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CARIES IN DECIDUOUS TEETH IN RELATIONTO MATERNAL INGESTION OF FLUORIDEJames P. Carlos, D.D.S., M.P.H.Alan M. Gittelsohn, Ph.D., M.P.H.William Haddon, Jr., M.D., M.P.H.THE prophylactic effect of fluoride in the pre¬vention of dental caries is well established, andthis effect is known to be greatest when teethare exposed during the period of calcification.Since much of the enamel of deciduous teethcalcifies prior to birth, the possible benefit frommaternal ingestion of fluoride during pregnancyis a subject of both practical and theoreticalinterest.A recent report (1) states that 25 ppm offluoride (as NaF) in water given rats duringgestation had no effect on caries incidence inthe offspring. Evidence regarding transpla-cental passage of fluoride is conflicting. Theexistence of a placental barrier which mediatesand perhaps impedes the transfer of the ionhas been suggested (2, 3). However, in man,a considerably higher cord-blood fluoride con¬centration has been demonstrated with mothersexposed to fluoridated water throughout preg¬nancy (4). Although these investigations areof interest, they do not answer the fundamentalquestion as to the effects of maternal ingestionof fluoride during pregnancy on the occurrenceof caries in the deciduous teeth of offspring.The authors are with the New York State Depart¬ment of Health. Dr. Carlos is senior resident inepidemiology, Dr. Gittelsohn is director of the officeof biostatistics, and Dr. Haddon is director of theepidemiology residency program. This investiga¬tion was supported in part by research grant 2G-558from the Public Health Service. The data on whichthis study was based were made available by Dr.David Ast, director, bureau of dental health, NewYork State Department of Health.This report provides such information for 178children who were in utero before and after thebeginning of water fluoridation in Newburgh,N.Y.MethodsThree cohorts of Newburgh children, each ex¬amined at 6 years of age, were studied. CohortA consisted of 52 children born in February,March, or April, 1945, just before fluoridationof the water supply began on May 2, 1945.These children served as a control group. Co¬horts B and C, consisting of 52 and 74 childrenborn in the same months 1 and 2 years later,presumably were exposed to water containing1-1.2 ppm sodium fluoride from birth, as weretheir mothers throughout gestation. Only chil¬dren born in Newburgh were included, with theexception of nine in cohort A who were born innearby towns, none of which had fluoridatedwater supplies. Data on caries prevalence intheir deciduous teeth were gathered for thethree cohorts in 1951-53 during an intensivestudy of the effects of water fluoridation (5).All examinations were made by the same per¬son. The cohorts did not differ significantlywith respect to sex, race, or the proportion ofchildren from various school districts.FindingsThe average number of decayed or filled teethand tooth surfaces at age 6 was very similar inall three cohorts (table 1). A slightly higherpercentage of children in cohort C were entirelyfree from caries than in either cohort A or B.658 Public Health ReportsHowever, the difference was well within chancelimits (P>0.50).Incisors and first molars begin intrauterinecalcification earliest (6). It might therefore beexpected that these teeth, because of theirlonger exposure, would evidence greater benefitfrom any prophylactic effect of prenatal fluo¬ride than cuspids or second molars. Table 2shows the percentage of children in each cohortwho were free from caries in each of these typesof teeth. No significant association betweenmaternal ingestion of fluoride and freedom fromdecay was demonstrated in any tooth group.DiscussionA comparison of the percentages of childrenfree from decay, as made here, is not an entirelysatisfactory indicator of possible differences be¬tween groups. Some sensitivity is lost since aperson with one decayed first molar, for exam¬ple, is given equal weight with one who hascaries in all four of these teeth. However, themore usual comparisons of the average numberof decayed teeth or tooth surfaces per personcan be misleading, because of stronger correla¬tions between the condition of teeth within in¬dividual mouths than between differentindividuals. The consequent lack of independ¬ence between observations of this type makesstatements about the statistical significance ofany observed differences hazardous. For thisreason, tests of significance of the differencesbetween the average number of decayed teethper child in the three cohorts were not used.However, the consistency of the data supportsthe conclusion that exposure of the pregnantwoman to fluoridated water had no observableeffect on the caries experience of the deciduousteeth of the children in this study.Table 2. Percentage of 6-year-old childrenhaving no caries in specific types of teeth,by cohort1 Mothers of cohort A were not exposed to fluorideduring pregnancy; those of cohortsB and C were exposed.2 By the chi-square test.Whether these findings indicate placental in¬terference with the supply of fluoride to theteeth in utero is debatable. Although not pos¬sible in this study, a determination of the fluo¬ride content of teeth at birth in relation to ma¬ternal ingestion of fluoride would help clarifythis. Even if no such barrier exists, there maybe qualitative and quantitative differences inthe effects of fluoride during the prenatal as op¬posed to the postnatal period of tooth calcifica¬tion. It is also possible that the effect of fluo¬ride which may reach the fetal teeth is maskedby postnatal fluoride ingestion. These pointsmerit further investigation.SummaryA study of three cohorts of children demon¬strated no significant association between theoccurrence of dental caries in their deciduousteeth and the ingestion of fluoridated water bytheir mothers during pregnancy.Comparisons made between 6-year-old chil¬dren born during the 3 months preceding fluori¬dation of the water supply in Newburgh, N.Y.,Table 1. Prevalence af caries in deciduous teeth of 6-year-old children, by cohort1 Mothers of cohort A were not exposed to fluoride during pregnancy; those of cohorts B and C were exposed.Note: df.decayed or filled.Vol. 77, No. 8, August 1962 659and those born during the same months 1 anid 2years later, showed little difference in the aver-age number of decayed or filled teeth or toothsurfaces, in the percentage of children entirelyfree from caries, or in those free from caries inspecific types of teeth.REFERENCES(1) Stookey, G. K., Osborne, J., and Muhler, J. C.:Effects of pre- and postnatal fluorides on caries.Dental Progress 2: 137 (1962).(2) Gardner, D. E., Smith, F. A., Hodge, H. C.: Thefluoride content of placental tissue as related tothe fluoride content of drinking water. Science115: 208 (1952).(3) Buttner, G., and Muhler, J. C.: Fluoride pla-cental transfer in the rat. J. Dent. Res. 37:326 (1958).(4) Feltman, R., and Kosel, G.: Prenatal ingestion offluorides and their transfer to the fetus. Sci-ence 122: 560 (1955).(5) Ast, D. B., Smith, D. J., Wachs, B., and Cantwell,K. T.: Newburgh-Kingston caries-fluorinestudy. XIV. Combined clinical and roentgeno-graphic dental findings after ten years of fluo-ride experience. J. Am. Dent. A. 52: 314 (1956).(6) Kraus, B. S.: Calcification of the human dentition.J. Am. Dent. A. 59: 1128 (1959).The Medical Center in the Nation's FutureI believe that the university-based medical centeris the key to the future of the nation's health. Meet-ing the challenges before us will require genuinebreakthroughs in all of the three basic elementswhich comprise the world of medicine-teaching,research, and service. Too frequently the medicalschool, the nursing school, the teaching hospital, theresearch program, and community health serviceshave been thought of as separate and distinct entitiesfunctioning independently of one another. It is myfirm conviction that they are, in fact, inseparable,and that our failure to recognize and build upontheir interrelationships has cost us dearly in dupli-cation of effort and dispersal of resources.The "medical center" concept, which has beengiven practical realization in recent years, offershigh promise for this kind of coordination. Typi-cally, such a center has as its nucleus a medicalschool for undergraduate training. The scientistsneeded to direct such a program can be retained,and can be most effective, if they have facilities forresearch. An environment which encourages thepursuit of new knowledge lends vigor to the teachingprogram.These same faculty members, and others attractedto the center, help to train graduate specialists invarious fields of the parent university-from whichfuture medical educators and researchers will berecruited. They also play a part in the training ofparamedical personnel.At the same time, the medical center strengthensthe teaching of clinical specialties, conducted inclose relation to patient care by a corps of clinicalteachers. The teaching hospital, therefore-whetherit is directly operated by the medical school oraffiliated with it-is an indispensable componentof the medical center. The clinical faculty, in turn,has growing responsibilities in the graduate trainingof interns, residents, and fellows.Medical - centers so conceived can and shouldprovide leadership in coordinating medical serviceswithin their areas, and in providing postgraduateand specialized training opportunities for prac.-ticing physicians, nurses, and others in the healthprofessions.Such a program-which combines basic andclinical research, teaching at many levels, andcoordinated medical services to the community-represents a logical and constructive developmentof the concept of coordination on which, I believe,our medical future depends.-BOISFEUILLET JONES,Special Assistant (Health and Medical Affairs) tothe Secretary, Department of Health, Education,and Welfare, from commencement address, Uni-versity of Mississippi Medical Center, Jackson,June 10, 1962.660 Public Health Reports

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Neurocardiac syncope (NS) is a common cause of syncope in children. The mechanism, though related to abnormalities in autonomic function, has not been fully elucidated, particularly in pediatric patients. This study assessed the heart-rate variability (HRV) response to head-upright tilt-table test (HUT) in children with NS and normal volunteers. Spectral and time-domain analysis of HRV was used to assess changes in autonomic function in 27 children (9 male, mean age 12.3 +/- 1.6 years) with a history of at least one episode of syncope and positive passive HUT and 27 age-matched normal volunteers with negative passive HUT before and during postural tilt and to attempt to relate such changes to specific types of hemodynamic response to tilt. Frequency-domain measurements of the high-(HF) and low-(LF) frequency bands and the ratio LF/HF were derived from Holter recordings and computed by fast Fourier analysis for 5-min intervals. Time-domain measurements of the SDNN, SDNNI, SDANN, RMSSD, and triangular index were derived from 24-h Holter recordings. There were no significant differences between clinical characteristics, time-domain, and basal frequency domain parameters of the groups. Mean values of LF and LF/HF ratio was increased and HF was decreased significantly in response to tilt in both patient and control groups. Mean values of LF and LF/HF ratio were higher and HF was lower compared to controls immediately after tilt. LF and LF/HF ratio showed a statistically significant decrease and a significant increase in HF during syncope in patients. The three subgroups of patients had similar patterns of changes in autonomic activity. The results of this study show that although the basal autonomic function was similar to that of the control group, patients with NS have a different pattern of response to the HUT. In our study, patients with NS demonstrated an exaggerated response to the HUT. This exaggerated response may be the factor that activates the pathological reflexes of NS. The pathological mechanism leading to NS appears to be independent of the specific type of hemodynamic response to HUT

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