oatmeal. After weaning the diets of 701 and 708 were always identical; they were well fed from 6 weeks to 6 months old they
were then on the same ricketsproducing !iiet . . Radiographs A, (701). and B (708) after six weeks of the defective diet; Radiographs d (701)
and D (708) aft.er eighteen weeks of the defective diet. See also F1g. 9, m text.
FIG. i.
L. G IHHADIATED CHOLESTEROL IN RICKETS.
FIG. 2. FIG. 3.
FIG. I.-Radiogram taken on admission
to hospital, September 19th, The
bones show very marked rachitic
changes.
FIG. 2.-Radiogram taken November
11th, 1925, showing the result of treat-
ment with irradiated cholesterol for a
period of three weeks. A considerable
degree of healing has occurred.
FIG. 3.-Radiogram taken January
6th, 1926. The tiones have completely
healed.
VALUE OF IRRADIATED CHOLESTEROL IN RICKETS. [
Ta& Ba1nd 618
. II:&DIC.U.IOftlr.U.
ments ate concerned, I have got no evidence that enlarged
tonsils of the type seen so commonly in children are pro-
duced by dietetic defect, but this may be because dogs do
not develop the condition at all, or because I do not keep
them long enough on bad diets. Clinically, however, it
would probably be agreed that chronic catarrh of the
l"('Spiratory passages of children,_ tendency to broncho-
pneumonia, rickets, attacks of diarrhoea, and, later,
enlarged tonsils, are intimately related.
. The catarrhal condition in children may develop at any
time, but often it appears in the first few weeks of life
and before post-natal conditions in themselves could be
accounted responsible for the absente of all resistance to
this of infection. It seems to me that such cases can
probably be explained on the basis of defective feeding of
the mother during pregnancy, and the defects are probably
of the type indicated by some of the experimental work on
animals described in this lecture-namely, a deficiency in
the diet of foods containing fat-soluble Yitamin, such as
milk, eggs, butter, cheese,. animal and fish fat, and a
FIG. 9.-Photograpbs of two puppies-E (701) and F (708)-after
weeks of defective diet. Animal 708 (badly fed mother) has
d.r-eloped severe " adult rickets " as compared with 701 (well fed
mother). For radiogr-aphs and details as to diet see F1g. 8 in
plate.
relati\e excess of cereals such as bread, oatmeal, and rice,
and other foodstuffs deficient in vitamin A. The basis of
this suggestion I have given above, and may be summarized
a; follows:
(1) It has been shown experimentally that these defects
in the inaternal diet increase the tendency of the offspring
to develop rickets. .
(2) The same defects in the diet seem, on the basis of the
statistics supplied above, to increase the susceptibility of
young animals to bronchopneumonia and inflammatory con
ditions of the respiratory tract, and, in general, to result
in puppies of lowered vitality.
(3) It is well known that the catanhal child may develop
this condition shortly after birth, and that it has a great
tendency to become rachitic and to develop broncho
pneumonia.. . . . .
(4) Puppies whJCh develop ru.: kets when feedmg on thes'.l
experimental diets frequently develop a catarrhal condition
of the alimentary tract sooner or later, the time seeming
to depend partly upon the kind of feeding of the mother
and the puppy in the pre-experimental days.
Not only is there some expel"imental support for the
suggestion, but experience shows that the dietetic defects
de-scribed are those most commonly met with in human
feeding. It is therefore probable that these defects of diet
of women during pregnancy and lactation are responsible
for some, and possibly much, of the illness and mortality
of young infants. The new teachings of diet have been
ap[)lied to some extent to the feeding of <hildren, and this
i> no doubt partly responsible for the decrease in infant
mortality during recent years, at a time when overcrowding
and some other hygienic defects are as bad as, or even
worse than, ever ; but it is necessary to extend the teaching
to the problem of maternal feeding. This would probably
show its first effect by reducing the infaut mortality of
children under 1 month of age, and, if the foregoing
suggestions and experimental results are true, would result;
in great improvement in the physique of children. It
would increase the resistance of infants to those infections
which produce catarrhal conditions of the respiratory and
alimentary tracts and all the other sequelae so gonerally
recognized as likely to follow. It would certainly result
in a better grown and less rickety type of child, and would
do something also to improve the structure of the teeth and
thereby to reduce the appalling amount of caries in the
teeth of children. It would probably also bring about;
improvement in the general health of the pregnant womau,.
and do away with some of the unfortunate expel"iences. to
which she is liable.
REFERENCES.
1 E. Mellu.nby: (a) BRITISH MEDIC.<L JOUBN.<L, May 24th, 1924. (b) Special
Report Series, Medical Research Council, No. 61. (c) Ibid., No. 93,
2 Huldachinsky: (a) Deut. med. Woch., 1919, 45, 712. (b) Zeit. f. ortlwp.
Cltir., 1920, 89, 426.
May Mellanby : (a) Lancet, December 7tli, 1918. (b) Briti1h Dental
Journ., 1923t 44
1
._!. (c) Ibid., 1923, 44, 1031. (d) Proc. Roy. Soc. N.,.d.
(Odontology/, ll.), xvi, 74. (e) British Dentallourn., May. let, 1924.
4 Mellanby, C. L. Patti8on, and J . W. Proud : BRITISH MEDIC.IL
J'OURNAL, 1924, ii, 354.
IIess and Weinstock: Journ . A mer. Mtd. Assoc., 1924, 83, 1558.
Schmorl: Ergebn. d,. inn. Med. u. Kinderlt., 1909i 4, 403.
7 Korenchevsky and Carr : Journ. Path. and Bact,, 923, 26, 389.
McCarrieon : Studiu in Deficiency Disease, Oxford Medical Publicationa,
1921.
Drummond: Biocllem. Journ ., 1919, 13, 95.
,. Gramer and .Kingsbury: Brit. Jown>. EXJtr. Path., 1924, 5, 300.
" Mori : Jolms Hopkina Hosp. Bull., 1922, 33, 357.
'l'HE VALUE OF IRRADIATED CHOLESTEROL IN
'fHE TREATMENT OF RICKETS.
BY
LEONARD G. PARSONS, M.D.Loxo., F.R.C.P.,
PHYSICIAN TO THE CHILDREN'S, GENERAL, AND INFANTS' HOSPITALS,
BIRMINGHAM.
(lVith Special Plate.)
THE fact that many foods and vegetabl e oils "ltich have
no antirachitic. value acquire that property after exposure
to ultra-violet rays is now common knowledge. Hcss anli
Weinstock1 have recently shown that the anti1achitic
factor is confined to the unsa.ponifiable fraction of these
sub"stances, and that it resides largely in the cholesterol
m phytosterol which they contain. During the year 1925
there appeared, almost simultaneously, three paper5--{)ne
by the British workers Rosenheim and Webster, in which
they produced evidence that irradiation of cholesterol con-
ferred antirachitic powers upon it; the others by two
groups of American worker5--{)ne by Hess, 'Veinstock, and
Helman, 3 proving that irradiation of cholesterol and
phytosterol re1,1dered these compounds antirachitic, and the
other by Steenbock and Daniels, showing that irradiated
sterols possessed antirachitic properties.
Usually about half the unsaponifiable material hom cod:
liver oil consists of cholesterol, but Drummond and Coward
have shown that this is not responsible for the
physiological effects of the vitamins A and D. These
re&ults have recently" been confirmed by Nelson and
Steenbock. The cholesterol obtained from cod-liver oil,
however can be rendered antirachitic by irradiation.
The results were all obtained with laboratory
animals, but Hess and Weinstock
7
state that inadiatcd
vegetables and dried milks possess curative value in f.lte
rickets of infants, and Cowell has demonstrated the value
of irradiated whole milk.
Hess has given irradiated cholesterol to infants, but I do
not know of any observations that have been published on
the results obtained by its use in the treatment of infantile
rickets.* I am indebted to Hess for the suggestion to use
irradiated cholesterol clinically, and also for the method of
irradiation. The cholesterol used was pure cholesterol
prepared by the British Drug Houses, . Ltd. A thin la
of this was placed in a Petri dish and irradiated by a
Since this was a paper bv Hess and . \\'einstock has beell
published (Lancet, 1926, i, 12), . in whlch they gi\c . the results of the
treatment of three cases of ricltets by irradiated cholesterol. In eucll
case the inorganic pbosl_)borus of the blood was increased and the
gram showed slight beahn&.
BRITISH MEDICAL JOURNAL
WNDON SATURDAY OCTOBER 19 1946
TEETH OF 5-YEAR-OLD LONDON SCHOOL-CHILDREN
(SECOND STUDY)
A COMPARISON BETWEEN 1929, 1943, AND 1945
BY
MAY MELLANBY
(Nutrition Building, National Institute for Medical Research. N.W.1)
AND
HELEN COUMOULOS, Ph.Q.Camb., D.D.S.Athens
(Girton College, Cambridge)
Between May, 1943, and the end of January, 1944, the mouths
of a large number of children aged 5 years and attending
L.C.C. schools were examined and charted* and a preliminary
report on this survey was made (Mellanby and Coumoulos,
1944). One of the objects of the work was to compare the
condition of the deciduous teeth of these children with that of
children of the same class and age group examined in 1929,
when a survey on similar lines, but with a less elaborate system
of charting, was made by one of us (M. M.).
In order to make the two investigations as nearly comparable
as possible the same schools were chosen in 1943 as in 1929,
any which were no longer available being substituted by
others of similar type in the same district. The number of
children examined in these schools was 1,604. In addition,
examinations of 266 children were made in a few schools in
districts not visited in 1929, but these were not included in the
main survey as they were not truly comparable.
In the report on the 1929 survey published by the Board
of Education (1931), figures were given only in relation to
children and not to the individual types of teeth. For the
sake of comparison, therefore, the 1943 results were given in
the same form, and it was clearly shown that, as regards both
structure of the teeth and caries, the general dental condition
was much better than in 1929. A summary of the findings in
the two surveys is given in the following quotation from the
report:
"It is clear that in the 14 years that have elapsed the picture of
deciduous tooth structure has changed for the better. Even so,
there are very few children with a full complement of perfectly
calcified teeth; however, in 1943 18.1% had only slight
M-hypoplasia compared with 7.8% in 1929, and there were fewer
with much M-hypoplasia-33.3% as against 58.5% respectively.
... 22.4% of the children in 1943 were 'caries-free,' compared
with 4.7% in 1929; and only 29.3% had much caries, as against
62.8% previously."
Since very few of the children were free from caries in 1929
it was decided to include in the caries-free group any who had
vnly one or two teeth which, according to the standards used,
were probably carious to a very slight degree. Even so, as is
seen from the figures quoted, only 4.7% of the 1,293 children
examined came into the so-called caries-free group. (It should
be noted here that the standards were much more severe than
those adopted at that time in routine inspections by school
dental surgeons, which are made for purposes of treatment.)
* For the sake of brevity this is referred to as the !943 survey.
The 1943 estimate of caries-free children as 22.4%, given in
the report (Mellanby and Coumoulos, 1944), was assessed on
the same basis as the 1929 figure for purposes of comparison,
but in arriving at the assessment a distinction was made between
those in whom no caries could be diagnosed by the methods
employed and those in whom there were one or two teeth
showing very slight caries.
It is intended in the present paper to give the structure of,
and the amount of caries in, the individual types of teeth as
found in 1943 and to compare them with data obtained in an
investigation made in 1945, the object of which was to ascertain
whether the great improvement found in 1943 as compared with
1929 was maintained. Sample schools from each district visited
in 1943 were taken for this purpose and the mouths of 691
5-year-old children were charted. The length of time that
elapsed between the first of the 1943 and the last of the 1945
inspections was 26 months, and the average period between
the inspections in the schools visited in both investigations was
just over 20t months.
Methods
All children of the age of 5 years (i.e., up to but not including
the sixth birthday) at school on the day of the examination
came under survey. This is a useful age group for the study
of deciduous teeth, since few have been naturally shed and all
have been subject to post-eruptive influences for a considerable
period-the anterior teeth for 4 to 5t years and the posterior
for 3 to 4 years. The percentages of teeth present in the
mouths at the time of inspection are shown in Table I.
TABLE I.-Percentages of Teeth Present at Time of Inspection
Type of Tooth 1943 1945
Upper:
Centrals
"
907 926
Laterals
"
960 983
Canines
"
998 996
1st rnolars 905 950
2nd molars 924 975
Lower:
Centrals
"
832 794
Laterals
"
979 980
Canlnes
"
999 999
lst molars 858 924
2nd molars 860 917
All types 922 944
In an ordinary room, with the best light available, each child
was subjected to as detailed an examination of the individual
4476
566 Ocr. 19, 1946 TEETH bF 5-YEAR-OLD LONDON SCHOOL-CHILDREN
BRITISH
MEDICAL JOURNAL
teeth as was possible by direct inspection and with a mirror
and probes, in order to obtain data which could be used
as a basis for comparative surveys. Special probes were used
throughout (S.S. White stainless ; No. 37 for hypoplasia, No. 12
for caries), and they were renewed from time to time. X-ray
photographs were not taken, as the technical difficulties involved
were too great; moreover, they are unnecessary in surveys of
this nature, especially when made on such large numbers of
children. Any caries undiagnosed by the methods used will be
relatively the same in the different surveys.
By means of symbols and notes the following conditions
were recorded on a simple chart designed for this work and
reproduced herewith :
Chart Showing Condition of Teeth
Nm.--.. ---- Ap. ...... .... ........... ........ - No._--
Addrus
Date ............................... -
ti=t---- -- --
.. ; :; ... .If_...... + ..... ;] .......... ::....... jl.............. ... , ........ ..
M-hypoplulo (1, :1, la G)
Mottllnc (1.2. l. 4. 5, 6)
1.... + .... j ........ j ...... .
Carte(l,l.J)
Teecl\ pf'ltlnt
Teeth prnenc
---- --
f--- ---- -- --. --- --- .. - -- - +--
Carift(l, :1. J) ...
M-hy,.,...ll (1,1. J_. G)
HottllnJ (I, 2. ), 4, 5, 6)
Occhlon_ ________ .........___ , ..________, ........... __
AtttttiOft, _________________ ,,,,,,. _________ _
Scaln. ------ ..----..---------
Other notet :
(l) Teeth present.
(2) Structure of each Deciduous Tooth.-The standards used
were evolved from the results of experiments on animals and
investigations on children's teeth made by one of us (Mellanby,
1918-34). Individual teeth were taken to be of good structure
when their surfaces were smooth, shiny, and white or creamy-
white in colour. Variations from this standard other than gross
hypoplasia are referred to as Mellanby- or M-hypoplasia, a
term first used by King (1940) to distinguish these types from
the gross hypoplasias (G-hypoplasia) which have long been
recognized and whicn are not common in deciduous teeth.
The M-type defects were originally described by one of us
(Mellanby, 1923, 1927, 1934), who found them in over
of the thousands of deciduous teeth examined. Unless the
teeth are dried and well illuminated, the defects are not often
easily visible to the naked eye, especially when they occur in
the molars, but they can be detected without much difficulty
when the tooth surfaces are lightly rubbed with a probe.
Degrees of roughness are not sharply defined, but merge into
one another. With practice--and this must be emphasized-
they can, however, be judged by the "feel" of the probe, and
the teeth can be grouped under the following headings:
Hy" : Good structure.
M-Hy,: Slightly defective.
M-Hy,: Defective.
M-Hy,: Very defective.
G-Hy: All varieties of gross or " textbook " hypoplasia.
The incidence of mottled enamel was recorded on the charts ;
but it will not be discussed here, as it is beyond the scope of
this paper. Teeth showing signs of mottling were graded
for M-hypoplasia and for G-hypoplasia in the same way as
unmottled teeth.
(3) Extent of Caries in Each Tooth.-The following categories
were recorded :
C,: No caries that could be diagnosed by our methods of
examination.
C, : Slight caries-i.e., very early and suspected fissure and
approximal caries.
C,: Moderate caries; cavities involving destruction of up to.
roughly one-quarter of the tooth crown (including under-
mining caries).
C,: Advanced caries; destruction of more than one-quarter of
the tooth crown (including undermining caries). In this
category were also included roots of decayed teeth and all
teeth which were assumed to have been extracted for
caries-i.e., all missing deciduous teeth except incisors,
which were considered to have been shed naturally.
(4) Arrest of the Carious Process.-A carious cavity was
regarded as arrested only when, by the feel of the probe, its
surface was very hard, though not necessarily smooth and
polished, as described in textbooks. A tooth. with such a
cavity was graded for caries according to the size of the arrested
area and included in that grade of caries. Early stages of arrest
were not recorded in these investigations.
(5) Treatment of Carious Teeth.-Silver nitrate applications
and fillings were noted, and the cavities so treated were classified
according to their size, in the same way as active or arrested
caries, though some allowance was made for removal of non-
carious tissue around a cavity in preparation for filling.
(6) Staining of the Teeth.-Records were made of the inci-
dence, colour, extent, and contours of stains on the enamel
surface or on a film adhering to it.
(7) Other conditions, which will not be discussed in this paper,
including the state of the mouth, accumulation of food, spacing
of the teeth, occlusion, attrition, and gingivitis, were also noted.
Results
Before considering the detailed results, it may be of interest
to compare the findings as regards the percentages of children
free or almost free from caries. Table 11 shows that in the
three main surveys (those made in schools in the same districts)
the improvement observed in 1943, and quoted above, was
continued in 1945, and a comparison of the combined main and
subsidiary surveys of 1943 with those of 1945 shows a similar
improvement in the latter. The percentages of children with
good dental structure also showed a progressive increase.
Year
1929
1943
11145
1943
1946
Structure
TABLE 11.-Percentages of Caries-free Children
Tolal No. of I
Children
Examined
1,293
1,604
632
% I %
Caries-free I Caries-free
(Seep. 565)
Main Surveys
I
134 90
222 43
Combined Main and Subsidiary Suney.<
1,870
I
149
I
93
I
881 242 39
Tota
47
224
285
242
281
The surface structure of the teeth examined in the two recent
investigations is shown in Table III, and is expressed both as
percentages and as average hypoplasia figures (AHF). Data
are. given for each type of tooth and for all types taken together.
The figures show that a considerable improvement in the struc-
ture of the teeth of London 5-year-old children as a whole
occurred between 1943 and 1945. Whereas 30.7% of the teeth
were of good structure (Hy.) in 1943, the figure had risen to
38.0% in 1945-a statistically significant increase of 7.3 0.49%.
There was a smaller percentage of teeth showing each grade of
M-hypoplasia in 1945 than in 1943 and the AHF was lower
(0.91 compared with 1.04). The improvement in structure in
1945 was marked in the incisors and canines, but the molars
showed little change. In both investigations the structure of
the upper incisors, especially the centrals, was much worse than
that of the lower incisors. The incidence of gross hypoplasia
(G-Hy) was low in both surveys as compared with M-hypo-
plasia, 1.9% of the teeth in 1943 and 2.3% in 1945 being so
graded, whereas there were 69.3% and 62.0% respectively with
M -hypoplasia.
The column headed " Hy Unclassified " includes teeth which
showed types of defect which could not be graded as definitely
M-hypoplastic or G-hypoplastic. In most types of teeth very
few of these defects were found, but in the canines there was
a somewhat higher incidence.
See note at foot of Table Ill.
OcT. 19, 1946
TEETH OF 5-YEAR-OLD LONDON SCHOOL-CHILDREN
BRITISH
MEDICAL JOURN.&L
567
Caries
The incidence and extent of caries, expressed as percentages
and as average caries figures (ACF),* are shown in Table IV.
As in the previous table, data are given for each type of tooth
and for all types taken together. The unbracketed figures in
the column headed "C, " include missing canines and molars,
which were assumed to have been extracted for caries (see
p. 566). .he figures in brackets _show these teeth as percent-
ages of the total number (see column 2).
In Table IV it is seen that there was less caries in 1945 than
in 1943. In the earlier period 69.9% of the teeth were caries-
free, while in the later the figure had risen to 73.5%-a
difference of 3.6 0.46%, which is significant statistically.
Taking the more severe degrees of caries (C, and C,) together,
the percentage se graded in 1945 was slightly lower than in
(Dental Disease Committee, Medical Research Council, 1936)
that in controlled dietetic investigations on children a striking
feature in the groups having a good calcifying diet rich in
vitamiP D was the relatively high proportion of teeth in which
the carious process was no longer active but had become or
was becoming arrested. Many of the children concerned in
the Sheffield investigations were under observation for a period
of several years, and it was found possible in some cases to
trace the gradualarresting of the carious process until the final
hard, smooth, and polished state was reached. When a
tooth showing this " healing " or arrest was sectioned after
being shed or extracted it was usually found to contain a large
amqunt of well-calcified secondary dentine. On the basis of
animal experiments (Mellanby, 1923, 1930) it seemed feasible
to conclude that the deposition of this secondary dentine was
TABLE lll.---Comparison of Tooth Structure in 1943 and 1945
Total No. of
I
I
Teeth Examined Good: M-Hy, M-Hy, Very Defective: G-Hy Hy Unclassified AHF*
Type of Tooth for Structure
I
(Seep. 566) Hy, M-Hy,
1943 1945 1943 1945 1943 1945 1943 1945 1943 1945 1943 1945 1943 1945 1943 1945
'
Upper:
% % % % % ~ ~
Centrals .. 3,324 1,262 182 250 339 362 343 261 94 60 39 88 02 02 137 1-14
Laterals .. 3,465 1,341 272 388 469 394 190 143 41 22 25 54 03 01 100 079
Canines 3,707 1,369 325 408 508 457 132 101 15 11 10
,.,
10 12 083 071
1st molars :: 3,268 1,282 82 87 321 392 499 429 70 64 28 28 00 00 157 148
2nd molars 3,427 1,342 60 52 292 395 540 457 94 86 13 10 01 00 168 158
Lower:
Centrals .. 3,091 1,097 717 851 242 140 32 04
!
06 00 02 05 003 00 033 015
Laterals .. 3,624 1,348 615 795 337 192 42 08 04 00 01 03 01 01 043 021
Canines 3,702 1,370 519 697 369 235 59 23 05 01 14 07 34 38 053 030
1st molars:: 3,119 1,235 184 223 385 398 365 325
I
40 3-1 25 28 01 00 127 1-17
2nd molars 3,104 1,241 75 75 341 375 486 454 63 81 34 15 01 00 156 155
-
Totals .. 33,831 12,887 307 380 363 338 263 220 42 35 19 23 06 06 104 091
AHF (average hypoplasia figure)
Total hypoplasia figure
Total number of teeth examined for structure (excluding those with G-or unclassified hypoplasia)
TABLE IV.-comparison of Caries Incidence and Extent in 1943 and 1945
Total No. of
c, c, c, c,
Total Carious
ACF*
Type of Tooth
Teeth Teeth
1943 1945 1943 1845 1943 1945 1943 1845 1943 1845 1943 1945 1943 1945
Upper:
% %
.,
% % /o
Centrals .. 3,392 1,280 624 705 98 50 162 172 116 73 376 295 077 081
Laterals .. 3,590 1,358 797 851 68 32 92 88 43 31 203 149 038 030
Canines .. 3,740 1,381 905 825 29 17 46 42 20 (02t) 16 (04t) 95 75 018 015
1st molars .. 3,740 1,382 580 61-1 87 83 133 174 200 (95t) 132 (50t) 420 389 095 083
2nd molars .. 3,740 1,382 435 486 172 177 181 236 211 (76t) 101 (25t) 565 514 117 085
Lower:
Centrals .. 3,112 1,098 951 983 27 09 15 08 07 00 49 17 008 003
Laterals .. 3,662 1,354 963 979 20 06 13 13 04 02 37 21 006 004
Canines .. 3,7:40 1,382 931 841 24 07 33 43 12 (OIt) 08 (01t) 69 59 013 012
1st molars .. 3,740 1,382 460 514 79 72 170 21-1 291 (142t) 203 (78t) 540 488 129 1-10
2nd molars .. 3,740 1,382 390 412 129 151 150 195 33-1 (140t) 241 (83t) 610 588 142 127
Totals .. .'!6.196 13,381 699 735 74 62 101 120
I
126 (47t) 3:3 (25tl 301 285 065 055
1
'
. - -
Total canes figure t See above.
*ACF (average caries figure)
Total no. of teeth (including extractions)
1943 (20.3% compared with 22.7%), and the same trend is
apparent, except in the case of the lower canines, when each
type of tooth is taken separately. In both investigations the
upper incisors, which were of much worse structure than the
lower, were also much more carious, the upper centrals being
more affected than the laterals. The average caries figures
(ACF) tended to be lower in 1945 than in 1943 for all types
of teeth together as well as for each individual type.
Arrest of the Carious Process
A point of much interest and, we believe, of great significance
is the arrest-<>r, as Miller called it, the spontaneous "healing"
-<>f the carious process, which represents a measure of the
defensive reaction of a tooth to attack by caries. It was shown
in investigations in Sheffield (Mellanby, Pattison, and Proud,
1924 ; Mellanby and Pattison, 1926, 1928) and Birmingham
* See note at foot of Table IV.
related to the arrest of caries and tc the type of diet eaten at
and after the time of the carious attack.
In the survey's here described arrest was recorded only when
the carious area had become definitely hard, though not neces-
sarily smooth and polished. It is interesting to note in Table V
that in 1943 11.7% of the carious teeth present in the mouths
of the children examined showed arrest and that in 1945 the
percentage was almost doubled-i.e., 21.5%. Had teeth show-
ing earlier stages of arrest been included the figures for both
surveys would undoubtedly have been much higher.
TABLE V.-Teeth Showing Arrest (Spontaneous "Healing") of the
Carious Process
1943
1945
No. of Carious Teeth
Present
9,182
3,203
% Carious Teeth Present
Showing Arrest
117
215
568 OcT. 19, 1946 TEETH OF 5- YEAR-OLD LONDON SCHOOL-CHILDREN
BtUTISH
MEDICAL JOURNAL

Treatment of Carious Teeth
In Table VI are shown the percentages of carious teeth
assumed to have been extracted (that is to say, the missing
canines and molars) and the percentages which had been treated
by silver nitrate application or had been filled. It will be seen
TABLE VI.-Carious Teeth Extracted, Treated by Silver Nitrate,
or Filled
\ Total No. of Treatment Total
(Including % % S1lver % Carious Teeth
I
Carious Teeth 1--------.---.---1 Percentage of
Extractions) Extracted Nitrate Filled Treated
1--:9-43-- .. --.. 10,886 157 67 27
1945 . . . . - 9-6 28 24
250
148
and difficult to remove by ordinary brushing, and, if removed,
usually returns. In the surveys here recorded the most common
stains observed' were black, very dark brown, or green. The
black and dark brown usually took the form of a border to
what appeared to be a film on the tooth, though it might be
more widespread, and the green often seemed to extend from
the gingival margin towards the incisal edge or cusps.
The percentages of children whose teeth were all free from
stain were 51.6 in 1943 and 35.5 in 1945. With black and dark
brown stains on some or all of their teeth there were 10.6%
and 11.3% and with green stains 34.9% and 46.5% respectively.
The teeth of a few children had yellow or lightish-brown stains
or a combination of two or more stains, but figures will not be
given for them here, as there were too few in any group to be
of significance.
TABLE VII.-Percentage Incidence of Caries in Teeth with Varying Grades of Structure
Jnc1sors Camnes Molars
--
Jrade of Structurt' Total No. Examined %Carious Total No. Examined
I
%Carious Total No. Examined %Carious
1943 1945 1943 1945 1943 1945 1943 1945 1943 1945 1943 1945
Hy, .. .. .. 5,992 2,837 11 12 3,126 1,514 15 1-1 1,281 550 83 70
M-Hy, .. .. .. 4,724 1,399 120 112 3,248 947 79 80 4,310 1,987 245 250
M-Hy, .. .. .. I 2,053 538 449 392 707 189 267 298 6,133 2,127 626 885
M-Hy, .. ..
"I
487 105 804 810 75 16 611 888 867 335 871 923
G-Hy .. .. .. 226 185 642 824 90 24 233 208 319 101 589 525
NOTE.-This table does not include the few teeth shown under the heading" Hy Unclassified" in Table Ill.
that there was less treatment of all kinds in 1945 than in
1943. This may, of course, be because there were fewer dental
surgeons to cope with the work.
Relationship between Structure of Teeth and their
Susceptibility to Caries
Attention has been drawn by one of us (M. M.) and by
others using the same criteria (Davies, 1939 ; Dental Disease
Committee, 1936; King, 1940) to the fact that there is a
direct relationship between the structure of the deciduous
teeth, according to the standards used, and their susceptibility
to caries: the less the M -hypoplasia the less, in general, the
caries. In the investigations described in this paper the same
relationship is evident, as is seen from Table VII.
When the teeth were of good structure (Hy,) only 1.1% of
the incisors, of the canines, and 8.3% of the molars were
carious in 1943, and the corresponding figures for 1945 were
1.2%, 1.1 %, and 7.0%. With each degree of M-hypoplasia
the percentage of carious teeth increased in both surveys, until
with very hypoplastic structure (M-Hy,) there were in 1943
80.4% of incisors, 61.1% of canines, and 87.1% of molars
carious, and in 1945 81.0% of incisors, 68.9% of canines, and
92.3% of molars.
The incidence of caries in teeth with gross hypoplasia was
not as great as in those with severe M-hypoplasia. This is under-
standable because, although the enamel of part of a tooth may
TABLE Vlll.--Amount of Caries in Relation to Superficial
Staining of Teeth
--------.------,,------
Children with
(a) No stain . . . . . .
(b) Black and dark-brown stains ..
(c) Green . . . . . .
Percentage of
Carious Teeth
1943 1945
301 231
193 154
334 330
ACF
1943 1945
066 048
041 030
072 088
be badly pitted, or even m1ssmg, the remammg enamel, laid
down at a different period of growth, may be quite well formed.
For this reason it was decided, in tabulating the relationship
between structure and caries, not to combine teeth showing
gross hypoplasia v1ith those affected by severe M-hypoplasia,
as was done in some earlier surveys (Mellanby, 1934).
Staining of Surface Enamel or of Films on the Enamel
Very little appears to be known about the superficial stain-
ing seen on the teeth of many children. It is often unsightly
It was noticed that many of the children whose teeth showed
the black and dark-brown stains were caries-free, and an attempt
was made to discover whether the stains were definitely associ-
ated with the incidence of caries. Table VIII indicates that in
each survey the percentage of carious teeth and the ACF of
children with black and dark-brown stains were lower, and
with green stains somewhat higher, than those of the children
with no stain. It thus seems from these figures that black and
dark-brown stains are associated with a lower incidence of
dental caries, whereas green stains may be associated with a
higher incidence, but we have no knowledge as to the reason
for these apparent associations.
Discussion
An account is given of two investigations on the condition of
the deciduous teeth of 5-year-old children attending L.C.C.
schools in 1943 and 1945, and a comparison is made between
these investigations and one of a similar nature made by one
of us (M. M.) in 1929. Since, however, no data are now
available in regard to the state of the individual teeth in
1929, the comparison is confined to the general dental
condition. In 1943 this was much better as regards both
structure and caries than in 1929, and in i945 it was still
further improved.
Though the 1943 and 1945 investigations were not controlled
in the way that animal experiments can be regulated, the groups
of children examined were comparable in that they were of the
same age group and social class and resided in the same districts
of the" L.C.C. area. From the dietary point of view there was
a degree of similarity during the war years, because the ration-
ing and " points " system of food distribution gave equal pur-
chasing opportunities to all families. The main point of
dissimilarity, so far as could be seen, was that the 1945
group of children had been subjected for a longer period to the
war dietary than the 1943 group--a fact to which attention
must be drawn.
Data obtained from the classification of individual teeth
emphasized the better dental condition of the children seen
in 1945 as compared with 1943. For instance, the percent-
age of teeth of good structure (Hy0) rose from 30.7 in 1943
to 38.0 in 1945, and of caries-free teeth (C.) from 69.9 to 73.5-
a statistically significant difference in each case-and the percent-
ages of teeth with the more severe defects of structure (M-Hy,)
and more advanced caries (C,), decreased appreciably in the
intervening period. The amount of arrest or spontaneous
" healing " of the carious process was almost twice as great
Ocr. 19, 1946 TEETH OF 5-YEAR-OLD LONDON SCHOOL-CHILDREN
in 1945 as in 1943-an indication that some powerful post-
eruptive influence had been at work.
If, as seems certain, this improvement in dental condition is
not accidental, but is related to some factor or factors of diet
or environment to which the children were subjected an
examination of possible factors may bring to light those
responsible for the facts observed.
It is claimed by some that carbohydrates play a prominent
part in the initiation of caries. Others say that poor dental
hygiene Js responsible, and yet others that heredity is an
important factor. So far as our knowledge goes, however,
there is no sound scientific evidence for any of these conten-
tions. To test the carbohydrate theory, King (1946) investi-
gated the effects of nightly supplements of boiled sweets and
chocolate-coated biscuits on the deciduous teeth of a small
number of infants living in two institutions. The supplements
were given when the children had cleaned their teeth just before
going to bed. There was no increase in carious activity in the
children over periods of from 6 to 24 months and at the end
of the test previously active caries had arrested. it
must be stated that the children had a good calcifying diet con-
taining cod-liver oil. This result does not support the view
that carbohydrates are responsible for the disease. The two
recent surveys on L.C.C. school-children also do not uphold
the theory. Less active caries and a greater proportion of teeth
showing arrest of the disease were seen in 1945 than in 1943,
but there is no evidence that the consumption of carbohydrates
among young children had diminished in the intervening period.
It cannot be argued, either, that the reduction of caries in
1945 as compared with 1943 was in any way related to better
dental hygiene, since as the war progressed civilian dentists
became fewer and toothbrushes were more difficult to obtain
(Magee, 1946).
..., If heredity were the potent factor in caries that it is some-
times claimed to be we should not see the deterioration in the
dental condition of native races that is so evident when they
come in close contact with Western peoples. An outstanding
example of this is seen in the American negroes who have
become completely Westernized in their habits and dietary. It
is well known, too, that both children and adults of the primi-
tive races in Africa who adopt the Western mode of life and
diet-those. for instance, living for long periods in the ports
and industrial areas-lose that freedom from caries which is
so common while they remain in their natural habitat, and
the sam.: deterioration is seen in Eskimos attached to trading
stations. It would seem, therefore, that some other cause for
the observed improvement in dental condition in 1945 as
compared with 1943 must be sought.
Previous investigations on children by one of us (M. M.)
and, by colleagues using the same standards (Deverall, Dental
Disease Committee, 1936; Davies, 1939; King, 1940) have
shown that resistance to caries is related to dental struc-
ture as diagnosed in these surveys-that is to say, the
better the structure the less the liability to decay. Unfortu-
nately this relationship is not always appreciated by dental
surgeons, many of whom recognize only the more gross forms
of hypoplasia. It has also been shown that the chief factors
required ior the production of well-formed teeth include a
sufficiency of calcium, phosphorus, and vitamins D and A. and
that these same factors in the diet after eruption of the teeth
tend to retard the onset of caries and to arrest the disease when
present. If vitamin D and calcium supplies are deficient other
food factors come into prominence. Certain constituents of
cereals, for instance, may under these circumstances be harm-
ful from the point of view of the teeth.
During the early stages of dental development mother and
child must be considered as one unit. The pregnant and
lactating woman must herself then be made as dentally fit
as possible to avoid absorption of toxins and to enable her
to masticate her food, and her diet must be such that the
developing foetus, and later the infant, is supplied with the
food factors necessary for the production of well-formed teeth.
After weaning, the child itself must continue to receive a
calcifying diet.
There is no doubt that in this country the diet of the majority
of people, and especially of the children, is far better to-day in
this respect than it was, say, 25 years ago. During recent years,
and particularly during the immediate pre-war and the war ,
years, pregnant and nursing women, infants, and children have
been encouraged (a) to consume more milk and eggs and so to
obtain larger supplies of calcium and phosphorus, as well as of ,
D and A; (b) to take vitamin D- and vitamin A-
containing substances, either as cod-liver oil or as one of the
proprietary products ; and (c) to eat more potatoes. Moreover,
for a number of years now vitamins D and A have been added
to some brands of margarine, and since the early days of the:
war this has been made compulsory for all brands. Again,,
calcium was added to some flours before the war, and since
1943 the addition has been a routine measure.
It seems probable that the improvementin dental condition
of 5-year-old children during recent years is directly related to
the enrichment of their diet in these respects. The children
examined in 1943 showed a considerable improvement on the
1929 group, and, as has been indicated in the tables in this
paper, the 1945 group, who had received calcifying supplements
for longer periods than their predecessors in 1943, showed an'
even greater improvement. Not only were their teeth better
formed and less carious, but a greater percentage that had been
attacked by caries had set up a resistance, as a result of which
the carious process had been arrested. The advantage of this
natural "healing" of carious cavities over treatment by filling
or extraction is obvious. Evidence is accumulated to show that
in some other countries, among them Norway and Sweden,
there has heen a progressive decrease in caries incidence during
the past few years and that it could be attributed to the
increased consumption of cod-liver oil, calcium, and vitamin
preparations. It is of interest to learn, in view of the con-
troversy on the effect of carbohydrates on the teeth, that in
Sweden the amount of chocolate and sugar consumed is high,
and continued so throughout the war.
Taking all known facts into consideration, therefore, it would
seem that nutritional factors offer the most likely solution to
the problem of tooth structure and freedom from caries, and
it appears to us that the incidence of the disease could be still
further reduced by giving diets rich in calcifying properties to
everyone, but especially to all pregnant and nursing women and
to infants.
It must be borne in mind, however, that in spite of the
improvement in dental condition described here, we in this
country have not yet gone very far along the road to perfection.
There are even to-day over 70% of L.C.C. school-children
between the ages of 5 and 6 years who have some decayed
deciduous teeth, and there are other parts of the country where
the situation is worse. It is evident, therefore, that we still have
a long way to go before we can guarantee that a child will
grow up without dental decay.
Summary
The dental condition of comparable groups of 5-year-old children
attending L.C.C. schools in 1943 and 1945 respectively is described
and discussed, and is compared with that found in 1929,
The general dental health of the children examined in 1943 was
much better than that of the 1929 group, and in 1945 there was a
further appreciable improvement.
The individual teeth in 1945 were significantly better in structure
and had less caries than those in 1943.
A point of special significance is that the percentage of carious
teeth showing arrest of the disease was almost twice as large in
1945 as in 1943. The percentage of such teeth extracted, treated by
silver nitrate, or filled was considerably smaller in the second
survey than in the first.
Superficial black or brown stains, which were observed on many
teeth, appeared in both surveys to be associated with a lower
incidence of caries, and green stains with a somewhat higher
incidence, than the absence of stain.
There was in both surveys a relationship between M-hypoplasia
and caries, the more severe the degree of structural defect the higher
being the incidence of the disease. Teeth with gross hypoplasia
showed a medium amount of caries.
It is suggested that the better condition of the teeth of 5-year-old
children in 1943 and 1945 as compared with 1929 was due to the
increased calcifying properties of the dietary of this country, and
particularly of pregnant women, infants, and young children during
recent years, and that the improvement observed in 1945 as com-
pared with 1943 was due in the main to the longer period the teeth>
examined had been influenced by the type 'of diet made availabk:
immediately before and during the war years.
570 OcT. 19, 1946
ADDISON'S DISEASE TREATED BY A GRAFT
UKlll.SH
MEDil.AL
Acknowledgments
Our thanks are extended to many who have helped us directly or
indirectly with the investigations and the preparation of this report.
We are especially grateful to Mrs. M. Kelley and Miss I. Alien
for their assistance with analysis of the results, the com-
pilation of the tables, and the arrangement of the text; also
to Dr. W. J. Martin, of the Medical Research Council, for the
statistical assessment of some of the figures. Others we would
particularly like to mention arc the London County Council and
Sir W. Alien Daley for their permission to carry out the inspections
and for making arrangements for us to visit the schools; the care-
committee workers; the medical officers of health and others in the
districts we visited who kindly suppiied us with much invaluable
information; and the head teachers and their assistants, especially
those who so willingly allowed us to pay them a second visit.
H. C. held a scholarship from the British Council, and the
expenses of the investigations were paid by the Medical Research
Council. To both of these bodies we are grateful.
REFERENCES
Board of Education (1931). Committee on Adenoids and Enlarged Tonsils.
Second Interim Report: The Association of Rickets and Dental Disease
with and Enlarrted Tonsils, London.
Davies, J. H. (1939). Brit. dent. J., 67, 66.
Deverall (Dental Disease Committee) (1936). Med. Res. Cncl. Sp. Rep. Ser.
No. 211. H.M.S.O., London.
King, J. D. (1940). Ibid., Nu. 241.
-- (1946). Lancet, 1, 646.
Magee, H. E. (1946). British Medical Journal, 1, 475.
Mellanhv, M. (1918). Lancet. 2, 767.
-- (1923). Brit. dent. J., 4t, I.
-- (1923). Proc. roy. Soc. Med., 16, 74.
-- (1927'. B-it. d" J., 48, 737.
-- (1929, 1930, 1934). Med. Res. Cncl. Sp. Rep. Ser, Nos. 140, 153, 191.
H.M.S.O. London.
-- and Coumoulos, H. (1944). British Medical Journal, 1, 837.
-- and Pattison, C. Lee (1926). Brit. dent. J., 47, 1045.
- -- (1928). British Medical Journal, 2, 1079.
-- -- (1932). Ibid., 1, 507.
-- -- and Proud, J. W. (1924). Ibid., 2, 354.
A CASE OF ADDISON'S DISEASE
SUCCESSFULLY TREATED BY A GRAFT
BY
L. R. BROSTER, O.B.E., F.R.C.S.
Surgeon to Charing Cross Hospital
AND
H. GARDINER-HILL, M.B.E., M.D., F.R.C.P.
Physician to St. Thomas's Hospital
This is the story of a young woman in whom, nine months
previous to our seeing her, a diagnosis of Addison's disease
had been made on clinical and biochemical findings. The
diagnosis was confirmed at the time of our examination, and
one of us (L. R. B.) subsequently ingrafted an adrenal gland
from a patient with the adreno-genital syndrome (hyperplasia).
As a result of this operation our patient lost her symptoms and
signs of Addison's disease, and sodium chloride withdrawal
tests showed that her blood sodium no longer fell below normal.
The last test (14 months after operation) showed that this
change had been maintained ; and she was now able to leave
off substitution therapy with sodium chloride without relapse.
Case History
Miss W., aged 33 (Jan., 1945), had not been well for six years,
the onset of her illness coinciding with tbe outbreak of war in 1939.
There were four groups of symptoms: (1) Depression and nervous
symptoms which had been present since the start. For a time she
had thought that these were due to the war. (2) Gastro-intestinal .
symptoms: during the whole period of her illness she had sutiered
on and off from what she described as a "nervy tummy." She felt
that it was on the move all the time and complained of attacks of
diarrhoea lasting for two or three days which alternate.d with bouts
of constipation. No evidence of organic disease had been found
by Dr. Wetherell, and it would appear that these attacks did
represent an irritable gastro-intestinal neuro-muscular mechanism. In
April, 1944, an x-ray examination was carried out, but the only
abnormality was a spastic descending colon. In May, 1944, .she was
seht to Sir Arthur Hurst. He discovered that she had achlorhydria,
and as a rcsuit of the acid therapy which he instituted the attacks
of diarrhoe? practically disappeared. (3) Extreme lassitude had been
noticeable from 1943 onwards, but it had been difficult to assess
the relative significance of psychological and physical factors.
Dr. Wetherell, in April, 1943, found her blood pressure to be
110/76, and the same level was found by Sir Arthur Hurst at his
examination at about this time. It was then that Addison's disease
was first suspected by Dr. Wetherell and Sir Arthur Hurst. (4)
Pigmentation : a smoky brown pigmentation was first commented
on by Dr. Wetherell and Sir Arthur Hurst in April, 1944, and it
had become more pronounced by the time we saw her in January,
1945.
In April, 1944, she was under Sir Arthur Hurst's care in
Oxford, and he notified Dr. Wetherell that he agreed with his
opinion -and that the probable diagnosis was Addison's disease.
Increased pigmentation and general asthenia troubled her
most ; and a low systolic blood pressure, 110, was the chief
physical sign. Her blood sodium at this time was 310 mg.
per 100 ml. (the normal level being 320). Sir Arthur Hurst
commented that no fall in blood chloride or rise in blood
potassium was found, but that neither was a constant feature
in early cases. He advised extra salt to the extent of four
teaspoonfuls daily, and the patient commented on an immedi-
ate improvement, saying that she felt stronger and fitter. Sir
Arthur Hurst felt that this might have been due only to
suggestion, but the improvement was so marked that he
thought it was the direct result of the increased sodium
chloride intake and further evidence in favour of Addison's
disease. He advised continuation of this treatment.
In October, 1944, the blood sodium level was 284 mg. per
100 ml. The patient was supposed to be on full substitution
therapy with sodium chloride, but Dr. Wetherell thought that
her ingestion of sodium chloride had been distinctly "sporadic."
He subsequently made arrangements for her to see Mr. Broster,.
and she came into University College Hospital private wing
under our care in January, 1945.
Ot)ler investigations had been carried out. Her blood count
on two occasions was normal. No occult blood had been
found in her stools, which contained no excess of fatty residue,
no inflammatory material, and no pathogenic bacteria. No
bacilli were found. A test-meal showed complete
achlorhydria. Her weight in adult life was normally 8 st.
(50. I kg.), and it remained at 8 st. until the spring of 1944.
She then lost weight to 7 st. 4 lb. (46 kg.), and has remained
at that since. Her menstrual cycle has been regular throughout
-5/28-day type.
On examination in January, 1945; when she came under our
observation, she had been under treatment with sodium chloride,
four teaspoonfuls daily, and injections of cortical hormone, but
there was still considerable pigmentation of her entire body.
There was a smoky brown discoloration of the nipples and in
the axillae, and patches of pigmentation on her buccal mucous
membrane. Blood pressure at that time was 120/80. There
were no abnormal physical signs in her cardiovascular system.
Chest and abdomen were normal, as were her secondary
sex characters. She was normally developed. Her weight was
7 st. 4lb. A radiological examination of the abdomen showed
a hazy area of calcification over the upper pole of the lefi
kidney which was interpreted by the radiologist as indicating
calcification in the adrenal gland on that side. The Mantoux
test was negative.
During the first week of her stay in hospital her temperature
chart showed a slight and irregular pyrexia up to 99.6 F.
(37.55 C.), but it never reached 100" (37.8 C.). Subsequently
her temperature was normal except for a slight recrudescence
of fever for a few days after operation.
To establish the diagnosis of Adc:son's disease her substitu-
tion therapy of salt and cortical hormone was discontinued for
a week. At the end of that time her pigmentation and asthenia
had definitely increased. Her blood pressure fell at the end
of a week off treatment to 95/80. Serum sodium at this
time was 295 mg. per 100 ml., and serum potassium 21 mg.
per 100 ml. We considered that these findings established the
diagnosis of hypocortical adrenalism.
After this sodium withdrawal test she was put back on s-odium
chloride treatment, and a week later the grafting operation was
carried out by L. R. B.
Description of the Donor
Miss H., aged 21, a robust young lady, was first seen in
1942. Her history was that at the age of 16 she began to
588 MARCH 26, 1932) CORRESPONDENCE [
Ttt.F.
MEDICAL jOURNAL
again at a greater disadvantage than in the first instance,
where the desire for ambulatory treatment overcame the
skill that was available for the reduction of the fracture
and its maintenance. Your correspondents admit that
anyone who puts an unpadded plaster next the skin
shoulders a certain responsibility, and that skilful applica-
tion is necessary ; moreover, if fractures are situated
higher up the leg than the ankle, sustained pull with
skeletal traction is required as a prelude to, and not as
a substitute for, the walking plaster. These admissions
are in themselves significant, and are much more in
accord with my own views on the matter. Having ob-
tained reduction, and maintained it by methods of exten-
sion which I have described, I have the majority of
patients on to their feet and walking with moving joints
in some form of retentive apparatus within three to four
weeks of their accident. Physiotherapeutic measures are
reduced, and an early return to work is the rule. Treat-
ment is in no way prolonged, and the security of the
fracture and freedom of the skin from trauma is guaran-
teed. These statements are not made with the view of
disparaging the advocates and modifiers of Dr. Bohler's
methods, but to point out that good results are con-
sistently obtained by a simple and safe measure, which
enables the large majority of patients to return to work
at an early date.
To those who persistently. urge the advantages of allow-
ing patients with fractured legs to walk about in plaster
immediately after reduction I would only ask the ques-
tion: " Would it be safe to let a fully reduced oblique or
spiral fracture of the tibia stand any weight-bearing
strain as soon as the plaster casing had been applied? ''
Plaster splints, even though unpadded, are not applied
direct to the fragments, and if there is not careful observa-
tion the slightest degree of wasting will cause the plaster
to lose its hold on the soft tissues over bone. Application
of a new plaster is not always a simple procedure, and
loss of position or angulation has been known to occur in
experienced hands.
The ambulatory ideal must be compatible with safety,
and, unless surgeons are sufficiently dexterous to ensure
that walking is possible as soon as the fracture has been
reduced, it is better to employ less active measures which
ensure safety. The term " ambulatory treatment" should
b::: used more discriminately than it is at the present time,
since many surgeons employ it to include treatment which
simply allows the patient out of bed before union has
occurred ap.d does not require the use of his limb ; while
for others it means that the patient must be bearing
weight on the injured limb almost immediately after
reduction has been effected. I do not decry the employ-
ment of early weight-bearing through an unpadded plaster,
if it can be guaranteed that the correctly reduced position
of the fracture is never lost ; but I also urge that the
patients can be treated with a minimum of discomfort,
and can. obtain an early return to work, by methods which
involve "confinement to bed for a week or so. When walk-
ing is started, events are almost unknown.
Safety, comfort, and early return of function are essential
in the treatment in any fracture.-! am, etc.,
London, \V., March lSth.
MEURICE SINCLAIR.
THE BARBITURATES IN ANAESTHESIA
SIR,-Every surgeon and every patient who has had
experience of the intravenous injection of one or other
of the barbiturates will be grateful to Dr. Magill for his
letter.
It would appear that the warnings of the Council of
Pharmacy and Chemistry are a little late in the :field, for
it is probable that experiments with the human subject,
carried out in the ordinary routine of surgical work,
already far outnumber those conducted by the pharmaco-
logists on experimental animals, and the clinical observa-
tions leave no room for doubt.
For myself, I regard the introduction of the intravenous
injection of pernocton or nembutal as the greatest advance
in the practice of anaesthetics during my professional life.
I do not think it is too much to claim that it has revolu-
tionized the psychic aspect of surgical operations, and
immensely minimized the discomfort of the post-operative
period. I confidently look forward to a time in the near
future when what has been described as " the catch-as-
catch-can " method of anaesthesia by open ether without
adequate basal hypnosis will cease to be employed in any
surgical clinic worthy of the name.
Pernocton preceded by morphine or omnopon has been
the method of choice in my own practice ever since it was
first brought to my notice by Dr, Macintosh, and I find
for it a field of usefulness far beyond the normal pre-
anaesthetic medication. For example, an injection of
pernocton may be all that is necessary in setting fractures,
passing sounds, cystoscopes, or sigmoidoscopes, extracting
radium needles, and many other procedures not commonly
regarded as particularly painful, but nearly always most
unpleasant. It is even possible to insert radium needles
with pernocton hypnosis alone without the patient know-
ing or remembering anything about it, as I found a few
weeks ago when operating upon a man of 92 to whom it
was not desired to administer inhalation anaesthesia.
For more considerable surgical procedures it is obvious
that the intravenous use of the barbiturates in conjunction
with local anaesthesia is a natural development that will
find increasing scope.-! am, etc.,
London, W.l, March 19th.
CEciL RowNTREE.
DIET AND DENTAL DISEASE
SJR,-You co.nclude your leading article on diet and
dental disease in the Journal of March 19th with the
words : " Hence the dental condition of this community
[Tristan da Cunha] appears to provide strong support
for the theory advanced by Mellanby and Pattison-
namely, that a cereal-free diet favours the normal develop-
ment of the teeth." Surely the theory of Mrs. Mellanby,
put .forward through a number of years a.nd given the
greatest publicity, was not :this at all, but rather that
dental caries was caused through a lack of vitamin D. It
would seem that only since her own work, as published in
the Medical Research Council's Report No. 159, has
thrown great doubt upon this, has she fallen back upon
the matter of cereals as being the most important factor.
Now as cereals are essentially acid-forming it will
be obvious that an excess of these in the diet will tend
to make the acid end-meta.bolites of the food definitely
overbalance the alkalis-in other words, that the im-
portant factor in the production of dental caries is a
chronic acidosis. There is no occasion to hypothesize, as
Mrs. Mellanby does, an anti-calcifying factor. Yet this
suggestion, particularly stressed by me, Mrs. Mellanby has
fought strenuously for many years. Nevertheless, the
theory that the acid-base balance of the blood is a matter
considerably affected, though not entirely covered, by an
alkali-forming diet, has received a great amount of support
from the work of a number of observers. In addition to
my own writings on the subject, the Toveruds' of Norway
have proved that in pregnant women the common negative
calcium balance can be repla,ced by a positive balance by
feeding additional vegetables and fruits, and not by
col-liver oil, and they expressly state that this is an im-
portant factor in tooth development. Hess shows that
vitamin deficiency plays no part in the production of
1
Toverud, K. and G.: Acta Paed .. xii, Sup. 11.
1
Hess and Abramson: Dental Cosmos, September, 1931.
MARCH 26, 1932] CORRESPONDENCE [
THE BRITISH ' 589
MEDICAL JOURNAL
caries, but that the amount of alkaline end-products of
the food does. Boyd and Drain show that a perfectly
balanced diet, whatever its constituents may be, brings
about an arrest of caries, even though cereals be present
in considerable amounts ; the balance of the diet being
not only in its constituent parts, but also in amount
to produce just the correct amount of energy. Jones,
Larcen, and Pritchard show that excess of vitamins in the
presence of an acid-forming diet will not prevent rampant
caries. And Helen 'Mackay and Rose have recently
published work showing that vitamin D has no relation
whatever to dental caries.
All this, moreover, is upheld by Mrs. Mellanby's own
work, in which the replacement of olive oil by cod-liver
oil saved only one tooth in every two children each year ;
or, if temporary teeth alone are considered, five teeth in
every 200 children each year. Her figures are not pre-
sented like this, but a critical analysis shows that this is
what they amount to. Mrs. Mellanby.hersel is evidently
dissatisfied with these results, for she says in her article in
the journal: " It appeared, however, that there might
be other factors apart from vitamin D influencing the
carious processes," as well there might be in face of
these figures. In these circumstances it seems hardly right
to give the credit of the theory that a diet containing an
excess of cereals is the cause of caries to Mrs. Mellanby,
when such a worker as Dr., Eric Pritchard, for example,
has been preaching for years that the whole matter is a
question of the acid-base balance of the blood.
There are, however, items other than those of diet which
will come into the problem, items which are of importance
in the lives of the islanders of Tristan da Cunha. An
acidosis may come about irrespective of the diet if the
other side of the metabolic equation, intake versus output,
is upset. The expenditure of energy, voluntarily or in-
voluntarily, is an important factor in the balance, .arid
as this is very much affected by all the circumstances of
civilization, this also must receive consideration, if the
best results are to be obtained. The children in Mrs.
Mellanby's experiment were all in bed ; their energy
expenditure therefore would be reduced to a minimum,
a.nd consequently the diet factor would be the most im-
portant. With children up and about, however, this
would add a very serious disturbing factor, and make the
obtaining of a perfect balance much more difficult.-!
am, etc.,.
F. w. BRODERICK, M.R.C.S.,
London, W.t, March 19th. L.R.C.P., L.D.S.
SrR,-1 cannot.let .the1eading article in the journal of
March 19th, on the subject of diet and caries, pass without
comment. Having spent the last eight years in the study
of health in Asiatic races, the following were my findings.
According to my personal experience, in the Indian
labourer the proportion of perfect teeth free from defect
was 68 per cent. in one group of 400, to 84.2 in another
of 1,000 ; in the Chinese from 48 per cent. to 69 per cent.
in corresponding groups. The second group in each case
represented new immigrant labour to M;alaya, and the
first, labour coolies who had been some years in the
country. I found also that there were three classes of
Chinese as regards dental standard: (1) Northern Chinese,
with a standard on a par with the Indian, (2) Cantonese
and Southern China inhabitants, and (3) Straits-born;
with the lowest standard. The women had a dental
standard about on a par with the men ; that of the
children between the ages of 2 and 14 years was very
defective, the proportions with sound teeth being I n d i a ~
27 per cent. and Chinese 4 per cent. This appeared to
3
Boyd and Drain: A mer . .Tourn. Dis. Cl!ild., October, 1928.
]ones, Larcen, and Pritchard: nmtal Cosmos, 1930.
Mackay and Hose: Dental Record, January, 1932.
Medical Research Council Report, Ko. 159.
be the state of affairs in every Eastern country visited-
that is, good teeth in the parents and extensive caries
in the rising generation. Mr. Mummery, school dental
officer, Malaya, has reported to that effect in the Malaya
Medical journal. I got information of the same kind
during tours in Java, Sumatra, Ceylon, and Siam. Even
in North Siam, which is well off the beaten track, 46 per
cent. of the school children suffered from caries. These
appeared to be the common features in all countries.
Caries is greatest in the larger centres of population,
where the sellers of delicacies pleasing to the young
palate are most abundant, and it affects most those
children who have pennies to spend.
In fact, dental caries would appear to be the first
influence of the spreading tentacles of civilization on the
outposts. There can be no question of vitamin D
deficiency among children who bake and play in the
tropical sun. Rice is the staple article of diet both of child
and of parent. If cereal is the cause of caries, why is caries
a recent development. Why have not the parents got as
bad teeth as their children?
Another line of inquiry that appears to have escaped
the notice of our investigators is that of our pampered
pets. These animals suffer excessively, not only from
caries and pyorrhoea, but also from septic ulceration of
tonsils and stomach, from obesity, rheumatism, skin
diseases, and premature old age. There is something
strangely familiar about this picture. It would be inter-
esting to know if these animals suffer from rickets and
from vitamin D deficiency and if excessive cereal is the
chief defect in their dietary.
Referring to the inhabitants of Tristan da Cunha, they
also are unable to acquire the sweet tooth, because no
sugar is grown or imported into the country. Caries has
become very prevalent among young Japanese, who are
put to sleep with a dummy consisting of a sweet wrapped
up in -linen. One can only arrive at one conclusion from
these observations, and that is that the cause of caries
among primitive races is the same as it has been in this
country-history repeats itself on the outposts-namely,
the growing use of refined carbohydrates, both as sugar
and as sweet biscuits, etc. This also is the con-
clusion of the British dental authorities. I hope to
submit further evidence on this subject at an early date.
-1 am, etc.,
D. H. c. GIVEN, M.D., D.P.H., D.T.M.,
March 19th. Surgeon Commander R.N.
SrR,-Letters have recently appeared in the journal,
and also in the Times, stressing the importance of general
factors in the aetiology of dental disease. While not
wishing to belittle the work which is being dene in this
connexion, I think there is some danger that we may
forget the more important factor of local cleanliness.
Caries occurs mainly in the teeth of the young, while
pyorrhoea affects chiefly those who are getting on in years.
On this account, some authorities consider that there must
be some form of antagonism between the two. I suggest,
however, that this antagonism is more apparent than real.
The local condition predisposing towards caries and
pyorrhoea is the same-namely, stagnation. When this
occurs in pits and fissures of the enamel, caries is the
result. When it occurs round the necks of the teeth,
pyorrhoea is the result ; but, as this is a much slower
process, it does not usually become troublesome before
middle life. Now by the time middle life is reached,
most of the vulnerable spots on the teeth have either been
filled or the teeth lost, the result being that the individual
enjoys a comparative immunity to caries. The organic
content of the teeth :ilso probably becomes less as age
advances, with the re.sult that they become less " palat-
able " to the micro-organisms concerneC:..
682 MARCH 20, 1954
INCARCERATED AND STRANGULATED HERNIA
BluTtsR
MEDICAL JOUilNAL
no hernia had been noticed before. There were 29
babies in this group and 18% of these died.
Group 2 consisted mainly of older babies in whom
an easily reducible hernia had been observed pre-
viously, but in whom the hernia had suddenly be-
come irreducible ; obstructive symptoms were minimal.
There were 16 babies in this group and no deaths.
It has been shown that, in the age group 1 week to
3 months, strangulated inguinal hernia is the common-
est, almost the only, cause of intestinal obstruction.
Owing to the ease with which an inguinal hernia
can be missed in a baby, it is essential that the inguinal
region should be carefully examined in' every infant pre-
senting with symptoms of acute intestinal obstruction.
We wish to express our thanks to the surgeons of the United
Cardiff Hospitals for permission to use the notes of cases under
their care, and to Professor A. G. Watkins for his criticism and
advice.
REFERENCES
He.-zfeld. G. (1938). Amer. J. Surg., 39, 422.
Potts, W. J., Riker, W. L., and Lewis, J. E. (1950). Ann. Surg., 132, 566.
Stammers, F. A. R. (1951). Ann. roy. Coil. Surg. Engl., 9, 189.
Thomdike, A., and Ferguson, C. F. 0938). Amer. J. Surg., 39. 429.
CHANGES IN DENTAL HYPOPLASIA
AND CARIES AMONG THE CHILDREN
OF FINNISH LAPPS, 1939-50
BY
R. V. HOLMES JONES, B.A.
AND
M. J. MYNOTI, B.A.
(From St. Thomas's Hospital Medical School)
In 1939 a small survey of Finnish Lapps was made in
order to discover the state of dental health among
children living a semi-nomadic existence far from
civilization (H. Mellanby, 1940). Since that time
Europe had been at war for six years and for seven
more has enjoyed a precarious peace. It was thought
that these disturbed living conditions might be reflected
among other ways in alterations in the structure of the
children's teeth and their susceptibility to decay. For
this reason the present survey was undertaken during
the summer of 1950.
Most of the children examined belonged, as before,
to the Inari Lapps, but a few families of nomadic
Fell Lapps were also inspected. Since the ceding to
Russia in 1944 of the Petsamo area in the far north of
Finland, the Skoltje Lapps have ceased to exist as a
separate entity. Some have b::come Russian subjects,
while others are scattered throughout the rest of Finnish
Lapland. The Fell Lapps inhabit the Enontekio and
Kilpisjarvi districts, sandwiched between Sweden and
Norway (see Map). In this area a walk was made
from Hetta northwards to the Norwegian border in
the company of the local postman, three " summer
villages " being visited. A few more children were
seen in schools at Karasuendo, on the Finno-Swedish
border, the total number of Fell Lapps inspected be-
ing ten. Ninety-two Inari Lapps were seen in Vuotso
and in Lapp huts scattered along the length of the
Utsjoki river and the Finnish bank of the Teno river
from Utsjoki to Karagasniemi.
Methods
Only the deciduous teeth of pure Lapp children between
the ages of 2 and 14 years were examined, a distinction being
made between pure Lapps and half-castes. Some of these
half-castes were Finno-Lapps (whose numbers are steadily
increasing as the Lapp population becomes less isolated), but

"- Karasuendo
Enontekio
-. Hetta
F1 Utsjoki
-")
! ! R Utsjoki
ia:; !
K aragasni<>m
Vuotso
Rovanieml
(
/
.
r./L '
__.,....... ,."""'---/

, '-._._ ........
FINNISH LAPLAND. 1950
the majority were German-Lapps, a permanent reminder of
the German occupation between 1941 and 1944.
Each mouth was inspected with an illuminated mirror
and a standard probe. The structure of the teeth was esti-
mated by the method described by M. Mellanby (1927a,
1927b, 1934), the grades of M-hypoplasia being judged by
rubbing a sharp pointed probe over the labial surface of
the teeth. The extent of caries in each tooth was also judged
by the same method as that used by Mellanby (1934), the
Dental Disease Committee (1936), and Mellanby and
Mellanby (1948), being estimated as caries 0, I, 2, or 3
according to the size of the cavity. To obtain average
hypoplasia and caries figures the total hypoplasia and caries
figures for each group were added up separately and divided
by the number of teeth examined for structure and caries.
This gave the average hypoplasia figure (A.H.F.) and
average caries figure (A.C.F.). A measurement of the extent
of healing caries was not attempted.
Results
The results are compared throughout with those obtained
in the 1939 investigation by Dr. Helen Mellanby.
Structure of Inari Lapp Children's Teeth.-When the
structure of the deciduous teeth of these lnari Lapp children
is compared with that found in 1939 (Table 1), there is seen
to be a slight increase in the A.H.F. The considerable
deterioration in structure of the complex teeth (molars) since
1939 has been incompletely counterbalanced by the improve-
ment found in the incisors and canines. However, further
analysis of the results into various age groups, as set out
in Table 11, shows that this general picture is erroneously
simple. While the A.H.F. of the 2-5-years age group was
slightly below the 1939 total average of 1.09, that of the
6-9-year-olds was higher. There were too few children
MARCH 20, 1954 DENTAL HEALTH IN LAPLAND
683
TABLE I.-Structure of Teeth of Jnari Lapp Children Aged 2-14 Years
Total No. of I % % % % %
A.H.F.
Teeth Examined MHYo M-Hy1 M-HYo M-Hy,. Gross
1939

Incisors and canines 1 216
736 I 324 4SS I 540 I 389 129 I 125 I 04 20 I - J.l I 081 070
Molars . . . . 221 641 154 5-6 402 332 385 443 58 13-1 - 34 135 167
I
1,377123.7j27-ilj47-3j36.22s:sj27-3j_3__1 ---7-3-l-=-[2-21!.091----w3 Total 437
Teeth wtth gross hypoplasia for 1950 are mcluded in the percentages, but are excluded from the calculations of the A.H.F.
TABLE H.-Average Hypoplasia Figure for Teeth of lnari Lapps,
1950, Arranged in Age Groups
2-S Years 6-9 Years 2-14 Years
No. of children .. .. 48 23 92
Incisors and canines .. 059 098 070
Molars .. .. .. 163 1-81 167
All teeth .. .. 097 139 H3
between 10 and 14 years with teeth whose hypoplasia could
be assessed to obtain representative figures for this age group.
Caries in lnari Lapp Children's Teeth.-The incidence and
extent of caries in the different age groups of Inari Lapps are
set out in Table Ill. Of the 92 children studied, only 6
TABLE 111.-lncidence and Extent of Caries in Deciduous Teeth
of lnari Lapp Children
No. of
%Carious A. C. F.
Age Group
Teeth Examined
1939 1950 1939
I
1950

2-5 years .. 208 843 240 229 039 036
6-9
.. .. 313 452 683 428 157 085
0-14
.. .. (57) (66) (439) (576) (092) (107)
11,361
------
Total .. 578 500 309 1-15 055
were caries-free. Nevertheless, this is an increase on the
number reported by H. Mellanby-namely, 3 out of 70.
When the total number of teeth is considered comparison
shows that the incidence and extent of caries have sharply
decreased over the intervening years. This change has
occurred almost entirely in the 6-9-years age group.
Relationship Between Structure and Caries.-Table IV
shows that teeth with good structure-namely, those with
no surface hypoplasia-are less liable to be attacked success-
fully by the carious process than those showing M-hypo
plasia. This relationship has been demonstrated in all pre-
vious surveys using M-hypoplasia standards (notably M.
Mellanby, 1923, 1934; Mellanby and Coumoulos, 1946;
Mellanby and Mellanby, 1948, 1950, 1951 ; King, 1940).
Furthermore, from a comparison with the 1939 figures it
will be seen that the percentage of hypoplastic teeth which
are carious is significantly lower in 1950 than in 1939.
Teeth of Fell Lapp Children from Enontekio.-Although
only 10 children in the Enontekio area were inspected (owing
to the great difficulty in reaching the nomadic families) and
eight of these were between the ages of 8 and 11 years, the
difference between the teeth seen in this group and those of
the settled Lapps was so pronounced that the figures seem
worth mentioning: 81% of the deciduous teeth were decayed,
as compared with 46% in the same age group (8-11 years)
of the Inari Lapps.
TABLE lV.-Percentage of Caries in Normal and Hypoplastic
Deciduous Teeth of lnari Lapp Children
Teeth with No Hypoplasia Teeth with 1-3 Hypoplasia
No.
I
%Carious No. %Carious
Simple, 1939 .. 79
I
76 170 247
.. 1950 .. 335 33 393 liS
Complex, 1939 .. 40 525 203 709
..
1950 .. 37 (432) 582 539
Total, 1939 .. 119
I
22-7 373
I
499
..
1950 .. 372
I
73 975 364
Teeth with gross hypoplasia have been excluded from this and other
tables dealing with structure.
Discussion
The chief finding of this survey is the decrease of caries
incidence amongst the 6-9-yearold lnari Lapps, although
the structure of their teeth, as judged by surface hypoplasia,
is worse than just before the war. As diet is believed to be
largely responsible for determining the structure of the teeth
(Mellanby, 1934; Mellanby and Coumoulos, 1947), and also
to influence the rate and extent of dental decay, the changes
of food habits among these Lapps during and after the war
have been investigated.
Dr. H. Mellanby (1940) found that the staple foods among
the Inari Lapps in 1939 were reindeer meat, dried fish,
potatoes, rye bread, and margarine. The universal drink
was coffee liberally sweetened with sugar. Two noteworthy
points are that almost all the salmon was at that time
sold to the tourist hotels and that very little fresh fruit was
eaten.
Although the Russo-Finnish war of 1939 did not appreci
ably alter the food habits of the Inari Lapps, throughout
the second war (1941-4) and the German occupation, in
the final stages of which 200,000 well-paid German troops
were present in Finnish Lapland, much more " European
food" was imported. Moreover, during this period the
Lapps enjoyed an economic boom, working for the Germans
and supplying them with meat and fish. So during the years
1941-4 the Lapps lived on a diet containing more cereals,
sugar, and potatoes than in 1939 but much less meat and
fish. In view of this it seems probable that the calcifying
power of their diet at this time was low. However, in 1944,
as one condition of the Finnish peace treaty with the
Russians, the Germans were driven from North Fin-
land. As the Germans retreated they employed a scorched
earth policy. In order to escape some of the con
sequences of this action the Inari and Utsjoki Lapps were
evacuated to Kalajoki in central Finland, while many of
the Enontekio Lapps moved over into Sweden. In the
Kalajoki community the Lapps existed on a subsistence
diet, and diseases such as typhoid were rampant, whereas
in Sweden and Enontekio Lapps were well housed and fed.
When they returned to their own country in mid-1945 almost
all the buildings had been burnt or blown up (we saw only
one house left standing since 1939) and living conditions were
extremely crude for the next two or three years. During
this time the Lapps lived largely on fish and meat, and food
supplied by various philanthropic organizations.
Since 1948 the diet has gradually been reverting to the
1939 pattern. The main differences to-day are that less
fish is sold to tourists, and that the Lapps seem more
conscious of the value of eating fresh fruit. In addition,
expectant mothers through Finnish Lapland are now visited
by the district nurses and considerable prenatal care is
exercised.
Although representative figures were not obtained, the
teeth of the 1Q-14year-old children might be expected to
show a similar structure to those inspected in 1939, these
teeth having been formed between 1936 and 1940. The
period of formation of those aged 6-9 years coincided with
the German occupation of Lapland, and it seems possible
to account for the defective structure of the teeth of the
children in this age group as being due to the particularly
low calcifying power of the diet at this time. The children
aged 2-5 years have recovered and slightly improved upon
the pre-war structure, as would be consistent with a diet of
higher calcifying power.
684 MARCH 20, 1954 DENTAL HEALTH IN LAPLAND
BIUTISII
MEDICAL JOURNAL
When considering factors which might be expected to
influence decay it will be realized that the teeth of the oldest
group have had a chequered existence since eruption. The
effects of these factors have been so balanced that the caries
figures are now the same as in 1939. Teeth in the youngest
group, with slightly better structure, show slightly less decay
than in thl!t year. But the striking change is that the A.C.F.
of children aged 6-9 is only just over half its 1939 counter-
part in spite of the teeth having a worse structure. In broad
terms, therefore, the post-eruptive influences since 1945 must
have been less damaging than in the previous years. This
can be explained either by an increased tooth resistance due
to a higher post-eruptive dietary calcium intake or by a
decrease in the factors favouring decay. However, if the
calcifying power of the diet during this time is reflected in
the tooth structure of the children under 5, the dietary
calcium since 1945 has been substantially the same as before
the war. Therefore it seems that the teeth of the 6-9-year-
olds are less carious, not because they are more resistant,
but because there are fewer external influences favouring
decay. Although more meat and fish was eaten during those
years the one factor in the diet which is known to have
decreased is sugar. A tentative conclusion on this evidence
must be that a low-sugar diet decreases the chance of caries.
With regard to the caries figures of the Enontekio and
lnari Lapps it is significant that in 1945 the former moved
over to Sweden, where they fed well by European standards
(with plenty of sugar and vitamin-fortified margarine), while
in their homes after their return they were able to trade
with smugglers travelling between Norway, Finland, and
Sweden who largely carry spirits, sugar, and margarine. So
in addition to their vitamins A and D intake (contributed
mainly by the margarine and fresh fish) being as high as,
or possibly higher than, that of the lnari Lapps, their
sugar consumption also was much higher. Now since the
state of their teeth is so much worse than that of the Inari
Lapps, they must have been subjected to factors favouring
decay to a much greater extent than the Inari Lapps' teeth.
In this case a high-sugar diet might b& incriminated.
Smnmary and Conclusion
The changes found in both Fell and settled Lapps
fall in line with other wartime studies and the con-
clusion of Toverud (1951) that "the knowledge gained
through the greatest dietary experiment forced upon
us strengthens the value of more natural foods and
less of easily fermentable carbohydrates in the prophy-
laxis against dental caries."
The teeth of 92 settled and 11 nomadic Lapp
children were inspected for caries and surface
hypoplasia.
The state of the teeth is compared with that existing
in 1939.
An attempt is made to correlate the changes found
in the teeth with the alterations in diet during the in-
tervening period.
We would like to thank Lady Mellanby for her guidance and
instructions before undertaking this survey ; and to express our
gratitude to Dr. H. Mellanby for her help, advice, and encourage-
ment.
REFERENCES
Dental Disease Committee (1936). Spec. Rep. Ser. med. Res. Coun. Lond.,
No. 211.
King, J. D. (1940). Ibid., No. 241.
Mellanby, H. (1940). British Medical Journal, 1, 682.
- and Mellanby, M. (1950). Ibid .. 1, 1341.
Mellanby, M. (1923). Brit. dent. i., 44, I.
- (1927a). Ibid .. 41, 737.
- (1927b). Ibid .. 48, 1481.
- (1934). Spec. Rep. Ser. med. Res. Coun. Lond., No. 191.
- and Coumou1os, H. (1946). British Medical Journal, l, 565.
-- - (1947). Ibid., 1, 753.
- and Mel19nby, H. (1948). Ibid .. :Z, 409.
- - (1951). Ibid .. 1, 51.
Toverud, G. (1951).-lnt. dent. J., :Z, 131.
CHILDREN'S NURSING UNIT
BY
JOS. A. GILLET, M.B., Cb.B., D.P.H.
Medical Officer of Health, County Borough of Rotherham
Following on a high infant death rate in Rotherham
during the winter of 1948 and early 1949, considered
to be largely due to cross-infection in hospital, the
health committee in March, 1949, approved a scheme
for the establishment of a children's nursing unit as
part of the home nursing service. It was to be at the
disposal of the family doctor as a first line of defence
so that a child could be nursed at home in its qwn
environment, except when conditions were such as to
make this impossible, or when special treatment neces-
sitated removal to hospital. It was also appreciated
that the value of the education of the mother in practi-
cal preventive methods and treatment during illness,
with the necessary equipment, even in what might ap-
pear at first sight to be hopeless domestic conditioq.s,
. would ultimately be of benefit to the community and
that such action would help to reduce the pressure on
hospital accommodation.
Preparations for the Scheme
Authority was given to obtain special nursing equipment,
including infants' clothing, treasure cots, the necessary
gowns, masks, storage cupboard, and nursing bags. Some
of this equipment was given to the service, the treasure cots
being presented by the Rotherham District Nursing Bene-
volent Association ; and the children's nightgowns, coats,
vests, etc., were either knitted locally or received in gift
parcels from New Zealand, the remainder being purchased.
One of the Queen's Nursing Sisters on the home nursing
staff undertook a postgraduate course covering children's
diseases, and she was made responsible (under the direction
of the home nursing superintendent) for this special service.
Later on in the year, a second nurse received similar train-
ing. During 1952 both nurses undertook further hospital
duty as refresher courses.
The doctors practising in the town were informed of the
facilities available and the unit began to function in June,
1949. Cases are notified direct to the superintendent, usually
by telephone by the general practitioners, and the special
home nurse visits the home to assess whether the case is
suitable and what equipment is needed. The equipment is
kept in the nurses' home and special containers are packed
and sterilized ready for use in infectious cases.
During the winter months cases are so numerous that the
two special nurses are unable to deal with them all, and
each home nurse attends the overflow cases on her district,
giving a specially detailed report on all cases after each
visit. Additional assistance is also given to the unit by
the Queen's candidates as part of their training. The fre-
quency of visiting depends on the child's condition ; often
it is necessary to pay three or four visits daily. The home
nurse is in frequent consultation with the general practi-
tioner, who is informed immediately if the child does not
appear to be responding to treatment. The parents are
encouraged to contact the nurses' home if they are unduly
worried about their child's condition, and a nurse (usually
the superintendent) pays a visit immediately. Night calls
have been very few, and it is felt that the assurance of a
visit from the nurse at any time removes a good deal of
the parents' anxiety.
Equipment
Details of the equipment now used by the unit are as
follows : 4 treasure cots ; 1 dozen sheets ; 2 pillows ; 3
enamel pails ; 6 wash basins ; 6 enamel trays. 6 by 4 in.
JAN. 5, 1952 TISSUE REACTIONS TO PROTEIN SENSlTlZA TION
cells, can be poured through glass wool, to which the
polymorphs adhere. The filtrate has only to be lightly
centrifuged to obtain lymphocytes-alive if suitably
handled. Do these cells carry the essential properties
required by the hypotheses ? If so, under what circum-
stances? Similarly, many more experiments need to be
performed before the explanation of the various types
of " antibody " found in asthma can be regarded as
" being on a scientific basis."
Summary
Protein sensitization in man is a suitable subject for
scientific study, especially when reinforced by animal
experiments. Two main types-the asthma-urticaria and
the tuberculin-trichophytiD type--are considered and con-
trasted. Some of the methods of controlling sensitization
reactions are discussed. Tentative hypotheses suggesting
further experimental work are outlined.
RBPBRBNCBS
Biggart, J. H. (1932). J. Path. Bm:t., 35, 799.
Blackley, C. H. (1873). Experimental Resrarches on the Causes
and Nature of Catarrhus Aestivus (Hay-fever-or Hay-asthma).
London.
Bovet, D., and Staub, A. M. (1937). C.R. Soc. Bioi., Paris, 124,
547.
Burnet, F. M., and Fenner, F. (1949). The Production of Anti
bodies, 2nd ed. Melbourne.
Chase, M. W. (1945). Proc. Soc. exp. Bioi., N.Y., 59, 134.
Code, C. F. (1937). J. Physiol., 90, 485.
CookeJ R .. A., and Sherman, W. B. (1950). In Pathologic
Pnysiolofy, edited by W. A. Sodeman, p. 706. London.
Coulson, E. ., and Stevens, H. (1949). J. lmmunol., 61, 119.
Cruickshank, C. N. D. (1951). Nature, Lond., 168, 206.
d'Abreu, A. L. {1940). Lancet, :Z, 421.
Discombe, G. (1946). 1, 195.
Ebert, R. H., Sanders, A. v., and Florey, H. W. (1940). Brit.
J. exp. Path., 21, 212. -
ravour, C. B., Fremont-Smith, P., and Miller, J. M. (1949).
Amer. Rev. Tuberc., 60, 212.
Gaddum, J. H. (1948). British Medical Journal, 1, 867.
Halpern, B. N. (1950). Acta allerg., Kbh., 3, Suppl. 1, 164.
Hare, R. (1926). Heart, 13, 227.
Harley, D. ,(1937). Brit. J. exp. Path., 18, 469.
- (1942). Studies in Hay-fever and Asthma. London.
Kabat, E. A. (1947). Amer. J. Med., 3, 535.
Koch, R. (1890). Quoted by Rich (1944).
Lawrence, H. S. (1949). Proc. Soc. exp. Bioi., N.Y., 71, 516.
Lewi!t T. (1927). The Blood Vessels of the Human Skin and
1heir Responses. London.
- and Grant, R. T. (1926). Heart, 13, 219.
Long, D. A., and Miles, A. A. (1950). Lancet," 1, 492.
Loveless, M. H .. (1940). J. lmmunol., 38, 25.
- (1941). lb1d., 41, 15.
Miller, J. M., and Favour, C. B. (1951). J. t>xp. Med., 93, 1.
Raffel, S. (1948). 1. inject. Dis . 8:Z, 267.
Ramirez, M. A. (1919). J. Amer. med. Ass., 73, 984.
Ratner
1
B. (1939). Amer. 1. Dis. Child., 58, 699.
Richr. A. R. (1944). The Pathogenesis of Tuberculosis. Spring-
neld Illiilois.
- and Lewis, M. R. (1932). Bull. Johns Hopk. HosTJ., SO, 115.
Rimington, C., Stillwell, D. E., and Maunsell, K. (1947). Brit. J.
exp. Path.
1
Zl, 309.
Salter, H. Hyae (1860). On Asthma: Its Pathology and Treat-
ment. London.
Seibert, F. B. (1944). Chem. Rev., 34, 107.
Squire, J. R. (1950). Clin. Sci., 9, 127.
Stull, A., Cooke, R. A., and Chobot, R. (1931). J. bioi. Chem ..
92, 569.
Wadley, F. M. (1949) Amer. Rev. Tuberc.,, 60, 131.
The annual report of the honorary secretary of the Joint
ruberculosis Council briefly records the work of the council
during the year. Probably the most important achievement
was the completion and publication of forms of record for
use in chest clinics. At the request of the Ministry of Health
the council drew up a memorandum on the internal admini-
stration of hospitals, and members of the council also assisted
the Ministry in drawing up a report on skiagraphic termi-
nology and radiographic technique. A trial of a four-digit
classification of tuberculosis was undertaken at the request
of the World Health Organization.
DENTAL DISEASE AMONG 14-YEAR.OLD
LONDON SCHOOL-CHILDREN
IN 1947 AND 1950
BY
MAY MELLANBY
AND
HELEN MELLANBY, M.D., Ph.D.
with the assistante of
JOAN JOYNER. B.Sc., and MARION KELLEY
(Prom the Nutrition Building, National Institute for
Medical Research, Mill Hill, London)
The Education Act of 1944, which raised the school-
leaving age to 15, gave the opportunity for making
dental surveys of the 14-year-old group. This age is
suitable for the examination of the permanent teeth, as
most types have erupted, with the exception of the third
molars, while few deciduous teeth remain to be shed. It
also provides an overall picture of the state of dental
fitness of a section of children the majority of whom
are about to leave school, and as such it will no doubt
be of interest to the public health authorities.
The two surveys with which this paper is concerned
were carried out during the winter months of 1947-8
and 195Q-1, but for the sake of brevity they will be
referred to as the 1947 and 1950 surveys. The London
County Council very kindly afforded facilities for
making the inspections, all of which took place in schools
under their authority, the number of children examined
being 1,216 in the earlier year and 1,089 in the later.
These children were unselected samples distributed
between modern, technical, and grammar secondary
schools, the proportions from each bearing a rough
relation to that of the total child population attending
the different kinds of secondary schools in the area.
In both surveys approximately 72% were from the
modern schools, 12% from technical schools, and 16%
from grammar schools. Since more children attend
modern schools, any differences between the teeth of
these children in the two surveys have more influence
on the total figures than have the differences between the
teeth of technical or grammar pupils. The samples of
children from the latter kinds of school were too small
to give more than an indication of possible differences
between them and the modems, especially where
individual types of teeth are concerned.
The exaQlination procedure and the charts used for
recording the dental condition of the children were
basically the same as those employed in the surveys of
5-year-olds from 1943 onwards (see Mellanby and
Coumoulos, 1946), but certain adaptations were made
to suit the charts for use with the permanent dentition
. (see Chart). Although external structure (as gauged by
M. Mellanby's probe method),- the incidence and extent
of caries, mottling of the enamel, tartar, gingivitis, align-
ment, and occlusion were recorded, in the present paper
only the results relating to the incidence and extent of
caries, gingivitis, and tartar are given.
"
Methods
Each child's mouth was carefully examined by one of
us with a standard probe and illuminated mirror, the
results for each individual being separately charted.
8 JAN. 5, 1952 DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
BllmsB
MEDICAL JoURNAL
PERMANENT TEEl r1
second molars, remained unerupted.
Name _________ _ Date ol81nh, ______ _
No. ___ _ Each case of apparent non-eruption
was judged on its merits ; for
instance, when the. deciduous pre-
cursor was either in situ or had very
recently been shed, or the outline
of the permanent tooth could be
seen through the gum, it was then
obvious that a given tooth had not
erupted. In the case of the second
molars the decision of non-eruption
versus extraction was sometimes
more difficult, but the. appearance
of the gum combined with the
stage of eruption of other teeth,
especially the other second molars
in the same mouth, usually pro-
vided sufficient evidence one way or
another.
k h ~ l __________________ __
Gln&lvltls 0. 1. 2. )
Tanar
Mottllng 0, I. 2. l
M-hypoplasia (0. I. 2. l) I G
Caries 0. I. 2.)
Teeth Present
7 6 s 4
)
2 I I 2
)
4
THth P.--nc
7 6 5 4
)
2 I I 2
) 4
Caries 0, I, 2.]
M-hypoplasia (0. I, 2. 3) I G
Mottllng 0. I. 2. )
Tanar
Gingivitis 0, I, 2. )
State of mouth--------
Allgnment ______ ~ - -
Occluslon _______ -"--
Stain _________ _
The expression of the incidence of caries alone,
whether given as a percentage or as the D.M.F. (decayed,
missing, filled) figure, does not in our opinion provide
a complete picture of the state of the teeth, as a group
of individuals with small cavities would appear on paper
to have the same amount of caries as a group in which
the cavities were large. In these surveys, therefore, when
caries was considered to be present in a tooth an attempt
was made to assess the extent by grading the lesion 1,
2, or 3 according to the following criteria :
Grade Ct. Slight Caries.-(a) Pits and fissures suspected
of caries on account of the probe sticking. (b) Indefinite
approximal caries (i.e., presence strongly suspected). (c) Tiny
visible cavities up to about 1 mm. in diameter.
Grade C2. Moderate Caries.-<:avities larger than those
in grade 1, but not involving more than one-quarter of the
crown.
Grade Ca. Severe Caries.--<:avities involving more than
one-quarter of the crown. In this last category were also
placed all teeth assumed to have been extracted for caries,
and those of which only carious roots remained.
When a history was obtained of teeth extracted for
regulation or following trauma, these were excluded
from all the results. Filled teeth were counted as having
been decayed, since it is unlikely that any of the children
examined would have bad " preventive " fillings inserted.
In assessing the probable size of a cavity before treat-
ment a small allowance. was made for removal of extra
tooth substance in preparation. For instance, very small
amalgam fillings in fissures of the molar teeth were
graded C
1
, and fillings anywhere which only just ex-
ceeded one-quarter of the crown were graded C
2
From
this assessment of caries extent, an average caries figure
(A.C.F.) was derived according to the formula set out
in the footnote to Table IV. It is fully realized that
this method of assessing the extent of caries can give
only an approximate result, as it relies largely on naked-
eye inspection, but when it is employed by the same
investigators for successive surveys it gives comparable
results.
A small proportion of teeth (approximately 3%),
chiefly upper canines, upper and lower premolars, and
Data. _____ _
5
5
6 7
'
7
When no carjes was detected in
any of a child's permanent teeth,
and there was also no evidence of
any such teeth having been ex-
tracted or filled on account of
decay, that child was considered
for the purpose of this investigation
to be caries-free, though no doubt it might have been
found to have decay had ancillary aids over and above
a probe and mirror been used. If only a sml{ll amount
of caries was detected in a child, such as one, two or
three grade 1 cavities, and there had again been no
extractions or fillings, that child was placed in a
separate category labelled " slight caries " to distinguish
it from children with more extensive lesions. These two
groups, the" caries-free" and those with "slight caries,"
together give an idea of the proportion of children who
at 14 would be considered to have "good" mouths.
Gingivitis, when present, was roughly divided into
three grades, depending on the degree of swelling and
hyperaemia, especially of the interdental papillae,
coupled with the extent of this in each mouth. Children
with " normal " gingivae were classified as 0. Their
gum tissue was a uniform pale pink with thin edges.
closely adherent to the tooth surfaces, the spaces between
adjoining teeth being filled by the points of the inter-
dental papillae. The appearance of the gum surface
was matt, due to the presence of stippling (King, 1945)
as opposed to the shiny surface seen in abnormal tissues.
Grade 1 (mild gingivitis) included children with shiny
and slightly swollen papillae between a few teeth, as
was most eommonly found in the lower incisor region.
Grade 2 (moderate gingivitis) contained those children
in whom large areas of the gingivae were slightly affected,
or who had considerable amounts of swelling and
hyperaemia round a few teeth, with the rest ,little
affected. Grade 3 (severe gingivitis) was used for those
children with very obviously thickened, reddened, and
swollen gum tissue. In some individuals this might be
confined to the anterior teeth, but in others it was more
extensive. A few in this group had advanced gingival
disease with ulceration and pocketing.
Tartar deposits on individual teeth 'were graded on
the charts as 1, 2, or 3, according'to whether they covered
up to one-third, two-thirds, or the whole of the buccal
or lingual surface. From these figures an average
assessment for each mouth was obtained, and the
children were then graded into four categories--o, 1, 2,
and 3.
JAN. 5, 1952 DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
Caries
The_ nu_mber of children examined in the two surveys
and dtstrtbuted between the three kinds of secondary
school are given in Table I, column 2. The totals for
I.-children Caries-free or with Slight Caries. and the
Average Number of Carious Permanent Teeth per Child
(D.M.F.)
1 2 3 4 5
Percentage Average
No. of
Percentage
with Slight No. <tf
Variety Children
Caries Carious
of Examined
Caries-free (Three or Teeth
Secondary
Less c, per Child
School
Cavities) (D.M.F.)
1947 1950 1947 1950 1947 1950 1947 1950
Modem .. 878 784 113 170 112 179 399 385
Technical
::I
151 138 132 140 166 154 3-68 404
Grammar 187 189 112 138 193 118 3-90 420
Total .. 1,216 1,089 115 181 13-1 188 394 379
. .
See text for delin.tions .
1950 were rather fewer, but the proportions attending
the modern, technical, and grammar schools were the
same on each occasion. In the 1947 survey 54% of
the children were boys and 46% were girls, whereas in
1950 the respective percentages were 55.8 and 44.2, the
average age on both occasions being 14 years 5 months.
The proportion of children considered to be caries-
free, according to the standards used, increased from
11.5% in 1947 to 16.1% in 1950 (Table I, column 3).
This increase was spread over the three kinds of school
being more pronounced in the modern than in the others:
The total percentage of children with very little decay
(Table I, column 4) also increased, but this was entirely
because the considerable improvement in the modern
pupils more than compensated for the reduced number
of such children in technical and grammar schools. The
average number of carious teeth per child (equivalent
to the D.M.F. per child of some authors) showed "
slight overall reduction, which was again achieved by
the modern schools' improvement exceeding the some-
what worsened state of affairs in the others. More boys
than girls were found to be caries-free in 195Q-about
19% as compared with 12%-whereas in 1947 the
difference in this respect was negligible.
In Table II an attempt has been made to gather
together from the literature a few comparative caries
figures for other groups, mostly children of fairly similar
age who had also been examined with a probe and
mirror. From this table it will be seen that in some
communities, such as Hagerstown (U.S.A.) and New-
foundland, caries incidence was high, only 4.6 and 0.8%
respectively of the children examined being caries-free
at 14 years of age. Children from Chicago, Trinidad,
and American Indian reserves gave intermediate figures
of 14.4, 13.8, and 23% respectively of individuals carie!l-
free. Where caries incidence in this age group was
considered to be comparatively low, as in the Isle of
Lewis, Scotland, the town of South Shields, England, and
Northern Italy, the of caries-free children
were 30.8, 25.8-50.6, and 38.4 respectively. African
and, more recently, Indian children were found by
M. Mellanby to be remarkably free from caries ; in the
latter case 65.8% of the 14-year age group at Lucknow
were in this category. From these figures' it will be
realized tl;!.at the London children in 1950, with 16.1%
of individuals free from decay, were better than some
groups, though a long way from the best so far reported,
even for this country-for example, Lewis and South
Shields.
The percentage of teeth present in the London children
at the time of inspection are given in Table Ill. These
figures represent the teeth actually seen in the mouth
(extractions as well as unerupted teeth being omitted
here), as compared with the possible total if every child
had 28 permanent teeth erupted. The very few third
molars observed were excluded. The majority of the
28 teeth per child were in situ, the percentages being
94.8 in 1947 and 95.9 in 1950.
Individual differences in the propbrtion of the various
types of teeth present in pupils from the three kind11
of school were on the whole very small. In 1947 the
percentages of upper and lower first molars were highest
in the grammar schools and lowest in the modern, the
difference being between 6 and 7%. In 1950 there was
no difference between the schools as regards upper first
molars, but of the lower first molars the grammar schools
now hat! the lowest percentage and the technical the
highest, the discrepancy between them being 6.8%.
TABLE H.-Comparative Figures for Dental Caries in Different Parts of the World,
No. of
Place Author
Date of
Individuals Age Group
Survey
Examined
Africa, Ke117a .. M. Mellanby(1934) 1929 103 Young adults
<\frica, Zanzibar M. Mellanby (1934)
Aver. 27 years
.. 1929 154 5-16 ..
U.S.A. American In- Klein a,;d Palmer (929-33 1,300 14 and 15,
dians in .. (1937)
Scotland, Iole of
King (1940) 1937 185 13-15
"
Lewia
U.S.A.
1
Hqentown, Klein et al. (1938) 1937 364 14
"
_ Madison
U.S.A., Chicqo .. Dean et al. (1941) 1939 2,832 12-14
"
Italy (four northern Schour and Masslcr r945
475 11-15
"
cities) (1947)
1945 247 16-20 ..
Trinidad .. King and Martin 1948
{406
12-14 ..
British ouida .. (1951) 100 12-14
..
Newf'oundlaad .. H. Mellanby (un- 1948 595 14
..
published work)
Soutlo.
Weaver (1950)
r
500 12 ..
1949 500 12
..
Enaland, North Weaver (1950) 1943 500 12
..
Shields 500 12 ..
India, Lucknow .. M. Mellanby (un- 1951 266 14
..
publlshed work) 1951 801 13-20 ..
Percentage
Percentage of
of Teeth Carious
Individuals
orD.M.F.
Caries-free
per I 00 Teeth
84
201
(approx.)
so
23
111
(approx.)
308
85
46
192
144 -
(average)
53-4 -
384 -
138
217
130
184
08
307
25-8 -
506 -
48 -
264 -
65-8
271
608
3-4
Average No. of
Decayed Teeth
per Person
(D.M.F.)
056
(approx.)
15

22
52
473
(average)
105
202
537
491
839
24
13
I
43
24
095
Comments
Deciduous and p er
manent teeth
Indians distributed be-
in tween 76 reserves
16 States
Rural fishina com-
munities
Described as
East U.S.A.
typ tcal
small
town
Average of eight se
ate communities
par-
per Deciduous and
manent teeth
Permanent teeth
East Indian and N egro
children
14 p.p.m. fluorine
water supply
Nesligiblc fluorine
in
10 JAN. 5, 1952 DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
B1Ul1811
MJmrc.u. JOUllNAL
A proportion of the spaces for unerupted permanent
teeth were still occupied by deciduous predecessors ;
for example, in 1950 there were 139 deciduous teeth
still retained, of which 33.1% were upper canines and
57.6% were second molars. No records were made of
decay in these teeth, all the figures for caries incidence
and extent given in this paper referring to the permanent
dentition only.
An analysis of the caries results for both surveys and
for each type of permanent tooth in the combined
schools is given in Table IV. Column 2, compiled from
the numbers of teeth inspected plus those extracted for
caries, shows the total numbers on which the analysis
is based. As is usual in most civilized communities,
the tooth most frequently attacked by disease was the
lower first molar (over 60% in each survey being
carious), with the upper first molar coming next. The
least attacked were the canines, the lower incisors, and
the lower first premolars.
TABLE 111.-Percentage of Permanent Teeth of Each Type
In Situ
Type of Tooth
Upper jaw:
Central incison ..
Lateral incisors ..
Canines .. ..
I st premolars ..
2nd premolars ..
1st molars .. ..
2nd molars ..
Lower jaw:
Central incisors ..
Lateral incisors ..
Canines .. ..
1st premolars ..
2nd premolars ..
1st molars .. ..
2nd molars .. ..
Totals for upper and
lower jaws
1
Type of Tooth
Upper jaw:
Central incisors ..
Lateral
..
..
Canines ..
I st premolars : : ..
2nd , .. ..
1st molars .. ..
2nd .. .. ..
Total for upper jaw .
Lower jaw:
Central h;tcison ..
Lateral , ..
Canines .. ..
1st premolars ..
2nd .. ..
tst mol.,;.; .. ..
2nd .. .. ..
Total for lower jaw ..
Total for u. and I. Jawa
Variety of
School
1947
990} {Modem
Technical 997 992
Grammar 997
{Modem 978}
Technical 987 982
Grammar 995
{Modem 973}
Technical 980 977
Grammar 989
{Modem 978}
Technical 967 975
Grammar 968
{Modem 916}
Technical 91-1 919
Grammar 941
{Modem 905}
Technical 957 921
Grammar 968
{Modem 938}
Technical 902 933
Grammar 935
JModem
998}
Technical 100 999
LGrammar 100
{Modem 99-7}
Technical 100 998
Grammar 100
{Modem 994}
Technical 997 995
Grammar 100
{Modem 957}
Technical 934 954
Grammar 957
{Modem 832}
Technical 844 842
Grammar 885
{Modem 832}
Technical 891 851
Grammar 909
{Modern 937}
Technical 924 934
Grammar 925
{Modem 945}
Technical 949 948
Grammar 962
1950
989}
998 988
991
983}
986 982
979
974}
960 967
944
991}
985 986
976
928}
938 933
-953
936}
938 93-6
938
968}
856 964
959
997}
993 996
994
997}
996 997
984
887}
998 998
100
974}
974 975
991
870}
890 87-8
899
878}
890 870
822
98-7}
983 95-8
958
959}
981 959
917
The caries incidence for all types of teeth together
was 14.6% in 1947 and 13.9% in 1950 (Table IV,
column 7). When the different types of teeth are con-
sidered individually, however, it will be seen that there
was more caries in 1950 among the upper incisors and
rather less in the first molars. 1l1e A.C.F. for these teeth
(column 8) showed corresponding increases in the upper
incisors and decreases in the first molars. The very slight
overall improvement in the caries position in 1950 com-
pared with 1947, therefore, was not achieved by a
uniform reduction of decay, but rather by the reduction
in the incidence of first molar decay exceeding the
increase experienced in the upper incisors.
The caries incidence and extent in the three varieties
of school are set out in Table V. From the total per-
centages at the bottom of column 7 it will be seen that
in 1947 the technical schools had the lowest overall caries
incidence and the modern schools the highest, though
the difference between them was very small (13.7%
compared with 14.8% of teeth affected). By 1950 there
had been a slight reduction of caries in the modern
schools (from 14.8 to 13.4%), whereas in the other two
groups the incidence had apparently increased a little
.(from 13.7 to 14.8% in the technical schools and from
14.5 to 15.4% in the grammar schools), though as the
samples were small too much importance should not
be attached to individual results for technical and
grammar schools. It will also be seen from Table V,
column 7, that the improvement in the caries position
TABLE N.--Caries Incidence and Extent in the Combined Schools
2 3 4 5 6 7 8
Total No.
Teeth Graded
Teeth Graded Teeth Graded Teeth Graded Total Carious
of Teeth c, c, c, Teeth (Equiv.
(including
c.
(Slight (Moderate (Severe ofD.M.F. A.C.F.*
Extractions)
(No Caries)
Caries) Caries) Caries) per too Teeth)
1947 1950 1947 1950 1947 1950 1947 1950 1947 1950 1947 1950 1947 1950
% % % % % % % % % %
2,415 2.169 939 908 H 44 25 41 05 09 61 84 010 015
2,392 2,141 950 832 23 3-8 23 29 04 04 50 68 008 010
2,380 2.101 994 999 03 01 02 01 02
-
06 02 o-ot 0002
2,379 2,162 951 960 18 24 26 20 OS 08 49 60 009 008
2,237 2,036 929 943 33 28 30 22 08 08 71 57 012 008
2,427 2,178 447 503 200 203 235 199 118 96 553 497 Hl2 088
2,270 2,105 825 84-6 13-6 105 36 42 04 07 175 154 022 021
16,500 14,877 861 86-7 63 84 55 &1 2-1 18 139 133 024 022
04 01 004 09 05 001 001
2,429 2,170 991 99& 05 03 -
2,427 2,171 993 991 03 00
04 01 004
-
07 02 001 0003
2,420 2",173 999 1000 01
-
-
006
- -
01 005 0001 0001
2,323 2,128 991 99-1 02 01 04 04 03 04 09 09 002 001
2,055 1,910 961 189 13 1-1 20 14 06 07 3-9 3-1 007 008
2,431 2,177 336 386 164 185 283 250 217 180 664 61-5 138 1-11
2,279 2,101 676 664 200 202 107 108 17 28 324 338 046 110
16,364 14,838 847 858 55 58 61 &6 3-6 32 153 144 C)-29 018
32,864 28,713 854 881 59 81 58 53 29 25 146 139 026 024
Total cartes figure No. or C, + UNo. or C,) + 3(No. of C ,)
A.C.F. (averaae caries fiaure) = Total numbel- of teeth, including cxtral:tions- Total JIWDber of teeth, illduding extrar.:tioas
JAN. 5, 1952
DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
of the modern schools in 1950 was largely attributable
to the marked reduction in the caries incidence in the
first molars, whereas in the other varieties of school
there was an increased incidence in these teeth. The
upper incisors showed more decay in all three kinds
of school in 1950, but it was greater in the technical and
grammar than in the modern schools. These differences
are also seen in the average caries figures (column 8).
The greatest discrepancies between the schools in the
respective surveys occurred in the lower second molars
in 1947 and in the upper and lower first molars in 1950.
13.9-are compared with the findings in other groups
in various parts of the world (see Table Il), it will be
seen that the London children occupy an intermediate
position. They have less decay than West Indian, New-
foundland, and some U .S.A. children, but more than
children from Lewis (Scotland), and many more than
groups of Africans and Indians.
When the percentage of carious teeth found in the
London children in 1947 and 195Q-namely, 14.6 and
Table VI, which indicates the amount of dental
treatment given to the London children, shows that
approximately the same percentage of carious teeth had
been extracted in the case of the children examined in
the two surveys-12.3 in 1947 and 11.5 in 195Q-while
there was a slight falling-off in the percentage of carious
TABLE V.--caries Incidence and Extent in Three Varieties of School
I

3 4
5 6 7 8
Total Carious
Teeth Graded C, Teeth Graded C, Teeth Graded C, Teeth Graded C, Teeth
A.C.F.
Type of
School
(No Caries) (Slight Caries)
(Moderate Caries) (Severe Caries) (Equiv. of D.M.F.
Tooth
per I 00 Teeth)
1947 1960 1947 1960 1947 1960 1947 1950 1947 1950 1947 1910
Upper law:
% % % % % % % % % %
{Modem
940 917 30 46 24 29 06 08 60 82 010 013
Central incisors Technical 93-I 867 33 69 30 70 Oc6 04 69 133 011 021
Grammar 944 881 29 30 24 74 03 15 56 118 009 021
{Modem
953 942 23 40 20 22 04 03 47 58 o-o8 009
Lateral incisors Technical 926 918 33 58 37 22 03 04 74 82 012 011
Grammar 954 900 16 3-8 27 54 03 09 46 100 008 017
{Modem
993 998 02 01 02 01 03 -
. 07 02 001 0003
Canines .. Technical 990 1000 07
- 03
-
- -
10
-
001 -
Grammar 1000 1000
- -
- - - - - - -
-
{Modem
94-9 952 20 24 27 1-7 05 08 51 48 009 008
ht premolars .. Technical 952 93-7 10 22 3-I 3-7 07 04 48 83 009 011
Grammar 959 955 20 2-1 1-6 2-1 05 03 41 45 007 007
{Modem
92-9 942 35 2-7 27 28 09 05 71 58 012 009
2nd premolars .. Technical 949 949 18 2-7 29 12 04 12 5-l 61 009 009
Grammar 91.5 948 3-4 31 45 12 06 09 85 62 014 008
{Modem
454 646 185 190 226 170 135 98 546 456 104 082
1st molars .. Technical 417 401 23-9 278 265 236 79 88 583 699 101 101
Grammar 438 39-1 23-8 204 257 308 67 98 562 809 095 1-11
{Modem
816 843 141 112 39 40 04 08 184 167 023 021
2nd molars Technical 872 882 96 92 26 38 07 08 129 138 017 019
Grammar 829 850 143 83 29 68
-
09 172 150 020 023
Lower jaw: !
0004 '{Modern
990 997 05 01 05 01 01
-
10 03 002
Central incisors Technical 1000 998
-
04
-
-
- - -
04
-
0004
Grammar 984 985
1-1 12 05 03 - - 16 15 002 002
{Modern
991 99-9 03
- 05 01 01 -
09 01 001 0003
Lateral incisors Technical 1000 998
-
-
-
04
- - -
04
-
0007
Grammar 995 987 05 03
- - -
- 05 03 001 0003
{Modern
998 999 02
- -
01 - -
02 01 0002 0001
Canines .. Technical 1000 1000
- -
- -
- - - - - -
Grammar 1000 1000
- -
- -- - - - - -
-
{Modern
990 890 02 01 05 03 03 05 10 10 002 002
I st premolars .. Technical 986 988 04
- 07 04 04
-
14 04 003 0008
Grammar 1000 988
-
03
-
06 -
03
-
12
-
002
{Modem
959 88-7 13 10 22 14 06 07 41 3-1 007 008
2nd premolars .. Technical 969 983 12 17 16 12 04 08 31 37 005 007
Grammar 964 974 12 10 15 18 09 -
3-6 26 007 004
{Modern
325 408 156 19-1 271 223 248 180 675 694 1-44 1-18
1st molars .. Technical 37-4 380 172 158 295 335 IS9 147 626 840 124 127
Grammar 358 309 195 181 329 309 118 202 642 69-1 121 140
{Modern
67-1 648 196 223 112 88 21 30 32-9 352 048 051
2nd molars .. Technical 749 709 169 166 7-9 98 04 26 25-1 291 034 044
Grammar 642 698 246 135 101 160 12 18 358 304 050 '049
{Modem
852 888 58 62 57 4-7 33 25 148 134 027 023
All types Technical 863. 852 57 63 60 63 20 22 137 148
I
024 026
Grammar 855 848 67 64 61 73 16 27 145 154 024 02\
See footnote to Table IV.
TABLE and Arrest of Decay
I 2 3 4 5
Treatment of Carious Teeth Percentage of Total
Percentage of
No. of
Carious Teeth with
Carious
Variety of
Total Moderate and Severe
Secondary
Carious Teeth Percentage Percentage
Percentage Caries Untreated
Teeth Showing
School
Extracted Filled
Treated (C, + C,)
Arrest of Decay
1947 1850 1947 1850 1947 1950 1947 1950 1947 1860 1947 1950
Modern .. 3,500 2,882 139 116 411 333 550 449 178 21-8 368 286
Technical .. 556 510 92 93 455 528 547 822 178 145 3-17 288
Grammar .. 737 710 7-1 128 544 528 615 655 88 125 423 122
Total .. 4,793 4,122 123 11-6 436 393 559 508 164 193 3-69 286
12 JAN. 5, 1952 DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
lhlmSB
MEDICAL JOURNAL
TABLE VII.-comparative Gingivitis Figures for Older Children
I
I
Percentage Percentage Percentage Percentage
No. of Avera!!e
Place Author
Date of
Children
Age of Children of( hildren of Children of Children
Gingivtili
with Severe Survey
Examined
Group Free from with Mild with Moderate
Figure
Gingivitis Gingivitis Gingivitis Gingivitis
ndon .. .. Mellanby and
{1947
1,192* 14 years 263 305 33-8 93 126
138
Lo
Mellanby 1950 1,069* 14
"
149 390 391 70
Sco tland, Isle ofLewis
(
Se
rural)
King (1940) 1937 185 13-15 " 38 - - -
HI
wfoundland .. H. Mellanby
published)
(un- 1948 595 14
"
210 287 .166 136 1-43
. idad
'tish
Trm
Bn
lnd
.. King and Martin !948 406
I
095
12-14" 170
I
-
I
- -
t-30 .. (1951) 100 12-14" 110
- - -
ia, Lucknow 1-08 .. M. Mellanby (un- 1951 265 14 272 43-8 230 60
published) 472 15-20 :: 288 392 250 70 110
...
In a few mstances gmg!Vl!ts and tartar figures on the charts were found to be mcomplete; these charts were therefore excluded in preparmg
Tables VII and VIII.
teeth which had been filled-43.6 in 1947 compared with
39.3 in 1950. There was therefore an overall reduction
of 5% in the proportion of carious teeth treated as
between the 1947 and 1950 surveys. A comparison of
the figures for the three kinds of school shows that
technical and grammar schools had had some increase
in treatment. It was in the modern schools where this
had been reduced, but it will be noted that it was the
children in these same schools who showed a reduction
1
in caries incidence (see Table V). A small amount of
apparently " arrested " caries was found in the two sur-
veys. This occurred in 3.69% of all untreated carious
teeth in 1947 and 2.66% in 1950 (see Table VI,
column 5).
Gingivitis and Tartar
The results of the gingivitis estimations based on the
..:riteria described above are given in Table VII. Here
it will be seen that only 26.3% of the children in 1947
and 14.9% in 1950 were considered to have no gingivitis,
approximately two-thirds in both years had a slight or
moderate degree, while relatively few, 9.3 and 7%
respectively, w'ere counted as having a severe type. It
would therefore appear that gingivitis was a common
condition among these children, and that its incidence
had apparently increased between 1947 and 1950.
A few comparative figures for other surveys are also
given in Table VII, showing that gingivitis, at least in
a mild form, is widespread, though its occurrence seems
to have no simple explanation. It is always difficult to
compare the findings for the incidence and degree of
gingivitis of different workers, since the standards vary,
quite apart from personal factors in the examinations.
For this reason the investigations to which reference
is made here are confined to those of ourselves and a
former colleague, J. D. King, who has latterly made an
experimental and clinical study of the subject. He
employs a more detailed classification than we, so that
his results for the West Indian children in Trinidad
and British Guiana are not strictly comparable with our
findings in London, Newfoundland, and India.
TABLE VIII.-The Association Between Tartar Deposits and the
Occu"ence of Gingivitis
1 2 3 4
No. of
Percentage of Avera!!e
Children
Children with Gingivttis
Grade pf Tartar Gingivitis Figure
1947 1950 1947 1950 1947 1950
t)
.. .. 469 366 655 817 099 124
1 .. .. 364 400 712 855 117 134
2 (moderate) .. 285 259 849 873 159 154
3 (extensive) .. 74 44 946 877 214 200
1,192 1,069 737 851 126 138
Table VIII (column 2) gives the number of London
children with various grades of tartar deposition from
0 to 3 (see above), from which may be calculated the
incidence of the different degrees and the average tartar
figures. The same table (columns 3 and 4) also gives the
associated occurrence and extent of gingivitis. The areas
of the mouth most commonly affected by tartar were,
as is usual, the upper first molar and the lower incisor
regions. Some 5% fewer children were free from tartar
in 1950 as compared with 1947, but 7% more had only
a slight degree; the average tartar figures (calculated
on the same basis as the average caries figures) will be
found to be almost identical for the two surveys.
Although many of the children with no tartar had
gingivitis, this was generally of a milder degree than
that experienced by children having calculus. With
increasing amounts of tartar the incidence of gingivitis
was also raised, until with extensive deposits (grade 3)
94.6 and 97.7% respectively of the children in the two
surveys had some degree of parodontal abnormality
(Table VIII, column 3). The average gingivitis figure
also increased considerably with moderate and extensive
amounts of tartar (Table VIII, column 4). In the Trini-
dad and Jamaican children examined by King a high
degree of association was found to exist between gingi-
vitis and tartar deposition when the location of the two
was restricted to the anterior part of the mandible (King
and Martin, 1951).
Conclusions ...,
On the whole we were favourably impressed QY the
state of these 14-year-old children's teeth. They were
better than we had anticipated, especially when
allowance was made for all the difficulties of the present
time. Any ditferences between the overall caries inci-
dence in the teeth examined in the two surveys were
slight, but some shift of caries away from the first molars
was discernible, and with this went an increase in the
disease among other teeth, especially the upper incisors.
Both surveys showed a high incidence of gingivitis, but
there was appreciably more in 1950 than in 1947, and
also slightly more tartar.
Snnunary
Two surveys of 14-year-old London County Council
school-children from modem, technical, and grammar
schools provide the clinical material for this paper. The
inspections were made with a probe and mirror.
The proportion of children found to be free from caries,
according to the standards used, was 11.5% in 1947 and
16.1% in 1950. These results are compared with figures
from different parts of the world, including other areas of

A detailed analysis of the incidence and extent of caries
in the different types of teeth is given for all the schools
]AN. 5, 1952
DENTAL DISEASE AMONG LONDON SCHOOL-CHILDREN
taken together in the two surveys. A separate analysis for
the three kinds of school is also given, but with few excep-
tions the differences between them were not large. A total
of 14.6% of the teeth in 1947 were carious, whereas for
1950 the figure was 13.9%. Comparative figures for caries
incidence in other groups of children are given.
Only small differences were found between the two surveys
as regards the amount of caries in the different types of
teeth, but in 1950 more upper incisors and fewer first molars
were carious than in the first survey.
The amount of treatment (fillings and extractions) which
the teeth had received is briefly considered. An overall
reduction of 5% was noted in 1950 as compared with 1947.
Some degree of gingivitis was found to occur in 73.7% of
the children examined in 1947 and in 85.1% of those seen in
1950. That this is a common finding in this age group is
substantiated by figures for other surveys.
Tartar deposits were frequently found, and there appeared
to be some relation between the amount of tartar and the
incidence and extent of gingivitis.
We wish to thank the London County Council and Sir Alien
Daley for permission to carry out the inspections, and we are
much indebted to the head teachers and staffs of the schools for
all the help they gave with the actual examinations. Our
thanks are also due to Miss I. Alien, of the Medical Research
Council's Statistical Department, for advice; and to the Medical
Research Council for financing the work.
REFERENCES
Dean, H. T., Jay, P., Arnold, F. A., jun., and Elvove, E. (1941) ..
Pub/. Hlth Rep., Wash., 56, 761.
King, J. D. (1940). Spec. Rep. Ser. med. Res. Coun., Lond.,
No. 241.
- (1945). Dent. Rec., 65, 9, 32, 55.
-- and Martin, W. J. (1951). Brit. dent. J., 90, 35. 63.
Klein, H., and Palmer, C. E. (1937). Pub/. H/th Bull., Wash.,
No. 239.
---and Knutson, J. W. (1938). Pub/. Hlth Rep., Wash.,
53, 751.
Mellanby, M. (1934). Spec. Rep. Ser. med. Res., Coun., Lond.,
No. 191.
-- and Coumoulos, H. (1946). British Medical Journal, 2, 565.
Schour, 1., and Massler, M. (1947). J. Amer. dent. Ass., 35, 1.
Weaver, R. (1950). Brit. dent. J., 88, 231.
=
INTESTINAL MACROCYTIC ANAEMIA
BY
G. M. WATSON, D.Ph., M.B., B.S., M.R.C.P.*
AND
L. J. WITIS, M.D., F.R.C.P.
r From the Nutfield Department of Clinical Medicine,
the Radcliffe Infirmary, Oxford)
The occasional association of pernicious anaemia with
intestinal stricture was discovered by Faber in 1895.
ln the succeeding years more cases were recorded, and
in 1924 Sey;derhelm and his associates claimed to have
reproduced the syndrome in dogs. In 19J9 Little, Zerfas,
and Trusler found a blood picture typical of pernicious
anaemia in a youag man on whom several operations
had been performed to cure an intestinal fistula which
followed acute appendicitis. This appears to be the
first record of pernicious anaemia in association with
intestinal anastomosis as distinct from stricture. Other
cases of this kind have since been reported, and the
lesion has usually been either a gastro-jejuno-colic
fistula or a stagnant loop of intestine. Tonnis et al. (1932)
reported a brilliant series of experiments on culs-de-sac
of the small intestine in dogs, and showed that the
anaemia which sometimes developed would respond to
liver extract.
*Australian National University Research Fellow.
In 1939 Barker and Hummel reviewed 51 cases of
human pernicious anaemia associated with intestinal
stricture or anastomosis, and we later brought the total
to 60 (Cameron, Watson, and Witts, 1949a). In these 60
case reports anastomosis was the basic abnormality in
23, while in 37 one or more strictures were present. The
strictures were mostly of the small intestine, but six were
in the colon. Of the anastomoses 14 were entero-
enterostomies or entero-colostomies, and nine were
gastro-colic or high jejuno-colic fistulae.
The syndrome of gastro-colic fistula is now well
known, its principle features being diarrhoea.
steatorrhoea, malnutrition, and anaemia. Renshaw
and his eo-workers (1946) have made a careful
clinical and experimental study of this condition. Dogs
in which a gastro-colic fistula was made by opera-
tion developed a syndrome similar to that seen in man,
including anaemia which in some cases became macro-
cytic and hyperchromic. In the dogs and in human
cases it could be shown that there was little passage of
gastric contents to the large bowel, and consequently
the symptoms could not simply be due to diversion of
food from the small intestine ; rather were they due to.
contamination of the stomach and small intestine by
colonic matter. In the cases of anaemia associated with
stricture or anastomosis the fundamental abnormality
appears to be the presence of a stagnant or obstructed
portion of small intestine. All these mechanisms may
lead to infection of the small intestine with colonic
organisms.
Prominent Features
The salient features of pernicious anaemia in associa-
tion with intestinal stenosis or anastomosis can be briefly
enumerated. The tongue is often sore, but there is free
acid in the gastric juice in more than half the cases.
Intrinsic factor has been demonstrated in one case
(Schlesinger, 1933), although it was absent in the only
other case in which it was looked for (Castle et al.,
1931). Steatorrhoea is not necessarily present, but there
have been few careful observations on tha fat excretion.
Subacute combined degeneration occurs in a fairly large
proportion of cases. The bone marrow is megaloblastic,
and the anaemia, which is macrocytic, responds to treat-
ment with liver, though it is sometimes rathe,r resistant.
No information is avai:able about the response to vitamin
8
12
, folic acid, or antibiotics. The anaemia may be
permanently cured by surgical correction of the intestinal
abnormality, though this cannot be promised with cer-
tainty. The syndrome has declined in frequency in recent
years owing to the decreased incidence of intestinal
tuberculosis, which has been the most frequent cause
of stenosis of the small intestine, and to technical im-
provements in surgery, which avoid the formation of
stagnant loops of intestine.
Present Investigation
The essential feature in macrocytic anaemia of intes-
tinal origin appears to be stagnation, whether from
stenosis or in a stagnant loop. The syndrome differs
from Addisonian pernicious anaemia in that the secretion
of hydrochloric acid and intrinsic factor by the stomach
may be normal ; and from sprue in that there need
be no steatorrhoea. It seems particularly appropriate
for experimental study because it is impossible to pro-
duce a megalocytic anaemia by operations on the stomach
in animals (Cameron, Watson, and Witts, 1949b), and
OCT. 22, 1932] AETIOLOGY OF DENTAL CARIES [
THE BRITISH 7 49
MEDICAL jOURNAL
= = = = = = = = = = = = = = = = = = = = = = = = = = ~ ~ = = = = = = = = = = = = = = = = = = = = - ~ - ~ - ~ - - - -
enamel, which is not necessarily " chalky" in character.
The rachitic fault, moreover, occurs in certain definite
parts of the tooth corresponding to a given period of
growth. Caries does not. Amongst the teeth most affected
by vitamin shortage in rickets are the lower incisors ; yet
these teeth are almost immune to enamel caries. Surely
if vitamin shortage in early life predisposed the teeth to
caries, the lower incisors would be amongst the most
susceptible, instead of being amazingly immune.
Mackay (1931), in a report on the association of vita-
min D deficiency and dental caries, showed that there was
only slightly greater incidence of caries in a group of
rachitic children, "22 per ceht. of whom showed hypoplasia
of the enamel, than in a control group of normal children
in which only 2.5 per cent. showed hypoplasia.
In any case the permeable point in the tooth surface
which becomes carious is quite often not a developmental
fault at all, and therefore has no relation to avitaminosis.
The depth of fissures is a morphological characteristic.
Recession of the gums which gives rise to cervical caries
is a fault of the parodontal tissues rather than of the
tooth, and recurrent caries is a matter of technique. Thus
at most vitamin deficiency can only account for one of
the four types of caries observed clinically-namely, the
interstitial group. Even so, the deficiency would have to
extend over a period of about twelve years to affect all
the teeth in the way that caries does, and should logi-
cally be most intense in the tvrelfth year, when the wisdom
tooth is developing. It seems more likely that the poor
calcification of the wisdom tooth is a racial retrogression.
Interstitial and fissure caries appear to be definitely
racial and hereditary in character. Tamil and Chinese
coolies working together show an extraordinary difference
in the incidence of caries. J. W. Field (1929) recorded
that 100 Tamils had seven carious teeth while 100 Chinese
had 163. Their diet was similar and so was their ex-
posure to sunlight, though the chewing by the Tamils
of betel nut with its caustic content might have had an
antiseptic effect on the saprophytes.
Up to the Third Dynasty Elliot Smith reports that the
Egyptians were free from caries. At this time an invasion
of a foreign race occurred, and caries became as prevalent
as it is in England to-day.* Even on Tristan da Cunha
(Sampson, 1932), where hereditary and not racial factors
predominate, of the 156 people examined 26 had an
average of eight teeth each, either carious or missing,
while 130 were caries-free, and these 26 were largely the
" foreign " element of the population, in contradistinction
from the 130, who were chiefly descended from the original
stock.
In clinical practice in England it is a matter of common
experience that good teeth run in families, so that what-
ever the factors may be which produce the faults and
crevices in which caries develops, they appear to be
hereditary.
IMMUNITY TO CARIES
There are certain cases of this which are significant.
The human subject presents two types of immunity to
caries. In one we find. a perfect set of teeth with shallow
fissures and faultless enamel. In the other type there are
deep fissures and numerous discoloured patches of enamel
which show traces of early caries, but the caries has now
become completely arrested. The former type appears
to have no flaws in which the organisms can lodge, the
latter appears to have a mouth which has become inimical
to the growth of the saprophytes concerned. If, as he
gets older, the man with perfect enamel gets recession of
the gums, the exposed necks of the teeth often decay,
yet the enamel remains immune, showing definitely that his
immunity had been due to absence of faults in the enamel.
* See page 760.
On the other hand the presence of faults alone is not
sufficient to produce caries, as M ~ Mellanby has shown
in her experiments on dogs where faulty enamel was
constantly produced, but caries never supervened. Indeed,
the dog is immune to caries, and yet it has both deep
fissures and permeable lamellae with dead tracts of den-
tine under them (Fish, 1929). The same observation may
be made in the human subject, for as we have seen the
hypoplastic teeth of rickets are not especially prone 1o
caries.
There is clearly a factor of susceptibility to an organism
or a group of organisms without which caries cannot
supervene. The apparently spontaneous arrest of caries
is due to acquired immunity and not to a vital reaction
in the tooth, since caries often becomes arrested in old
broken-down dead roots as well as in deep fissures in
vital teeth.
Normally, a change to relative immunity takes place as
children grow up. No doubt this is to some extent due
to the fact that most permeable faults have by this time
been treated, or the tooth has been lost, but it may result
in part from a change of diet from milk and sticky carbo-
hydrates to savouries and t h ~ use of tea, alcohol, and
tobacco. In the same way the use of betel nut may
account in some degree for the relative immunity of the
Tamil.
CONCLUSION
Thus all the evidence seems to point to caries being
a saprophytic phenomenon occurring in morphological
fissures, developmental enamel faults, or in the permeable
necks of teeth. In no case can its occurrence be prevented
by vital reaction on the part of the formed tooth, though
its extension may be delayed. The prevention of decay
appears to be possible only by rendering the mouth un-
suitable as an environment for the saprophytes concerned,
or by breeding a race free from morphological crevices
and deelopmental enamel faults, whose gums will never
recede.
REFERENCES
Boedecker, C. F., and Applebaum, E.: Dental Cosmos, 1930, xxii,
1001
Field, J. W.: British Medical journal, 1929, i, p. 707.
Fish, E. W.: Dental Record, 1929, xlix, 151.
Idem: British Dental joumal, 1932, liii, 563.
Jefferies: British Dental journal, 1932 (in the press).
Mackay, H. M. M.: Lancet, 1931, ii, 1230.
Sampson, W. E. A.: Britis/1 1Je11tal journal 1932, p. 397.
Smith, G. Elliot: Archaeological Survey of Nubia, 1907--8, ii,
"Report on Human Remains at Cairo."
THE AETIOLOGY OF DENTAL CARIES*
BY
MAY MELLANBY
My only claim to address you is that of one who has
devoted many years to physiological and biochemical
research, chiefly in relation to teeth and their associated
tissues. My approach to the subject of dental disease is
therefore somewhat different from that of the clinician,
and though we must ultimately arrive at the same
destination, we travel by different roads. As none of us
can claim to have reached the. goal, it is perhaps only
n.atural that we should each tep.d to emphasize the points
elucidated in the course of our own work. No doubt the
very fact that Dr. Fish and I have approached the subject
from different angles and hold such opposing views
prompted the committee to invite us to open this dis-
cussion.
*Read in opening a discussion in the Section of Comparative
"Iecticine at the Centenary Meeting of the British Medical Associa-
tion, London, 1932.
750 OcT. 22, 1932) AETIOLOGY OF DENTAL CARIES [
THE B R I T I ~ R
MEDICAL ]OURNAL
ANIMAL RESEARCH
My real interest in dental problems arose about 1917,
.vhen I noticed that the teeth of my husband's experi-
mental animals varied in character. The teeth of the
rickety puppies were irregularly arranged in the jaws and
were often rough and pigmented, while the teeth of those
free from disease were white, shiny, and in perfect align-
ment. The failure of all recognized methods of preventing
dental disease indicated the need for a different method
of approach to the problem, and the opportunity arose,
in these puppies, to study the factors modifying the
development and resistance of the teeth and related
tissues.
A diet was found on which the puppies grew well while
their teeth were of poor quality. By making small, and
apparently insignificant, additions or alterations to this
diet the structure of the teeth and jaws could be com-
pletely altered. It was shown that:
1. For the production, in puppies, of well-formed teeth
an adequate supply of fat-soluble vitamins, especially
vitamin D, is essential. (This vitamin can be synthesized
in the body by the exposure of the skin to sunlight or to
the rays from an ultra-violet lamp.)
2. Cereals antagonize the action of vitamin D and tend
to produce badly formed teeth when this vitamin is
d ~ ~ ~ . .
3. The diet must contain some calcium and phosphorus,
the chief components of teeth and bones, but the amount
necessary depends largely on the vitamin D available.
When vitamin D is plentiful the quantity and ratio of
calcium and phosphorus (above a certain minimum) are
of little importance, but when the supply is small, and
especially wheri cereals form a large part of the diet,
calcium and phosphorus assume a much greater signi-
ficance. It is, for instance, possible by raising the
calcium in some diets, especially when butter is the
source of the vitamin, to convert an insufficiency of
vitamin D into a sufficiency.
4. If a mother is fed during pregnancy and lactation
on a diet deficient in vitamin D, the offspring show
defective calcification of the deciduous teeth ; but the
defects are less marked than those found in the permanent
teeth when the puppies themselves are fed on the same
deficient diet, for the mother sacrifices her own stores
ot essential substances, and may in the process subject
herself to hium if the dietetic conditions are severe.
These experiments have recently been repeated, and the
main results confirmed and extended by many other
investigators.
Vitamin C has been shown to influence the structure of
guinea-pigs' teeth (Zilva and Wells, 1919, and later Hojer
and others), but as far as I know it is rare to find defects
in man of the type induced in these animals by a deficiency
of vitamin C. On the other hand, the structural defects
commonly found in human teeth are in many respects
similar to those found in puppies fed on diets deficient in
vitamin D, and the fact that human dietaries are often
deficient in this vitamin suggests that the defects in the
teeth of the experimental dogs and man are of similar
origin.
Each vitamin has certain specific functions, and as we
learn more about these substances the terminology has
to be altered. The term " vitamin A " now has a
narrower meaning than it originally had when it covered
the anti-infective growth factor (to which it is now
limited) and the anti-rachitic or calcifying factor (now
called vitamin D). Both vitamins are fat-soluble, growth-
promoting, and affected by heat and oxygenation, and it
.vas for this reason that their actions were at first thought
to be due to one entity. In my earlier publications the
term " vitamin A " therefore includes both the calcifying
and the anti-infective vitamins.
Although caries-like lesions have been produced experi-
mentally in some animals, dogs' teeth appear to be
immune to the disease. The normal variations in the
minute enamel structure in different species, together with
a natural or acquired immunity to the disease, may
account, in part at least, for the difficulty of producing
caries in some animals as compared with others. For
these and other reasons experimental results are not
necessarily applicable to the human subject, but they
give a lead, and further work on these lines should prove
fruitful.
HYPOPLASIA AND CARIES
Owing to the difficulty of obtaining a working basis by
means of animal experiments, l have adopted an indirect
method of testing the liability of human teeth to caries.
A large number of shed and extracted teeth (mainly
deciduous) were examined, both superficially and histo-
Jogically, for structure and caries. In the majority the
surface enamel was rough, and the minute structure of
enamel and dentine was defective, the latter containing
interlobular spaces. It was, in fact, clear that the
ordinary standard for " hypoplasia " (giving about 3 per
cent. of deciduous human teeth as hypoplastic) was not
comprehensive enough, and that only comparatively gross
defects were ordinarily included in this term. I have
therefore used the term " hypoplasia " to denote defective
structure of any degree or kind, and the term " gross
hypoplasia " for those forms of superficial enamel defect
which are commonly recognized. Hypoplasia was found
in over 75 per cent. of the human deciduous and in the
majority of the permanent teeth examined. The deciduous
incisors, largely developed in utero and during lactation,
were better calcified than the .later-formed molars. For
instance, about 60 per cent. of the incisors appeared
normal on histological examination, as compared with
1 per cent. of the second molars.
Nol only were the great majority of teeth in my collec-
tion defective in structure, but there was definite asso-
ciation between structure and caries. The worse the
structure, the greater was the liability of the teeth to
decay. Only 20 per cent. of the normal teeth were
carious, as compared with 94 per cent. of the severely
hypoplastic. This close association was found also in
groups of Sheffield, Birmingham, and London children.
In my experience, there is generally less hypoplasia and
caries among the richer children and those living in
institutions than among the poorer. Although the asso-
ciation between hypoplasia (as I have described it) and
caries has been shown to be a close one, " gross hypo-
plasia " is not so definitely associated with dental disease.
RICKETS
If structural defects are due to a deficiency of vitamin
D, and these defects are associated with a liability to
caries, it would be expected that the teeth of rickety
children would be more liable to disease than those of the
average child. The evidence, though not unanimous,
generally confirms this expectation. Lawson Dick (1916)
found that hypoplasia (gross) was common in the 600
rickety children he examined, and concluded that it was
probably the chief factor in premature decay. J. G.
Turner states that caries is rather more common in rachitic
cases, and M'Gonigle, who examined some thousands of
children, comes to a similar conclusion. Again, Wilson and
Surie, working among native Indians, conclude that rickets
and caries are coexistent. In the Board of Education
inquiry (1929) it was found that most of the 1,300 London
school children examined showed signs of rickets and caries.
Rose and Mackay, on the other hand, compared the
OcT. 22, 1932] AETIOLOGY OF DENTAL CARIES [
THE BRITISH 7 51
MEDICAL JOURNAL
amount of dental caries in some children, whom they had
treated for rickets as babies, with that found in children
who at a similar age had suffered from other diseases.
They found that although hypoplasia (gross) was confined
to the rachitic group, caries was only slightly greater in
that group than in the other. The number of rickety
children examined ( 42) was small ; it is possible, too, that
the treatment they received would delay the carious
process. Again, on the basis of recent work it is probable
that many of the control children had also passed through
a stage of defective calcification, possibly of less severity
but longer duration. Some years ago Mr. J. W. Proud,
L.D.S., and I examined the teeth of about 200 children
diagnosed both at school and in infancy as rachitic, and
found a higher percentage of caries in their teeth than in
those of the average child.
PossiBILITIES oF DIETETic CoNTROL
Having proved to my own satisfaction that the better
the structure of the teeth the less the liability to caries,
and that structure could be controlled by diet, my next
step was to see whether it was possible by variations in
diet, especially in the vitamin D and cereal content, to
alter the rate of initiation and spread of caries. To this
end, from 1921 onwards a series of tests was made in
Sheffield, in conjunction with Dr. Lee Pattison, on groups
of children, most of whom had badly formed and carious
teeth. It was shown that:
1. When the vitamin D content of the diet was
increased, and especially when at the same time all cereals
\Vere omitted, the initiation and spread of caries were
greatly reduced, while the " healing " or arrest of carious
areas was very marked.
2. When the vitamin D content of the diet was
decreased and extra cereal-for example, oatmeal-was
given, the development of dental caries was increased.
An extension of the Sheffield investigations on a larger
scale and over a longer period has been made in Birming-
ham on behalf of the Medical Research Council by Mr.
A. Deverall, L.D.S., and Miss M. Reynolds, S.R.N., and
the results corroborate those obtained in Sheffield. Boyd
and Drain (1928) made some significant observations on
a group of children suffering from diabetes. In the
course of treatment these children were given a diet
devoid of cereals and consisting largely of milk, cream,
butter, eggs, meat, cod-liver oil, vegetables, and fruit
(that is, a diet rich in vitamin D and calcium), and
the process of dental caries was stopped. Later they
fed some non-diabetic children on a similar diet, and
again found that active caries was arrested. Bunting
also found that of the methods investigated for com-
bating dental caries, dietary measures such as the in-
clusion of much milk were the most important. He,
however, believes that protection is through a change )n
environment rather than through an increase of resis-
tance of t h ~ teeth themselves.
Further evidence bearing on the experimental and clinical
observations has rec:ently been obtained from Tristan da
Cunha, the inhabitants of which rarely suffer from dental
caries ; their diet includes foodstuffs containing vitamin D
and calcium, but is devoid of cereals, and the children are
breast-fed for long periods. Other examples of peoples
comparatively free from dental disease are the Eskimos
and some tribes in tropical lands. Under natural con-
ditions the diet of the former is rich in fat-soluble vitamins
and free from cereals. In tropical countries breast-
feeding is prolonged in many native tribes, and although
the diet consists largely of cereals and the vitamin D
content may be low, the skin is exposed to the sun's rays,
and the necessary vitamin D is thus synthesized in their
bodies. As soon as civilization reaches these peoples the
conditions are altered in relation to both diet and clothing.
Ultra-violet rays are often prevented from reaching the
skin, even of young children. During a visit to Africa
some years ago I examined the mouths of hundreds of
natives, and found that, although the majority had
excellent teeth, the more the tribes conformed to civilized
conditions the worse was their dental condition. Heredity
has certainly failed here.
In order to test the resistance of erupted teeth, animal
experiments were made resulting in the deposition of
secondary dentine. A potent calcifying. diet during the
period of irritation resulted in abundant well-formed
secondary dentine ; if the calcifying factor was deficient
there was no apparent reaction or the secondary dentine
formed was imperfect in structure. Here, then, is further
evidence that dental reaction can be influenced by nutri-
. tional factors.
Contrary to Dr. Fish's experience, I did not often find
a "fully calcified barrier" between primary and secondary
dentine. This problem, together with that of the charac-
ter and significance of translucent zones and '' dead
tracts,'' will be discussed by others who are much more
competent to speak on the subject.
SUMMARY AND CONCLUSIONS
To summarize, fat-soluble vitamins (especially vitamin
D) are essential both for calcification of the teeth and for
their resistance to disease. The quantity required depends
on other factors of diet and environment, including
calcium, cereals, and ultra-violet light. The natural foods
containing vitamin D, with which calcium and vitamin A
are often associated, are, unfortunately, comparatively ex-
pensive. They include egg yolk, milk, suet, butter, and
I -cheese. (Milk is an excellent food, but I am not yet con-
vinced that there is sufficient evidence that fresh milk is
better than the pasteurized product.) Cod-liver oil and
some other fish oils are the richest known natural sources
of vitamin D ; it is present in fat fish (for example,
herring, mackerel, and salmon), and also in animal fats
(except that of the pig). Vegetable oils as prepared for
consumption in England do not usually contain the vitamin.
Cereals are cheap, easily stored and transported, and are
therelore very common articles of diet ; they are not only
devoid of vitamin D, but contain some toxamin, which
tends to hinder calcification ; the greater the part they
play in the dietary the greater must be the intake of
vitamin D and calcium to antagonize their effect.
The clinical work mentioned is only the beginning of
this important aspect of nutritional science, for we do not
even know the optimum amount of vitamin D required in
relation to the other factors of diet and environment.
The literature published during the past decade shows
that more attention is being focused on dental caries as
a disease resulting from metabolic rather than purely
local disturbance. If I have played any part in this
new outlook I shall feel justified in having entered the
field of dental research.
In conclusion, while I readily admit that the liability
of a tooth to decay must depend upon many factors, both
intrinsic and extrinsic, I believe that the structure of the
tooth is a factor of the highest importance, that this
depends in turn upon the diet during the period of growth,
and that after eruption its resistance to caries can also
be influenced by dietetic conditions. We must, therefore,
I believe, concentrate upon the development of more
perfect teeth and later also upmi. increasing their resistance
to decay. The practical application of our present know-
ledge should in time help to diminish the scourge.
JULY 9, 1932) CORRESPONDENCE (
THE BRTTISH 75
MEDICAL jOURNAL
The campaign was inaugurated in April, 1931, and
the first annual meeting was held on June 30th, 1932.
The report on the year's work stated that office accom-
modation and clerical assistance had been provided by the
Paddington School for Mothers, and that the London
Public Medical Service had in dealirig with
the remuneration of the doctors working under the
campaign. Valuable assistance was given by the School
for Mothers, the health visitors, the public assistance
officers, and the doctors of Paddington. In the months of
October and May reports were sent to the medical officer
of health, by the doctors, on the health of each infant
on their lists.
Correspondence.
THE ACTION OF ERGOT PREPARATIONS
SIR,-Dr. J. H. Burn's letter in the Journal of June
25th criticizes certain statements contained in my article
on the clinical action of ergot preparations. I have read
the letter with interest, and welcome this opportunity
of saying that nothing in the paper in question was
intended to imply that ergotoxine was without impor-
tance, or that when suitably administered it was other
than a useful therapeutic agent. Beyond this, however,
I cannot agree with Dr. Burn's observations.
He accepts my view that the reason why ergot came
to be used in obstetrics was because of its remarkably
prompt and energetic action when given by the mouth.
This action I have been able to show is not due to
ergotoxine, but to another constituent of ergot as yet
unidentified. In view of his. admission, it is difficult to
understand why Dr. Burn should object to the statement
that these findings stand in opposition to previous beliefs
and show that ergotoxine plays a subsidiary part in the
clinical action of the drug. It is possible that he has
overlooked Fig. 4 of the article, which was not specially
referred to in the text. This figure shows a portion of
a continuous tracing in which the action of ergotoxine
is contrasted with .that of ext. ergot liq. (1914). Two
milligrams of ergotoxine given by the mouth showed an
almost negligible effect on uterine contractions during
three hours following the administration, whereas two
drachms of liquid extract of ergot given after this period
produced a vigorous effect in thirteen minutes.
The second part of the letter deals with a different
matter, and one of much greater importance. Dr. Burn
points out that ergot is now used in different circumstances
than was the case 100 years ago, and states that the
action which is now desired is the one associated with
ergotoxine, and not the one which follows the administra-
tion of the active principle which I have described. This
is a matter which was not discussed in my paper, and I
may perhaps be allowed to make a few comments on
it now.
The chief uses of ergot in present-day practice are (1)
to check post-partum haemorrhage, (2) to lessen the likeli-
hood of uterine haemorrhage in the first twenty-four
hours or so of the puerperium, and (3) to promote involu-
tion of the uterus. The first condition-the checking
of post-partum haemorrhage-is not likely to be well ful-
filled by ergotoxine given alone, because its action, even
after intramuscular injection, is too slow. Dr. Burn
agrees that in treating this condition the rapidly acting
" new " principle of ergot may have a use as an alterna-
tive to pituitary extract. Regarding now the second and
third indication, it may well be questioned whether the
avoidance of haemorrhage and the involution of the
uterus are more likely to be helped or hindered by causing
the uterine muscle to go into a prolonged spasm, or
by making it contract with unnatural force and frequency
for several days on end. Assuming, however, that in
special cases this is deemed to be desirable, the most
suitable means for bringing it about must be decided.
It is generally stated that ergotoxine produces a pro-
longed spasm of the uterus, and Dr. Burn claims that
the prolonged and persistent contraction is a special advan-
tage. I venture to suggest that this spasm is less real
than is usually supposed. In the manometric tracings
of the intrauterine pressure in the puerperal uterus, a
rise in the base line is present only for a short time after
the administration of reasonable doses of ergotoxine ; in
none of my cases has it exceeded one and a half hours,
and after this time the effect is that of strong contractions
occurring at intervals. As previously pointed out, a con-
siderably greater spasm can be obtained by the use of
B.P. liquid and solid ergot extracts given in doses which
cause no ill effect, than by ergotoxine given in dosi's
.hich may cause undesirable symptoms. The duration
of the spasm in these cases is usually about one and a
half hours, and is followed for a long period by strong
contractions occurring at regular intervals. The duration
of this second effect is moce than two hours, but my
tracings were not continued long enough to measure the
exact time.
The question thus becomes a simple one. Is it better
to give a dose of ergotoxine-preferably by injection-at
long intervals, or a dose of liquid extract of ergot by
the mouth every four or six hours? It seems to me
to be immaterial which method is used.
Finally, Dr. Burn suggests that a use for the " new "
principle might be its administration during labour to
stimulate uterine pains in a manner similar to pituitary
extract. Ergot ceased to be used for this purpose many
years ago on account of the high foetal mortality following
its administration. The prtlvis ad parttlm became the
pulvis ati mortem. There is no reason to believe that
this undesirable effect was due only to and
it seems probable that the foetal death was due to that
very spasm which my tracings have recorded, and which
is brought about by the unidentified principle. For these
reason$ I must strongly dissociate myself from any
suggestion that these extracts might be used during
parturition. In the above remarks no mention has been
made of ergotamine. All that is said of ergotoxine is
meant to apply equally well to the other ergot alkaloid.
After careful consideration I can find no reason .to alter
the statement made in the concluding paragraph of my
article, which reads :
" It can be stated with reasonable certainty that the
characteristic action of ergot known to the old obstetricians
is due to a substance which has a prompt and energetic
action, and which is not ergotoxine, ergotamine, tyramine, or
histamine. From this it follows that the ergot alkaloids,
hitherto supposed to be all-important, play in reality but
a subsidiary part in the clinical action of the drug."
-I am, etc.,
Obstetric Unit, Uniwrsitv College
Hospital, July 4th.
CHASSAR MoiR.
DIET AND THE TEETH
SrR,-In the Journal of March 19th is a paper by Mrs.
Mellanby and Dr. Pattison, in which they again demon
strate that a dietary rich in vitamin D and calcium
and phosphorus leads to good dentition. They again
stress their cereal toxamine theory, and it seems to be
time that the facts be examined without the usual pre-
judice coming irito the matter. If the Mellanby Diets
8 to 4 are examined closely some astonishing facts are
revealed. I have used Sherinan's figures for analyses
as the authors of the paper did. In dietetic work I have
always understood that the first essential in testing the
effects of any food material is to have dietaries which
76 }ULY 9, 1932) CORRESPONDENCE r
THE BRITISH
MEDICAL JouRNAL
are strictly comparable, and adequate in all respects ex-
cept the one under review. In much of Mellanby's work
I do not find any of these postulates filled.
The origin of the cereal toxamine theory was the fact
that puppies did not do well on diets containing cereals.
The dietary in Experiment 46, reported in No. 140 of
the Medical Research Council Special Reports, is typical
of the rest. In it we find that separated milk, lean meat,
and linseed oil supplied a caloric intake of about 200 only,
and the addition of white bread increased the intake to
330 up to 600. It is no wonder that in all Mellanby's
work we find the puppies that grow more rapidly are those
which were given more or less sufficient calories on which
to live. The dietary was woefully deficient in every
particular apart from a dietetic knowledge, and obvious
to anyone who has bred litters of puppies. In this
matter it is as well to stress the fact that Hopkins's
postulation of " accessory food factors " found universal
acceptance because he presented evidence that lack of
calories had nothing to do with his rats, and that is a
classical lesson which should not be forgotten.
It is now general kLJ.owledge that cereals as a whole
are very poor in calcium and rich in phosphorus. For
instance, 15D grams of white bread will contain
mately 0.03 gram of calcium and 0.14 of phosphorus,
which gives a Ca: P ratio of 1:4.6 ; similarly 150 grams of
oatmeal will contain approximately 0.1 Ca and 0.588 P,
with a ratio of I : 5.9, and so on through the cereals. The
essentially carnivorous dog is forced in this experimental
work to obtain over 50 per cent. of its energy
ments from cereals which contain essential salts for
calcification in a ratio very different from that required
in the ideal dietary. The dietary is an ideal high-
phosphorus-low-calcium rachitogenic one without any
necessity to postulate a harrnful substance in the cereals.
Now if we examine the Mellanby-Pattison human dietaries
8 to 4 we can construct the following table:
Diet
I
Total Ration
'.I Total Nutrients I: To tit( Calories
I.
Protein
8 4.3 21.75 14.3
7 5.1 18.1 14.3
6 4.7 18.7 14.3
5 5.4 17.6 13.7
4 5.8 18.0 13.1
Carbohydrate
8 7.6 38.5 25.4
7 16.3 58.3 46.3
6 14.5 55.3 42.4
5 17.9 58.2 45.1
4 17.4 59.0 46.2
Fat
8 7.8 39.75 58.9
7 6.6 23.6 42.1
6 6.8 26.0 44.7
5 7.5 24.2 42.3
4 6.8 23.0 40.8
It is at once obvious that the authors did not find that
" surprisingly little difficulty was experienced in providing
substitutes for cereals," as we see that the carbohydrate
in Diet 8 has dropped to supplying only one-quarter of the
calories instead of the generally accepted half. The
change from the cbnditions in Diet 7 is very marked, as
there is a decrease of 53.4 per cent. in the energy supplied
by carbohydrate. In this series of diets the protein con-
tent has been the only constituent which has remained
constant. The fat content varies from 23 to 39.75 per
cent. of total nutrients ; and more astonishing than any-
thing else in the whole of the diets is the variation in the
milk content. This ranges from one-third to well over one-
half of the ration. The different ages of the children
emphasize the variety of the rations. If we assume the
average weight of the children in Experiment 8 to be 19
kilograms and those in Experiment 4 to be 27 kilograms,
we can express the diets in terms of grams per kilogram
of the body weight, and can then arrive at the percentage
variation of each constituent in these two rations, which
are chosen as they are at the extremes of the scale.
Foon IxnKE rN GRnrs PER Kn.or.RD! OF BonY \YEICHT
DietS Diet 4
Per cent.
Variation
... 127.0 90.0 -40.0
}>rotcin ... 4.6 3.1 -33.0
Carbohydrate ... 8.0 10:5 +30.0
l'at 8.4 4.1 -51.0
l\Iilk 63.1 20.0 -68.3
l\Ieat 7.6 4.7 -38.0
Calchnn ... 0.09 0.04 -55.6
l'hosphorus 0.10 0.06 -40.0
It is now clear that not a single component of the
diets remained constant. They are not comparable. The
widest variations are seen to be in the milk and calcium
intake, which is a truly astonishing state of affairs. What
was the matter with these children on Diet 8 that they
were in bed for the six months of the experiment? We
see that their calorie intake was as much as 127 per kilo-
gram, whereas, I believe, active, as opposed to bed-ridden,
children of that age require abut 90 calories only. This
excess of calorie feeding was, of course, conditioned by the
large amount of fat in that diet. The milk ration will
also bear analysis .. We see that it varies more than
any other article in the diets.
J\IiLK
I Calcium
Phosphorus
Per cent. Per cent.
Diet of ri'otnl of Total
I Amount I Per cent. Amount
Per cent. Hatiou Calories
of Total of Total.
8 1.4 82.3 1.1 57.9 59.3 34.5
7 1.07 82.3 0.83 52.0 50.9 25.2
6 1.29 85.7 1.0 55.5 54.8 27.6
5 0.9 81.8 0.69 49.3 47.5 20.9
4 0.64 64.0 o.s 33.3 33.3 15.3
'
Sherman and Hawley's (1922) work has not been re-
futed by any experimental evidence ; they proved that
the calcium of milk is utilized by the growing child to a
much higher degree of efficiency than an equal quantity
of calcium in vegetables which were prepared with great
care to make them acceptable to the children. In view
of this work and the subsequent confirmatory results it is
regrettable that in the Mellanby diets the milk content
varied from 63 to 20 grams per kilogram of body weight,
and the calcium from milk varied from 1.4 to 0.64 gram
per day. From the time that Hoobler (1912) studied the
calcium retention of the infant we have known that a
high fat content in the dietary leads to greater retention
of calcium. Aschenheim (1913) soon confirmed these re-
sults, as he found increased calcium excretion with low
fat diets, and though they were probably adding vitamin
D without knowing it, the Mellanby diets show a varia-
tion in fat content, and so vitamin A and D content,
which should not have been permitted. In Diet 8 we
find 70 grams of butter and cream and 0.4 gram of
radiostol ; in Diet 7, 28.4 grams of butter and cream, and,
I presume (it is not clearly printed), 0.25 gram radiostol.
With such a wide variatim) in vitamin A and D content
it is manifestly absurd to attempt to saddle the cereal of
Diet 7 with any defective dentition developing while on
the ration: I know that Mellanby deprecates the term
" optimal amount," but she should therefore be all
the more careful to have strictly comparable amounts of
such minutiae as vitamins and minerals in her rations.
This she has not attempted to do.
It is remarkable that " incrc::tsed oatmeal " in Diet 4
is only 51 grams, or roughly 2 grams per kilogram of body
weight. As oatmeal is especially singled out for its
malign influence on the deposition of calcium, it appears
somewhat remarkable to me that the crofters and farm
labourers of North-East Scotland should have any
teeth or straight bones in view of the shockingly large
amounts of " toxamine " they have G.bsorbed for years,
including their growth years. I can assure Mrs. Mellanby
}ULY 9, 1932) CORRESPONDENCE
[ 77
==============:r-=-
that I have lived in a bothy and have seen the teeth
these men have and the porridge they eat. As a group,
they are very superior to the townspeople in every
physical particular ; oatmeal and milk is far more im-
portant in their dietary than potatoes and meat.
Here in West Africa the tribe with which I am at
present concerned live on cereals, the millets, a little sour
milk, and occasionally meat. Their teeth are not good,
but the women have very much better teeth than the
men. Many perfect sets are to be seen. The reason is per-
sonal hygiene. The Munshi tribe eat cereals, yams, and
sesame. The incisors are filed to points, yet I found no
dental decay in over 200 people examined. The difference
to the Hausa is that they get adequate calcium and phos-
phorus in their beniseed and vitamin D from the sunlight.
The da Cunha report (published in the same
issue) remarks on the fact that milk is plentiful and is
fully used, and that eggs of hens anp penguins form a
fair proportion of the people's dietary. They are thus
supplied with adequate vitamins and the most perfectly
assimilable form of minerals for calcification. They eat
a little cereal flour, apparently about 47 lb. a year per
man, woman, and child, or about an average of 4 grams
a day. It is a fair presumption that the flour is eaten
when it arrives in the island, and so more than 50 grams
a day will be taken until it is finished. During these
periods of cereal-eating one should expect to find caries
develop, and then be healed when the administration of
" toxamine " had ceased. Apparently this is not
The argument that other seaboard populations enjoy
as admirable a dietary as the islanders, yet suffer from
caries, needs amplification. Where are these populations
which are as stringently isolated as the people of Tristan
da Cunha? Are they of European stock also? Is their
isolation so complete that they are compelled to eat fish,
extremely digestible ; eggs, full of first-class protein and
vitamins ; and milk, full of all the salts that the human
needs in their most assimilable form along with their
cereals? The Tristan da Cunha teeth are admirable, with
or without cereals, because the islanders have perforce to
eat admirable calcifying foods.
Examination of Mrs. Mellanby's work as a whole and
of the latest human experiments in particular shows that
the dietaries used are not comparable, and such misleading
basal facts have led her into her anti-cereal theory. Diet
8 is listed as cereal-free ; it could also be listed, as opposed
to Diet 7, as vitamins A and D rich, fat rich, or carbo-
hydrate poor. Such variations are not permissible in first-
class research, and I maintain that up to the present
no evidence whatever has been produced that cereals are
actively harmful.
One must not fail to see the wood for the trees. There
can be no question but that cereals are deficient in the
particulars I have enumerated as well as in vitamins when
used as their flours. But because cereals are cheap and
easily prepared the poor use them as a substitute for foods
which are biologically of more importance. It is this sub-
stitution of a poor food for richer foods which has caused
Mrs. Mellanby to postulate actively harmful effects from
their use. Because the Hausas in times of famine use
water instead of sour milk in their porridge, and they die
of all sorts of nutritional diseases, I should not dare to
postulate an actively harmful principle in water. The
Hausa has substituted something valueless for something
of value, not something harmful for something beneficent.
-I am, etc.,
Dietetic. Research Laboratory, W. E. McCULLOCH, M.D.
Katsina, 1\. :'\igeria.
" FALLEN IDOLS "
SrR,-My work has lain largely in the field of rhinology,
but, like Sir James Berry, I recall the period when acute
appendix belonged essentially to the domain of the phy-
SICian. Many cases, which it fell to my lot to treat as :1n
internist, rapidly yielded to heavy dosage with sodium
salicylate, like an acute tonsillitis. Yet, with one or more
recurrences, the risk of serious complications impelled one
to refer such cases to surgical colleagues for interval
appendicectomy. But I believe that " the great change
in fashion "-that is, the early operation in acute appendix,
which arose in 1896, and which Sir James Berry attri-
butes in part to Dr. H. P. Hawkins's monograph-was in
part due to the influence of epidemics of influenza.
I am reminded, moreover, that at that time an infected
antrum or other sinus infection was rarely operated on or
even diagnosed. Now the " grippe," that swept Europe
in 1889 and Great Britain in 1890--91, and the subsequent
epidemics, caused an enormous increase in the incidence
and severity of nasal sinusitis. A new clinical group arose,
and in meeting its requirements rhinologists developed new
diagnostic and therapeutic methods. Successful results
in so many cases of semi-acute and chronic sinusitis prob-
ably led to undue enthusiasm in applying these newly
acquired resources to the acute cases. Hence, maybe,
changes in the clinical picture rather than change of
fashion led to new methods being applied alike both in
the surgery of acute appendix and acute sinusitis, and
what eventually becomes accepted as correct treatment
will be determined by the light of riper experience.
May I suggest that sinusitis and appendicitis are further-
more linked by the possibility that increased incidence of
sinusitis and other forms of focal sepsis may have in some
measure determined the increased incidence of appendicitis
and other gastro-intestinal secondaryinfections.-I am, etc.,_
Bristol, July 2u<l. PATRICK \VATSON-WILLIAMS.
'' THE USE OF THE SELF ''
SIR,-Dr. A. J. Brock, in his letter in your issue of
June 25th, has made certain statements, both as to the
aim of my technique and my method of employing it,
which, if unanswered, must leave your readers with an
erroneous impression. First, Dr. Brock writes:
"His !.Aiexandc>r's] job, he tells us, is the> correction of
imperfect or inadequate functioning.' Apparently he aims
at teaching his pupils to ' make a betttCr use of themselves,'
and this hy an ' energetic scheme of exercis<s ' " : and again,
" Mr. Alexander obviously finds that of those who practise
the exercises with determination a large number have not
time to fall ill, while others who are already ill forget their
troubles in the t>nthusiasm: of the game."
Throughout the subject-matter of my hook, and also
in the letter you were good enough to publish on June
18th, I emphasized (1) that my work is solely concerned
with the restoration and establishment of a trustworthy
sensory appreciation of the use of the psycho-physical
mechanisms, by means of a technique which depends
upon the employment of a consciously dilecled primary
control, and (2) that any improvement in " imperfect or
inadequate functioning '' which accrues from the applica-
tion of this technique comes about, not as a direct, bnt
as an indirect result of improvement in direction of use
and of the restoration of .trustworthy sensory .appreCiation,
Anyone who will do me the justice to read carefully
the first chapter of my nook (especially pages 33 to 35),
where I describe in detail the application of my technique,
must see that in every instance the preliminary step if!
the inhibition of any misdirection of use that has become
habitual, and that therefore such a method presupposes
of necessity the elimination of what is involved in any
scheme of " exercises," whether " energetic " or other-
wise, or of what Dr. Brock calls " psycho-physical
gymnastics.''
Secondly, I join issue with Dr. Brock when he writes
that " every practitioner with a modicum of intelligence
soon learns it [that is, the fact that the individual is in
essence a psycho-physical unity, and a functioning unity
at that] from experience." I would ask how the practi-
tioner puts into practice in his diagnosis and treatment
what he has learned " from experience " about this fact.
JUNE 24, 1944
IMPROVED DENTITION' OF LONDON SCHOOL-CHILDREN
BRITISH
MEDICAL JOURNAL
837
THE IMPROVED DENTITION OF 5-YEAR..()LD
LONDON SCHOOL-CHILDREN
A COMPARISON BETWEEN 1943 AND 1929
BY
MAY MELLANBY
(Nutrition Building, National Institute for Medical Research, N.W.1)
AND
HELEN COUMOULOS, D.D.S.Athens
(Girton College, Cambridge)
Historical
It is now established that certain nutritional factors play a pro-
minent part in determining the structure of the dental tissues and
their resistance to disease. Interest in this subject was first
roused by the investigations on animals and children made by
one of us (M. M.) which began in 1917 and have continued up to
the present time.
(a) Animal Experiments
It was shown in experiments on puppies and other young
animals that perfect and imperfect teeth could be produced at
will by small variations in the diet during the period of tooth
development (Mellanby, 1918). "The chief among these deter-
minants were the fat-soluble vitamins, and especially vitamin D
(which in the earlier days was called the calcifying vitamin).
This substance acted in association with the calcium and phos-
phorus of the diet, and for optimum effect required a sufficiency
of these elements: in the absence of vitamin D, even large
quantities of calcium and phosphorus in the diet did not result in
perfectly formed teeth and jaws. A deficiency of this vitamin
in the mother's diet during pregnancy and lactation, especially
with a low intake of calcium, caused the decidmms or milk teeth,
and to a less extent the permanent teeth, of her puppies to
be imperfectly calcified, even when, after weaning, their own
food contained abundance of these substances ; if the puppies
continued on the same defective diet as the mother their perma-
nent teeth were very badly formed-more so, -in fact, than if
the mother's diet during pregnancy and lactation had been good
from the point of view of tooth development. It is seen, there-
fore, that the mother's diet during these periods may to some
extent affect the teeth of her offspring for life.
In the living animal, teeth of perfect structure were trans-
lucent and felt smooth when their surfaces were rubbed lightly
with a probe, whereas varying degrees of roughness were
encountered when the teeth were of imperfect structure. It
was shown that there was a close correlation between the sur-
face appearance or texture of the teeth, determinable in situ,
and their minute architecture as seen in microscopical sections
made after death.
(b) Investigations on Children
When a large collection of children's shed and extracted
teeth was examined and graded according to the standards
developed and adopted by M. M. on the basis of the animal
experimental work, perfect structure and all grades of imperfec-
tion were found, although some 80% came into the latter
category. Teeth of good structure were on the whole found
to be much less carious than those of defective structure,
78% of the former, compared with 6% of the latter, being
caries-free. This 'relationship, however, did not necessarily
apply to the comparatively few teeth with gross enamel defects
obvious to the naked eye-forms of dental hypoplasia which
used to be, and indeed still are, the only ones generally
recognized.
From 1922 onwards a series of investigations on children in
a Sheffield tuberculosis hospital (1924, 1926, 1931, and 1934)
and in three Birmingham Cottage Homes (1934) were made in
co-operation with medical and dental colleagues. These investi-
gations showed that those dietary factors which promoted .veil-
calcified teeth also influenced them after full eruption and
tended to retard to some extent the onset and spread of t:aries.
Thus there was in the Birmingham study significantly less inci-
dence and spread of caries in a group of children receiving
additional vitamin D and olive oil than in the control group
getting extra olive oil without the vitamin : for instance, in
the permanent teeth already erupted at the beginn;ng of the
investigation an increase of only 8% of carious teeth was
found in the vitamin D group in 2t years, compared with 13.8%
in the control group. Moreover, there was an even greater
difference in those which erupted during the actual period of
the investigation, the structure of which teeth may have been
influenced by the diets (i.e., 7.6% of these teeth were carious
in the vitamin D group, compared with 17.8% in the control
group). In these series of investigations the most important
dietary factors for delaying the onset and spread of decay were
milk, cod-liver oil, and irradiated ergosterol (vitamin D,). With
low vitamin D and calcium it was found that increasing the
cereal content of the diet allowed the disease to spread more
rapidly than in the controls with comparatively little cereal,
probable reasons for this being that there are some anti-
calcifying substances in cereals.
The above facts and many other experimental and clinical
results were brought together in three special reports of the
Medical Research Council published in 1929, 1930, and 1934
(M. Mellanby) ..
More recently these investigations on the initiation and
spread of caries in children's teeth have been repeated and
extended in different parts of the world (Anderson et al., 1934 :
McBeath, 1932, 1934; McBeath and Zucker, 1938; McBeath
and Verlin, 1942; McKeag, 1930; Schiotz, 1937), so that to-day
medical and dental clinicians as well as scientific investigators
are realizing more and more that nutrition plays an important
part in dental disease. They do not always, however, fully
appreciate the long period during which dietetic factors must
be operative in order to promote good dental structure and
increase resistance to disease. For instance. they often expect
results after a few months' administration of cod-liver oil,
whereas the treatment should begin in early intra-uterine life
and continue during the period of growth, and in a modified
way probably throughout life.
The direct cause or causes of dental caries in human beings,
as distinct from the predisposing factors, are not yet known,
but in the work referred to above there was enough evidence
to demonstrate that a great improvement could be obtained if
the dietary of pregnant women, infants, and children were
changed to one of higher calcifying quality. The teeth of the
new generation would then be of better structure and less prone
to decay. It seemed, indeed, that such a step must form the
basis of any policy likely to lead to mass improvement of
teeth-a point of view which has been constantly urged by
one of us for many years. The dietetic changes advised were :
(I) an increased consumption of milk, eggs, and other foods
comparatively rich in calcifying factors ; (2) a decreased intake
of cereals, such as bread, oatmeal, and oatmeal preparations ;
and (3) the addition to the diet of cod-liver oil or some other
source of vitamins D and A, especially the former.
(c) National Dietary Changes related to Above lnvesti[?ations
During recent years interest has become focused on public
health in relation to food, and the Government has made a
special effort to improve the standard of nutrition of pregnant
women, infants, and young children. In the past quarter of a
century antenatal clinics and infant welfare centres have been
established in increasing numbers to advise on the feeding of
both mother and baby. Rickets, so common in the 1920's and
earlier, has become comparatively rare in England owing largely,
no doubt, to the increased consumption of milk and to the
greater therapeutic, as well as the prophylactic, use of cod-
liver oil and other substances containing vitamin D. The con-
dition of the teeth of the group of children examined in the
present investigation could not have been greatly iQfluenced
by school feeding, since the majority did not go to schooluntil
they were 5 years old, though a few went to nursery classes
or schools ; but it is of interest to remember that as long ago
as 1906 the London County Council made official arrangements
for the supply of school dinners to necessitous children, and
in 1910 milk and cod-liver oil could be supplied to children
whose home conditions were unsatisfactory or when malnutri-
tion was threatened or present. In addition there were an
increasingly large number of other children receiving milk, on
payment, as the result of voluntary school milk clubs. Only
in 1934, however, when the Milk Marketing Board was set up,
was a scheme put into operation to supply milk (at first one-
third of a pint and later two-thirds of a pint a day) to children,
irrespective of their physical condition, in any part of the
838 JUNE 24, 1944 IMPROVED DENTITION OF LONDON SCHOOL-CHILDREN
BRITISH
MF.o:cAL JouRNAL
country at the reduced rate of td. per one-third pint bottle, or
free iri necessitous cases.
With the war have come other advances: cheap milk, cod-
liver oil, and orange juice, and a priority of -eggs, have become
available to all pregnant and lactating women, to infants, and
to young children. Dinners are provided at most schools, and
their quality has been greatly improved ; their provision no
longer depends on financial or medical necessity, but has been
developed as part of the Government's wartime food policy,
and many parents take advantage of the scheme. Calcium
carbonate has been added to bread (7 oz. to 280 lb. of flour),
and the nutritive value of all margarine has been improved by
the addition of vitamin D. and vitamin A.
(d) Reasons for Present Investigation
While these steps have been taken with the object of bettering
the general nutrition of the community and especially of guard-
ing against diseases of childhood such as rickets and concomitant
ills, it is obvious that the changes in the dietary are in the
main those which the animal and human investigations men-
tioned above have shown to be necessary for improving the
nation's teeth. It seemed of considerable interest, therefore, to
see whether there was any evidence that such an improvement
had in fact taken place. Fortunately, it was possible to make
an inquiry into the question which would provide an answer
so far as children attending L.C.C. schools are concerned,
for in 1929 a dental examination of some 1,300 unselected 5-
year-old children (i.e., children who had not yet come under
the full influence of the school dental service) in these schools
was made by one of us (M. M.) for the Board of Education.
The surface structure of the enamel and the presence and
extent of caries in each tooth were recorded; later some of
the findings, together with other records made on the same
children, were published by the Board of Education (1931). By
using the same criteria and examining the same age group
attending these schools to-day it would therefore be possible to
see what, if any, improvement had taken place in the inter-
vening 14 or 15 years. '
Dr. W. Alien Daley, the School Medical Officer to the London
County Council, was approached, and the Council's permission
to carry out an investigation was readily given.
The Present Investigation
When any school visited in 1929 was closed or was no longer
used as an infants' department, one or more other schools in
the same neighbourhood, as near as possible to that previously
inspected, were taken as substitutes. In addition, a few schools in
other districts were visited, but they are not included in the main
tables.
In 1929 the schools were divided, with the help of the local Care
Committees, according to their level in the social scale. For the
purpose of the present investigation, therefore, the Care Committees
were again approached, and after consultation they made- a rough
classification into four grades ; but they could not guarantee that
their groupings were comparable with those made in 1929, which
were indicated by the signs B+, B, B-, and C. Moreover, tlrere
is now a greater mixing in the schools than hitherto of children
from families of different social and financial levels. This is due
to many causes, including the clearance of slums and the building
of large blocks of flats, the transference of families from one area
to ano!her owing to destruction of homes from enemy action,
evacuat10n schemes, etc. Then, again, the financial status of many
families has been. altered, either raised or lowered, as a result of
the war. .
In the present survey the dental examinations were shared by us,
the majority of children being inspected by H. C. From time to time
during the course of the survey, and especially at the beginning, the
teeth of many children were examined separately by both investi-
gators, the two records being compared so that as far as possible
the same standard would be kept ; this was especially necessary
for the grading of structure, in which the personal factor plays
a prominent part. We were in agreement in most cases; where
differences did occur they were generally small.
Detailed examinations of all teeth were made for signs of
M-hypoplasia (see next paragraph), gross hypoplasia (the generally
recognized varieties), and caries. Other conditions of the teeth,
including their alignment, the presence of mottled enamel, and the
state of the gums, were noted, but are not considered in this paper.
Since results of the 1929 investigation were given as percentages of
children showing varying degrees of hypoplasia and caries, ~ i m i l a r
figures will be given here. A more detailed analysis of our findings
will be published later.
(a) The Structure of the Teeth
The standards used for structure were similar to those adopted
in the 1929 Board of Education survey, which were evolved from
the results of the investigations referred to above. Individual teeth
were taken to be of normal or perfect structure when their surfaces
were smooth and shiny, like those of the teeth of puppies given
a mixed diet relatively rich in vitamin D and containing the neces-
sary calcium and phosphorus. Teeth showing imperfections of sur-
face structure were classified into three grades : slightly defective,
defective, and very defective. These types of defects will be referred
to as M-hypoplasia, a term first used by J. D. King in 1940 to
distinguish them from the previously recognized gross or G-types,
which are rarely seen in deciduous teeth. The M-type defects were
originally described by M. Mellanby (1923, 1927, 1934), who found
that some 80% of 1,500 deciduous teeth were so affected.
The surfaces of the teeth with M-hypoplasia show varying degrees
of roughness which are not always visible to the naked eye when the
teeth are in situ, but can easily be detected when their surfaces
are lightly rubbed with a probe ; the degree of roughness as indi-
cated by the " feel " of the probe can be judged with practice.
A sufficiently reliable clinical assessment of the enamel surface
texture is obtained if the test is confined to the buccal aspect of
the teeth. When each tooth had been considered separately a
general computation was made for the structure of all the teeth of
a given child, keeping so far as possible to the method of assess-
ment used in the 1929 investigation but dividing the children into
only four groups instead of seven: Good structure, Little M-hypo-
plasia (I and 2), Some M-hypoplasia (3 and 4), and Much M-hypo-
plasia (5 and 6). The figures in parentheses refer to the 1929
grouping. The few cases of gross hypoplasia were included in
Group 4.
Although 1,604 children were examined in the main survey and
included in the caries incidence tables, 33 of them had lost too
many teeth for it to be possible to classify for structure, reducing
the number for this purpose to 1,571.
In Table I the structure of the teeth in the two investigations
is set out. It is clear that in the 14 years that have elapsed the
- .
TABLE I.-Incidence of M-hypoplasia in Deciduous Teeth
I
Total
Number of
I
Children None
1943 1,&71 12
1929 1.139 0
Percentages of Children Showing :
Little
I
Some
181 474
78 33-6
Muc h
3
5
33
58
picture of deciduous tooth structure has changed for the better.
Even so, there are very few children with a full complement of
perfectly calcified teeth ; however, 'in 1943 18.1% had only slight
M-hypoplasia, compared with 7.8% in 1929, and there were fewer
with much M-hypoplasia-33.3% as against 58.5% respectively.
In Table 11 the findings are given when the schools are divided
according to their estimated social status. There are no great
TABLE Il.-lncidence of M-hypoplasia in Deciduous Teeth at the
Different Social Levels
Social Grading
Total Percentages of Children Showing :
No. of,
of School
Children None Little Some Much
Highest grade (B +)
1943 .. .. 180 0& 2&8 490 247
1929 .. 133 0 128 308 564
2nd grade (B)
1943 .. .. &82 10 148 &02 340
1929 .. 423 0 99 364 537
3rd grade cB -)
1943 .. .. &58 18 180 451 351
1929 .. 190 0 47 300 653
4th grade (C)
1943 .. .. 243 DB 202 449 342
1929.
.. .. 393 0 54 333 613
differences in these groups in 1943, although the tendency is for
the highest-grade schools (B+) to have teeth of rather better struc-
ture than the schools in the other three grades, which differ little
on the whole. In 1929 there was a suggestion that the quality of
structure was worse in the lower-grade schools.
(b) Incidence of Dental Caries
For the grading of caries each tooth was examined by probe and
mirror and put into one of four categories, as follows :
No caries that could be diagnosed as definite caries by our
methods of examination. (No radiographs were taken.)
Slight caries: Very early and suspected fissure and approximal
caries.
Moderate caries : Cavities involving destruction up to roughly
one-quarter of the tooth, crown.
Advanced caries: Destruction of more than one-quarter of the
tooth crown.
JUNE 24, 1944 IMPROVED DENTITION OF LONDON SCHOOL-CHILDREN
BRITISH
MEDICAL JOURNAL
839
Fillings and arrested caries were classified very roughly according
to the extent of the crown involved and included as carious. If
deciduous molars or canines had been lost it was assumed that they
had been extracted for advanced caries, since they should normally
be present at the age under review.
When each tooth had been graded separately the children were
divided into four groups according to the total amountof caries
present ; the method of assessment used was as nearly similar to
that of 1929 as possible: No caries,* Little (1 and 2), Some (3 and
4), and Much caries (5 and 6). The figures in parentheses relate
to the 1929 classification, when seven groups were distinguished
instead of four.
Table Ill gives a comparison of the relative amount of caries for
the two investigations: 22.4% of the children in 1943 were "caries-
free," compared with 4.7% in 1929 ; and only 29.3% had much
TABLE Ill.-lncidence of Dental Caries in Deciduous Teeth
Total Percentages of Children Showing:
Number
of
I
No Little Some Much*
Children Caries Caries Caries Caries
1843
I
1,804
I
224 259 224 293
1929
I
1,293 47 117 208 628
I
Only 6% of the children in this category in 1943 would correspond with
the C6 group (very bad caries), compared with 54% in 1929.
caries, as against 62.8% previously. Actually the improvement is
even greater than these figures suggest, because in 1943 only about
6% of those in the "Much" caries group could be classed in the
C6 category (very bad caries), compared with 54% in the earlier
investigation, which included a number of edentulous children. No
edentulous child was seen in 1943. In both investigations the
amount of caries varied considerably from one school to another ;
in 1943 the percentages of caries-free children ranged from 5 to 37
and of "Much" caries from 50 to 11.5. In 1929 the comparable
figures were 0 to 15.4% and 79 to 39% respectively.
Table IV indicates that in 1943 there was distinctly less caries in
the B+ schools than in the other three grades, which differed little
TABLE IV.-lncidence of Dental Caries in Deciduous Teeth at the
Different Social Levels
I
Percentages of Children Showing:
Social Grading I Total
No. of
of School
Children
No Little Some Much
Caries Caries Caries Caries
Highest grade (B +) I
1943 . . . . 193 295 285 212 207
1929
2nd grade CB)
.. 147 61 177 156 606
1943 .. .. 598 208 277 220 215
1929
3rd grade CB-)
.. 480 65
. 113
226 596
1943 .. .. 569 229 238 211 325
1929
4th grade (C)
.. 210 3-8 105 229 628
1943 .. .. 246 115 2112 272 281
1929 .. .. 456 28 105 195 671
I
among themselves. In 1929 there was a slight tendency for the
amount of caries present to increase from the better to the poorer
schools.
(c) Subsidiary Suney
As already mentioned, a subsidiary survey was made of several
schools in districts not visited in 1929. The findings are therefore
given separately. The amount of hypoplasia was about the same
as that found in the schools in the main survey, but there was less
decay: 35% of the children had no definite caries.
TABLE V.-Incidence of M-hypoplasia in the Subsidiary Survey
Social Grading
Total Percentages of Children Showing:
No. of
of School
Children None Little Some Much
grade (B +) 134 08 127 619 246
3r grade (B-) .. 128 0 148 461 391
Total .. .. 262 04 137 542 317
The schools an came into the B+ and B- categories. In the
former, 135 children were seen, of whom 40.7% had no definite caries
and only 11.1% had " Much " caries. The teeth of the 131 children
* There are children included in this group in whom very early
caries was present in two or three teeth, and whom to-day we should
probably prefer to include in a separate group between caries-free
and little caries; but the standard here used is that adopted in 1929,
when so few children were seen with anything approaching a caries-
free momh.
TABLE VI.-lncidence of Dental Caries in the Subsidiary Survey
Total
Percentages of Children Showing :
Social Grading
No. of
Little Much
of School
Children
No Some
Caries Caries Caries Caries
Highest grade (B +) 135 407 252 230 111
3rd grade (B -"') .. 131 290 191 252 267
----
Total .. .. 266 350 222 241 188
in the B- schools were not as good from this point of view as
those in the B+ schools, but nevertheless 29% of the children
were" caries-free" and 26.7% had "Much" caries. The percentages
of " caries-free " children in the individual schools ranged from 27
to 44 and those with "Much" caries from 38 to 8.
(d) Arrest of Caries
In the Sheffield investigation carried out by one of us (M. M.)
in co-operation with Dr. Lee Pattison, and referred to above, a
striking featut"e noted in groups of children having a good calcifying
diet was the relatively high proportion of decayed teeth in which
the caries was no longer active--in other words, in which the caries
had become arrested. Many of these children were examined at
regular intervals over long_ periods, and it was found possible to
trace the gradual arresting of the carious pJocess. It is therefore
significant that in the present survey typical arrest was found in at
least some teeth of 28% of all the children caries.
(e) Association of M-hypoplasia and Carie9
A close association exists between the quality of a tooth and
its resistance to decay, as has been mentioned above: To assess this
relationship accurately it is necessary to consider individual teeth,
but it was thought that a rough indication might be obtained ,Y
correlating the structure of the teeth and the amount of caries per
child, taking for this puJ1)ose only those cases in which no canines
or molars were missing. None of the few children with perfect
and under 5% of those with nearly perfect dentition were placed
in the two worst categories of caries, whereas 38% of the children
with "Much" hypoplasia had also "Much" caries and only 8%
were " caries-free." It is interesting to note that 34% of those with
" Some " hypoplasia had no caries and 40% had " Little " ; this
suggests that some post-eruptive influence (direct or indirect) was
at work, though it must be borne in mind that these children
were under 6 years of age and the molars still had a long period
in the mouth in which they might become carious.
Discussion
The data obtained in this survey show clearly that there has
been a distinct improvement since 1929 in the dental condition
of 5-year-old children attending London County Council
elementary schools. The quality of the teeth is now better ; in
1943, 19% of the children had teeth of good structure, com-
pared with 8% in 1929, while the percentages with very defec-
tively formed teeth (i.e., teeth with "Much" M-hypoplasia)
were 33 and 58 respectively. The reduction in the incidence
of dental decay is even more striking: in 1943, 22% of the
children were "caries-free," compared with 5% in 1929, while
only 29% had "Much" caries in 1943, as compared with 63%
in 1929. When the schools were grouped according to social
status there was little difference in dental condition as regards
both structure and caries between the various grades, though
the teeth tended to be rather better in the highest-grade schools
in 1943 and in the two highest grades in 1929.
These observations, however, do not show whether the
improvement is of recent occurrence or whether it has been
gradual in this social stratum of London during the past 14
or 15 years. Since, however, the teeth of the 1943 5-year-old
children were in the main formed in the immediate pre-war
years and the first year of the war, the cause of the improve-
ment in these particular children must be sought among factors
operative at and since that time and contrasted with the con-
ditions in the years 1922-9, when the teeth of the children
examined in the previous survey were developing. Can the
improvement be attributed to the changed dietary referred to
earlier, which has increased the intake of vitamin D and calcium
by the provision of cheap milk and of cod-liver oil to infants
and young children, together with the addition of vitamins D
and A to the margarine and of calcium carbonate to the bread ;
or is it due to other unknown influences which have been
brought to bear on child life in London during these years?
No categorical answer can be given to this question, because
there still remains much to be discovered not only about the
relation of nutrition to dental conditions but also about the
840 JUNE 24, 1944 fMPROVED DENTITION OF LONDON SCHOOL-CHILDREN
BRITISH
MEDICAL JOURNAL

immediate cause of caries. All we can do in attempting to
answer the question is to argue from established knowledge
and see to what extent this explains the observations.
It is known that the structure of the deciduous and perma-
nent teeth of young animals is affected by the diet during their
period of tooth development, both in utero, during lactation,
and especially after weaning, when much greater defects in
dental structure of the offspring may result from diets poor in
calcifying properties. The mother has a large quantity of
calcium in her bones and sometimes stores of vitamin D in
her body ; these substances she undoubtedly sacrifices to some
extent to her offspring when she herself is deficiently fed, but
these offspring will have little or no stores of vitamin D
after weaning, so that a poor calcifying diet taken at
this time very soon exerts its baneful influence. The same
principle probably applies in the case of the child, and it is
therefore very important that the pregnant and lactating woman,
and later the infant itself, should have diets rich in the factors
necessary for the production of well-calcified teeth.
The experimental evidence that dental structure is largely
controlled by the ingesti!)n of enough vitamin D, calcium, and
phosphorus is so strong that it is difficult to avoid the con-
clusion that the improvement in dentition of the 1943 children
has resulted largely from the changes in dietary in the imme-
diate pre-war and early war period. If this is the case, and
if mothers and children are taking and continue to take full
advantage of the additional improvements in dietary that I:Wlve
been placed !lt their disposal during the last year or two, it
safe to predict that children's teeth now being formed
wdl be even better than those of the children seen in the 1943
survey.
While, therefore, the reason for the improvement in dental
structure seems clear, the cause of the reduction in dental caries
is less certain. Since M. M.'s early investigations on children's
teeth showed that those of good structure were less liable to
caries than those of poor structure, and since the structure of
the teeth in this survey was better than in 1929, some reduction
in the amount of caries was to be expected from this cause
alone. The reduction observed, however, was greater than
could be explained on this basis, so that some other contributory
factors were evideptly at work.
Investigations carried out by M. M. and her colleagues and
others have shown that the dietary factors which promote wetl-
calcified teeth also tend to retard the onset and spread of caries,
apart from their influence on structure. The dietary of the
young children in the 1943 survey has been improved from
this point of view even beyond the standard reached during
the immediate pre-war period and early part of the war, when
their teeth were being formed, and it is considerably better
than the dietary at the corresponding period in the lives of
the 1929 group of children. It might be surmised, therefore,
that the reduction in caries in 1943 as compared with 1929 is
due in part to the better structure, which is related to better
calcifying dietary, in part to the post-eruptive influence of the
even better dietary condition of the war years, and possibly in
part to other unknown changes. What these other factors are
that may share the responsibility for the diminution of caries in
these children can only be conjectured. Some would say that
changes in the carbohydrate intake or the fluorine intake or
of food consistency, or a greater use of the toothbrush have
played -a part. Unfortunately the basis of these suggested
factors is too insecure at the present time to allow their effects
to be assessed adequately.
If the present national food policy has been responsible, as
seems likely, for much of the improvement of the teeth here
reported, this only emphasizes the importance of still greater
efforts on the part of central and local government in the
same direction, for even to-day 78% of these 5-year-old chil-
dren have some decayed teeth. Parents must be taught to realize
that the consumption of milk and vitamin D is a sine qua non
for improvement of the teeth of their children, and they must
be induced to co-operate more willingly in this health-giving
project. Much has already been done by the staffs of welfare
centres, school medical and dental officers, Care Committee
workers, and teachers ; but unfortunately there still remains a
fair proportion of parents who, for one reason or another, fail
to take full advantage of the dietary supplements at their
disposal.
The facts emerging from this investigation can be regarded as
heartening and as providing evidence that we are at last taking
steps in the right direction to attack successfully the most
widespread of the ills of civilized man. Florid rickets-the
cruder manifestation of defective calcification---'has been vir-
tually eliminated in England by better feeding of pregnant and
lactating women, and of infants and children. It is possible
that the elimination of dental caries may not be attainable until
its immediate cause is known, but even without this knowledge
it is probable that a continuation and extension of the present
nutritional policy and its more whole-hearted adoption by the
public would bring about further improvement in the archi-
tecture of teeth and in their subsequent resistance to decay.
It would then at least be possible to present to dental surgeons
a situation which they could tackle hopefully.
Summary
The results are given of two large-scale dental surveys of 5-year-
old children in the same or comparable schools of the London
County Council in 1943 and 1929.
During the intervening period a greal improvement has taken
place both in the structure of the deciduous teeth and in their
resistance to decay. (a) 19.% of the children had teeth of perfect
or nearly perfect structure in 1943, compared with 8% in 1929, and
only 33% had very defectively formed teeth (i.e., teeth with much
M-hypoplasia), compared with 58% in 1929. (b) In 1943 22% of
the children were, according to the standards used, " caries-free,"
compared with about 5% in 1929.
That there is still great room for improvement dental condition
is demonstrated by the fact that even at the present time between
'56 and 95% of children in individual schools visited in two
surveys had dental decay in at least some of their teeth.
It is thought that the observed improvement in the dental condi-
tion of this age group may be largely due to the changes in feeding
habits which have been .developing in recent years-in particular to
the introduction in 1934 of the cheap milk scheme of the Milk
Marketing Board and later to the wartime food policy, which
included (a) increased allowances of milk together with cod-liver
oil and fruit juices to pregnant and lactating women, to infants, and
to young children ; (b) the addition of vitamins A and D, to
margarine ; and (c) the addition of calcium carbonate to bread.
These are dietetic changes that investigations on animals and chil-
dren carried out by one of us (M. M.) since 1917 have established
as essential for the improved dental condition of the general child
population.
Our thanks are due to many people who have helped us directly
or indirectly with this investigation. These include : the London
County Council and Dr. W. Alien Daley for their permission to
carry out the inspections, for making the necessary arrangements at
the schools, and for their kind interest in the progress of the survey ;
the Care Committee Organizers for grading the schools and for other
valuable assistance; and Miss Irene Alien for general help, and
especially for working out the results given in the tables. Last,
but by no means least, we want to thank the head teachers of the
infant schools and their assistants, without whose willing and
interested co-operation the work would have been impossible. H. C.
holds a scholarship from the British Council. and other expenses
were paid by the Medical Research Council ; to both of these
bodies we are very grateful.
BIBLIOGRAPHY
Anderson, P. G., et al. (1934). J. Amer. dent. Ass., 21, 1349.
Board of Education (1931). Committee on Adenoids and Enlarged Tonsils.
Second Interim Report: The Association of Rickets and Dental Disease
with Adenoids and Enlarged Tonsils, London.
Dental Disease Committee (1936). Med. Res. Cncl. Sp. Rep. Ser. No. 211,
H.M.S.O., London.
King, J. D. (1940). Ibid., No. 241.
McBeath, E. C. (1932). J. dent. Res., 12, 723.
-- (1934). Amer. J. pub/. Hlth., 24, 1028.
- and Zucker, T. F. (1938). J. Nutrit., 15, 547.
-- and Verlin, W. A. (1942). J. Amer. dent. Ass., 29, 1393.
McKeag, R. H. (1930). Brit. dent. J., 51, 281.
Mellanby, M. (1918). Lancet, 2, 767.
-- (1920). Dimt. Rec., 40, 63.
--(1923). Brit. dent. J., 44, l.
--(1927). Ibid., 48, 737.
-- (1929). Med. Res. Cncl. Sp. Rep. Ser. No. 140, H.M.S.O., London.
-- (1930). Ibid., No. 153.
-- (1934). Ibid., No. 191.
-- Pattison, C. Lee, and Proud, J. W. (1924). British Medical Journal, 2, 354.
-- -- (1926). Brit. dent. J., 47, 1045.
-- -- (1928). British Medical Journal, 2, 1079.
--(1932). Ibid., 1, 507.
Schiotz, C. (1937). Norske Tandlaegefor. Tidskr.
In an address to the Conference of the Children's Nutrition
Council (Wales) at Cardiff on May 13, Mr. Eddie Williams reminded
his audience that the object of the Council was " to ensure that no
child, by reason of the poverty of its parents, shall be deprived
of at least a minimum of food and other requirements necessary for
full health." He strongly advocated the institution of school meals
throughout Great Britain.
JUNE 10, 1950 DENTAL CARIES IN LONDON SCHOOL-CHILDREN
DENTAL STRUCfURE AND CARIES IN
SYEAROLD CIDLDREN A'ITENDING
LONDON COUNTY COUNCa SCHOOLS
RESULTS OF FIVE SURVEYS (1929-49)
BY
HELEN MELLANBY, M.D., Ph.D.
AND
MAY
(From the Nutrition Building, National Institute for Medical
Research, Mill Hill, London)
In 1929, at the request of the Board of Education, the
teeth of children attending L.C.C. schools were
examined. Fourteen years later a similar survey was under-
taken, with the idea of seeing whether there had been any
improvement or deterioration in this period (Mellanby and
Coumoulos, 1944). It was then decided to make a series
of two-yearly inspections, using the same criteria, and the
latest of these was made in 1949. The object of the present
paper is to summarize the most recent findings and to
compare them with those 'of the previous surveys.
In the earlier work it was shown that the dental condition
of this age group, as regards both structure and caries, had
improved from 1929 to 1947 (Mellanby and Mellanby,
1948). Since we made no examinations between 1929 and
1943, it is not possible to say at what rate the improvement
took place or whether it was regular during that period,
but there is no doubt that it was very definite and signifi-
cant (Mellanby and Coumoulos, 1944). Many more chil-
dren had teeth with good structure in 1943 than in 1929,
and the percentage of caries-free plus almost caries-free
children rose from 4.7 to 24.2 during the 14 years. In
1945 the percentage in this latter category was 28.1, while
in 1947 it had risen to 37.5. It was therefore with great
interest that the 1949 survey was made.
As it was realized that it would not be possible to
examine as many children in 1949 as in 1943 and 1947-
namely, 1,870 and 1,590 respectively-it was decided to
limit the number to approximately that of 1945, when
691 children were seen. So far as possible the same
schools were visited as in that year, but, since there were
many more 5-year-old children on the registers, a random
sampling method was used to obtain the requisite number.
Six hundred and ninety-two children were examined ; their
average age was 5 years 6 months-one month older than
the average for each of the previous three surveys.
The inspections were conducted in the same way and
according to the same standards as before (Mellanby and
Coumoulos, 1946; Mellanby and Mellanby, 1948).
To get some indication of the extent of the lesions,
apart from the percentage of carious teeth, a number (1,
2, or 3) was allotted to each carious tooth, according to
the severity of the disease (Mellanby and Coumoulos, 1946).
The total so obtained for any group of teeth was then
divided by the number in the group, thus giving the average
caries figure (A.C.F.). The greater the number of teeth
with little or no caries the lower the A.C.F. A similar
principle was adopted in order to assess the extent of
M-hypoplasia (A.H.F.), the number 1 being given for
M-Hy
10
2 for M-Hy
2
, and 3 for M-Hy
3
The few teeth
showing gross and unclassified hypoplasia were excluded
from these calculations.
As in the other investigations of this series, any missing
incisors were assumed to have been shed. Very few of
the 13.3% of missing lower incisors would have been
carious, and as only 5.2% of the upper were absent any
decayed among them would have made little difference to
the caries total. Missing canines (0.2%) and molars (upper
6% ; lower 13.4%) would have been extracted at this
age and were therefore included in the severe caries (C
3
)
category.
As many workers now use the D.M.F. (decayed, missing,
and filled) method of expressing their results, we have
added the corresponding nomenclature as subheadings
where applicable (see Tables 11 and Ill).
In order to reduce the size of the tables for this paper,
the four grades of structure (Hy
0
to M-Hy
3
) given indi-
. vidually in previous papers have been combined into two
categories, as have the four grades previously given when
assessing caries (C
0
to C
3
).
Results
From the tables it can be seen at a glance that the
gradual improvement in the dental condition previously
noted was not maintained. There was indeed a falling
off in 1949.
Structure.-lt is clear from Table I that there were fewer
well-formed teeth in 1949 than in the previous survey;
79.8% of all teeth were graded as Hy
0
or M-Hy
1
in 1949
as compared with 84:5% in 1947, but there were more,
on the average, than in 1945, when 71.6% came into
this category. The percentage of some individual types
TABLE I.-Tooth Structure in 5-year-old London Children .
.
Percentage of Teeth with
Percentage of Teeth with
Percentage of Teeth with
Total No. of Teeth Good or Fairly Good Gross or "Textbook " Extent of M-hypoplasia
Type of Examined for Structure Structure
Poor Structure
Hy8oplasia (A.H.F.)
Tooth
(Hy,.+M-Hy,)
(M-HYo+a>
( -Hy)
1943 1945 1947 1849 1943 194S 1947 1949 1943 194S 1947 1849 1943 194S 1947
1849 1
1943 194S 1947 1948
Upper jaw:
3,324 1,262 2,931 1,230 S2-l 612 828 791 43-7 32-1 142 188 3-9 66 30 23 137 114 068 083 Central incisors
Lateral incisors 3,46S 1,341 3,023 1,308 74-1 780 886 893 2H 16S 82 88 2S 54 27 2.1 100 079 061 073
Canines .. 3,707 1,369 3,119 1,3811 83-3 865 93-6 938 147 112 44 81 10 H 07 02 183 071 OS9 o-70
1st molars .. 3,268 1,282 2,869 1,248 403 479 647 &82 S69 493 349 43-1 2-8 28 04 08 lS1 148 128 141
2nd molars 3,427 1,342 2,960 1,307 3S2 44-7 S38 46-11 63-4 S43 461 1134 13 10 01 02 168 1S8 1-44 1114
Lowerlaw:
3,091 1,097 2,S3S 1,044 9S9 99-1 996 984 38 04 03 02 02 OS 02 04 033 OIS 006 013 Central incisors
Lateral incisors 3,624 1,348 3,097 1,333 9S2 987 994 98-7 46 08 OS 01 01 03 02 02
1
. o-43 021 010 042
Canines .. 3,702 1,370 3,109 1f372 888 932 963 989 64 24 07 1-7 14 07 03 00 OS3 030 019 0117
1st molars .. 3,119 1,23S 2,700 1.172 S69 619 878 829 40S 3S6 118 383 2-S 26 03 08
1127
117 077 1-24
2nd molars .. 3,104 1,241 2,15S 1,171 416 450 778 728 S49
s.J-S 219 187 3-4 lS 03 04 156 155 102 1-18
Total .. 33,831 12,887 29,098 12,548 670 716 845 798 30S 2SS 142 194 19 23 08 07 104 091 067 088
A few of the teeth included in the column headed " Total No. of Teeth Examined for Structure" could not be classified into any of the grades shown in this table.
Therefore the percentages do not add up to 100 in all instances.
1342 JUNE 10, 1950 DENTAL CARIES IN LONDON SCHOOL-CHILDREN
llamsH
MmiC.U. JOUIINAL
of teeth in the better-structure group was as high or nearly
as high as in the best year so far recorded (1947). The
average hypoplasia figures (A.H.F.) for all types of teeth
are given in the last column of Table I. Only a small
amount of gross hypoplasia was found in any of the
surveys, the latest figure being about the same as that
obtained in 1947.
Caries.-From the figures given in Table 11 it is seen
that 1947 was the year in which there was the greatest
TABLE H.-caries-free Children and Caries-free Teeth Among
London 5-year-olds
Children Teeth
Year
% Caries- %Caries-free
Total No. free (i.e., with +Those Total No. Percentaae
Examined noD.M.F. Almost of Teeth Caries-free
Teeth) Caries-free
1929 1,293
47
1943 1,870 149 242 36,196 699
1945 691 242 281 13,381 735
1947 1,590 281 375 30,839 797
1849 882 148 248 13,328
I
733
0 0
The percentage of canes-free children at this time was
percentage of children free from caries-namely, 28.1 %.
In 1949, as in 1943, only 14.9% were in this category.
The proportion of caries-free teeth, however, was higher
in 1949 (73.3%) than in 1943 (69.9%), though not as high
a'S in 1947 (79.9%); it was, in fact, the same as in 1945,
when it was 73.5%. The distribution of caries among
was again observed in 1949, as in the previous surveys of
this series and in the earlier investigations of the authors
and of other workers (M. Mellanby, 1923, 1927, 1934;
Deverall, 1936; Davies, 1939 ; King, 1940; H. Mellanby,
1940), that the teeth of. poorer structure, as judged by the
degree of M-hypoplasia, were more prone to decay than
were those which were better formed.
Summary
The main findings in a series of dental surveys among 5-
year-old children attending public elementary schools in the
London County Council area have been given ; the results of
the last four surveys made at intervals of approximately two
years are, for the reasons stated earlier (Mellanby and Mellanby,
1948), set out in more detail than those of the original survey
of 1929, on which the others were based.
At the time of the fifth and latest survey of 1949 propor-
tionately fewer children were caries-free-namely, 14.9%-than
on the two previous occasions, when the figures were 28.1 and
24.2% respectively ; the position had, in fact, reverted to that of
1943. In 1929 the number of children so classed was negligible.
The percentage of caries-free teeth (73.3) had not fallen in
1949 to the same extent relatively as the percentage of caries-
free-children, but was comparable to the figure obtained in the
third survey made in 1945 (73.5%). Dental structure, on the
other hand, although not in general as good as in 1947, was
better than in 1945.
It is difficult at present to suggest a reason for this apparent
lapse between 1947 and 1949, following the previously observed
improvement in the dental condition of children of the same
TABLE III.-caries Incidence and Extent in 5-year-old London Children
Type of
Tooth
Total No. of Teeth ! Free From or with only with Definite Carious ercentage anous eet
I
Slight Caries Cavities (i.e., D.M.F.
per I 00 Teeth)
Extent of Caries
(A.C.F.)
i Percentage of Teeth Percentage of Teeth I p c T h
I
(C,+C,) (C,+C,)
__
Upper jaw:
Central incisors
Lateral incisors
Canines ..
1st molars ..
2nd molars ..
Lower jaw:
Central incisors
Lateral incisors
Canines ..
1st molars ..
2nd molars ..
Total
3,392
3,590
3,740
3,740
3,740
3,112.
3,662
3,740
3,740
3,740
1,280
1,358
1,381
1,382
1,382
1,098
1,354
1,382
1,382
1,382
2,974
3,095
3,180
3,180
3,180
2,576
3,114
3,180
3,180
3,180
1,274
1,351
1,384
1,384
1,384
1,081
1,338
1,384
1,3M
1,384
36,196 13,381 30,839 13,328
722 755 83-4 782
865 883 92-7 900
934 942 950 83-1
667 694 759 71-2
607 663 796 742
97-8 992 990 888
983 985 988 881
955 948 97 3 884
53-9 586 624 555
519 563 682 578
773 797 849 808
the various types of teeth is seen in Table Ill. Though
the 1949 results were in general very similar to those of
1945, more decay was found in the lower molars and
less in the upper. Tbe percentage of carious lower first
and second molars increased from 48.6 and 58.8 to 54.0
and 61.3 respectively, and the carious upper molars were
reduced from 38.9 and 51.4 to 35.7 add 44.2% respectively.
The A.C.F. for all types of teeth are given in the end
column of Table Ill.
Structure and Caries.-Table IV shows the relationship
between structure and caries in the last four surveys. It
27-8 245 165 207
13-5 117 73 100
66 58 5-l 18
33-3 306 242 289
392 33-7 204 258
22 08 09 H
17 15 Jot 18
45 52 27 38
461 41-4 376 4411
481 43-6 31-7 422
227 203 15-1 181
376 295 222 301
203 149 106 14&
95 15 69 81
420 389 306 35-7
565 51-4 344 442
49 17 1-7 33
3-7 2-1 1-7 21
69 59 41 115
540 486 43-3 1140
610 588 430 813
301 265 203 267
077 061 042 056
038 030 020 028
018 015 013 017
095 083 065 078
1-17 095 064 D-78
008 003 003 0011
006 004 003 0011
013 012 007 010
129 HO 100 121
1-42 127 095 128
065 055 042 054
age group ; it may represent merely a periodic fluctuation, or
it may mark the beginning of a progressive deterioration. It is
hoped to make a sixth survey in 1951, when it will be seen how
the trend has resolved itself. Discussion of the possible factors
influencing the results should then be more profitable.
We wish to acknowledge our indebtedness to Sir Alien Daley and
the London County Council for permission to carry out the inspec-
tions ; to the head teachers and staffs of the schools for their willing
co-operation in the scheme; to Mrs. M. Kelley and Mrs. J. Joyner
for their assistance in connexion with the preparation of the report;
and to Miss I. Alien, of the Medical Research Council's Statistical
Department, for help and advice.
TABLE IV.-Percentage Incidence of Caries in Teeth with Varying Grades of Structure in 5-year-old London Children
Percentage Carious
Structure of Teeth Incisors Canines
'
Molars
1943 1945 1947 180 1943 1945 1947 1MB 1943 1945 1947 1Nl
Good or fairly good (Hy.+M-Hy,) .. .. 59 45 6f 88 48 3-8 43 118 208 21-1 262 384
Poor (M-Hy,+,) 00 00 .. .. 517 460 375 323 301 330 142 224 656 700 442 &08
--
Gross hypoplasia 00 .. .. 00 642 624 360 387 23-3 208 344
-
589 525 344 380
JUNE 10, 1950
DENTAL CAJliES IN LONDON SCHOOL-CHILDREN
Davies, J. H. (1939).
Deverall, A. (1936).
No. 211.
REFERENCES
Brit. dent. J., 67, 66.
Spec. Rep. Se'r. med. Res. Coun., Lond.,
King, J. D. (1940). Ibid., No. 241.
Mellanby, H. (1940). British Medical Journal, l, 682.
Mellanby, M. (1923). Brit. dent. J., 44, l.
- (1927). Ibid., 48, 1481.
-- (1934). Spec. Rep. Ser. med. Res. Coun., Lond., No. 191.
-- and Coumoulos, H. (1944). British Medical Journal, l, 837.
--(1946). Ibid., 2, 565.
-- and Mellanby, H. (1948). Ibid., 2, 409.
CANCER OF THE BREAST TREATED BY
OOPHORECTOMY
BY
RONALD W. RAVEN, O.B.E., F.R.C.S.
Surgeon to the Westminster Hospital (Gordon Hospital);
Surgeon to the Royal Cancer Hospital
The treatment of advanced cancer remains an important
problem, and any encouragement we gain in an endeavour
to help these patients should be made known so that others
may benefit. The case record is therefore presented of
a patient with advanced cancer of the breast who was
treated solely by bilateral oophorectomy ; the disease dis-
appeared entirely during the six months following the
operation, and she was free from demonstrable disease
22 months later. This patient called attention to the fact
that the various lumps increased in size immediately before
menstruation, and it was this observation which made me
decide to perform the operation. The experience of others
has been sought in the literature and is presented to enable
an assessment to be made of the present position in order
to plan for a further step forward.
Case Report
A married woman, aged 50, with two children, was seen
on April 13, 1948, with multiple lumps.
History.-Two years previously she noticed a swelling of the
right side of the face in the region of the parotid salivary gland
and pre-auricular lymph nodes. In July, 1947, a small pain-
less lump, which increased in size, appeared above the inner
end of the left clavicle. In 1947, she noticed a
large lump in the left breast and a small lump on the outer
aspect of the left arm. Other similar nodules developed in
the skin over the right shoulder, chest wall, and right loin.
These lumps varied in size with the menstrual cycle, being
largest just before menstruation began. Her general health
was good ; there was no loss of weight.
Menstrual History.-Menstruation started at the age of 16;
the cycle varied from 21 to 26 days ; the duration of periop
was 7 to 8 days. During the past two years she has lost clots.
Examination.-Her general condition was good and no
abnormality was detected. A nodular lump 3.4 by 2.2 cm.
was seen in the right parotid region. In the left supracl::lvicular
region a hard irregular swelling 5 by 2.5 cm. was found. There
was no abnormality in the right breast. A hard irregular lump
3.5 cm. in diameter was found in the upper and inner quadrant
of the left breast, attached to overlying skin and somewhat
tethered to underlying structures. Hard fixed lymph nodes
were present in the left axilla. In the right axilla there were
no enlarged lymph nodes. Multiple nodules WFfe seen in the
skin over the right shoulder, left arm, chest wall, and right
loin. The abdomen was normal. Radiological examination
of the chest, dorsal and lumbar spine, and pelvic bones n:vealed
no metastases. A blood count showed : red cells, 4,080,000
per c.mm. ; white cells, 6.400 per c.mm. ; Hb, 78% ; C.I., 0.98 ;
anisocytosis was rather marked ; leucocytes appeared normal
(Figs. lA to 2B illustrate the case.)
Operation.-On July 7, 1948, a bilateral oophorectomy was
performed and the skin nodule from the right shoulder region
was excised.
Pathologist's Report on Specimens.-" (a) Both ovaries:-
There is an enlargement of one ovary by a cyst with water
.,contents (2.5 by 2 cm.) ; the other ovary appears normal.
Microscopy shows that the ovarian cyst has a thin lining of
luteal cells. In the other ovary there is a wide, ill-defined zone
of theca-cell formation; otherwise there is no abnormality.
(b) An elliptical piece of non-ulcerated skin (2.2 by 1 cm.) with
underlying fat (1.2 cm. deep) in which there is a firm white
growth merging into the dermis and projecting on one part of
the cut surface. Microscopy reveals a secondary spheroidal-cell
carcinoma arranged as compact groups, narrow cords, and
isolated cells in the subcutis and deep layers of the dermis."
FIG. 1A.-Tumour in right
pre-auricular region. Before
bilateral oophorectomy.
FIG. 2A.-Skin nodule below
left clavicle. Before bilateral
oophorectomy.
FIG. lB.-Tumour in right
pre-auricular. region has
disappeared after bilateral
oophorectomy.
FIG. 2u.-Skin nodule below
left clavicle has disappeared
after bilateral oophorectomy.
Subsequent Progress.-on August 17 the lumps were smaller ;
and some skin nodules had On October 26 the
swelling in the right parotid region had practically disappeared ;
the lump in the left breast was very soft, 2.5 cm. in diameter.
On January 25, 1949, there was a residual area of slight
thickening at the site of the original tumour in the left breast,
a small lymph node in the left axilla, and an area of thicken-
ing in skin of the left arm. On February 22 all lumps had
disappeared ; the tissues of the left breast were soft and pliable
and resembled a normal breast ; there were no enlarged lymph
nodes in the left axilla ; the face was normal ; and all the skin
nodules had disappeared. On May 23, 1950, the patient was
well, with no sign of carcinoma.
"
Historical Basis
As long ago as 1896 a new treatment was introduced
for advanced cancer of the breast by G. T. Beatson, of
Glasgow. The patient was referred to him by Dr. J. W.
ETIOLOGY OF DENTAL CARIES.
The appearance of the edition of Lippincott's Quick
Rrferrnce !Jook tor Jlcdicine and by Dr. GEORGE E.
REHBERGER, two years aftc"r the fifth edition is ample proof of
the wide popularity of thi s compendium. The presrnt issup has
bee_n brought up to date by substantial changes in about thirty
articles.
9
Lfppincoff' 8 Quick Reference BotJk f or Jledi ciue antl Surge.ry. By
licorge E. Rchhrrger, M.D. Sixth edition, r evised. London: J . B. Lippincott
Coml'any. (:Sup, t oy. Svo ; i llust rat ed. 65s. net.)
PREPARATIONS AND APPLIANCES.
1\IonrFIED HAY's PHARYNGMCOPE.
Du. E. E. BunNIER (Margate) \Hit es : This instrument , which
has been made to my design by 1\Iessrs. l\fayer and Phelps, is
a modification of Hay's pharyngoscope. It is very much
smaller, and consequent ly better borne by a . sensitive patient,
and is especially useful in examining children. The lens,
being placed at the extreme end of the instrument , gives a most
l'xcellent view of the post-nasal space and of the larynx.
The pharyngoscope should be introduced in the mouth with
the light switched on, pressing lightly on the tongue to get
under the arch of the soft palate; the patient should be told
to close his mouth and breathe through the nose so as to bring
the soH palate forward.
E'l'IOLOGY OF DENTAL CARIES.
Mns. :\fELI.Axm:'s TIEPOllT o:-. DENTAL STRUCTUllE
IN Does.
A To:-;srL-Hnr.mNG FoRCEPS.
Dr. A. G. V ARIAN (Wal ford) calls attention to the merits of I
a new tonsil-holding forceps , heie illustrated. He writes : The
of the instrument over ollh' rs I have personally used
are as follows : (1) The sliding, detachable fastener prevents
the teeth fl-om biting through t]H, tissue of the tonsil, since,
by means of it, one can judge the exact amount of pressure -
" IT is well known that some people with n()g) ccted mouths
have teeth free from caries, whereas others who take great
ca re in matkrs of oral hygi ene have extensive caries. In
fact, the most rigid adherenco to the commonly. accepted
rules of dental h:vgiene constitutes no safeguard against
a drntal di sPase." This pnssage, taken from the intro-
duc tion to Diet oncl the 1'ccth: An Study,'
by May Me llanhy, expresses in a nutshell the criticism,
on clinical grounds, of the hitherto generally prevailing;
view that the producti on of dental caries depends
ext:lmi,ely on conditicns external to the teeth. It suggcst s,
moreover, tl:nt, in looking for the etiology of dental disease,
the possi bility must not be neglected that some constitu-
tional factor might be r-esponsible; in short, that in dental
structures there might he a dJensive mechanism, in main-
taining whose integrity the body as a whole may take some
part. A hint as to the direction in which such a dcfeusi\'C
mechani sm is to be sought appeared in Professor Edward
Mellanby' s well-known work on the function in the animal
economy of vitamin D. 'l'his vitamin, Professor 1\fellanby
showed, has a specific controlling effect over the function
of bone formation, as much over the development of the
jaws as over that of other bony parts. Mdlanby,
following up this point, made the further observation that,
not only the formation of the jaws but the
of the teEth directly dependent on the presence at the
right time of vitamin D in the diet.
During the t\\clve years that have elapsed bince this
ohsc>nation wns made, Mrs. 1\fellanby, with financial
support from the .Medical R esparch Council, the panPI
practitioners of Sheffield, and the Dental Board of the
United Kingdom, has continued her investigation of tho
etiology of dental disorders, and in the volume issue d thi s
week by the Modi< a! lkseardt Council (the fir st of a seri<'s
of three)' she gives an account of her experimental studies
on diet and dental structure in dogs. Her main con-
clusiorf is that " the minute structure of the developing
t uot h and the reaction of the developed tooth to caries
are influenced by the chemical nature of dietetic in-
gredients, \Yhich, after being digested and absorbed, arc
carried into the blood stream to tlw tissues of the body,
and thus to the t eeth. They also indicate that the structure
of the periodontal tissues is depe ndent on the chemical
nature of the food during the developmental period, and
that the diet during this early period is also related to
the future onset of periodontal disease."
to obtain a suffi cient hold. (2) It never slips or tears
away; it holds, but does not bit e through. (3) It is solidly
built of stainl ess steel, has strength to stand hard work, and
can be taken apart for cleaning. I have found it highly satis
factory in every way, and can thoroughly recommend it to
those who know the annoyance of most types. lt has been
made fur me, on my instructions, Ly Down Bros. , Ltd.
A SAFETY RADit:M NEEDLE.
Attention was called in the Jou/'nal of .January 4th (p. 29)
to the mechani cal problems of radium therapy, and, in parti
cular, to the danger arising from the liability to detachment
or breakage of rad ium needles and tubes. In this
connexion we have received a letter from the
managing direclot of \Vat son and Rons (Eiectro
Medi cal), Ltd., of Sunic House, Parker Street,
A
1'-ingsway, \V. C. 2, describing a radium needle in
use at the Radium Institute of the Belgian Red
Cross in Brussels.
This needle, as shown in the accompanying illns
!ration, has a flat head with two holes for the
thread. The cells {c) are placed in position and the needle is
closed with a mandrel (B), the length of which varies according
to the numh<' r of cells. The mandrel also has a flat head with
two holes. The thread is passed through the hol es of the
11 eedlc and of the mandrel, thus fixing the two firmly together.
such a needl e is very strong, and the danger of a thread
breaking is minimized by two being used. At the point of the
"';edlc there _is a narrow channel (A) w!lich allows the passage
of a very tlnn mandrt>l for the expul siOn of the radium cells
after use.
1'1tc Earlier Gronp of ExpeTiments.
Having, in the earliet chapters of the report, cleared
the gronnd by describing the normal of develop-
. ment, eruption, and shedding of the teeth in dogs, an<l
given a detailed account of the methods adopted in he r
invest igation, Mrs. :Mcllanby ::.ets out the experimental
evidence for the conclusion that dietetic factors play a
predoininant part in determining the character of tho
teeth and jaws as regards \)oth the ir general development
a nd their microscopic structure. 'J'he first group of experi-
ments concerned the influence on dentition of vitamins
associated with fats, and showed in gen-eral that calcifica-
tion was largely dependent on the presencE> in the di et
of a vitamin of somewhat similar distribution an1l pro-
pertic-3 to vitamin A. The differences in distribution
het11 een this vitamin and the unknown factor favourable
to calcification we re sufficiently marked, however, to suggest
that the two suhstanccs were not identical, a-nd the latter,
eventually differcnti a ted as a separate entity, is now known
as vitamin D, or the calcifying o1 antirachitic vitamin.
'Medical Resea rch Council. Di et ami the Teeth: An Ex.pe'imontnl
Study. Part. I. Dental Strndure in Dogs. By May Mellanby. II. M.
Stationery Offi ce. 1929. 17s. 6tl. net.
FEB. rs, rg3o]
ETIOLOGY OF DENTAL CARIES.
"'hen this inYestigation was started the distinction bdwren
Yitamins A and D had not vet bec>n c>stablisl](>d, and Mrs.
:1\-Iellanln pre,entina IH'r a'crount in historieal srqnence,
does not identify th: calcification-promoting s11hstance with
,-itamin D till chapter x, in the tarliPr chapters refernng
to it as the " calcifying vitamin " or a " fat-soluble
Yita1nin."
Such a method of presntation has undoubted advantages;
the reader watches the facts as they aC'ClllllHlate, and at
the appropriate moment s-ees the conclusions in the process
of formation. On the other hand, perhap' some greater
clarity might lltwe been gained if, in the course o_f the
nanative, earlier experiments had hetn mter-
preted in the light of more recent discoveries.
Influence of Fitamin D.
The development of perfect teeth, it was found, could
be ensured by giving an adequate supply of >itamin D,
either as it appears in natural foods-fo: example, egg-
yolk, milk, suet, and eod-li>er oil-or as it may be artifi-
cially produced, by irradiating the ergosterol content of
food, or by irradiating the animals' skins. In the presconce
of this vitamin it was diffieult to choose a diet so low in
its <'nlcium and phosphorus conteni, or otherwise so un-
favourable to calcification, as to interfere materially with
the normal development of the dental tissus. On tlHJ
other hand, it was easy to choose a diet defieient in
vitamin D, for the foods containing this substance are
few in number and, in general, expensive. It would s-eem
to follow--if the factors controlling the dentition of the
dog and the human subject are the same-that the ordinary
diet of the pomer classes in this country, which consists
in the main of bread, oatmeal, barley, sugar, fruits, jam,
vegetables, lean meat, and white fish-all of them vitamin D
defic-iPnt mbstances-will tend to produce imperfect tEeth.
Other Food Constituents.
Prohins, carbohydrates, most vegetable fat5, and foods
suc-h ns cereals, oranges, and egg-white, gave no videncc
of caleifying power. Bacon fat appeared to have but little
effect, and hydrogenated animal fats none at all. An in-
crease in the cereal intake had a effect on
calcification, apart altogether from its effect on the rate
of growth. Of the cereals tested, oatmeal had the greatest
deraleifying power, and white flour the least; iNtermediate
between t!H:'sc were maize (next to oatmeal), then barley,
rye, wholemeal flour, and ri('e. Wheat and maiz<' germs
also had an unfavourable effcd on calcification. In evPrv
ease, howeYcr, the influence of cereals could he entirely
oYercome by including in the diet a sufficiency of vitamin D.
It was not found possible to ascribe the anti-calcifying
eff,ect of cPreals to any one known constituent, such as
(a) the absolute or rclativ,e amounts of calcium and phos-
phorus, or (b) the carbohydrate, fat, or protein, or (c) the
ratio of the mineral substances. The eYidence
suggested that cereals contain an anti-calcifying faetor
(" toxamin ") of unknown composition, which actively inter-
feres with the normal development of the teeth. This
unknown substance is dstroyed by boiling with dilute
hydrochloric acid, and, to a. less extent, by boiling with
alkalis_; it may also be destroyed or antagonized in the
process of malting. When_present in the grain it is stable
to fairly high temperatures, and it resists digestion with
diastase and, partially, with trypsin ..
Calcium and Phosphor11s.
For the production of p-erfect teeth the diet must natur-
ally contain some ealcium and phosphorus, though only
small quantities of these are required if the diet is rich
in vitamin D. If the vitamin D intake is >ery low extra
calcium may have some beneficial effect, but in the com-
plete absence of vitamin D perfect calcification will not
occur, lwwcver much calcium and phosphorus is given in
the diet.
liiaternal Feeding.
Proprr maternal feeding on the lines indicated is of
great importance in the production of good teeth in the
developing Poorly calcified deciduous teeth were
produc<'d in the offspring feeding the mothPr on a
dtct d0ficicnt in Yitamin D. The 'o prodtH<d wen,
ho\\"EVN, le.<s marked than those found i" tl"' pcnnan<'nt
tedh when the puppy itself was fcd on tl><' same diet.
It seems probable that, under 0ertaia <onditions, store<!
vitamins may he drawn npon, the maternal organi;,m
saerificing to th<' cmbrvo the factor;; essential for its normal
development and even though she ]Jerself
Sllffers through doing so. The C'haracter of the defec-ts
in the deciduous teeth depends on the amonut
of ,itamin stored in the tis:;ues before
anc! tlH' amount present in her diet during ancl
lactation. The maternal feeding "as found to affect also
the future structure of the permanent teeth, for when the
moth2r':; diet contained abundant vitamin D, and the
offspring, after \\'eani11g, \\ne fed on a diet dPficient in
this substance, the permmwnt tceth, though defPctive in
structure, were not nearly so dcfecti>e as those of puppies
"hose motlwrs' diet had also been deficiPnt in this vitamin.
In a c!cfici<'ncy in the mother's diet during
may influence the offspring throughqnt its !if<'. F'urthcr
evidenee of vitamin storagP was afforded by the facE that
when the diet of a pnppy was chang<'d from one rich in
vitamin D to one deficient in this substance, ckcalcification
did not occur at once, and ddecti,e formation of the d('ntal
strudnres appeared after a eomparati,ely long intenal.
Effect of Irradiation.
Though Yitamin D has such a limited distribution it
can be produced by ultra-Yiolet irradiation of foods con-
taining the ergosterol. Thus, olive oil and
p<>anut oil, though ordinarily without effect on the t>.eth,
became powerful calcifying agents after irradiation. The
aetivity of milk and butter was greatly enhanced by irradia-
tion, and substances which interfered with calci-
fication--for example, oatm('al and ftour'---by this UH:'ans
were made to assist the process. The application of ultra-
violet radiations tQ. the skin was not nearly so ffective
in p1omoting calcification as a. diet rieh in vitamin n.
Exposure of dogs to sunlight, though beneficial to calcifica-
tion of the teeth in eertain condition;;, proved in somo
of the cases ta: he practically ineffective when the did nas
markedly anticalcifying.
'
ROYAL MEDICAL BENEVOLENT FUXD.
AT the last meetin!l's of the conimittee of the Roval Medical
Benevolent Fund tl1e following sums were voted Decembei
1,342, January, 1,037-making a of 2,379; no ff'wer
than 113 necessitous 1nedical men, their widows, or families
being helped thereby.
During the winter months the number of applicants is inevit-
ably large; for somP. the occasion is illness or the lack of
ordinary comforts, but for most it is the death of a husband
or father who has bf'en unable to make provision for wife Dr
family. The committee urgently appeals for subscriptions,
donations, and legacies. Cheques should be forwarded to the
Honorary Treasurer, R.oyal Medical Benevolent Fund, 11,
Chandos Street, Cavendish Square, London, W.l.
The following are particulars of five cases recently helped.
""idow, aged 50, of L.R.C.P. and S., whose husband died snddenlv in
September, 1029, at the age of 51, from heart failure. The widow who
is in very delicate hea.Hh, was left an income of 50 per annum' with
children dependent on her. Voted grant of 36 and a special gift of 14.
M.D., aged 60, marriccj, .S}tfie!ing .frpm .tubercu,Josi.s and in
has hf'cn and -W!J_eri proceeds-' are. lflYestcd W1If giye an
income of 135. Applicant has one son and two daughters the two
eldest have secured posts. Voted 40. '
Widow, aged 60, of M.R.C.S., L:it..P. Her husbnnd suffered ill hea!ih
all his life, and was never able to work- sufficiently to save any moriey.
At his death in November the widow and one daughter were left wltii "
capital of 200. The daughter fortunately has been trained and will
obtain employment. Yotcd 26 and special gift of 10.
Two daughters, aged 61 and 58, of L.F.P.S., whose only income ls TT
each, gifts from friends, and deposit interest on the sum of 57. Yoted
J!36 each.
Daughter, aged 70, of M.R.C.S. Has been in bed during the whole of
the' last twelve months. Income from charities 30, old age pension 26.
Voted 30.
The Royal Medical Benevolent Fund Guild still receives
many applications for clothing, especially for coats and skirts
f<Jr ladies and giils holding secretarial p<:>sts, and suits for
working boys. 'l'be Guild appeals for second-hand clothes and
hou.sehold . articles. The gifts should be sE'nt to the Secretary
of the Gmld, 58, Great Marlborough Street, W.l.
BRITISH MEDICAL JOURNAL
LONDON SATURDAY AUGUST 28 1948
THE REDUCTION IN DENTAL CARIES IN 5YEAROLD
LONDON SCHOOL-CHILDREN (192947)
BY
MAY MELLANBY
AND
HELEN MELLANBY, Ph.D., M.B., Ch.B.
(Nutrition Building, National Institute for Medical Research, Mill Hill, London}
The present paper is a continuation of a series describing
the dental condition of 5-year-old London County Council
school-children in 1929, 1943, and 1945 (Mellanby and
Coumoulos, 1944, 1946). Between July and the end of
October, 1947, 1,590 such children were examined with
the object of finding whether the improvement observed in
1943 and 1945 had been maintained. The children lived
in the same areas of London, and in the majority of cases
attended the same schools as those used for the earlier
surveys. A few of the schools previously visited were no
longer available ; substitutes in the same localities were
then provided by the London County Council. As before,
only children who had attained their fifth birthday but had
not yet reached their sixth were selected, the average age
being the same as in the other surveys. Although the
presence of any permanent teeth erupting or erupted
was recorded, this report refers only to the deciduous
dentition.,
In this 1947 survey the methods and standards adopted
were similar to those used previously, full details of which
can be found in the earlier papers.
Methods
Structure.-The structure of the individual teeth of each
child was assessed according to the method devised and
first used by M. Mellanby as early as 1923 and since then
also employed on numerous occasions by others, including
King, Coumoulos, Deverall, H. Mellanby, and Davies.
In essence the method consists in rubbing the labial surface
enamel of each tooth with a fine probe of standard size and
sharpness (S.S. White Stainless No. 37}. After some practice
it is possible to grade teeth in the mouth by the smoothness or
roughness felt with the probe. It was shown many years ago
that .this external enamel texture could be correlated with good
and poor microscopic structure (M. Mellanby, 1934). On
sectioning, smooth teeth showed what were judged to be well-
. calcified enamel and dentine, whereas external roughness was
usually associated with a less well-calcified minute structure,
in particular with dentine containing interglobular spaces. The
various macroscopic grades of surface roughness or defect are
referred to as M-Hypoplasia (M-Hy) to distinguish them from
gross or "textbook" hypoplasia (G-Hy), which is the only
type whose existence is commonly recognized by dentists. Gross
hypoplasia, the aetiology of which is not fully understood, is
uncommon in deciduous teeth in this country ; it is readily
to the naked eye, the teeth so classed having obvious
enamel pits or, in some instances, areas from which the enamel
is lacking.
In surveys of this kind there are always some teeth whose
structure it is difficult or even impossible to grade. This situ-
ation may arise, for instance, when a tooth has some structural
defect which does not correspond to any of the grades described
below. These teeth are included in Tables under the heading
" Hy unclassified." A small proportion of teeth were so carious
and others had such heavy deposits of tartar over certain areas
that no opinion could be formed about their original surface
structure. Where for either reason it was impossible to make
a satisfactory estimate of the average structure the teeth are
recorded as being present in the mouth but are not included
in the structure tables.
By the probe method described, each tooth whose struc-
ture could be assessed was graded according to the following
symbols:
Hy0 : No hypoplasia; smooth shiny surface-good structure.
M-Hy,: Slightly rough surface-slightly defective tooth.
M-Hy,: Rougher 'surface-definitely defective.
M-Hy,: Vecy rough-vecy defective.
G-Hy: All varieties of gross or " textbook '' hypoplasia.
Caries.-Bach tooth was examined for caries with a
standard probe (S.S. White Stainless No. 12) and illumin-
ated mirror.
Any decay that could be diagnosed by this method was
graded as 1, 2, or 3. Grade 1 included very early and
suspected fissure and approximal caries and cavities up to the
size of a pin-hole ; grade 2 included all cavities from pin-hole
size up to one-quarter of the crown ; and grade 3 contained
thc,>SC teeth with more than one-quarter of the crown decayed,
those of which only the roots were left, and all
missing canines and molars, which were assumed to have been
extracted on account of caries. Obvious undermining decay
was taken into account in judging the size of a cavity. Any
incisors not present were counted as naturally shed.
A child's dentition was regarded as caries-free only when
no caries, active or arrested, was recorded on the chart.
A mouth containing one, two, or three teeth which were
included in grade 1 caries, but none in the other grades,
was described as being "almost caries-free." This system
of classification was adopted in order to obtain figures
which could be compared with those obtained in the 1929
survey, when so few children were completely caries-free,
according to the above standards, that the two groups
''caries-free" and "almost caries-free" were combined;
even so the total was then only 4. 7%.
Other structure and caries, a
number of other conditions were noted for each mouth.
These included . the arrest of the carious process, treat-
ment of caries, mottling of enamel, the state of the mouth,
spacing of the teeth, obvious tartar, gingivitis, occlusion,
attrition; and the' presence or absence of stain, but not all
these conditions are considered in this report.
4573
410 Auo. 28, 1948 DENTAL CARIES IN LONDON SCHOOL-CHILDREN
BluTISH
MEDICAL JOURNAL
General Resnlfs
Before the detailed analysis of the data obtained in the
latest survey is considered in relation to that of the earlier
investigations a brief general comparison may be made.
TABLE I.-Percentages of Caries-free Children
I Total No. of
%
%
Total
Year
I Children
Almost
Examined
Caries-free
Caries-free
%
1929 .. .. .. 1,293
- -
47
1943 .. .. . . 1,870 149 93 242
1945 .. .. . . 691 242
I
39 281
1947 .. .. .. 1,&90 181 94 37&
Percentages of caries-free and almost caries-free children not separately
estimated in 1929.
The number of children whose dentitions were of. good
structure showed obvious improvement from survey to
0
/o
40
30
Zil
survey, and the upward trend
observed in 1943 and 1945 in
the proportion of children
who, according to the probe
and mirror method, could be
described as caries-free or
nearly so continued in 1947
(see Table I and Graph). It
was found that, whereas only
4.7% of the children examined
in 1929 could be so classed,
the figure had risen iln 1943 to
00''------
24.2%, in 1945 to 28.1 %, and
;;. ;;. -;;_ in 1947 to 37.5%. . ....
er-
Showing increase in percentage
of caries-free and almost caries-
free children, 1929 to 194 7.
The percentage of teeth
present in the children's
mouths at the time of the
1947 survey differed only
slightly from the percentages found at the earlier inspec-
tions. The respective figures for 1943, 1945, and 1947 were
92.2, 94.4, and 93.9%.
Detailed Results, 1943--7*
Structure.-Table 11, which compares the results of the
three surveys, shows the percentages of teeth included in
the different grades of structure and also gives a computa-
tion of the extent of defective structure expressed as the
average hypoplasia figure (AHF). The AHF is arrived at
by allotting a number to each grade of M-hypoplasia (l for
M-Hy,, 2 for M-Hy,, and 3 for M-Hy.) and dividing the
The detailed 1929 results do not appear in these tables, as they
were not published and the charts were lost early in the war.
total hypoplasia figure so obtained for any group of teeth
by the total number of teeth in the group, excluding those
showing gross hypoplasia. Thus the greater the number of
teeth classed as of good structure (Hy,) or included in the
less severe grades of M-hypoplasia, the lower the AHF.
As is seen from the average hypoplasia figures (AHF),
there was an improvement in structure in each type of
tooth from 1943 to 1945 and from 1945 to 1947. The
actual reduction in the AHF in the latest survey as com-
pared with the previous one was greatest in the upper
centrals and lower first and second molars, but the per-
centage reduction was substantial in all the lower teeth,
as in the upper centrals. The least change in percentage
reduction of the AHF in 1947 as compared with 1945
occurred in the upper molars, but these teeth are often
covered by a thin film of tartar, and it appears to us possible
that their hypoplasia figures may be less reliable than those
for other types of teeth.
Turning to the proportion of teeth showing the various
gnides of structure, it is seen that 47.1% were of good
structure (Hy,) in 1947, as compared with 38.0% in 1945
and 30.7% in 1943. The progressive improvement from
survey to survey was distributed among all types of teeth
except the upper molars, which showed little change in
structure in all three surveys. A possible reason for this will
be considered in a future paper. In 1947 both the first and
second lower molars were much better than in 1945. This
was particularly evident in the case of the second molars,
whose improvement in this. period was approximately
179% (i.e., from 7.5 to 20.9%). As in the previous surveys,
the upper teeth of all types were on the average of poorer
structure than their counterparts in the lower jaw. The
incidence of gross hypoplasia was lower in 1947 than
formerly, whether the teeth were considered en masse or
in individual types.
Caries.-As has been already stated, the amount of caries
in the 5-year-old L.C.C. school-children underwent a con-
siderable reduction in 1941 as compared with 1945 and 1943.
Table Ill shows the incidence and extent of caries in each
type of tooth and in all types together for the three surveys.
Like the structure of the teeth, their condition as regards
caries is expressed in two ways-first, as percentages of teeth
included in the various grades, and, as the average
caries figure (ACF). For the latter the same principle is
adopted as for the AHF. The number 1, 2, or 3 is allotted
to each carious tooth according to the severity of the
disease, and the total caries figure is divided by the number
of teeth in the group concerned. The smaller the ACF
the less the degree of caries in the group as a whole. The
table indicates that there was improvement at each succes-
sive inspection in all types except the lower central incisors,
TABLE H.-comparison of Tooth Structure in 1943, 1945, and 1947
Total No. of
Good:
Very Defective I Gross Hy l Hy Unclassified I
Teeth Examined M-Hy, M-Hy, AHP
Type of Tooth for Structure
Hy. M-Hy,
1943 194S 1947 1943 1945 1147 1943 1945 1947 1943 194S 1947 1943 1945 1947jt943 1945 1947! 1943 1945 1947 ft943 1945 1947
Upper Jaw: % % %
94 ib 08
% % %
Central incisors 3,324 1,262 2,931 182 :zs-o 412 33-9 362 388 343 261 134 39 66 30 02 02 003 137 114 088
Lateral incisors 3,465 1,341 3,023
272 38-6
469 394 428 190 '143 80 41 22 02 25 54 27 03 01 05 100 0 79 081
Canines .. 3,707 1,369 3,119 325 408 4&1 508 457 48& 132 101 42 15 11 02 10 11 07 10 12 1-1 083 071
059.
1st molars .. 3,268 1,282 2,989 82 87 81 321 392 &&8 499 429 33& 70 64 14 28 28 04 00 00 003 157 1-48 128
2nd molars .. 3,427 1,342 2,110 6-o 52 12 292 39S 488 S40 4s-7 43-2 94 86 29 13 10 01 01 00 00 168 158 144
Lower Jaw:
M3 242 140 &3 32 04 02 06 00 01 02 05 02 003 00 00 Central incisors 3,091 1,097 2,53& 717 8s-t 033 015 008
Lateral incisors 3,624 t,348 3,oar 61S 19S 811 337 192 911 42 08 04 04 00 01 01 03 02 01 01 003 043 021 010
Canines .. 3,702 1,370 3,109 519 697 791 369 235 171 S9 23 08 05 01 01 14 07 03 34 38 27 053 030 019
lst molars .. 3,119 1,23S 2,700 184 223 341 38S 39-6 &29 I 36S 32S 113 40 3-1 011 25 26 03 01 00 01 127 1-17 077
2nd molars .. 3,104 1,241 2,7&& 1S 75 341 375 &89 486 4S4 110 63 81 09 34 15 03 01 00 00 156 15S 102
Totals .. 133,83112,887 29,011 307 380 47-1 l63 336 374 1 263 220 1311 42 35 07
I
19 23 08
I
06 06 0051 104 091 087
I
*AHF (average hypoplaaia &gure) - Total hypoplasia figure
Toa.al. No. of teeth examined for structure (excluding those with gross or unclassified hypoplasia)
AUG. 28, 1 Sl48
DENTAL CARIES IN LONDON SCHOOL-CHILDREN
BRITISH 411
MEDICAL JOURNAL
TABLE rn.--comparison of Caries Incidence and Extent in 1943, 1945, and 1947

I
!
I
I
I
I
I
Total No. of
I
Total Carious
Teeth
C, c, c, c.
Teeth
ACF*
Type of Tooth
I
1943 1945 1947 I t943 t945 1947 1 1943 1945 1947 1 1943 1945 1147 1943 1945 1947 1 1943 1945 1947 i 1943 1945 1947
Upper Jaw:
I
%
7781
% % % %
I
%
Central incisors .. 3,392 1,280 2,974 624 705 98 50 56 162 172 138 116 73 29 376 295
2221
077 061 042
Lateral incisors .. 3,590 1,358 3,095 797 851
89-4 I
68 32 33 92 86 61 43 31 22 203 149 108 038 030 020
Canines .. .. 3,740 1,381 3,180 905 925 931 29 17 19 46 42 42 20 16 09 95 75
89 I
018 015 013
1st molars .. .. 3,740 1;382 3,180 580 611 894 87 83 85 133 174 143 200 132 89 420 389 308 095 083 085
2nd molars .. .. 3,740 1,382 3,180 435 486 858 172 177 140 I 181 236 117 21-1 101 87 565 514 344 1 117 095 084
Lower Jaw:
Central incisors .. 3,112 1,098 2,576 951 983 983 27 09 07 15 08 06 07 00 03 49 17 17 008 003 003
Lateral incisors .. 3,662 1,354 3,114 963 979 983 20 06 05 13 13 09 04 02 02 37 21 17 006 004 003
Canines .. .. 3,740 1,382 3,180 931 941 959 24 07 14 33 43 23 12 09 04 69 59 41 013 012 007
1st molars .. .. 3,740 1,382 3,180 460 514 587 79 7-2 5-7 170 211 188 291 203 188 540 486 433 129 110 100
2nd molars .. .. 3,740 1,382 3,180 390 412 670 129 151 112 150 195 119 331 241 188 610 588 430 142 127 096
Totals ..
'
36,196 13,381 30,839
!
699 73-5 797 74 62 62 101 120 85 126 83 86 301 265
2031
065 055 042
.. '
-----
*ACF (average caries figure)= Total
Total No. of teeth (including extractions)
T\BLE IV.-Percentage Incidence of Caries in Teeth with Varying Grades of,Structure
Grade of Structure
1
1
____________

_______________________ c_a_ni,n_es _______________________ M __ __________ _

Total No. Total No. Total No. I % C
Examined % Carious Examined % Carious Examined o anous
__ t943 t945 1147
Hy, ..
M-Hy,
M-Hy,
M-Hy,
Gross Hy
5,992 2,837 7,921 11 12 24 3,126 1,514 3,886 15 H 18 1,281 550 1,927 83 70 119
4,724 1,399 2,789 120 112 187 3,248 947 2,050 79 80 82 4,310 1,987 8,033 245 250 307
2,053 536 649 449 392 368 707 169 152 267 296 151 6,133 2,127 3,124 626 665 434
487 105 33 804 810 615 75 16 10 61-1 689 . 867 335 164 871 923 604
226 165 178 642 624 380 90 24 32 233 208 344 319 101 32 589 525 344
NoTE.-This table does not include the few teeth shown under the heading " Hy Unclassified "in Table U.
where both incidence and extent of caries remained the
same in 1947 and 1945. Here so few teeth were carious
even in 1943 that little improvement could be expected.
. The proportion of caries-free teeth of all types increased
from 69.9% in 1943 to 73.5% in 1945 and 79.7% in 1947.
In the latest survey the most striking increase in this respect
was in the upper and lower second molars, where there
was most scope for improvement. It is of interest to note
that although in 1947 over 70% of the children examined
had at least some caries, yet the disease occurred in only
about 20% of the teeth, including fillings and extractions.
The proportion of carious teeth had diminished by approxi-
mately 33% since 1943.
Relation between Structure and Caries.--All previous
surveys using M-hypoplasia standards for structure showed
that the better-formed teeth were less liable to decay. This
was also true of the 1947 survey, as can be seen by reference
to Table IV. For example, the incisors with no hypoplasia
had a caries incidence of 2.4%, whereas those with grades
M-Hy, and M-Hy, had a caries incidence of 16.7 and
36.8 %, respectively. Of the very few incisors in the M-Hy3
grade 51.5% were carious. The corresponding figures for
TABLE V.--Teeth showing Arrest ("Spontaneous Healing") of the
Carious Process
No. of Carious Teeth
Present
,
1
' % Carious Teeth Present
Showing Arrest
--1--1
1943 9,182
1945 3,203
1947 6,270
117
215
14-2
TABLE VI.--Carious Teeth Extracted, Treated by Silver Nitrate, or
Filled
Total No. Treatment Total
of Carious
% I%Silverl
Percentage
Teeth (Including
%
of Carious
Extractions) Extracted Nitrate Filled Teeth Treated
1943 .. 10,886 157
I
67
I
27 250
1945 .. 3,545 96 28 24 148
1147 .. 6,245 156 24 44 224
I
molars with no hypoplasia and with M-HY, and M-Hy2
were 11.9%, 30.7%, and 43.4%. As in the case of the
incisors, there were relatively few molars in the M-Hy3
grade, but 60.4% of them were carious .
Other Conditions.--There was less arrest or "spontaneous
healing" of decay in individual teeth in 1947 than in 1945,
though more than in 1943 (see Table V). The reason for
this is not clear. The amount of treatment of carious
teeth (see Table VI), which was lower in 1945 than in
1943, had risen in 1947 nearly to the 1943 level, and the
percentage of extractions was almost identical in these two
surveys.
Reference has previously been made (Pickerill, 1923;
Ayers, 1939; Pincus, 1941 ; Pederson, 1946; Mellanby
and Coumoulos, 1946) to the superficial stains commonly
seen on children's deciduous teeth, and to the fact that
mouths in which black ;md dark-brown stains occur appear
to be associated with a lower incidence of caries, and green
stains with a higher incidence. In the 1947 survey this
was again the case (see Table VII).
Discussion
An account has been given of a further survey, made in
1947, of the dental condition of 5-year-old children attend-
ing London County Council schools. Comparison has been
made between the results of this work and those obtained
in the examination of children of the same age group
attending the same or neighbouring schools in 1929, 1943,
and 1945. The main findings as regards the incidence of
TABLE VII.-Percentage Incidence of Carious Teeth in Children with
and without Superficial Staining of Teeth
Percentage of
ACF
Carious Teeth
1943 1945 1147 1943 1945 1147
Children having :
301 23-1 19-8 066 048 041 (a) No stain .. ..
(b) Black and dark-brown stains 193 154 124 041 030 02&
(c) Green stain .. .. 334 330 280 072 069 064
412 AuG. 28, 1948 DENTAL CARIES IN LONDON SCHOOL-CHILDREN
BRITISH
!\IEDICAL JOURNAL
------------------
caries per child, observed over this period of 18 years, are
set out in Table I and the Graph. It will be seen that the
improvement has been great, especially between 1945 and
1947. In the first period of 14 years the average increase
in the percentage of caries-free or nearly caries-free
children was at the rate of 1.4% per year; in the second
period of approximately two years it was 1.95% ; and in
the third period, also of about two years, it was 4.7 %.
Tables Il and Ill indicate that the structure of the teeth
also has greatly improved from 1943 to 1947 and that the
incidence and extent of caries per tooth have been substan-
tially reduced.
These surveys were preceded by experimental investiga-
tions on animals, begun in 1917, and by controlled studies
on children which were the natural outcome of the animal
work. The earlier experiments were devoted to a study
of the food factors which affected the structure of the
teeth, and ultimately it became possible to state the chief
dietetic conditions favouring good and poor structure. For
the former it was essential that the diet during the period
of tooth. development should be rich in available calcium
and phosphorus and in vitamins D and A. Indeed, it was
this work, in association with the researches of E. Mellanby
on the subject of rickets, which first helped !o prove the
existence of a calcifying vitamin (vitamin D). The factors
resulting in defective structure were mainly associated with
both the quantity and the type of cereals consumed when
vitamin D and calcium were deficient in the diet.
The clinical investigations on children showed the impor-
tance of the animal experiments in demonstrating the
factors controlling dental structure ; for these human
studies pointed to the conclusion that, other things being
equal, well-calcified teeth, according to the criteria used,
were less liable to caries than badly calcified teeth.
Another fact of importance made clear by the animal
experiments was that those diets which produced teeth of
good and poor structure, respectively, also increased or
decreased the resistance of teeth to a stimulus such as
attrition, quite apart from their original structure. Thus
teeth of either good or poor structure, when worn by
friction, produced well-formed secondary dentine when
the diet was of a highly calcifying nature, but produced
badly calcified secondary dentine or none when the diet
was deficient in calcifying properties.
Examination of children's teeth which had been subject
to attrition indicated ,the same kind of reaction to this
stimulus. A matter of greater importance, however, as
was shown by investigations in Sheffield and Birmingham,
was that a diet of high calcifying properties given after
eruption of the teeth, whatever their structure, could prevent
or retard the onset of caries, or, if the disease had already
developed, bring about the deposition of well-calcified
secondary dentine and ultimately the arrest of the carious
process (Mellanby, 1934).
This effect of the post-eruptive diet in altering the resis-
tance of teeth to caries, as opposed to the control of their
development and structure by the diet before eruption, was
substantiated by surveys made in 1945 on three groups of
5-year-old children, one group attending private schools,
another attending London County Council schools, and the
third comprising mainly destitute or illegitimate children
living from an early age in public institutions and in most
cases attending the institutional schools (Coumoulos and
Mellanby, 1947). As a group, the institutional children
had worse-formed teeth than the L.C.C. or private-school
children, but nevertheless had relatively less caries. On
the basis of experimental and clinical evidence and
of the conditions under which the children were reared it
seemed fair to postulate that the pre-eruptive diets of the
private school children were better in calcifying properties
than those of the children who became the responsibility
of the institutions, and thus their teeth were of better struc-
ture ; but on the other hand it appeared that the post-
eruptive diets of the institutional children, who received
regularly a diet rich in calcifying properties which included
cod-liver oil, were on the average better in this respect than
those of the private'-school group, so. that, in spite of the
poorer structure, the teeth became more resistant to invasion
and allowed less caries to develop.
Thus all these studies emphasize the importance of feed-
ing children, first via the mother and later independently,
on diets which will result in better calcification and greater
resistance of the teeth.
It might be asked, then, whether there is evidence that
the rapid improvement in the dental condition of the
London County Council school-children, as regards both
structure and freedom from caries, between the years 1943
and 1947, and especially between 1945 and 1947, as com-
pared with the period 1929 to 1943, is due to causes
indicated by the earlier experimental and clinical investiga-
tions. Certainly on the basis of that work such improve-
ment would be expected to result from the series of changes
in the dietary of this country during the war years. It was
well known to those familiar with the subject that one of
the main defects of the pre-war British dietary was its poor
calcifying qualities.
Early in the hostilities, when restrictions in both quantity
and quality of food necessitated the best possible use of
available supplies, one of the first steps taken by the
Government, on the advice of nutritional scientists, was to
direct foods with high calcifying properties to those classes
needing them most-namely, expectant and nursing mothers
and infants. For example, from July, 1940, all expectant
mothers could claim a milk priority of 1 pint (568 ml.) a
day. After the chilq was born two pints (1.14 litres) a
day were allotted between mother and child for the first
year, so that if the mother fed the baby herself then the
two pints were available for her own consumption. From
the age of 1 to 5 years the child's own allocation was 1 pint
a day. This was reduced to half a pint (284 ml.) for home
consumption when school age was reached, but could be
supplemented by 1/3 or 2/3 pint (190 or 380 ml.) daily
at school. In December, 1941, oil was made avail-
able at a reduced rate through welfare centres, clinics, and
food offices to children aged 6 months to 2 years, and in
February, 1942, provision was extended to all children up
to the age of 5 years. Expectant mothers were eligible for
the oil from these official sources from December, 1942 ;
and in April, 1943, vitamin A and D tablets were instituted
as an alternative. At this time the vitamin D content
of the Ministry of Health's cod-liver oil compound was
raised from lOO to 200 international units per gramme,
and has remained at this level. More eggs have also been
available to mothers and young children than to non-
priority classes.
Besides these special allocations there have also been,
during and since the war years, a series of nutritional
changes which have affected the whole population of the
country, including, of course, the mothers and growing
children. In this case also the calcifying as well as certain
other qualities of the diet have been improved. For
instance, 1940 all margarine has had to contain vita-
mins D and A. In July, 1940, the vitamin D content was
at the rate of 30 international units per ounce (approx.
l i.u. per gramme); in November, 1941, it was raised to
60 i.u. (2 i.u. per gramme) and in January, 1945, to 90 i.u.
per ounce (3 i.u. per gramme) ; the vitamin A content has
been from 450-550 i.u. per ounce (16-20 i.u. per gramme)
throughout this period. With a weekly ration of 3 to 4
oz. (85-113 g.) of margarine for the average person,
Aua. 28, 1948 DENTAL CARIES IN LONDON SCHOOL-CHILDREN

413
it has been possible for each to receive between 12 and
50 i.u. of vitamin D and 200 to 300 i.u. of vitamin A per
day from this source alone. Again, from 1942 onwards
calcium has been added to all flour ; at first the rate was
7 oz. (200 g.) of calcium carbonate per sack of 280 lb.
(127 kg.); later in 1946 the amount was doubled. This addi-
tion of calcium was necessary because the raising of the ex-
traction rate of the flour from the pre-war level of 70-73%
to the wartime level of 85%, or even higher, greatly
increased the phytate content of the flour, and phytate is
known to decrease the availability of calcium in the food.
This additional calcium was also an important adjunct to
the dietary of people because of the limited
amounts of milk, eggs, and cheese available. The larger
amount of added calcium was sufficient to neutralize the
harmful anticalcifying properties of the phytate, and any
excess was available to help in promoting or maintaining
the calcification of bones and teeth anti for other physio-
logical functions which required optimal calcium supplies.
Prior to the war many mothers had neither the desire
nor the means to procure for themselves or their children
adequate supplies of such foods as milk, eggs, and cod-liver
oil. Recently, however, there has been an increasing
awareness, on the part of both the medical and the lay
population, of the nutritional benefits conferred by these
foods ; and, generally speaking, money has not been a limit-
ing factor, since Government subsidies have brought them
within the reach of most families. If, however, people
cannot afford to buy milk even at the subsidized rate, it
may be obtained free of charge for expectant mothers and
children under 5 years of age ; and cod-liver oil, which was
previously supplied at reduced rates, can to-day be had
without cost under the welfare service.
It appears, then, from the foregoing account of recent
diet changes, that an important reason for the more rapid
improvement in, the dental condition of children between
1945 and 1947 as compared with the preceding years is
clear-cut. For the first time in the course of these surveys all
the expectant and nursing mothers and all the children up to
the age of 5 years have been in a position to obtain in-
creased quantities of calcium and vitamin D via estab-
lished milk, cod-liver oil, and egg priorities, and they have
benefited further by other Government outlined
above ; so that throughout the whole antenatal and post-
natal life of the latest group of children examined, who
were born between November, 1941, and October, 1942, the
diet available has been of consistently better calcifying quali-
ties than that of the subjects of the earlier surveys. The
pre-eruptive diet has produced better-calcified teeth than
were formerly observed, and the post-eruptive diet has
tended still further to increase the already higher resistance
of these teeth to caries.
It must not be forgotten, however, that even to-day the
majority of children in the young age group studied have
some carious teeth, and it seems most likely, on the basis
of the present hypothesis, that this is due, in part at least,
to the fact that many mothers do not avail themselves of
all the special foods at their di,sposal. In order, therefore,
to get some idea of what proportion of the mothers
whose children were examined in 1947 actually took up
their special allowances, a point was made of asking any
who were present at the examination some simple questions
on the subject. The numbers involved are too small to
be of significance, but they give an indication of the general
trend.
Of the 224 women questioned, 68% stated .that they drank
their priority milk, and 65% of the children were said to have
consumed a pint of milk a day during the pre-school period.
In answer to the question, " At what age did you begin to give
this child cod-liver oil ? " 30% of the mothers said that it was
given from the age of 8 weeks or less, but the amount and the
length of time for which it was given varied. It was estimated
that about 14% of the children had not had any oil
or alternative vitamin concentrate at any time, while the
remaining 56% had had one or other of these supplements for
some period during the first five years of life.
Theie figures suggest that there is still need for greatly
increasing the numbers of women .and children making use
of the food priorities mentioned. This, of does not
mean that the problem of caries would thus be solved.
Indeed, it probably cannot be solved while the actual factors
directly initiating the condition remain obscure, but when
these are brought to light it may be possible to control
the disease more directly and efficiently. Meanwhile the
evidence grows stronger from year to year that the best
way at present available to make a primary attack on this
great health evil is to feed pregnant and nursing women,
infants, and children along the lines which a,re known to
produce well-constructed teeth and jaws and to increase
resistance to decay-in other words, to ensure that both
pre-eruptive and post-eruptive diets are relatively rich and
balanced in available calcium and phosphorus and in
vitamin D.
Summary
The dental condition of 5-year-old children attending London
County Council schools in 1947 has been described and com-
pared with that of similar groups examined in 1929, 1943,
and 1945.
The progressive improvement found in the two previous
surveys has also been observed in 1947. The rate of increase
in the percentage of caries-free or almost caries-free children
between 1945 and 1947 has been more rapid than between 1943
and 1945, and certainly much more rapid than between 1929
and 1943. The same trend has occurred between 1943 and
1947 in the structure of the individual teeth and the incidence
and extent of caries, the improvement being greater in the
second two years than in the first two.
As in the 1943 and 1945 surveys, it is again suggested that
the improvement is due to the increased calcifying properties
of the dietary of this country, and particularly that of pregnant
and nursing women, infants, and young children. The marked
improvement in 1947 is thought to be mainly due to the fact
that for the first time in these surveys the diet has been of
consistently better calcifying qualities over the whole antenatal
and post-natal life of the children concerned.
We wish to express our 'thanks to the London County Council and
Sir Alien Daley for permission to undertake this survey ; to the
head teachers of the schools and their staffs for their willing
co-operation; to Mrs. M. Kelley, Miss I. Alien, and Miss J.
Robinson for their help in the preparation of this report; and to
the Medical Research Council for financing the work.
BIBLIOGRAPHY
Ayers, P. (1939). J. Amer. dent. Ass., 26, 3.
Coumoulos, H. (1946). Nature, 158, 559.
-- and Mellanby, M. (1947). British Medical Journal, l, 751.
Davies, J. H. (1939). Brit. dent. J., ()1, 66.
Deverall, A. (1936). Spec. Rep. Ser. med. Res. Coun., No. 211.
Lmtdon.
King, J. D. (1940). Spec. Rep. Ser. med. Res. Coun., No. 241.
London.
Mellanby, H. (1940). British Medical Journal, l, 682.
Mellanby, M. (1929, 1930, 1934). Spec. Rep. Ser. med. Res. Coun.,
Nos. 140, 153, and 191.
-- (1937). Brit. dent. J., 62, 241.
-- and Coumoulos, H. (1944). British Medical Journal, 1, 837.
- - (1946). Ibid., 2, 565.
Pederson, P. 0. (1946). Tandlaegebladet, 50, 210.
Pickerill. H. P. (1923). Brit. dent. J., 44, 967.
Pincus, P. (1941). Ibid., 70, 52.
(For fuller references to related work see Mellanby, M., and
Coumoulos, H., 1944 and 1946.)
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