IN BRIEF

PRACTICE
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Disease can affect dental development in children.
Congenital conditions can interfere with provision of dental treatment.
Underlying disease and its treatment can affect the timing of dental treatment in children.
Diseases of childhood influence the choice of anaesthesia.
Close co-operation with paediatricians is important in managing children with
serious conditions.
Liaison is needed not neglect.
10
VERIFIABLE
CPD PAPER

General medicine and surgery for dental practitioners

Part 10: The paediatric patient
M. Greenwood1, J. G. Meechan2 and R. R. Welbury3

Medical problems in children can cause unique difficulties for the safe provision of dental treatment.1 Such problems can
affect the type and timing of dental treatment as well as methods of control of pain and anxiety. In this paper, conditions
which influence the choice of anaesthesia as well as those which affect dental development are discussed.

POINTS IN THE HISTORY niques such as relative analgesia (RA) can be

GENERAL MEDICINE AND used with success in some of these patients but
SURGERY FOR DENTAL Background information there are limits to what can be achieved since
PRACTITIONERS: Some conditions are relevant since they affect a level of co-operation and understanding is
1. Cardiovascular system
oral and dental development and will often be required.
discovered in a thorough history. These include Organ transplantation is a procedure which is
2. Respiratory system
disorders of bone such as cleidocranial dyspla- relatively commonplace today and the number
3. Gastrointestinal system
sia where delayed eruption and multiple super- of children with renal, heart, heart/lung, liver
4. Neurological disorders numerary teeth occur and fibrous dysplasia and bone transplants will increase. The dental
5. Liver disease which can produce malocclusions (see Muscu- team can play an important role in pre-trans-
6. The endocrine system loskeletal paper in this series). Disorders plant assessment as it is vital that any focus of
7. Renal disorders localised to the teeth such as amelogenesis infection is eliminated prior to transplantation.
8. Musculoskeletal system imperfecta provide a challenge to preventive Disorders of different organ systems have
9. Haematology and and restorative dentistry. Other disorders such been described in the earlier papers in this series.
patients with bleeding as dentinogenesis imperfecta may be associated Problems that impact on the younger patient are
problems with osteogenesis imperfecta and surgery may discussed more fully here.
10. The paediatric patient be hazardous. Referral to an oral surgeon is sen-
sible in such cases. Hypodontia2 occurs in ecto- Cardiovascular conditions
dermal dysplasia and successful management of A number of conditions may require antibiotic
this condition often requires co-ordinated spe- prophylaxis. Procedures that involve manipu-
cialist treatment. The general dental practition- lation of the gingival margin can produce a
er, however, has an important role in the man- transient bacteraemia which may cause infec-
agement of these patients. tive endocarditis in ‘at risk’ children. The cur-
The medical history in a child patient rent recommendations for antibiotic prophy-
1Lecturer, 2Senior Lecturer, Department of
should follow a similar theme to that of an laxis for children to be treated under local and
Oral and Maxillofacial Surgery, The Dental
School, Framlington Place, Newcastle
adult but there are differences in emphasis in general anaesthesia are given in the British
upon Tyne NE2 4BW; 3Professor, Paediatric certain areas. It is useful to obtain information National Formulary.3 Some cardiac defects
Dentistry, Glasgow Dental School, regarding previous levels of compliance with require antibiotic prophylaxis throughout life,
Sauchiehall Street, Glasgow G2 3JZ treatment since disorders that interfere with these include pulmonary and aortic stenosis,
Correspondence to: M. Greenwood
E-mail: beryl.leggatt@ncl.ac.uk patient co-operation can make routine dental coarctation of the aorta and ventricular septal
treatment difficult. Conditions such as signifi- defects. A repaired patent ductus arteriosus
Refereed Paper cant physical and mental disability, severe should not require cover 6 months after the
doi:10.1038/sj.bdj.4810555
© British Dental Journal 2003; 195: convulsive disorders and extensive behav- repair and cardiac transplant patients may not
367–372 ioural problems can create difficulties. Tech- need prophylactic antibiotics once the ECG is

BRITISH DENTAL JOURNAL VOLUME 195 NO. 7 OCTOBER 11 2003 367

PRACTICE

normal. Close consultation with the cardiolo- clotting factor(s) prior to surgery and usually the
gist is required. provision of antifibrinolytic therapy following
The patient may have Down Syndrome (tri- treatment. Treatment planning and timing of
somy 21). This occurs in 1 in 700 live births. In intervention must be co-ordinated with the
nearly half of Down’s patients, congenital car- haematologist. Children with platelet deficien-
diac anomalies are found and thus the need for cies (Fig. 1) may require a platelet transfusion or
antibiotic prophylaxis should be considered for if the problem is one of idiopathic thrombocy-
bacteraemia producing procedures. There is topaenic purpura then a pre-operative course of
some degree of learning disability in all these steroids can increase platelet numbers to an
patients and immunological defects predispose acceptable level for surgery (greater than 50 x
them to infection. Down’s patients have a higher 109 per litre).
risk of developing acute leukaemia than the gen-
eral population.

Respiratory conditions
Asthma affects about 12% of all children. The
severity varies from mild to moderate to severe.
In mild cases attacks are only occasional and
can be precipitated by infection. Between
attacks patients are asymptomatic. In moderate
cases episodes are severe and recurrent but
patients are symptom-free between attacks.
Exercise induces bronchoconstriction. When a
child suffers from severe asthma, attacks vary in
severity but the child is never asymptomatic and
the illness affects growth and lung function. A Fig. 1 A palatal bruise in a child taking immuno-
history should always ascertain the degree of suppressants. This has led to a low platelet count
Common conditions severity of the asthma and the efficacy of pre-
scribed treatment.
Cystic fibrosis is an inherited disorder of Neurological conditions
Asthma affects 12% exocrine glands. It occurs in 1 in 2000 births and Enquiry should be made about any history of
of children and is inherited as autosomal recessive. Mucus has convulsions since the stress of dentistry may
an increased viscosity and pancreatic insuffi- induce fits in epileptic patients. Epilepsy affects
epilepsy affects 5% ciency in childhood occurs. Diabetes mellitus 3-5% of the paediatric population and most
of the paediatric may be a complication and some patients have cases are idiopathic. Attacks may be stimulated
population. cirrhosis of the liver. Recurrent respiratory infec- by hyperventilation, fever, photic stimulation,
tions may occur resulting in bronchiectasis. withdrawal of anticonvulsants (or poor compli-
ance), lack of sleep, over sedation, over hydra-
Haematological conditions tion, emotional upset and some medications eg
Disorders such as anaemia and leukaemia, in antihistamines. The use of relative analgesia can
addition to interfering with wound healing may be of great benefit for children with a history of
also lead to a bleeding tendency and consultation convulsions in the dental chair.
with the haematologist or oncologist is essential Cerebral palsy is the leading cause of signifi-
before considering surgery on such children. cant disability in children. Uncontrolled move-
It is important to enquire about Sickle-cell ment and abnormal posture are the main handi-
disease in patients of African, Asian and West caps but other neurological and mental
Indian descent since the administration of a problems can also occur. Epilepsy, visual and
general anaesthetic to an undiagnosed sufferer hearing impairment are features which may
can cause severe complications. Deoxygenation cause difficulties with dental treatment.
during anaesthesia causes the erythrocyte to A number of children with hydrocephalus
deform into a sickle shape which causes the cells have shunts which drain cerebrospinal fluid
to aggregate and inhibits blood flow in small (CSF) from the brain to other areas of the body
diameter vessels. A finger prick Sickledex test, if thereby reducing intracranial pressure and pre-
positive should be followed by haemoglobin venting brain damage. An older form of shunt
electrophoresis. In patients of Mediterranean drained fluid from the brain to the ventricles of
descent, the possibility of thalassaemia should the heart (atrio-ventricular) and these require
be borne in mind. antibiotic prophylaxis prior to bacteraemia–pro-
It is important to enquire about possible ducing treatment. A newer shunt which drains
bleeding disorders. Congenital disorders such as fluid to the peritoneum (atrio-peritoneal) does
haemophilia and acquired clotting disorders not require such prophylaxis.
preclude surgical dental treatment outside the
hospital environment. The most common hered- Renal conditions
itary haemophilias (sex-linked recessive) are Renal disease in children mainly comprises the
Haemophilia A (Factor VIII deficiency) and so-called nephritic syndromes which may
Haemophilia B (Factor IX deficiency). These progress to chronic renal failure (CRF). Progres-
patients require replacement of the appropriate sion to CRF leads to the need for dialysis and

368 BRITISH DENTAL JOURNAL VOLUME 195 NO. 7 OCTOBER 11 2003

 PRACTICE

possibly transplantation. CRF patients may

cause difficulties with management due to corti-
costeroid and other immunosuppression thera-
py. Potential problems include:

• Impaired drug excretion

• Anaemia
• Bleeding tendencies
• Associated anticoagulant therapy
• Hypertension
• Infections eg hepatitis B
• Renal osteodystrophy
Fig. 3 Caries due to prolonged use of sweetened liquid
Hepatic conditions oral medicines
Chronic liver disease with impaired hepatic
function is uncommon in childhood (Fig. 2).
Problems can be categorised into: can produce xerostomia in children include
antihistamines and major tranquillisers. Table 1 Points in the history
of a paediatric patient
• Coagulation disorders A summary of salient points in the history of
• Previous levels of compliance
• Drug toxicity a child dental patient are shown in Table 1. with treatment
• Disorders of fluid and electrolyte balance It should not be forgotten that abuse of • Asthma
• Problems with drug therapy drugs during pregnancy can produce oro-facial • Diabetes
• Infections defects in children. For example, cleft lip and • Cystic Fibrosis
• Conditions needing antibiotic
palate are seen in the foetal alcohol syndrome prophylaxis (see text)
and cigarette smoking can cause reduction in • Sickle Cell Disease
crown size of primary teeth. Cocaine misuse by • Thalassaemia
• Bleeding disorders
mothers has been associated with tongue-tie in • Epilepsy
their offspring.5 • Shunt in hydrocephalus —
antibiotic prophylaxis in
Craniofacial disorders atrio-ventricular type
• Cranio-facial disorders
Certain inherited or acquired craniofacial dis- • Renal disorders
orders eg temporomandibular joint ankylosis, • Hepatic conditions
should be enquired about since access to the • Drug therapy
mouth may be limited causing difficulties with
treatment. In some cases surgical correction of
the deformity is necessary before intra-oral
procedures can be performed.
Fig. 2 Severely bilirubin stained teeth that started
mineralising pre-liver transplant at age 2.5 years. Examination
The second permanent molars are normal The degree to which it will be possible to achieve
compliance with dental treatment can be obvi-
ous very quickly in a consultation. The child
Endocrine conditions may have a condition that interferes with their
Insulin controlled diabetic children who ability to co-operate.
require a general anaesthetic should be treated In cleidocranial dysplasia there may be
as in-patients because the starvation required delayed eruption and multiple supernumerary
before the procedure would render them hypo- teeth whilst in fibrous dysplasia and cerebral
glycaemic. Hospitalisation will enable them to palsy a malocclusion may be present as men-
be stabilised pre- and post-operatively on an tioned earlier. The disorder may specifically
intravenous drip that will control both sugar affect the teeth eg amelogenesis imperfecta or a
and insulin. There is no contraindication to systemic condition may be associated with an
treatment in general dental practice under abnormal dentition. Dentinogenesis imperfecta
local anaesthetic or local anaesthetic with RA may be associated with osteogenesis imperfecta
as long as the treatment time does not interfere or hypodontia with ectodermal dysplasia. There
with a normal snack intake. Extra carbohy- may in addition be extensive caries that has
drate can always be taken in liquid form prior been exacerbated by drug therapy.
to a procedure. Patients with Down Syndrome tend to have an
open mouthed posture with a protruding tongue
Drug therapy which can cause difficulties with dental treat-
Although there have been positive moves ment. Tooth development and eruption is retard-
towards the provision of sugar-free medication4 ed. An anterior open bite is common, as is a class
cases are still seen in which the progress of den- III malocclusion. The incidence of cleft lip and
tal caries has been exacerbated by drug therapy palate is increased in these patients. Periodontal
(Fig. 3). This can be due either to the direct effect disease is severe and has an early onset but caries
of sugar-based medicines or by an indirect incidence, by comparison, is surprisingly low.
action such as xerostomia. Medications which In cystic fibrosis there are recurrent chest

BRITISH DENTAL JOURNAL VOLUME 195 NO. 7 OCTOBER 11 2003 369

PRACTICE

infections and often a productive cough. Many ever this should be avoided in epileptic children
patients also have nasal polyps and recurrent and those with cardiac pacemakers.
sinusitis which may preclude the use of RA due Children with mild or moderate asthma, if
to the poor nasal airway. The salivary glands asymptomatic at the time of treatment, do not
may be enlarged. The enamel may be hypoplas- need prophylaxis pre-treatment. If oral medica-
tic and eruption dates may be delayed. Medica- tion is being taken, this should be continued to
tion may produce oral signs, for example the prevent rebound bronchospasm. If the asthma is
pancreatic replacement drug pancreatin may severe there is greater risk of bronchospasm
produce oral ulceration. being induced by GA or the stress of surgery. If
The possibility of child abuse is an important GA is required the child must be in optimal con-
phenomenon which should always be borne in dition ie no evidence of respiratory infection and
mind if findings on examination appear to be an in-patient facility should be available.
inconsistent with the history. An injury where In children with cystic fibrosis, sputum clear-
there has been a long delay between the incident ance is assisted by regular physiotherapy.
and attendance for treatment is a cause for suspi- Amoxicillin or flucloxacillin are used (often
cion. Injuries which do not ‘fit’ with the history long-term) as prophylaxis against chest infec-
and multiple injuries, particularly those which tion. If respiratory function is poor, GA is con-
appear to be of different ages are also cause for traindicated. Tetracycline, which is a very effec-
concern. Child abuse, whilst more common in the tive broad spectrum antibiotic may need to be
lower social classes, is by no means confined to given when children develop multiple drug sen-
these groups. Local area Child Protection Com- sitivity.
mittee Guidelines will be available to guide the Diabetes and cirrhosis can also cause difficul-
dental practitioner in their referral. ties with dental treatment provision. In children
with diabetes, infections and surgical procedures
GENERAL AND LOCAL ANAESTHESIA, which create stress or alter food intake may dis-
SEDATION AND MANAGEMENT turb diabetic control ie diabetic children are best
CONSIDERATIONS IN THE PAEDIATRIC DENTAL managed under LA if possible. Any infection
PATIENT should be treated vigorously. In children with
The possibility of local anaesthetic toxicity is cirrhosis, routine dental treatment is not usually
more likely in children than adults due to their a problem. A physician should be consulted if
Local anaesthesia smaller size. A dose of 1/10th of a cartridge per GA or surgery is needed due to the possibility of
kilogram as a maximum is recommended;6 this bleeding tendency, anaemia and the possibility
means that two cartridges is the maximum in a of drug toxicity.
Toxic doses of local healthy 20 kg 5-year-old. The use of local Intravenous sedation is unsuitable for use in
anaesthetics are more anaesthetics should be reduced in children with children since the response is unpredictable. Rel-
liver disorders. The use of any drug, including ative analgesia is the technique of choice. Rela-
likely in children local anaesthetics in children with severe hepatic tive analgesia has been shown to be an accept-
compared with adults dysfunction should be discussed with the super- able and cost-effective alternative to general
as a result of their vising physician. The use of local anaesthetics anaesthesia in children having minor oral sur-
smaller size containing vasoconstrictors eg epinephrine gery.9 The contraindications to the use of RA
(adrenaline) should be avoided when injecting include respiratory disorders. Acute upper respi-
into an area with a compromised blood supply ratory tract infections necessitate postponement
such as a mandible which has been irradiated for of treatment whereas chronic obstructive air-
the treatment of childhood malignancy. ways disease is an absolute contraindication.
Intraligamentary techniques of local analge- Children who suffer from myasthenia gravis
sia should not be employed in children who are should not be treated with RA outside a hospital
at risk of infective endocarditis when dental environment since they are at risk of respiratory
treatment which does not require the provision arrest and even in the hospital setting consulta-
of antibiotic prophylaxis is being performed. tion with the physician is essential before con-
This is because the administration of an sidering anything other than local anaesthesia.
intraligamentary injection itself produces a bac- Children with severe behavioural problems and
teraemia.7 Intraligamentary anaesthesia is the those who suffer from claustrophobia are not
technique of choice however in the mandible for suited to RA as they may not be able to tolerate
children with bleeding disorders such as the nasal mask. Certain surgical procedures in
haemophilia when restorative dental treatment children, such as labial fraenectomy, are not
is required. possible under RA as the mask denies access to
In patients with sickle cell disease, if practica- the surgical site.
ble, LA with or without RA is preferable to GA. If Oral sedation is not in widespread use for chil-
a GA is required in a patient with the sickle trait, dren in the UK to facilitate dental treatment. As
careful oxygenation must be ensured. Patients with any other drug, allergy to an oral sedative
with the disease itself may need a pre-anaesthetic obviously precludes its use. Drugs which are used
transfusion so that the level of haemoglobin A is in the UK include benzodiazepines, chloral
at least 50%. hydrate derivatives and promethazine. Hepatic or
The use of transcutaneous electronic nerve renal impairment is a contraindication to use of
stimulation has been shown to be effective in outpatient oral sedation. Similarly the concurrent
reducing injection discomfort in children,8 how- administration of any central nervous system

370 BRITISH DENTAL JOURNAL VOLUME 195 NO. 7 OCTOBER 11 2003

 PRACTICE

depressant prevents the use of oral sedation. In atrician is essential prior to the use of antibi-
addition, chloral hydrate derivatives and promet- otics in children with significant renal or
hazine should be avoided in the presence of car- hepatic impairment.
diovascular disease. Polypharmacy is best avoided The use of anti-metabolites to treat childhood
in any sedation technique. malignancies such as leukaemia is not a contra-
Children who have had a previous episode of indication to dental treatment but it does affect
infective endocarditis must be referred for spe- its timing. Consultation with the appropriate
cialist care for bacteraemia-producing proce- paediatrician is again important in order that
dures. This is because the use of intravenous essential treatment can be performed at the opti-
antibiotics (which is required for these individu- mal time during cyclical anti-cancer therapy
als) is not recommended in general dental prac- when platelet and white cell counts are accept-
tice. The potential for endocarditis is not a con- able. This treatment is best completed in a hospi-
traindication to endodontic treatment of the tal setting whilst the patient is undergoing
permanent dentition where cleansing, shaping chemotherapy.10
and adequate obturation of root canals can be The production of a healthy mouth should be
achieved, but the provision of endodontic treat- the ‘accepted norm’ before transplant surgery
ment in the primary dentition of children at risk and consultation with the transplant team and
of endocarditis is contraindicated. physicians is essential to determine the influ-
In patients with Down Syndrome the possibil- ence of the organ deficit on dental treatment.
ity of cardiac anomalies should be borne in mind. The transplanted heart reacts differently to the
These anomalies may require antibiotic prophy- normal heart to epinephrine.11 This is apparent
laxis for procedures which may produce a bac- after the use of epinephrine-containing dental
teraemia. Immunological impairment means that local anaesthetics.12 It is sensible to use dose
respiratory infections are more likely and there reductions or even avoid use of this vasocon-
may be additional congenital abnormalities of strictor in the child who has had a cardiac trans-
the respiratory tract. The hypoplastic mid-face plant. The need for antibiotic prophylaxis is only Wound healing
may cause difficulties with endotracheal intuba- present in the early post-heart transplant period
tion. General anaesthesia may also be complicat- but the management of all transplant patients is
A number of
ed by the possibilitiy of atlanto-axial subluxa- complicated by maintenance drug therapy.
tion when extending the neck if care is not taken. Steroid therapy may necessitate the administra- conditions affect
These patients, when institutionalised, have tion of a steroid boost prior to stressful proce- wound healing in
increased likelihood of hepatitis B carriage. dures and the possibility of adrenal crisis must children.
Some of the cardiac conditions requiring be borne in mind. The use of post-transplant
antibiotic prophylaxis were mentioned earlier. immunosuppressant therapy can increase the In those at risk,
In such patients careful attention must be paid to risk of haemorrhage and post-surgical infection. prophylactic
treatment planning as the maximum use must Post-transplantation therapy with drugs such as antibiotics should be
be made of each antibiotic administration. A ciclosporin and nifedipine leads to gingival
balance needs to be struck between the length of overgrowth similar to that seen with epanutin. prescribed
each treatment visit and minimising the number Regular oral hygiene review is essential and
of antibiotic exposures. repeated surgical visits for gingival recontour-
Individuals who have disorders likely to ing may well be required.
adversely affect wound healing should be
treated with prophylactic antibiotics. These CONCLUSIONS
include children with decreased resistance to Advances in medical care (especially in the
infection. Metabolic disturbances such as treatment of childhood malignancy and organ
uncontrolled diabetes and long-term use of transplantation) mean that dentists are
corticosteroids also affect wound healing. Well increasingly likely to encounter medically
controlled diabetic patients should be consid- compromised children. The keys to successful
ered ‘normal’ in relation to healing. Haemato- treatment are:
logical problems such as anaemia, leukaemia
and cyclic neutropaenia also affect healing • Accurate medical history
ability. Children on immunosuppressant thera- • Close liaison with medical colleagues and not
py and those being treated with anti-metabo- neglect
lites or local irradiation are also at risk of post- • Rigorous preventative programmes
surgical infection. The objective of • Dental intervention at times appropriate to
prophylactic use of antibiotics is to achieve medical care
optimal drug concentration in the initial blood • Regular follow up
clot. Timing of antibiotic administration is
aimed at having optimal blood levels of the
antimicrobial at the end of the surgical proce- 1. Shaw L S. Medically compromised children. In: Paediatric
Dentistry. (2nd ed) Ed R. R. Welbury. Oxford: Oxford
dure (ie when the clot forms) as opposed to the University Press, 2001.
prevention of distant infection (eg endocardi- 2. Hobkirk J A, Goodman J R, Jones S P. Presenting complaints
tis) when the antibiotic concentration has to be and findings in a group of patients attending a hypodontia
clinic. Br Dent J 1994; 177: 337–339.
optimal at the time of initial gingival manipu- 3. British National Formulary 43. British Medical Association,
lation (usually at the start of the surgical proce- 2002.
dure). Consultation with the supervising paedi- 4. Maguire A, Evans D J, Rugg-Gunn A J, Butler T J. Evaluation

BRITISH DENTAL JOURNAL VOLUME 195 NO. 7 OCTOBER 11 2003 371

PRACTICE

of sugar-free medicines campaign in north-east England: 9. Shaw A, Meechan J G, Kilpatrick N, Welbury R R. The use of
quantitative analysis of medicines use. Comm Dent Health inhalation sedation and local anaesthesia instead of general
1999; 16: 138–144. anaesthesia for extractions and minor oral surgery in
5. Harris E F, Friend G W, Toley E A. Enhanced prevalence of children: a prospective study. Int J Paed Dent 1996; 6: 7-11.
ankyloglossia with maternal cocaine use. Cleft Pal Craniofac 10. Fayle S A, Duggal M S, Williams S A. Oral problems and the
J 1992; 29: 72–76. dentist’s role in the management of paediatric oncology
6. Meechan J G. How to avoid local anaesthetic toxicity. Br Dent patients. Dent Update 1992; May 152-159.
J 1998; 184: 334-335. 11. Gilbert E M, Eiswirht C C, Mealey P C, Larrabee B S, Herrick C
7. Roberts G J, Holzel H S, Sury M R J Simmons N A, Gardner P, M, Bristow M R. β-adrenergic supersensitivity of the
Longhurst P. Dental bacteremia in children. Paediatric Cardiol transplanted human heart is presynaptic in origin.
1997; 18: 24-27. Circulation 1989; 79: 344-349.
8. Wilson S, Molina L de L, Preisch J, Weaver J. The effect of 12. Meechan J G, Parry G, Rattray D T, Thomason J M. Effects of
electronic dental anesthesia on behaviour during local Dental Local Anaesthetics in Cardiac Transplant Recipients.
anesthetic injection in the young, sedated dental patient. Br Dent J 2002; 192: 161-163.
Paediatric Dent 1999; 21: 12-17.

One Hundred Years Ago

The Dental Requirements of the Army

The subject of the dental needs of the Army covers so much ground that it is
impossible to do justice to it in the time allowed for reading a short paper such as
this must necessarily be, therefore I do not propose to regard the question from
either a purely scientific or statistical standpoint, but rather to give some idea of
the actual condition of things, and to offer suggestions as to a practical remedy.
Until the middle of the last century the Army was mainly recruited from the
Agricultural population which provided men of naturally robust physique.
Nowadays a very large percentage of recruits are town bred, and not to be com-
pared, as regards physical fitness, with the husbandmen of the old days. This lack
of really sound health and strength manifests itself in the imperfect condition of
the teeth of many of the men who present themselves for enlistment, and are con-
sequently rejected for “loss or decay of many teeth.”
Mention must be made of one of the contributory causes - Viz., neglect during
childhood. Though this does not come within the scope of my paper, it has a very
direct bearing upon it, and emphasises the necessity of teaching the masses of the
people the importance of dental hygiene. We are all aware of the good work that
is being done in certain schools, but the pity is that regular attention to children’s
teeth is not universal. That, however, will be long in coming, and the Army sur-
geon has to take the would-be recruit as he finds him.

A. F. A. Howe, LDS, Honorary Captain in the Army

Br Dent J 1903, 24: 772-773

372 BRITISH DENTAL JOURNAL VOLUME 195 NO. 7 OCTOBER 11 2003

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.