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period for which the first members were appointed, members of it are to be elected in the manner prescribed by regulations to be made by the board. The board has power to appoint officers and make by-laws. The registrar appointed by the board is to keep a register of dentists, and names may be removed if the practitioner be convicted of crime. Penalties are inflicted for wilful falsification of the register, and for unregistered persons using the title of "dentist," "dental surgeon," "dental practitioner," or other names implying that they are registered. Unregistered persons are not to perform operations. The qualifications necessary for registration are: "Any person who is a licentiate in dental surgery of the Royal College of Surgeons of England, the Royal College of Surgeons of Edinburgh, the Royal College of Surgeons, Ireland, the Faculty of Physicians, Glasgow, the Dental College, Sydney; holds such diploma, certificate, or other title, status, or document as may be recognised for the time being by the board as entitling the holder thereof to practise dentistry or dental surgery; has been for the period of two years immediately before and is at the passing of the Act bond fide engaged as a principal in the practice of dentistry, dental surgery, or pharmacy in South Australia, and shall produce or transmit to the registrar information of his name and address and a declaration signed by him in the form provided by the second schedule hereto; is registered or entitled to be re-registered in the United Kingdom as a graduate in dentistry of a medical school or university granting degrees in dentistry upon a curriculum and examination. No person who, at the passing of the Act, is engaged as a mechanic only in making artificial teeth, or making other materials into appliances for other dental purposes, shall be entitled to be registered unless he is registered under the Dentists Act of the United Kingdom and has been resident in South Australia for three years."-Adelaide Observer, Nov. 30, 1901.
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Journal of the
British Dental Association
FEBRUARY 15, 1902.
Is the Symmetrical Extraction of the First Permanent Molars Justifiable?
BY MR. ELOF FORBERG (STOCKHOLM, SWEDEN).
READ AT THE ANNUAL GENERAL MEETING HELD IN LONDON, AUGUST, 1901.
MR. PRESIDENT, LADIES AND GENTLEMEN,-Whilst in other departments of dental science during the last decades progress has been made, so great that scarcely any other branch of the healing art is able to exhibit anything equal, the present question, in spite of all that has been said and written on the subject, remains almost the same as it was half a century ago. Even to-day we find about the same arguments advanced for the extraction of the six-year-old molar as in the year 1830 or 1840.
A doctrine preached for such a length of time unrefuted easily gains the character of a dogma; and in fact some authors who have dared to call its truth in question have been treated almost as heretics. When I, nevertheless, dare to stand up in the defence of the first permanent molars, it is not only because I have after more than twenty-five years' experience and thorough study of the question, arrived at an opinion that differs from the one generally advocated, but also because I find it high time to oppose that, if I may say so, wholesale extraction of the teeth in question which has been recommended in some lately published works on the subject. I want also now, when I have the honour of speaking before the British Dental
Compare "The Odontologist, or How to Preserve the Teeth," &c., by J. Paterson Clark, London, 1854; Fox and Harris, "Diseases of the Human Teeth," Philadelphia, 1876, &c.
Association-which has done more than any other dental society in the world for the benefit of the school children and the preservation of their teeth-to use this opportunity to call the attention of the members of this Association to the great import of the question for the future welfare of the little patients, an import that it seems has not been so generally understood as its great consequence deserves.
The subject of the symmetrical extraction of the first permanent molars that formerly has been debated principally by English and American authors, has in later years been the subject of controversy also on the Continent.
On one side, Fenchel, Röse, Greve and others have shown how essential it is to preserve these teeth. Fenchel strongly recommends the use of hygienic measures for the preservation of children's teeth, and especially of the first permanent molars, the extraction of which he calls "the most barbarous act that a thinking dentist can possibly be guilty of." On the other side the subject in question has not been without its defenders. Dr. Sternfeld, in a recently issued publication,' which has created a good deal of attention, enthusiastically praises the symmetrical extraction of the first permanent molars.
Dr. Sternfeld, in using as a starting point Dr. Andrieu's wellknown monograph on the extraction of the six-year molar, advocates extraction in the following cases :—
(1) Where the teeth are badly decayed and the pulp exposed; (2) where the size of the jaw is not in proportion to the teeth, or, in other words, where the jaw does not give sufficient room for the teeth; and (3) where the teeth are irregularly placed or crowded.
He advocates extraction "as a first-class prophylactic measure," because it gives room not only for the anterior teeth, but also for the coming third molars, which he holds not to be as bad as they are generally credited with being.
It is, of course, not now my intention to enter into a more thorough criticism of Dr. Sternfeld's work: this is not the proper place, and besides, it would carry me too far to do so. The subject is so rich that it is much easier to write a book than to condense it into a paper. I will only investigate the subject in order to see whether the said authors have advanced any new and decisive proofs, and whether the question thereby has been conclusively solved. As the main argument for the symmetrical extraction of the first permanent molar it is generally advocated—
(1) That according to various statistics that tooth should be more liable to caries than any other tooth.
(2) That the extraction gives room for the remaining as well as for the coming teeth.
1 Ueber die sogenannte frühzeitige Extraction, &c., by Dr. Alf. Sternfeld, Vienna,
If we more critically examine these arguments, we will soon find that both of them rest only on vague presumption.
The dental statistics which up to the present time have been published are of a very different kind, some being founded on extractions of different teeth, some on teeth treated at a polyclinic or in private practice, and others, again, on the examination of school children's teeth and of the conscript soldier's teeth. It is easily to be understood that the first two of the above statistics cannot be used as a foundation to build a statistic on, or about the frequency of dental caries in general, or the liability of the different teeth to this affection; so the only course to which we can turn for a complete average is through the public schools and the conscripts.
Some authors have quite simply compared statistical figures obtained from such different sources as the above-named, a procedure which, self-evidently, must be stamped as wholly unreliable. In order to compare statistical figures, we must take into consideration different factors, such as age, sex, race, &c. One of the above-mentioned authors, Greve,' says: "If you wish to obtain a somewhat uncriticisable statistic on the frequency of caries in the different teeth, you must compare the first permanent molars between the ages of six and seven years, with the second permanent molar between the ages of twelve and thirteen years, which up to the present time has not been done."
The Committee on Investigation of School Children's Teeth, appointed by the Swedish Dental Society, has gathered material comprising about 18,000 children. From this extensive material I have worked out some statistical tables, showing the comparison above asked for. The statistics gathered for this paper comprises 15,000 children, of whom 8,021 are boys and 1,979 girls, between the ages of seven and sixteen years, children from both higher and public schools from different parts of Sweden. Therefore the figures given may be considered fully reliable. From my statistical tables, as most nearly touching upon the subject of my paper, I wish to show the result of the comparison between the first and the second molar.
In order to start fair for this comparison, we must in the first place take into consideration the different times of eruption. The first permanent molar appears with pretty great regularity about the ages of six and seven years, but the time for the appearing of the second molar spreads over a period of several years. The only dependable source for the comparison is, therefore, to see at what time both teeth have appeared in the like number-for example, for 100 children. If we look at Table XIV., we learn that the first molar at the ages of seven to eight years corresponds in number approximately with the second molar in the upper jaw, between the
Ueber die Berechtigung der fruhzeitigen Extraction des sechsjahrigen Molaren, Deutsche Monatschrift f. 2., 1896.
ages of fourteen and fifteen years, but in the lower jaw between the ages of fifteen and sixteen. If we then on Table XV. compare the frequency of caries between these teeth in the above-mentioned ages, we obtain the following summary:
In looking at these figures, it ought to be hard to dispute that (within the years in question) the second molars in the upper jaw are relatively more liable to caries than the first molar; in the lower jaw, on the contrary, this difference is hardly worth mentioning as far as the boys are concerned. With the girls the difference seems to go in the opposite direction; but this latter number ought not to carry any great weight, as the figures 41, judging all, must be too small owing to the small number of girls of that age in the public schools who were to be examined. Therefore incidental factors have played a great part, and made the figure lower than it otherwise ought to have been. Judging from all the rest, this figure ought not to be lower than fifty per cent., or, as in the case of the boys, about the same as for the first molar.
In a paper' read at the International Dental Congress in Paris. last year I gave a comparison between the frequency of caries in the first and second molars, gained from statistics of nearly 7,000 children, which comparison showed similar figures to the above. My clinical experience leads me to believe that the first molar, on being released from the dangerous proximity of the second deciduous molar, will not be so exposed to the attacks of caries as before, but, on the contrary, the second molar's liability to the attacks of this disease rather increases than decreases. A support to this, my supposition, is to be had from the statistics mentioned, which shows that, while the frequency of caries of the first molar from the ages of six to about eleven years increases on an average about nine per cent. every year, it remains nearly stationary during the following years, whilst the figures relating to the second molar during the same length of time. are doubled. This is still better seen in the tables that follow my above-mentioned paper. According to this, the tooth seems to offer considerably greater resistance against the attack of caries after the tenth or eleventh year than before.
I have just shown that the first molar, on account of unfavourable hygienic conditions during the period of six to eleven years, rapidly attains a high percentage of caries, but that it remains about stationary afterwards.
Etude sur les enfants dans les écoles de suède; translated and republished in the Dental Cosmos.