103 517 DENTAL HEALTH AND DIETS OF ELEMENTARY SCHOOL CHILDREN IN BERRIEN SPRINGS. MICHIGAN Thesis for the Degree of M. S MICHIGAN STATE COLLEGE Virgmia EIizabeIIu Buck I945 THESIS This is to certify that the thesis entitled "Lentai Health and Lists of Elementary echooi Children in Lerrien perings, Michigan." presented by Virginia Elizabeth Buck has been accepted towards fulfihnent of the requirements for p. . 5. degree in P0008 81‘ Nutrition Date .__>i w .._—____ $5.1 ‘94- _"__-_.' -3." ... '1'.'_-¢'_ '_&'i_ ‘_ _. .n...‘_-|_1__ -_ {LI IIIIII. . DENTAL HLALTH AND DIETS OP ELEMSKTARY SCHOOL CHILDRSN IN bERRIhfl thINGS, mICHIGAN by Virginia Elizabeth ggck A THESIS submitted to the Graduate School of Michigan State college of Agriculture and Applied Science in partial fulfilment of the requirements for the degree of MASTER OF SCIENCE Department of Foods and Nutrition school of Home Economics 1945 THESIS TABLE OF C OEITELJTS Page Introduction............................................. 1 Retiew of Literature .................................... 3 Method .................................................. 19 Description of Subjects ........................... l9 flatbed 0f COlleCting dental date 0.0000000000000000 20 Method of collecting dietary data ................. 21 Method of collecting medical data ................. 22 Method of analyzing data .......................... 22 Results and Discussion .................................. 23 Dental status of subjects ......................... 25 Heights and weights or subJSCtS OOOOCOOOOOOOOOOOOOO 25 Diets If subjects ................................. 27 Summary ................................................. 40 Appendix 4.2 List of Literature cited ................................ 47 ACKN O IIIIIEDGi‘u-i EN T The writer wishes to acknowledge her grateful appreciation to Er. 3.3. weine, Superintendent of the berrien Springs Public schools, to miss Mabel Uassell, Director of the Emmanuel Mission- ary college Training School, and to the children of both schools, whose cooperation made this study possible; to ur. Fred Warthei- mar, who made the dental examinations; to miss mary Lewis, who first suggested this study; and to ur. Margaret A. Ohlson, whose criticisms, suggestions and help have been invaluable. 11 Number 10 ll 'rABLaS Title incidence of dental caries in permanent teeth of children by age and sex as re- ported by different investigators. Reports of different investigators as to the diet relationship and dental caries. neports of different investigators as to the inadequacies of American diets. the "t“ values calculated from incidence of denta1.caries in Group £_and Group 1;, Average heights and weights of boys and girls in Group i. mean intakes of Specific nutrients of Group 3 (by age and sex). mean intakes of specific nutrients of Group E (by age and sex). mean intakes of specific nutrients, of child- ran with less than the average number.of ce- ries for their age group, as compared to the mean intakes of all children.in the age group. Percentage of children, age 6 to 9, below the National Research council standards for speci- fic nutrients. Percentage of children, age 10 to 12, below the National Research Council standards for speci- fic nutrients. Percentage of children, age 13 to 15, below the National hesearch council standards for speci- fic nutrients. iv rage 13 24 26 28 50 32 55 56 INTRODUCTION Dental caries is one of the most prevalent diseases of the present time. It is rare, indeed, to find an adolescent child udth no decayed teeth, and examinations of men inducted into the armed forces have shown that from 22 to 40 per cent of those rejected were rejected because of tooth and mouth conditions (Editorial, 1941). Although it is well known that dental caries is common, few observers are agreed as to the cause of dental caries. An examination of the various theories of dental decay (Lynch, D.F., Kettering, C.F., and Gies, W.G., 1939) reveals that there are at least two opposing schools of thought. One group holds to the theory that dental decay is a result of some factor present in or missing from the oral environment. The other group contends that dental decay is the result of poor nutrition. Some of those who believe that dental decay is dependent upon the oral environment contend that the chemical composition of the saliva is the important factor, while others argue that the number of acid-forming bacteria controls the oral environment. Among the exponents of the theories of nutrition are those who emphasize the role of fluorine in prevention of caries. Still others maintain that the amount of carbohydrate, and especially refined -2... sugars, in the diet is the main factor in control of caries. Still others believe that dental decay is dependent upon the amount of vitamin D in the diet. Finally, there are those who hold to the theory that dental decay can be prevented by a diet which is adequate in all nutrients. However, these various groups as yet have not reached agreement; and so it would not seem ill-advised to investigate further the cause of dental caries. When repeated dental examinations of children in a cer- tain school in southwestern hichigan revealed that these children were more free from caries than children attending the surrounding schools, it was decided to observe these children and note what differences there might be between them and other children of their age group. As the first investigations revealed the fact that these children were all from one religious sect which laid unusual emphasis upon diet, it was decided to observe especially the diets of the children and to compare them with the diets of other children from the same geographical location. It was hoped that such observations might add to our information concerning the re- lationship between diet and dental decay. The observations noted are reported in this paper. REVIEW OF L1T4RATURE Knutson, Klein, and Palmer, in 1938, published the re- sults of the dental examination of 4,416 children in Hagers- town, Maryland. Table 1 shows the number of permenent teeth decayed, missing or filled (DMF) per 100 children, by age and sex. The DMF of permenent teeth for boys increased gra- dually from a rate of 25.2 per 100 children at 6 years of age to 667.8 at 15 years of age. For girls, the corresponding increase was from 33.3 to 619.0. Table 1 also shows the mean caries rates per 100 child- ren by age and sex found by East (1941) in the examination of 528,843 children. As can be seen by the table, these rates correspond closely to those reported by Knutson, et a1. Studies in England by holleston (1943) showed that 49 per cent of 2,096 rural children, age 4 to 14, had an excess of dental caries (4 or more decayed teeth at any period). Rolleston could find no differences between sexes. Miller (1943), also working in England, found that:of British Army recnuits (age 18) at enlistment,; the average numbers of teeth missing, requiring extraction, requiring filling, filled and sound, were 3.7, 1.3, 5.3, 0.6 and 34.2, respectively. The studies of Knutson, et a1. (1938) and East (1941) show an increase in caries rate with age, and also show an .Amemfi .acasnpomv npaeom ofiapza no pqupnmnon opwpm awwHEOfi: on» no nmsamnppos coph .Hm hp acme mcofipmnfisaxc Hepcon * -4- man wmb dam Hmm 05H nmm QOHc man has NwH mmH emceaaeo OOQBMQ WWO fl manna NHIOH one matna NHIOH atm mane» owe Acmeeaaeo nHHVAmm.aecaav *Hooncm oHHQSn mmnfinam :mfiaamm aw amncafino mbw Cob bwm mmm NmH NwH 33 0-1 H cs nmw awn and man mod uwa HM” 9H EHE C ooQBC mduw NHIOH manna NHIOH Aemnsaaeo may Am.osceov *Hoonom haremofloam .o.2.m a“ mmnwaflno m.mwm m.HnH mquo 0.0Nv m.mmm n.bHH schnafizo ooa\mmfiamo amen wfiuma Halo #HINH Hana muse» ewe Ammacafigo www.mmmv haeaav pwam o.oam o.bnm w.mom H.¢bn m.mmm c.n©m w.mmm H.mmH $.om n.mn mHch m.c©© m.mom m.mmn N.bmn c.mbm n.mnm b.mba $.0Hfi ¢.wm m.mm donwafino cad\m2n ma ¢H ma NH H tObCUOiC) LN mama mwd Aempeaane mae.ev AuanV mafiama wmm .nHwHM .compscm wmpsoman we arm use was an amenafiso Ho swamp pgmsnihmm ca mmflhao ampuoc we mozmcfiouH .wMOpxmflpmmbmH pacemkhflv an .H manna -5- apparent higher incidence of caries for girls at each chrono- logic age than far boys. East found, also, that the incidence of caries was greater in latitudes above 40 degrees, in com- munities where the mean winter temperature is below 300 F., in sections where the number of hours of sunshine per year is less than 2600, and in larger cities. The effect of the seasons upon the incidence of caries is shown by East (1938), Erpf (1938), and cheath and Zucker (1938), all of whom reported that there is a higher incidence of caries during the winter and early spring than there is during the summer and autumn. That economic status has no apparent effect on the inci- dence of dental caries has been demonstrated in studies by Klein and Palmer (1940) on children in New Jersey and in New York City (1942). In both cases, the total number of per- manent teeth, decayed, missing or filled, did not differ significantly between high and low income groups. Miller and Crombie (193%) also found that there was little differ- ence in economic status between a group of 25 children with no caries and a group of 25 children with excess caries. The study of Miller and Crombie (1939) seemed to in- dicate that first-born children had less dental caries than later-born children. in their group of 25 caries free child- ren, 15 were eldest children, 4 second and 6 third children, Whereas in the group of 25 caries active children, 8 were ~6- eldest children, 4 second, 5 third, and 8 fourth or later. However, in 1943, Berk in a study of 198 5-year-old children concluded that the place of the sibling in the family group is a relatively unimportant factor in the incidence of den- tal caries in children. Klein and Ealmer (1940) found that the results of an analysis of dental caries in 4,416 elementary school child- ren indicated that brothers and sisters of children suscep- tible to caries have over twice as many caries in both the permanent and deciduous teeth as do brothers and sisters of immune children. There seems to be some confusion among authorities as to the effect of infantile rickets on the incidence of den- tal caries. Eliot, et a1. (1943) found in their study that 36 per cent of non-hypoplastic teeth were carious, whereas 50 per cent of hypoplastic teeth were carious. This would indicate a positive relationship between dental caries and rickets. However, Shelling and Anderson (1936) found that the incidence of dental caries in a rachitic group of child- ren was not greater than in a non-rachitic group. The reports of different investigators as to the re- lationship of diet to dental caries is noted in Table 2. To control dental caries by dietary means, at least four methods have been suggested. One of these methods has grown out of the discovery that in communities which have a high- er amount of flourine in the drinking water, there is a low- -7- er incidence of dental caries. This has led to the suggestion that drinking water be fortified with l p.p.m. of flourine (Dean, et a1., 1941; bibby, 1944). Dean, et a1. (1939) observed that the number of carious teeth per 100 children in communities where the water supply contained 1.7 to 1.8 p.p.m. of flourine was 201 and 205, re- spectively. In two communities where the water supply was practically free of flourine (0.2 p.p.m.), the corresponding figures were 401 and 633. These findings have been confirmed by other investi- gators, including Deathsrage (1943) who found fewer caries and a higher rate of teeth with no caries in selectees who had used drinking water containing 0.5-1.0 p.p.m. flourine during the whole of their life or during the first 8 years than in selectees who had used water containing 0 to 0.1 p.p.m. flourine. Another method advanced for dietary control of caries is to inhibit the consumption of refined sugars and other car- bohydrates. In 1936, Jay, et al. reported the results of an experiment in which a group of fifty-one children living in an institutuion were observed for a period of 17 months. Dur- ing the first twelve months of the study, while on a low-sugar diet, 13 per cent of the children showed clinical signs of ac- tive dental caries. uuring the following 5 months all of the children received an unrestricted amount of candy. At the -e- .mmfiumo .uaflno mom moomhpsm .gflno .Hmm maommpslw .oafino non mcomHRSm prqoc Ho packed msownmo can mo.a escapee Baa w¢.m maoflemo ems on.¢ .epflpomumoflumo .oonynmofihmo 3me0 cages .Ho meemcfibm dosage. m3. .mmfinmc oaflpom mo mamfim HmOHeHHo omsonm wna .mmaneo oafipom can flow mnmfinmo am: on ompnommn mom was» mmmq .mofipmo abapom can ROH use» mama “mavens as: on umpnoaon was nopo measap nab cum mpamm Hwhmcfie ea ache .pmae champeam Hflo nobfia you son“ Q dwempab Mo .D.H 00m HHo hoped coo Song a maflmpwh Mo .D.H 00¢ ado empaflneoo oz maehnooqaeop m.ma .namdm Mo qupasfimqoo owmnoad masunooqmmmp m.OH .nmwzm mo eoHPQEbmeoo ommuobe hence we pesosm wopcwppmohnp pcfic nmwfimusoa pone HaeoapsahpmeH page coaonqfiH capmnmfiu mm nowm concHHAo hunch no masonw spam mpeaczpm hpfimnmbfis: mmn nofiuspapmna as ea mnfibfia amncawxo Hm nmhcafino ¢b nmhrafino omH Ammmav manna one whom add -eoe ego epsmmoz Amwmav .Ha no .mehaaoo Aonoav .Ha pa .aah hmnmav .m.m .pmua evacuees mo macapficeoo amazon mpommpsm mo wean mpomfipsm mnonawfipmo>nH .mmfinmo Hmpnoc was manmeoapmaoa poau on» ow mm weepamfipmmaqfi pqmnohuau Mo makeoam .m manna -9... end of this time 44 per cent of the group showed evidence of active caries, an increase of 31 per cent. Bunting (1939) believes that dental caries is determined by the presence in the mouth of specific types of acid produc- ing bacteria, e.g., £,acidgphilus, the growth of which is en- couraged by sugars and starches in the diet. he, therefore, suggests that "the only practical method for the reduction and elimination of Q, acidophilus overgrowth in the mouth is by drastic reduction of sugars and starches in the diet." Jay (1940) and Collins, et a1. (1942) also recommend the re- duction of sugars and carbohydrate to prevent dental caries. Whyte (1943) found that a group of boys, age 6 to 16, receiving for two months a daily supplement of 2 oz. fudge or macaroon bar, had a higher incidence of dental caries than a group of controls receiving no supplement of sweets. As these studies do not take into consideration the fact that 2 oz. of fudge comprises about 250 calories which would un- doubtedly replace other food in the diet, they are difficult to analyze; for there is a question as to whether the increase of incidence of caries is due to the added sugar or to other subtracted nutrients. In France, Dechaume and Oauhepe (1943) reported that of 500 children examined in 1942, 30 per cent had no caries. In 1941, only 17 per cent of the children examined were free from caries. They believed that this apparent anomaly could be -10- explained by the fact that the diet, though restricted, was alkaline in character, and that cakes and sweets had disappeared. A third method proposed for dietary control of dental caries is by vitamin D therapy. East (1938) found that when three teaspoonfuls of cod liver oil, or 400 units of vitamin D milk, were added to the diet of children, the rate of caries increase was greatly reduced. McBeath and Zucker (1938) observed that the administration of graded amounts of vitamin D as viti- min D milk resulted in graded caries prevention. In 1942, McBeath and Verlin published a further study on the role of vitamin D in control of dental caries. in this ex- periment, five groups of about forty children each were observed during one school year. No changes were made in the diet, ex- cept the addition of vitamin D to the milk or four of the groups. During this time, the control group showed an increase of 4.50 new carious surfaces per child. In the group receiving a daily supplement of 400 units from cod liver oil, there were 2.48 new carious surfaces per diild. The maximum effect obtained in this Study (a reduction to 1.65 new carious tooth surfaces) was shown in the group receiving a daily supplement from cod liver oil of 800 units of vitamin D per child. Still another method has been suggested for the nutrition- al control of dental caries; this method insists upon a well- balanced diet containing an Optimal amount of all the nutrients which are known to maintain good health in humans. One of the first investigators to note the influence of an optimal diet -11- upon the teeth was Boyd. In 1928, Boyd and Drain published their first observation of the influence of a diet rich in min- erals and vitamins in arresting dental caries in a group of diabetic children. They noted that in a group of 28 well con- trolled diabetic children, there was no further progress of dental caries, although 82 per cent of the children had shown definitely progressive caries prior to the establishment of the dietary control. Further observations published by Boyd (1940) 1942; 1945; 1944) have confirmed the first reports, and have led him to conclude that the progress of’dental caries can be stopped by giving the child an Optimal diet. The conclusions drawn by Boyd have been criticized, be- cause, it is claimed, the arrest of dental caries in the dia- betic children was due not to the nutritional value of the diets but to the low amount of carbohydrate in the diets. To answer these criticisms, Boyd (1944) re-analyzed his data in terms of fat versus carbohydrate in the diet. He could find no constant or significant difference in the average rates of progression of caries between two groups of children whose carbohydrate ingestion differed by 100 per cent. Howe, et a1. (1942) observed that a group of children who had received nutritional guidance for a period of over 3 years had 66 per cent fewer cavities than another group who had re- ceived no such instruction. The difference was greatest in the 11 to 12 year group (83 per cent fewer cavities) and least in -11- upon the teeth was Boyd. In 1928, Boyd and Drain published their first observation of the influence of a diet rich in min- erals and vitamins in arresting dental caries in a group of diabetic children. They noted that in a group of 28 well con- trolled diabetie children, there was no further progress of dental caries, although 82 per cent of the children had shown definitely progressive caries prior to the establishment of the dietary control. Further observations published by Boyd (1940) 1942; 1943; 1944) have confirmed the first reports, and have led him to conclude that the progress of'dental caries can be stopped by giving the child an optimal diet. The conclusions drawn by Boyd have been criticized, be- cause, it is claimed, the arrest of dental caries in the dia- betic children was due not to the nutritional value of the diets but to the low amount of carbohydrate in the diets. To answer these criticisms, Boyd (1944) re-analyzed his data in terms of fat versus carbohydrate in the diet. He could find no constant or significant difference in the average rates of progression of caries between two groups of children whose carbohydrate ingestion differed by 100 per cent. Howe, et al. (1942) observed that a group of children who had received nutritional guidance for a period of over 3 years had 56 per cent fewer cavities than another group who had re- ceived no such instruction. The difference was greatest in the 11 to 12 year group (83 per cent fewer cavities) and least in -13- the 6 to 7 year group (27 per cent fewer cavities). Bowes (1938, 1943) found that in two groups of dental patients, clinic and private, no diet was adequate in all essen- tials. The greatest number of deficiencies or deviations from desirable standards were shown in the carbohydrate-fat ratio, iron, and vitamins D and B. Within the past ten years many studies have been made of the dietary habits of American families (Table 3). In 1935, Cowles, in an observation of the winter food consumption of Wisconsin farm families, noted that 26.3 per cent were defi- cient in calories, 7.0 per cent in protein, 15.6 in calcuim, 31.6 in iron, 21.0 in phOSphorus, 3.5 in all of these nutrients, and 10.5 in four or more nutrients. The common dietary errors were the use of few vegetables other than white potatoes, small consumption of citrus fruits and almost complete lack of use of whole grain cereals. Many of the families failed to use sufficient milk, but the consumption of meat was very high. The adequacy of the diet was clearly and directly related to the money value of the food eaten. No deficiency in protein, calcuim or phosphorus, and little deficiency in calories oc- curred when as much as$2.40 per adult male was spent per week. This was due, however, to the large quantity of food consumed, rather than to Judicious selection. Bersook and Halverson (1940), in reporting the nutritional adequacy of the diets of 50 families in Pasadena, California, .cmncawzo we won k.5 ampflnwn (me who: schnappsn poem mo mbflpmmm (wrm msowpmpomwfimwfi Hmowmmna mmomc .pnmfimz hcon cw houmfioflw (mo mumpmm cmpmo new unmofiwfinwflm : r .mam cw mEmmHn .HE 00H you .ws 0.0 Boamn an o» 6:50“ mm; cooan we oxmpnfi o sasspwb .mcfiamo Bony Eocmmnh cam camps“ asfio taco nwfin nomspon acapmamnnoo oz .mmapmo on cowoAm ea .conasdxm own no name» ma nouns nonoafizo on 90 .pch mpmdwmmm do can 30% hambwpaamm .oxmp:« mascamo a“ bozmfioflmmo mno>mm 0p mpwnmoos 4 .cpmcmmpm Hmfinmm one we Mamaummo psopm o cHEspH> cam asflono no mmxwqu .cpavmmpm Hashes Edfiwsws Mo mam: umqo pzcnm awbmakopfih cam mafia Imam» mo mmmmpsH .ooom adonm mm; mpasum mo mxmazw ownoamo hafimm .mpaac woos can «an .mpmao name was was .mpoaa seem as: wow .mpmac Moon was Wmm .mpmfio Has“ an: 9mm .mpoas aooa can won .pmfic spends (cm as on: mmHHHEmw ma “mpsmanpsn one: no a a“ pmoofimoc mmwafiemw ma .mSMOQQmonn ma ommowno :fl cmncaflno mane mmmmmqqmg maccfis QH sofipwasqcn Hmyrm asaHoaao apnea mmaaaaae ache aaa awaaaa> mmHHHSmw spam mnmrwmmd an maaaaaaa on “nemav .Hm pm .hnnmm Amemav .Hm pm .mamaso» Amemflv EmHHE “Hemavmaaaopoapm Aoemav :cmhmb namm one Moompom mo.am msnfioamo :fi .fiw.ma macaw ad mo.an nqfiopoam.nw .mo.b “mm«HOHme mmaawzmu a“ unoaoflumc mmHHHsmu Ho $9.0m .8nmu qfimnoomfim Amnaav amazon mpeonnza no mqofipacnoe Hmoamhnm mpoonpsm no mpmfln maoonpsm unapomuvmoan 5903 Q3283 Ho 3326035 on» 0» mm encammapmobfi Packet; ho mphomom .n 3nt -14- found that most of these families spending less than $2.08 per person per week obtained an inadequate din. The families gen- erally had adequate intakes of protein, iron and vitamin 0. The calcium intake of 21 families was inadGQuate; only 8 fami- lies obtained between 4,000-6,000 I.U. of vitamin A; and ap- proximately one-third of the families were receiving less than the recommended amount of vitamin B1. As to calories, more families with ample funds for food had an ample caloric intake than those on restricted budgets. Twelve families were found to be deficient in three or more essential items; eighteen families had an adequate diet. The investigators reported that the milk consumption of these Pasadena families was some- what above the rest of the country, and the fruit and fresh veg- etable consumption much higher. They could find no correla- tion between high calcium intake and freedom from caries, nor was there any correlation between lack of caries and high food expenditure. A dietary study of 29 boys and 23 girls, 14 to 19 years of age, on a lacto-ovo-vegetarian diet, reported by Facts and Eppright (1940), revealed the following as the average daily intakes: for boys, 3156 calories or 48 calories per kilogram of body weight, 90 gm. protein or 1.4 gm. per kilogram, 1.44 gm. calcium, 1.96 gm. phosphorus, and 0.0182 gm. iron; for girls, 2017 calories or 35 calories per kilogram of body weight, 53 gm. protein or 0.90 gm. per kilogram, 0.79 gm. calcium, -15- 1.01 gm. phosphorus, and 0.0094 gm. iron. Stiebeling (1941), in reporting the survey conducted by the united States Departments of Agriculture and Labor in 1936-37, points out that of the families studied, 27 per cent had good diets, 38 per cent had fair diets and 35 per cent had poor diets. Fifty per cent of farm fmnilies had good diets, 25 per cent fair diets and 25 per cent poor diets; whereas of village and city families, 20 per cent had good diets, 45 per cent had fair diets and 35 per cent had poor diets. Farm families apparently fared better than village or city families because they ate larger quantities of protective foods. Stiebeling's report verifies the observation of other investigators that families which had lar- ger incomes had better diets than those with smaller incomes. Mack, et a1. (1942) made a.study of the dietary habits and nutritional status of 147 children of families living in a college community. The results were compared with those for children of an industrial community of lower economic status. The children in the community in which income and educational status of the parents were higher were found to show generally better nutritional status. Although the intake of protective foods varied with income in both communities, intakes of these foods throughout all income groups of the college community were higher than those of the industrial groups. Milam (1942), in a nutrition survey of a small North Car- olina community in 1940-41, found the dietary levels of calories, vitamin bl, riboflavin, calcium, and vitamin 0 to be below that -15- recommended by the National Research Council. The diets of high school students in New York City, as reported by Wiehl (1942, 1944), show that of 2,000 pupils from low-income families, 21 per cent had less than two-thirds of ‘the standard allowances for calories, 5 per cent for protein, 28 per cent for calcium, 1? per cent for iron, 38 per cent for vitamin A, 14 per cent for vitamin 51’ 25 per cent for ribo- flavin and 29 per cent for ascorbic acid.‘ The calorie intake for private high school pupils was, on the average, approxi- mately equal to their estimated calorie needs. Youmans, et a1. (1942), working in Tennessee, found the mean intake of calories for boys and girls, age 7 to 9 years, to be 1,726; for boys and girls, age 10 to 12 yaars, it was 1,855; for boys, age 13 to 15, the mean caloric intake was 2,494; and for girls of the same age, 1,691. In the spring of 1942, widdowson and McGance made a sur- vey of the diets of 52 boys in schools in England. The nutri- tive value of the diets was compared with results obtained from a similar study in 1936-39. it was found that the calorie supply from meat, fats and sugar was lower in 1942 than in the previous study, but the total calorie intake was maintained by an increased consumption of unrationed feeds. All diets con- tained as much protein, 0a, P, re, and vitamin B1 as in the previous study, but the average intakes of animal protein had fallen to between 33 and 47 gm. and vitamin C to between 15 -17- and 17 mg. daily. A study of the diets of 524 high school girls in Minne- sota and Kansas in 1939-40 (Leichsenring, et a1., 1943) showed low consumption of eggs, milk and green and yellow vegetables. The observed calorie intakes were less than those recommended by the Committee on roads and Nutrition of the National Research Council. The protein content of the diet, approximately 70 gm. per day, failed to meet the recommended daily allowance of 80 gm. for girls 13 to 15 years old and 75 gm. for girls of 16 to 20 years. At all ages the intake of Ca, P, and Fe were below the proposed standards. The mean intake of vitamin A.appeared to be adequate, but some individuals received much less than the recommended allowance of 5,000 I. U. daily. The intake of vita- min C was variable. so serious deficiency of vitamin 51 was noted, but the riboflavin intake was probably inadeQuate. Hardy, et a1. (1943) conducted a survey which extended from January 1939 to August 1941 and included 7,393 children of different national and racial groups and a wide distribution of economic and social conditions in the city of Chicago. The following are the major findingsof the survey. Gross physical manifestations suggestive of poor nutrition were exhibited by 60 per cent of the children examined. natings of poor general condition varied from 48 per cent at the relief level to 13 per cent at the highest level. The diet patterns of 72 per cent of the children failed to meet a standard of adequacy lower than that recommended by the National Research Council. The diets -18.. of 89 per cent of the Negro children failed to reach the min- imum adequate standard. The foods least often lacking were protein foods and those most often lacking, fnuits and vege- tables. Dietary inadequaciee were common at all ages and in no age group were the diets of more than one-third of the children classed as adequate. Inadequate diets occurred in all the socio-economic groups examined; 92 per cent at the lowest level and 41 per cent at the highest. As can be seen from the above discussion as summarized in Tables 2 and %, dietary surveys have revealed many defi- ciencies in the average American diet. Evidences of malnu- trition have been reported which confirm the poor dietary habits. Very few investigators have tried to correlate the average diets of American families with their dental health. Those investigators who have reported the effect of diet upon dental decay usually have worked with controlled diets. In the investigation reported in this paper, the usual diets of the elementary school children studied were observed in order to discover whether the dental health could be correlated with the quality of the food ingested. METHOD In order to investigate further the relationship of diet to dental caries in children, two groups of elementary children were chosen for observation. gaggpmg consisted of 92 children from the Emmanuel Missionary College elementary School. The children's ages ranged from 6 years to 15 years. Their school grades ranged from the first through the eighth year. The Em- manuel Missionary college slementary School is a private school controlled by the Senenth-day Adventist church. It is situated on the campus of ummanuel Missionary College, about two miles from the village of berrien Springs, Michigan. Host of the children attending this elementary school live within five miles of the snhool. Some of the children live in berrien Springs, or on outlying farms. Many of the children live in a small residential settlement close to the college campus. The occu- pations of their parents range from farmers to laborers to college teachers. All of the children come from seventh-day Adventist homes. As repeated examinations of the teeth of these children have revealed a lower incidence of caries then found in the ex- aminations of the teeth of children in the surrounding area, and as the Seventh-day Adventist families lay stress upon diet, this group Ias chosen as the experimental group in this study. For clarity, the group of children from the Emmanuel Missionary college Elementary School will be known throughout this paper as Group ;. The control group, Group 1;, consisted of 113 children from the Berrien Springs Public Schoel. These children were chosen at random from the school files, but the age, sex, and school grade of each child was matched as closely as possible to the age, sex, and school grade of the children in the exper- imental group. The Berrien Springs Public School is located within the village of serrien Springs. serrien Springs is si- tuated in the southwestern portion of Michigan in the county of Berrien. It is approximately 12 miles from St. Joseph, niche igan, and about 20 miles from South Bend, Indiana. Some of the children observed in this group lived in the village of herrien Springs, while others lived on surrounding farms. Their parent's occupations were for the most part faruers and laborers, but a few'children came from homes of the professional class. No in- quiry was made as to the religious affiliations of these fami- lies, but it is not believed that there were any Seventh-day Adventist children among this group. This group was chosen as the control group because of its proximity to the ummanuel Mis- sionary college Elementary School. it was hoped that this would lessen any variations due to the physical environment. Hence- fcrth, the group of children from the Berrien Springs Public School will be known in this paper as Egggp ll. .Method of collecting dental dgtg,--All dental examinations of the children were made on two successive days in rebruary, 1945, The children were examined by ur. Fred Wertheimer, a dentist from the Michigan State Department of Public Health. The examinations were made by an exploratory tine and, hence, do not show those cavities which are not reached by the tine. At the time of examunation, a record was made for each child of the number of deciduous teeth which were decayed or filled, and of the number of permanent teeth erupted, decayed, filled, missing or requiring extraction. This method of dental ex- amination has been the standard procedure of the michigan State Department of Public Health. Method of collecting dietary dgtg.--The dietary habits of the children were observed by personal interview with each child. Each child was interviewed once. In order to do this, two months were required, beginning the latter part of January and continu- ing until the latter part of March, 1945. The children were int terviewed singly, during the school hours, at the school, but in a room apart from the regular class. Each child was asked to tell what he had eaten the day before, and the approximate proportions of food. This was recorded by the interviewer as the child was talking. at the same time, the interviewer tried to put the child at ease and to encourage his participation in the interview. if, after recording the diet, it was noticed that one or more of the “basic seven" foods was lacking from the menu, the child was asked to reveal, if possible, when he had last eaten that food. He was also asked specifically about the amount of candy and other sweets which he had consumed re- cently. Several questions of a more general nature were also asked. The forms used in the interviews are found in the ap- pendix of this report. It had been planned originally to interview each child twdce in this same manner, but as time did not permit, this plan was abandoned. It had also been originally planned to interview'the mother of each child, but as a few such inter- views did not reveal any additional information beyond that supplied by the child, this plan was discarded as being unne- cessary. method 2; collecting medical dgtg.--The height and weight records, as well as the records of past diseases, of the child- ren in 9.1222. g were copied from the school's medical reports. In firggp_;; there were no medical records available. for this group the record of past diseases was received from the child at the time of the interview» In Egggp l; the heights and weights of a few of the younger children were measured by the interview- er. It was possible to do this when the interviewer had access to a.room in which there were scales and measuring rod. Methods 2;.ana1yzing dgtg.--The nutritive values of the diets were calculated by the short method of analysis (Donal- son, E.G., and Leichsenring, J.M., 1944). Data were subjected to standard statistical analyses by the methods outlined by Baten (1938). RES ULTS AND DISCUSSION A comparison of the um values for Groups _I_ and _]_Z-I_ (Table l) with the values reported by Knutscan, et a1. (1938) and those reported by East (1941) shows that the caries incidence for Groups _I_ and _I_I_ is greater than the previously reported values for all age and sex groups except for girls, 10 to 12 years of age, in M I. In this group, the .UMF per 100 children is 2853227. The DMF per 100 children for the same age and sex group, as reported by knutsen, et a1. (1938) ranges from 265.7 to 374.1. seat (1941) reparted the mean caries per 100 children for girls, 9 to 11 years of age, as 282.6. *t appears, therefore, that although the dental caries rate is somewhat above average for all the other groups studied, the dental ca- ries rate for girls, 10 to 12 years of age, in E5122. _I_ is well within the range of data for children of similar economic sta- tus, or perhaps even slightly below that range, as reported by Knutsen, et a1. (1958) and East (1941). The mean mm per 100 children is greater for 93232. I; in each age and sex group than it is for 93222 1;. However, "t" values (Table 4) indicate that the only group in which the dental caries incidence is significantly lower for 931.12 _I_ than for @222. I; is the group of girls from 10 to 12 years of age. In 9323?. i, the girls of 10 to 12 years of age had a DEF of 2831227 per 100 children. in 9.11322. _I_I_, the corresponding fi- gure was 5211224. The “t" value for these two figures is 3.09; there is less than one chance in a hundred that this is a ran- dom result. Table 4. The "t" values calculated from incidence of dental caries in Group I_and Group II, 553 Degrees of Ereedom "t" values BOYS 6-9 37 0049 10-12 30 1.59 13-15 35 1.58 GIRLS 6-9 35 0.89 13-15 32 0.21 It has been established that when boys and girls are grow- ing rapidly there is a greater need for nutrients (Sherman, 1941). Also during rapid growth, there may be competition among the various parts of the body for the nutrients supplied. If not enough nutrients are provided to meet all demands,the more es- sential tissues tend to develop at the expense of structures less essential to life. because of this and the fact that all groups of the experimental children showed extensive dental -25- decay, it was considered wise to investigate the heights and weights of the children studied. As it was not possible to record the heights and weights of most of the children in Eggpp II, the children in EEEEE.£ were divided into "low-caries" and "high-caries" groups in or- der to obtain a similar comparison (Table 5). At 6 to 9 years the "low-caries” group represented all those who had less than 2 carious teeth; the "high-caries“ group represented all those with 2 or more carious teeth. At 10 to 12 years, the ”low-caries“ group was composed of all those with less than 4 carious teeth, ,whereas the ”high-caries" group was composed of those with 4 or more carious teeth. at 13 to 15 years of age, the “low-ca- ries" group represented those with less than 6 carious teeth, and the "high-caries” group represented those with 6 or more carious teeth. 2 In each age-sex group the mean weight is compared with the ranges for-height and weight as found in the heredith Tables. It will be noticed that the average height and weight for each age group is well within the Meridith range, indicating that the children in ggppp_;.were growing normally. The heights of these children, however, are toward the top of the range while the weights are near the middle of the range, which would tend to show that these children are tall and thin. In three age-sex groups the differences in height and weight between the “low-caries" and the “high-caries" groups J. n 4|..I \. C in... J. O I“! HJC. w. l. O . \la\u l J -4 I4.1\|m .a I (er V C. U r rs ,.xY D C d0 0 &V b Cu¢LCQ ,(HU -..I!0 O.) 0 \1-4- \JO). 10.x”. \I. .. «1114.1. '. 4. P DCF. n CU Q m Nzr C F{ w h C ( HO O o( Foo ,«r 3“ .o A N l a.“ \l 3 "Pteknfi‘énfrrvlhahs + \J‘ AVJ ))laIII a if)- 1.. ' a! WU 14'. :1 r.) ‘14. MLMLHIW. u. “film” U17». km 1N9 t. Qrw ON. on!” i .L ,r rprrLUo . m AANH A1114“. EPIHVK P aux .9 )0 _ v! 0 IJ. O". O . JO 4.. \4... '42.“ a 0“ 0 JV. 4!: at WW 0. re. P O N 3 fl . [.0 \. «\qu b mam .rL-WO Intflhfl (D H "3 H LO 0 Olt n C‘ O H C) O o m d‘ to A— O '0 D hoflm m wGHHmOIKOH sea-me me-ma oaauoa nmumm Haume mm-ae ”neaavmpaememr 0p uawvHeoor mmqmm .3H .m pnmamw pan «4 m a nmaeaano .pa .aa rmeeaano .pa .; emaefiano m 0 mo .oz pgwwmk prmwmh mo .02 Paw 0% pamflmm Mo .03 whom munch manna mnwmh manna mummh . o . 5W macho a“ manfiw can when we mpnwfims one mpnwfimn owwaobw .n canes -27- is almost negligible. These groups are the boys and girls, 6 to 9 years old, and the girls, 13 to 15 years old. However it will be noticed here, that the "high-caries" groups are slightly larger than the “low-caries" groups. Among the boys, 10 to 12 years of age and 13 to 15 years of age, the “high-ca- ries" groups are definitely much larger than the "low-caries" groups. But in the group of girls, 10 to 12 years of age, the “low-caries" group shows an excess in height and weight over the “high-caries" group. It is usually considered that an adequate diet will pro- duce better growth than an inadequate diet. If this is true, it would be expected that the taller and heavier children in this study had better diets than the others. But it has also been maintained that an adequate diet will prevent dental ca- ries. If this is true, then it would be expected that the "low- caries" children, who in all age-sex groups but one were the smaller children, would have the better diets. In order to try to understand this apparent anomally, an analysis of the food intakes of the children studied was necessary. The mean intakes of specific nutrients for ggpgp_£.by age and sex are shown in Table 6. It will be observed that in every group the mean number of calories ingested is below the standard set by the National Research Coundil. The same is true for iron and niacin intakes. In only one group (boys 6 to 9 years of age) is the calcium intake considered adequate, Lc Thiamine hibo- niacin mg. mg. mg. 6-9 1035:0040 3.1910067 901i2e6 ”no Stag 1.0 1.5 10 10-12 1.30:0.35 2.0830.87 8.1t2.5 NRO Sta 1.2 1.8 12 6-9 1.09:0.20 1.6110.33 7.5:1.9 1.28:0.38 1.79:1.08 7.3il.8 10-12 NR0 sta 1.2 1.8 12 13_15 l.15iO.54 1.68:0.78 7.512.4 Th1 a through courtesy of the Loma Linda T rood Count 30 mean 1e- is- the ‘Eew 10.8 18 by are search ever, nges- s in- uate the hree n in- vita- ncil 118 -29- although it approaches adequacy in the group of girls, 10 to 12 years of age. 1'he intakes of ascorbic acid are adequate in only three age-sex gro ups; the intakes of thiamine in four groups; and the intakes of riboflavin in four groups. The mean intakes of vitamin A in each group are above the National Re- search Council standards, however the very large standard de- viations indicate that many of the children did not reach the mean intake, while a very few greatly exceeded it. These few children tended to raise the average of the whole group, thus giving a mean that is unrepresentative of the intakes of the group. The mean intakes of specific nutrients for Qgpgp‘££.by age and sex are shown in Table 7. Here, it will be noticed that the mean caloric intake for boys and girls, 6 to 9 years old, is adequate, but for the other age-sex groups, the mean number of calories ingested falls short of the National Research Council standards. A comparison with Egggp.l_reveals, however, that in every age-sex group, the mean number of calories inges- ted by figpgphll is greater than the mean number of calories in- gested by Egggpng. In Qgpgp_gl.the protein intake is adequate in four age-sex groups, the calcium intake in two groups, the iron intake in three groups, the ascorbic acid intake in three groups, the riboflavin intake in five groups and the niacin in- take in three groups. As in Egppp.ln the mean intakes of vita- min A for Eggpp'll_are all above the National Research Council standards, however, here again the large standard deviations Age of Thiamine uibo- Ni Subjects flavin acin mg. mg. mg. 5’9 l.5810.21 2.32:0.77 10.9+4.4 NRO St 1.0 1.5 10 10'12 1.4710.37 2.26: . + NRO Sta, 1.2 1.g 71 13.§§3.7 15‘15 1.3310.42 2.48i1.25 15. i , NRC Ste 1.6 2.4 262.0 NRC Sta 1.0 1.5 10 15-15 1.29:0.39 1.96:0.91 11.5:4.9 The in- , the 3m pro- 561' nu- these ;e of nay up- on- as- 31'1“ ts [‘8 N611 -51- indicate that many of the children do not have an adequate in- take. It would seem from Tables 6 and 7 that, on the whole, the children from firggp L; are better fed than the children from Egggpfli. This is especially true in intakes of calories, pro- tein, iron, riboflavin and niacin. The reason for the lesser amount of protein, iron and niacin ingested by the children in Group I may be explained by the fact that the children were mostly non-meat eaters because of religious principles. As meat is one of the main sources of protein, iron and niacin, diets lacking this food would be likely to be low in these nu- trients. As the children in grggp Ll in general had better diets it is regrettable that data concerning the growth of these children were not available. On the other hand, £3232”; seems to have higher intake of calcium, vitamin A.and ascorbic acid than Egggp_££, This may be explained by pointing out that a decrease in meat consump- tion in Group I probably was accompanied by an increased con- sumption of fruits and vegetables. Calcium, vitamin A and as- corbic acid have all been shown by experimentation to play a role in tooth formation. The role of these nutrients in con- trolling dental decay is not as well understood. In Table 8, the mean intakes of the specific nutrients for all the boys and girls in each age group is noted. Here it will be noted that the mean intake of each nutrient is well "'an $1”. In Table 8 o for their age group, Thiamine nibo- Niacin flavin mg. mg. I118. Mean intakes , for all childre 1.38 2.10 9.6 Mean intakes £0 children with 1e than 2 carioust 1.41 1.99 9.6 a NRC Standard 1.0 1.5 10 Mean intakes 3 for all children 1.33 1.99 10.2 Mean intakes for children with ients less than 4 ca- rious teeth 1.32 1.96 9.1 as NRO Standards 1.2 1.8 12 Mean intaka for all boys 1.38 2.19 11.5 Mean intake for boys with less .n than 6 carious teeth 1.23 1.57 10.0 NRC Standards 1.6 2.4 16 Mean int ekes for all girls 1.23 1.84 9.6 Mean intakesfor girls with less 0- than 6 carious teeth 1.06 1.61 8.0 at IRC Standards 1.4 2.0 14 .e 16. " Values 0 -35.. above the standard for boys and girls, 6 to 9 years of age. In the 10 to 12 year old group, the National Research council standards are met for protein, vitamin A, ascorbic acid, this- mine and riboflavin. In the group of boys, 13 to 15 years old, the National Research Council standard is met for vitamin A ’ only, and the same is true of girls, 13 to 15 years old. These data seem to indicate that as the children grow older, their food intakes become less and less adequate, While their rate of growth becomes more rapid and the incidence of dental caries becomes greater. Table 8 also shows the mean intakes of the specific nutrients for the "low-caries" groups. In almost every case, these values are lower than the mean intakes for all children; however in each group, the differences in mean intakes is so small that it could well be considered within the range of error for the method used. Tables 9, 10 and 11 compare the percentage of children in 23232”; who are below the National Research Council standards for each nutrient with the percentage of children in §£222.2£. who are below these standards. As in Tables 6 and 7, these ? tables again show that on the whole the children in Q5222_II_ are as well fed, or better fed than the children in £5252 I; and again, this is especially true in intakes of calories, pro- tein, iron and niacin. however, again, it will be noticed that in several cases there are fewer children in gaggp'I‘below the National Research Council standards for calcium, vitamin A and -. 4- L 1‘. L; S . _uz -’1 aciji 1 1!? ?5 *300» l .5 I “11-4 h.“.4. vi't ..‘ Iron .21 9 k ulci n, IJ- c 1 ‘91 £12 .I-‘* . th f" = ,. (’1 CH 0 ’ J 2 '(3 .I.{ . O u. l a 9-. 4 ’ ' . o it P! o I ‘. k+g ,4 c 4\ a) O '7'? L " 10 L0 1.3 CI 50 10 IF‘ '0 r0 .0 ~u O. 97 7.1 O ‘1 1,;. 33. 7 l4 ;\ if 3 10.0 v 1" 1 .‘ k”\ l" r W uh 2J.O (“\ “"3 C‘ll 20 II 92.9 (0 [U 01 20 0k .- 71 .4 I 53.8 {*3 0.. rfn V“; c 33.2 23.1 15 II u.(‘ H.cm w... m.,c p.a c.\m L.um r.cm w.ct pH Hm m.mar n.“ m.a, a.“ a.rw a.m, H.aa w.mc H.aa ea H 011-1. .. L? L- .2. m.na w.um m.nm m.am u.mw m.nu m.bc m.nu m.mm DH HH u.mn m.u m.wm w.\m a.rm o.m» c.mb $.32 c.Hc HM H A- x. I .. a. an o. .r, a o .. V--.) . a e a. x t m, a a (vs (Scar ( n- . Ravi r Kr- \rr NH w.fl N.H mu coma ma m.a on 00mm aquacuwpm own .pwa .maw .maa .er .h.H .mr .una .am :Hbmam Icnflm mcflfimana anoram ©H0d. cfinacomd .fi ~ Cwfimp Sn 0 U pom mcmmwawpm aflomsoo zonaommm ammofipmz can ac. adaoamo .zmawafinc go mwwpcmcacm mflmpomn mmflaoamo d‘ .ofl manna ~35- N 0 “JP; P... ... 0.0a r4 (‘3 h... a O \l C CR.- C (Us. j...) “0‘ N. rL x rd .(M VLF. fl c a 34:7,) 54. f, r. tr \411441. _ fl. f L- '\ 1‘ . z . :11- ) x .. r (L..\ t 1 Pk -. ._ N . I mu Lu... . A. n. e. n A... ) _x tr, 5.0 f) a. . pl. LLIL I..|.l \ rut. aim r-5 (1 3 Vi (I. r‘ \1 f' “5.3mm C .m C 1 UK) N“ -57- ascorbic acid than in E2222.£l3 Between girls of 10 to 12 years of Egggp_l_and firggp'lg.are found some differences that cannot be noted between the other groups. Here it is observed that firggp.l has fewer girls below the National nesearch Council standards in calcium, vitamin A, ascorbic acid, thiamine and riboflavin. This is the only group in which the diets of 25352 I_may be said to be better than those of §£222.ll3 The mean intakes of nutrients observed here may partially explain why the larger children are in the "high-caries” groups. It has been pointed out previously that with a faster rate of growth, there is more competition within the body for food nu- trients. It would seem logical, then, to assume that with a similar intake of nutrients, the group of children who were growing faster would be more likely to have a greater rate of dental decay than the slower growing;grddn. The nutrients which in the slower growing child are used to build teeth may be needed in the faster growing child to build bones and muscle. However, this explanation does not account for the group of girls, age 10 to 12, who had a low incidence of caries and a rapid rate of growth. The analysis of the diets of girls, 10 to 12 years old, in Egggp_g.showed that their food intakes were better in calcium and vitamins than the food intakes of the correSponding children in group_££, In no other groups were the differences in diet so striking. It may be assumed from this that when the diet approaches adequacy, an increased rate of -38- growth may be accompanied with a 1ow incidence of caries. It would seem from the above discussion that dental caries is not a simple effect which can be attributed to one prevail- ing cause, but rather the result of a multiplicity of factors among which may be adeQuacy of diet and rate of growth. This study apparently confirms the observations of Boyd (1940) that as diets more nearly approach adequacy, children grow more ra- pidly and also have fewer dental caries. Ho clear-cut observation could be made as to the effect of carbohydrate upon dental caries from this study. For the most part, the carbohydrate consumption for ggggp_g was greater than for Egggp'gl, but this did not hold true in all cases. The num- ber of servings of sweets (sugar, cookies, cake, soft drinks, etc.) per child per day of the “low-caries" group and the"high- caries“ group in Q3232.I_was computed. In the “low-caries" group the mean number of servings of sweets was 3.0 per child per day. In the "high-caries" group, the mean number of serv- ings was 3.5. This difference does not seem large enough to warrant any conclusion that sweets may increase dental caries. No correlation could be found between the incidence of dental caries and the intake of vitamin D, but again the data .are too few to warrant any conclusion. Thirty-eight per cent of children in the ”low-caries" group were known to be receiv- ing vitamin supplements. Forty per cent of the children in the "high-caries" group were known to be receiving vitamin sup- -59- plements. in each group, approximately one-third of the vita- min supplements were known to be cod liver oil or cod liver oil concentrates. The other supplements were not identified, but in some cases these may have been multiple-vitamin compounds containing vitamin D. l. 3. SUMMARY Dental examinations were made of elementary school child- ren in two schools in the same geographical location. The children in $5252 I had fewer decayed, filled, or missing permanent teeth than the children in 25232.33, The differ- ence in caries rate, however, was considered significant only for girls, age 10 to 12 years. Heights and weights of "high-oaries* children of £5232 I were generally greater than heights and weights of “low- caries" children. However among girls, 10 to 12 years of age, the heights and weights of “low-caries“ children were , greater than the heights and weights of “high-caries" child- ren. No data on height and weight were obtained for ggggp, 11. Little difference could be found between diets of children in 93:922. _I_ and Q3933 E, or between diets of "low-caries" and "high-caries“ children, but it was observed that in all groups most of the diets failed to reach the National Research Council standards of adequacy. However girls, 10 to 12 years of age, in gm I had diets better in calcium, vitamin A, and ascorbic acid than the corresponding child- ren in Egggg II. this same group also showed fewer child- ren failing to meet the National Research Council standards 5. -41- for calcium, vitamin A, ascorbic acid, thiamine and ribo- fla Vin 0 An accelerated rate of growth seemed to be accompanied by an increase in dental caries, unless the diet was improved in proportion to rate of growth. No correlations could be found between amounts of carbohy- drate, sweets, or vitamin supplements ingested and incidence of dental caries. However, the data were inadequate to conclude that either sweets or vitamin D influence the pro- gress of dental caries. APPENDIX HEALTH RECORDS Name of Child Schoolgk_ Date Birth date __Age Sex Parent Address <__ Height-Wiight Record ' Disease accord I“ Year ' Weight 'Height When did child have the following diseases: German measles___, Red measles Mumps Influenza Chicken Pox Pneumonia infantile Frequency of colds Paralysis Rheumatic broken bones fever Diphtheria Surgery f Scarlet fever_ Small :01: Tubercu1031s Meningitis Diarrhea Otherw How often are dental examinations Remarks:- made of child? DIET RECORD : INTERVIEW Record of All Food That Was Eaten on One Day name Date Day School v ‘R Breakfast Noon Meal Description of food Amount Description of food Amount Night Meal Between Meals Description of food Amount Description of food Amount __..—_l,__ ‘ Diet Record : Interview (Cont'd) If not eaten yesterday, when did you last have the following foods? Orange or grapefruit, or Juice Tomato, or juice E88 Butter or substitute Brand Cheese Milk to drink Leafy vegetables, spec. Meat, fish, chicken Meat substitute, spec. Was any food served yesterday which you did not eat? What was it? Why didn't you eat it? lhen did you last have the following: Ice cream (cones, sundaes, sodas, etc.) Candy Chewing gum ‘_ Soft drinks (cokes, soda pop, etc., spec.) Coffee Tea Remarks: FOOD AND DIET HABITS Name Date w_School Do you usually eat about the same breakfast? UIf not, explain Do you drink milk?w Number of glasses per day What foods don't you Like? What foods do you not eat? What foods do you like especially? Do you take Cod Liver Oil? Name of preparation and brand Amount daily Do you take other vitamin preparations? Name of preparation and brand a, Amount daily Where did you eat lunch yesterday? What hour did you get up this morning? Yesterday?_, What hour did you go to bed last night? How did you spend last summers vacation? LIST OF LITERATURE CITED Baton, W.D. Elementary mathematical Statistics. New Ybrk: John Wiley & Sons, Inc., I958, 338 pp. Berk, s. 1943. Some factors concerned with the incidence of dental caries in children. Multiple pregnancy, and nu- trition during prenatal, postnatal and childhood periods. J. Amer. Dent. Assoc. 30: 1749-1754. Bibby, B.G. 1944. Use of fluorine in the prevention of dental caries. I. Rationale and.approach. J. Amer. Dent. Assoc. 31: 228-236. Borsook, H. and Helverson, W.L. 1940. Nutrition and health in Pasadena. Amer. J. Pub. Health. 30: 895-900. Bowes, A. D62. 1938. reaching nutrition to dental students at the Universfiy of Pennsylvania. J. Amer. Diet. Assoc. 14: 5460 Bones, A.DeP. 1943. Dentistry and diet. J. Amer. Dent. Assoc. 30: 1560-1367. ‘ Boyd, J.D. and Drain, C.L. 1928. rho arrest of dental caries in childhood. J. Amer. Med. Assoc. 90: 1867. Boyd, J.D. 1940. The role of diet in the control of dentinal caries. J. Amer. Dent. Assoc. 27: 760-756. Boyd, J.D. 1942. Nutrition as it affects tooth decay. J. Amer. Diet. Assoc. 18: 211-215. Boyd, J.D. 1943. Prevention of dental caries in late child- hood end adolescenne. J. Amer. Dent. Assoc. 30: 670-680. Boyd, J.D. 1943. Long term preventicn of tooth decay among diabetic children. Amer. J. Dis. Child. 66: 349-561. Boyd, J.D. 1944. rhe need for betterment of children's diets. J. Amer. Diet. Assoc. 20: 147-149. Boyd, J.D. 1944. Dental caries as influenced by fat versus carbohydrate in the diet. Amer. J. Dis. Child. 67: 278- 281. Bunting, s.«. 1939. Diet and dental caries. N.Y. State J. sea. 39: 18-21. (Nutrition Abst. and Rev. 9: 1064, 1939-1940). Collins, n. 0., Jensen, AAL. and Becks, H. 1942. Study of caries-free individuals. 2. is an optimum diet or a re- duced carbohydrate intake required to arrest dental ca- ries? J. Amer. Dent. Assoc. 29: 1169-1178. Cowles, M.L. 1935. A.study of winter food consumption in Wisconsin farm families. J. Amer. Diet. Assoc. 11: 322- 330. Dean, H.T., Jay, P., Arnold, F.A. (Jr.), McClure, r.J. and Elvove, A. 1939. Domestic water and dental caries, including cer- tain epidemiological aspects of oral L. acidophilus. Pub. Health Rep. Washington. 54: 862- 888.- (F:trition Abst. and net. 9: 743, 1939-1940). Dean, H.T., Jay, P., Arnold, r.A. (Jr.) and Elvove, E. 1941. Domestic water and dental caries. 1. A.denta1 caries study, indluding L. acidophilus estimations, of a population se- verely affected’hy mottled enamel and which for the past 12 years has used a fluoride-free water. 2. Astudy of 2, 832 white children, aged 12-14 years, of 8 surburban Chicago Communities, including Lactobacillus acidophilus studies of 1,761 children. Pub. Health nap. Washington. 56: 365-381; 761-792. (Nutrition Abst. and nev. 11: 332, 1941-1942). Deatherage, C.r. 1943. Fluoride domestic waters and dental ca- ries experience in 2026 white lllinois selective service men. J. Dent. has. 22: 129-137. (Nutrition Abst. and usv. 13: 288, 1943). Dechaume and Cauhepe. 1943. La carie dentaire chez 1'enfant. Presse med. 51: 236. 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