Stomatology in general practice : a textbook of diseases of the teeth and mouth for students and practitioners

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22101914979

Med

OXFORD MEDICAL PUBLICATIONS

Preface

‘ He that Jceepeth his mouth keepeth his life ’

There is a somewhat ill-defined territory lying between medicine and dentistry, which to many practitioners is to a certain extent a terra incognita.

There is also practically the whole field of dental disease and its treatment which is certainly the same to the general practitioner of medicine. It is from a firm conviction that these fields should be recognized and well known that this book has been written. An attempt has been made to throw a beam of light across this territory, so that its main features and important points will stand out in bold relief ; it has not been my object to try to illuminate the minute details of the whole area to be covered.

It should be understood that this book is not meant to replace what will be found in the usual textbooks on medicine, surgery, and dental surgery, it is rather meant to correlate, amplify, and elucidate much of the information there given.

To expect a medical practitioner or student to read a modern textbook on dental surgery would be futile ; the information which would be of value to him would be so scattered and confused with technicalities as to occasion only a waste of valuable time. Yet no one can doubt at the present time that it is absolutely essential that practitioners of medicine should be familiar with the pathology and means of treatment of the more common diseases arising in connexion with the oral mucous membrane, teeth, and jaws.

vi STOMATOLOGY IN GENERAL PRACTICE

Again, dental students and dentists should have a clear conception of the cause, diagnosis and course of all those oral lesions which are so intimately associated with dental or peri-odontal tissues, and it is hoped that this book will form a useful complement to the increasing number of dental publications dealing exclusively with operative dentistry.

The part played by chronic infections of the teeth and buccal tissues in giving rise to grave secondary systemic and local disorders is rapidly becoming more generally recognized, and it is not sufficient that a practitioner should be content with advising the patient to ‘ get his teeth seen to ’ or ‘ to go to the dentist ’, and thereby absolve himself of all responsibility. In view of the extent to which dentistry is at present practised by unqualified, untrained, and illiterate individuals, it is eminently desirable or even necessary that every medical practitioner should be in a position to be able to tell a patient exactly what the oral condition is, to see that the seriousness of the condition is recognized, to give sound advice as to treatment, and to see that the latter is carried out.

Very valuable indications, too, from a diagnostic point of view, may be frequently gained from a critical examination of other tissues in the mouth than the mucous membrane of the tongue. Not only so, but in a large number of cases a medical practitioner is obliged by circumstances to undertake treatment — to give only two instances : ‘ toothache 5 is treated by extraction, and fracture of the jaw by a four-tailed bandage — typical examples of simple, empirical, but frequently eminently bad methods of treatment resulting entirely from lack of training or teaching.

There should be no lack of training or teaching, it should be compulsory for every medical student to attend a short class on dental surgery or stomatology before his final examination, in order to ensure that he at least has some knowledge of diseases which will be confronting him

PREFACE

Vll and complicating his work every day of his professional life. Such a course is obligatory in this university, and the present publication is a somewhat amplified form of lectures which have been delivered during the past year to a postgraduate class of medical practitioners and also to medical students.

As regards the general scope of the work, diseases of the mucous membrane and the jaws have been described rather from an setiological point of view, and the treatment indicated. Tumours of the jaws arising from dental tissues have been dealt with more fully, because this subject is usually very inadequately dealt with in general textbooks, yet such cases require early diagnosis in view of their tendency to malignancy. Fractures of the jaws and the indications for the various kinds of splints have been described somewhat fully, since I have found this subject to be generally but imperfectly grasped.

The pathology, preventive and remedial treatment of dental disease, have been discussed in some detail with especial reference to the physiological means of immunity ; surgical methods of treatment have been described to such an extent as will enable the reader to adopt rational and correct methods from a palliative point of view chiefly, and to this end a short list of necessary instruments recommended for the purpose has been added in an appendix.

Special chapters have been devoted to the effects of systemic diseases upon the oral tissues, and to the effects of oral sepsis upon systemic conditions.

A rapid but effective method of recording the examination of school children’s teeth has been described in an appendix.

No particular reference lias been made to diseases of the tongue, these are generally sufficiently well recognized, and in any case lie outside the scope of this book. The original matter in the work includes the combined surgical and viii STOMATOLOGY IN GENERAL PRACTICE mechanical method of treating cleft palate ; the preventive treatment of dental caries ; surgical treatment of dental arthritis ; and a simple method of treating fractures of the jaw.

It has not been thought necessary to include a bibliography in a book of this kind, but most of the standard works have been consulted and reference has been made to current literature.

The majority of the illustrations are original, for a few I am indebted to the kindness and courtesy of others ; acknowledgement of these is made in the text.

H. P. P.

Contents

CHAPTER PAGE

I. Historical .... 1

II. The Development, Anatomy, and Physiology

Chapter I Historical

Two things are obvious from a study of the earliest records of the practice of Medicine ; the one that even in those remote times diseases of the buccal tissues and the teeth were not infrequent, the other that the treatment of these diseases was carried out by the practitioners of Medicine. In fact, it is only in comparatively recent times that medical practitioners have ceased to pay the same attention to such diseases as they formerly observed.

The origin of any systematized practice of medicine is found to be coeval with the beginning of a condition of higher civilization, doubtless being a case of demand and supply, that is to say, that as man receded from a purely natural mode of life and his environment became more artificial, so doubtless fresh diseases sprang up demanding the increasing care and thought of the more mentally trained of the community, i.e. the priests. Among diseases which thus arose were pathological conditions of the teeth and oral mucous membrane, due most probably in great measure to those dietetic changes which are inseparably connected with the social evolution of the human race.

One of the first nations to undergo such evolution was undoubtedly the Egyptian, and of this race we have records which date back to about thirty-seven centuries before the Christian era. The ‘ Ebers 5 papyrus, the compilation of

PICKERILL T> which was probably started about that time, gives detailed descriptions of the treatment then in vogue by the priests for many maladies, and amongst them a large number of prescriptions for the treatment of diseased buccal tissues. Curiously, nearly all these contain honey — probably to cover the taste of the other obnoxious ingredients. There are no indications that the Egyptians of this period practised surgery of the teeth in any form (apart from the use of applications), and although it has been stated that mummies had been found with teeth filled with gold this has so far lacked actual proof.

Asklepios, the god of Medicine (twelfth to thirteenth centuries b.c.), is believed to have been the first to introduce the practice of extracting teeth.

Hippocrates (460 b.c.), the ‘ father of Medicine ’, and himself one of the Asklepiadi, was the first to make any systematic study of the teeth, their development, diseases, and treatment. He wrote a book De dentitione , concerning diseases accompanying the eruption of the deciduous teeth, and described the intra-uterine formation of teeth.

It is very probable that the term ‘ milk teeth ’ dates from this time, for Hippocrates says in De carnibus, ‘ the first teeth are formed by the nourishment of the foetus in the womb, and after birth by the mother’s milk. Those that come forth after these are shed are formed by food and drink.’

He recommended counter-irritation for painful teeth and extraction for loose teeth, and also prescribed many fanciful dentifrices and mouth-washes for the preservation of the teeth. That an ulceration of the tongue might be caused by a rough or sharp tooth was first noted by him, and he taught too that many lesions of other organs were associated with oral disease. He introduced the wiring together of the teeth in cases of fracture of the jaws — a method which has recently been ‘ rediscovered ’.

HISTORICAL

Aristotle (384 b.c.) made many remarkable observations on the comparative anatomy of the teeth, but also seems to have originated the error that men have more teeth than women ; he speaks of iron forceps being used to loosen teeth, the latter being afterwards extracted with the fingers.

Celsus (30 b.c.), who, if he was not a great physician himself, by his writings gave a very good account of the practice of medicine in Rome in his time. He described various forms of stomatitis, including probably what is now known as Cancrum oris , since he says that the ulceration might spread extensively and lead to the death of the child. He advised the extraction of teeth in certain cases, but only after a large number of sedative applications had first been made and failed. He also devoted considerable attention to fractures and dislocations of the lower jaw, and described a ‘ four-tailed ’ bandage.

Another writer of the same period, Scribonius Largus, who is said to have accompanied the Emperor Claudius to England in a.d. 43, is of some interest to us in that he inveighed strongly against the growing tendency to specialization. He treats of the cure of odontalgia by fumigations and masticatories, and relates that the Emperor’s wife owed the whiteness of her teeth to the use of ammoniacal toothpowders. With this writer seems to have originated the theory, not yet extinct, that caries of the teeth is due to the action of small worms, and that these can be expelled by suitable fumigation.

In Galen we have another name inseparably connected with the history of Medicine, and, if one may judge from his writings, no small part of his work related to the teeth. He first noted that teeth were supplied with nerves, and he considered that caries was due to a corroding action from within — similar to ulceration. He enumerated a large number of remedies for odontalgia, but seems to have been somewhat afraid of extraction and its after effects. He appears to have been the first to distinguish between dental myelitis and periodontitis, though he likewise promulgated an error, which still exists, that human teeth are capable of growth after complete formation in order to compensate for physiological attrition.

In the early Middle Ages some of the most eminent exponents of the art and science of Medicine were the Arabians. Of these, Rhazes (circa a.d. 850), Avicenna (a.d. 980), and Abuclasis (a.d. 1050) were the most famous. These all included the treatment of dental and other oral disorders in their practice ; they invented quite a large number of instruments for removing calculus, loosening teeth (previous to extraction), regulating teeth, and for the performance of actual cautery. Abuclasis has the merit of having applied transillumination for the diagnosis of oral tumours. The sun was the illuminant, and only swellings which freely transmitted light were to be operated upon, tumours opaque to sunlight were to be avoided. The same surgeon also advocated the re-implantation of teeth which had been dislocated by trauma, and ligatured them in position with fine gold wire.

Passing on now to more modern times, namely the sixteenth century, we find such men as Vesalius, Eustachius, and Fallopius all paying considerable attention to the jaws and teeth, more especially, of course, from an anatomical point of view. Vesalius, for instance, described accurately for the first time the anatomy of the roots and pulp -cavities of the teeth ; he noted also that the ‘ wisdom ’ teeth, although completely formed, frequently did not erupt at all. F allopius paid considerable attention to the development of the teeth, and, considering that of course the microscope was unknown to him, his descriptions are wonderfully accurate ; whilst to Eustachius belongs the distinction of publishing the first book on the anatomy of the teeth ( Libellus de dentibus, 1563).

HISTORICAL

Ambroise Pare, who flourished in this period, was essentially a surgeon ; he was neither anatomist nor theorist, but confined himself almost entirely to the practice of Surgery, and in this the surgery of the mouth was an important part. He devised and used obturators for the treatment of acquired clefts of the palate ; for fractures of the jaw and dislocation of the teeth he used practically the same method as Hippocrates ; whilst for the extraction of teeth he had an elaborate array of formidable-looking instruments called pelicans, besides files, lancets, levers, &c., for other operations connected with the teeth.

During the seventeenth century Highmore described the Maxillary antrum, but although he recognized that diseased teeth might be associated with a continuous discharge from the antrum, he did not regard this as pathological but as quite a natural or normal occurrence, and did not even suggest that the condition should be treated. In fact no form of treatment was adopted for empyema of the antrum until the beginning of the next century, when William Cowper showed that by extracting the first molar tooth and perforating the antrum through its socket, the sinus could be cleared out, irrigated, and drained.

During the same period the microscope was devised by Leeuwenhoek, and the minute investigation of human tissues received a fresh impetus ; probably the first bacteria ever seen were described by Leeuwenhoek as ' animalculee ’, found in the deposits removed from interdental spaces in the mouth.

Somewhere about the year a.d. 1700 the treatment of the teeth began to be recognized as a speciality, for Pierre Fauchard1 says 'that about that time in Paris it became necessary to pass an examination to qualify as a dentist \ Pierre Fauchard was himself a surgeon practising oral and dental surgery, and had been ' the disciple of Alexandre

1 Le Chirurgien Dentist e, 174C.

Poteleret, Surgeon-in-chief to His Majesty’s Ships, who had great experience in diseases of the mouth’.

The great John Hunter paid a considerable amount of attention to the anatomy, pathology, and surgery of the teeth. His two books — The Natural History of the Human Teeth (1771) and Practical Treatise on the Diseases of the Teeth (1778) — placed the subjects for the first time in England upon a rational and scientific basis. Hunter was a great exponent of the operation of implantation and transplantation of teeth, and strangely enough, although he knew naught of bacteria, insisted upon the necessity of boiling the tooth which was to be used. Despite this, however, the operation fell into disrepute owing to the cases of syphilis which were reported to have been thereby transmitted.

Thomas Berdmore, dental surgeon to George III, and who was contemporaneous with Hunter, recognized the necessity of medical students knowing something concerning the diseases and surgery of the teeth, and so held classes for that purpose, as also did Fox, a surgeon on the staff of Guy’s Hospital at the beginning of the last century.

Thus we have briefly traced the origin and course of ‘ Stomatology ’ from the earliest records down to within measurable distance of the present time. We have seen that all those whose names are inseparably connected with the history of general medicine have also materially assisted in the growth and development of this special subject, and all that we know we owe to the gradual but persistent accumulation of facts and data by these and such -like men.

Chapter II

THE DEVELOPMENT, ANATOMY, AND PHYSIOLOGY OF THE TEETH AND ADJACENT STRUCTURES

Teeth are commonly said to be dermal appendages and to be analogous to hairs and nails. This is very misleading, and indicates only a small part of the truth. By far the greater part of a tooth — the part which gives it its characteristic shape and structure — is mesoblastic in origin ; that is to say, the dentine, pulp, and cement are derived from mesoblast, whilst the cap of enamel covering the crown is the only part which arises from the epiblast. It does not accord with our present purpose to give a detailed description of the development of the teeth, but yet it is essential that there should be a clear conception of the salient points in such development.

The accompanying diagrams (Fig. 1) illustrate graphically the various stages in the development of the lip, the labiodental sulcus, and the teeth ; for a fuller description readers should refer to other works.1

Points which should be noticed are (i) the very early period at which development commences ; (ii) the condensation of mesoblastic tissue before the advancing epithelial downgrowth ( Zahnleiste ) — f barring ’ as it were its further advance. It is essential that this should occur ; if it does not form in this manner a kind of odontoma results, to which we shall refer later, (iii) The very early presence

1 Cunningham, Anatomy, 3rd edition ; or Tomes, Dental Anatomy, sixth edition.

and proximity of the permanent to the deciduous tooth-germ on the lingual side of the jaw.

Calcification commences at the line of junction of the epithelium and mesoblastic cells, in the tooth -germ.

Fig. 1. Diagrammatic representation of the development of the teeth and lips. A, Medial section of the mandibular arch, about the fortieth day, (1) downgrowth of epiblast. b, Division of epiblastic down growth into (1) Lippenfurche and (2) Zahnleiste. c, Further development of b, Lippenfurche much thickened. Bulbous extremity to Zahnleiste and commencing division at 3. Condensation of mesoblast at 4. d, Central cells of Lippenfurche atrophy and disappear, thus labio-dental sulcus (5) and lip (6) is formed. Epiblast at end of Zahnleiste has become differentiated into enamel organ (7). Condensation of mesoblast (4) is forming dentine papilla and tooth-sac (4). The offshoot of the Zahnleiste towards the lingual side is beginning to form the enamel bud for the permanent tooth-germ (3). e, Stage at which calcification of deciduous tooth is well advanced and permanent tooth-germ fully formed and to the lingual side. Condition at birth or shortly afterwards.

Enamel is formed on the lower surface of the epithelium, develops upwards and outwards, and its developing margin increases in circumference until completion.

The enamel organ gradually disappears ; part of it, however, remains as a thin pellicle of hardened epithelial cells on

THE DEVELOPMENT the surface of the enamel after eruption (literally, the skin of one’s teeth), and is known as Nasmyth’s membrane. The enamel, therefore, when it is completed, is without the pale of nourishment as derived from the blood-supply to a tooth.

Dentine is formed on the upper surface of the ‘ dentine papilla’, grows inwards and downwards, and its developing margin decreases in size.

Calcification on the surface of the dentine papilla ceases after a time (from two and a half to three years after eruption), and the uncalcified central portion becomes the ‘ pulp ’ of the tooth.

The precise nature of the union effected between the enamel and the dentine is not known. (In fully developed teeth the cap of enamel can be suddenly split off a tooth by the application of heat.)

During development the tooth is surrounded by a connective-tissue sac, fibrous in its outer and cellular in its inner portion ; from this is developed internally the cement which covers the dentine of the root, and externally the periodontal ligament which is the bond of union between the tooth and the alveolar part of the jaw-bone.

The alveolus is developed synchronously with the teeth. It is largely absorbed when the deciduous teeth are shed, it redevelops with the eruption of the permanent teeth, and undergoes more or less complete atrophy upon loss of the latter.

In the manner thus indicated, the ten deciduous teeth and their permanent successors are developed, the permanent molars are developed in a precisely similar manner by backward prolongations of the Zahnleiste, as the horizontal ramus of the jaw develops in a backward direction.

The skiagram shown in Fig. 2 illustrates the condition of affairs in an infant of one month. It is important to notice, firstly, how near to the surface are the enamel organs of the deciduous teeth, and therefore, that local lesions of the oral mucous membrane, i.e. stomatitis either bacterial in origin or caused by too hot food, may injuriously affect the teeth by causing an irregular cessation of function of the enamel-forming cells.

Secondly, the existence of permanent tooth-germs should be remembered, and the commencing calcification of the

Fig. 2. Skiagram of the jaws of an infant one month old. Note the commencing calcification in the first 'permanent molar. (From Symington and Rankin’s Atlas of Skiagrams, by permission.)

first permanent molar is obvious in Fig. 2. So that even at this early age the occurrence of systemic disorders may cause the teeth, the enamel especially, to be hypoplasic (i. e. pitted or honeycombed).

For purposes of description teeth are divided into three portions — crown, cervix (or neck), and root. The crown has five surfaces, which are named respectively medial and distal, labial (or buccal) and lingual, and occlusal (or incisive). The medial surface is that which is towards the centre-line of the mouth, supposing all the teeth were spread out in a straight line from the incisors. The other surfaces are self-explanatory, and it will not be here necessary to describe the features of these in more detail,

Fig. 3. Upper and lower jaws, showing sections of the teeth in situ. All the molar teeth have not been cut at quite the same level. For instance, the second upper molars have been cut through a little higher than the first molars, and hence do not show the division into three separate roots. The variation in the position and number of the root canals, especially in the lower molars, is also shown.

except to point out that the medial and distal surfaces of adjoining teeth are always convex from above downwards, and from side to side, and should touch each other only at the ‘ point of contact ’ about two-thirds of the distance between the cervix and the occlusal surface.

Any deviation from this normal contact conduces to the occurrence of disease.

It is essential, if only for the operation of extraction, that the number and disposition of the roots of the teeth should be quite familiar to the operator. For instance, the details of the accompanying illustration (Fig. 3) should be able to be visualized at any moment.

Notice particularly that in the upper jaw the incisor roots are circular, the canines oval to triangular, and the premolars oval (the first upper premolar as a rule has two roots), the two small buccal roots, and the large palatine root of the molars : in the lower jaw the incisor roots are oval from before backwards ; the premolar roots are less oval and shorter than the corresponding upper teeth ; the two roots of the lower molars are very much flattened from before backwards, and are placed one anteriorly and one posteriorly. The roots of the third molars or wisdom teeth in both jaws tend to coalesce, and those of the lower teeth to be curved backwards, on account of the close proximity of the contents of the inferior dental canal ; indeed, the inferior dental nerve occasionally grooves, or perforates, the root of this tooth.

The Enamel which covers the crowns of the teeth is thickest in the occlusal or incisive portion, having here a thickness of about 2*5 mm. and gradually becoming thinner towards the pervix, where it terminates. It is highly important to realize that the enamel is not a f veneer 5 merely, but is of substantial thickness, and being one of the hardest organized substances in nature is eminently adapted for cutting and grinding even the hardest of food. Tested in the dynamometer between plates of hard vulcanite, the cusps of teeth will withstand, without fracture, a pressure of 3501b. suddenly applied— a force considerably greater than anything which is likely to be applied during mastication.

In minute structure, enamel is composed of hexagonal prisms which are somewhat flexuous in outline, but in a general direction run inwards at right angles to the surface, and it is in such direction that enamel is most readily fractured or cleaved. Although enamel is said to contain no organic matter, yet occasionally painful sensations are conveyed from stimulation of its deeper portions ; this is due to the presence in that situation of small ovoid spaces, ‘ enamel spindles,’ filled with protoplasm and connected with the dentinal fibrils.

The surface of the enamel, as the author has shown,1 is normally traversed by minute corrugations, or imbrications , running at right angles to the long axis of the tooth ; these are more developed in civilized than in uncivilized races, and are a factor in the retention of food-stuffs.

Enamel is of course in a plastic state when first laid down, and subsequently becomes intensely hard ; this hardening process is, though, as I have elsewhere shown, not complete when the tooth is erupted, but should continue for a considerable time afterwards, being probably aided by the infiltration and deposition of lime salts from the saliva. Teeth in which this has taken place to a maximum extent have a yellowish dense appearance, and I have termed them ‘ sclerotic 5 teeth ; teeth in which it has not occurred have a whitish opaque appearance, and these I have classified as ‘ malacotic ’ teeth (pa\ai<6s = soft).

Enamel of the latter class I have shown to be exceedingly permeable to a stain like silver nitrate, whereas sclerotic enamel is scarcely permeable at all. Sclerotic enamel shows a greater degree of hardness when tested by a diamond point in the sclerometer, and a greater resistance to decalcification by acids than malacotic enamel.

The Dentine is composed of a calcified matrix of collagen through which run tubules, converging from the periphery to the pulp chamber, and containing the sentient distal processes of the odontoblast cells of the pulp. Thus, in transverse section, dentine is seen to be perforated by numbers of minute 1 Prevention of Dental Caries and Oral Sepsis , London, 1911.

‘ holes ’ — in the living condition filled by the f dentinal fibrils ’, in the devitalized state by air or organisms ; in any case dentine is to be regarded as a porous material, capable of absorbing and transmitting substances either beneficial or deleterious (Fig. 4). The fact that dentine contains normally a considerable proportion of sentient, soft, ‘ living 5 tissue has also to be remembered when operating upon it. It is now believed that dentine is laid down in a laminated manner at right angles to the direction of the tubules, and in this direction, when it is decalcified either artificially or by disease, it is most readily cut and removed.

Further, Mummery has adduced considerable evidence to prove that the ‘ odontoblasts ’ are not the cells which form the dentine, but osteoblasts which are interspersed between the large cells called ‘ odontoblasts \

Dentine is in any case only a modified bone, and this view of its development, which is generally accepted at the present time, shows its formation to be exactly analogous to bone.

The teeth correspond to other bones in having a central medulla, modified certainly, but analogous. The chief point of difference between the teeth and other bones is the fact that the integument in this situation has become highly calcified and the greater portion of its organic nature has disappeared. If this integument had not become so calcified it would probably not occur to any one to classify the teeth as other than bones.

The Pulp is composed of a stroma of delicate connective tissue imbedded in which are blood-vessels, nerves, and specialized cells. A capillary network is formed at the periphery, and just beneath its surface the nerves break up into the plexus of Raschkow ; thus the pulp is most vascular and most sensitive at the periphery.

The specialized odontoblasts form a single layer of epithelioid cells on the surface of the pulp, and because they adhered to the dentine rather than to the pulp when the latter was forcibly removed they are termed the membrana eboris . No nerves have been proved to enter the dentine, and the extreme sensitiveness of the latter has been accounted for by the fact that the terminations of the nerves in the plexus of Raschkow arborize around the odontoblasts and their proximal processes.1

The medulla, or pulp, in shape is a small replica of the tooth, a small cornu being situated under each cusp, and