Oral sepsis in its relationship to systemic disease

Front matter

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Preface

In the preparation of this little book, the aim has been to present as briefly and clearly as possible the rather complex relationship which frequently exists between infections of the gum and alveolar process and certain systemic disorders. This has necessarily involved a discussion of some of the more complex problems of bacteriology, immunology, and pathology as well as of dentistry. In so small a space it has not been possible to take up any of these subjects in great detail, and for this reason those especially interested in certain particular phases are referred to the writings of Rosenow, Billings, Schottmiiller, Poynton and Payne, Libman, Vaughan, von Pirquet, Wolff-Eisner, Richet, Rosenau and Anderson, and other investigators to whom we are indebted for many of our more recent ideas which have a bearing upon this very important subject.

In the opinion of the writer, the discovery of the relationship which frequently exists between the various chronic infections and systemic disease marks a great practical advance in the science and therapy of medicine. For centuries it has been evident to physicians that certain acute inflammatory lesions give rise to systemic disturbances. One of the main advances of recent years, therefore, has been the disclosure of the fact that small and apparently innocent infections which give rise to little or no local disturbance may likewise be the source of serious generalized disease.

For the proper care of medical cases, the hearty and intelligent cooperation of the dentists is absolutely essential. In the writer's experience, it has been found

8 PREFACE

that the teeth should be taken into account in nearly every medical case. For this reason, the welfare of the affected individual demands that the dental surgeon understand and appreciate the problems and aims of the physician, and that he be willing at times to sacrifice apparently useful teeth for the sake of the patient's general welfare. Consequently, the main purpose of this volume has been to assemble facts which show, first of all, that dental sepsis is an extremely common condition, and, second, that it may cause serious systemic disorder in many different ways.

For the sake of completeness, it has been necessary to discuss some of the purely dental problems. These have been discussed purely from a pathologic viewpoint based upon an experience with more than one thousand carefully studied medical cases observed in a consulting office practice on whom dental roentgenograms were made as part of a routine examination. In all over eight thousand dental films were taken. It is believed and sincerely hoped that the views here expressed are in harmony witli those of the dental surgeons who have given the problem of oral sepsis the attention and study it deserves. For a more detailed account of this subject from a dental standpoint, the reader is referred to the publications of the investigators in this field: G. V. Black, and A. D. Black, Hartzell, Price, Khein, Thoma, Grieves, etc.

Finally, I wish to acknowledge with thanks the hearty

cooperation of my friend and coworker in this study,

Rex Dively, under whose direction the roentgenologic

work was done, to L. S. Milne and W. A. Myers, my

Trott, for their careful work in clinical pathology, and

to Miss Elizabeth Leas, assistant in the roentgenologic

] a) ) oratory.

William W. Duke.

Kansas City, Mo,

Introduction

PAGE

History '. * 17

Publication of Benjamin Rush on the Relationship Between Defective

Teeth and 111 Health 17

General Observations Concerning a Relationship Between Defective Teeth

and 111 Health ■ 20

Relative Importance of Caries, Malocclusion, Infection of Food, Pyorrhea,

and Alveolar Abscesses in the Causation of Systemic Disease . 21

Frequent Occurrence of Oral Sepsis 22

Variation of Oral Sepsis, with Age and Dental Work, etc 22

Aims of the Dentist in the Past and at Present 23

CHAPTER II Etiologic Factors 24

Brief Discussion of :

Microorganisms 24

Mechanical factors 24

Relative importance of the various factors 25

Frequency with which several factors coexist and its cause .... 26

The Role Played By:

Infection 27

Various microorganisms 28

Mechanical factors 32

Lowered resistance to infection 32

CHAPTER III Sources of Origin 37

Statistics Concerning the Occurrence of Alveolar Abscesses 37

Sources of Infection of Root Pulp ,,,,.,. 42

10 CONTENTS

PAGE

Statistics Concerning the Relative Frequency with which Treated Teeth

Become Infected 42

Teeth purposely devitalized 43

Crowned teeth not purposely devitalized 45

Root remnants 45

Pathology of Alveolar Abscesses 4(5

Mode of development 4G

Time of onset 47

Symptoms of Alveolar Abscesses 47

Symptoms of acute abscesses 47

Osteomyelitis of jaw 40

Symptoms of chronic abscesses 49

Diagnosis of Alveolar Abscesses 50

Interpretation of roentgenograms 50

Significance of radiolucent areas 52

Significance of radiolucent areas in bone other than that of the

alveolar process 52

Comparison between infection in the alveolar process and that in

the bone elsewhere in the body 53

Viability of Organisms in Alveolar Abscesses 56

Importance of the Root Canal and Necrotic Roots as a Source of Reinfection of healing abscesses 56

Treatment of Periapical Infections 57

Illustrations of Palliative Measures in the Treatment of Alveolar Abscesses 59 Importance of Careful Root Canal Work Immediately after Devitalization of a Tooth 67

CHAPTER IV METASTATIC INFECTION Spread of Infection from a Primary Focus 71

Influence of Lowered Resistance to Infection 71

Streptococcic lu lections 72

Selective affinity of streptococci 72

Transmutation of species of streptococci 72

Relation of selective affinity to virulence of organisms 71

Diseases which may be caused by streptococci 74

General Virulence of Organisms 75

The Role of Local Injury in Determining Site of Localization of Infection 75 Relation of Local Injury in Determining the Nature of the Pathologic

Process Caused by Infection 76

Comparison Between the Result of Infection in Normal Individuals and

Those Subjected to Various Poisons, Injury, Strain, etc. ... 77 Comparison Between the Effect of Poisons, Injury, Strain, etc., upon Normal Individuals and Those Having Chronic Infectious .... 77

CONTENTS 11

Chapter V Nonrelated Infection As Influenced By Oral Sepsis

PAGE

Influence of One Infection upon Another 79

Acute infections 79

Chronic infections 79

111 Effects of Sepsis upon Individuals with Syphilis of the Nervous System SO Illustration of the influence of an acute infection upon the symptoms

of tabes dorsalis 81

Illustration of the effect of chronic sepsis in a case of general paresis 82 Illustration of the relief obtained by the removal of sepsis in a severe

rapidly progressive case of tabes dorsalis 82

Conclusions Concerning the 111 Effect of Sepsis upon Patients with Syphilis

of the Central Nervous System ' 83

Importance of Eradicating Sepsis as a Preliminary Step in the Treatment of Syphilis of the Central Nervous System 83-84

CHAPTER VI Nature of the Toxic Products Formed by Organisms Which Ordinarily

Take Part in the Pathology of Oral Sepsis 85

Allergy as Illustrated by the Action of Tuberculin 85

Comparison Between a Tuberculin Reaction and that Produced by Inoculation with Living Bacilli 86

Comparison Between Tuberculous Infections and Other Infections . . 86 Comparison Between the Local, General, and Focal Reactions Observed Clinically After the Use of a Vaccine, etc., and After the

Acute Onset of a New Infection 87

Influence of Acute and Chronic Infections upon Chronic Infections in

Gum and Alveolar Process 88

Influence of Oral Sepsis upon Other Coexisting Infections Localized in

Remote Organs SS

Untoward Effects Occasionally Caused by the Extraction of Infected

Teeth 88

Beneficial Results Frequently Obtained by the Extraction of Infected

Teeth 89

Functional Disturbance in Infected Organs as a Result of a Toxic

Effect of Oral Sepsis 90

Sensitization and Tolerance for Bacterial Proteins 90

Relation Between the Systemic Effect of an Infection and Sensitization and Tolerance 91

Sensitization against Proteins not of Bacterial Origin 91

Symptoms of Anaphylaxis in Animals 92

Symptoms of Anaphylaxis in Humans .,..,..,,... 92

12 CONTENTS

PAGE

Sensitization 93

Methods of Producing Artificial Sensitization 93

Protein Sensitization as Observed Clinically 93

Examples Showing High Degree of Protein Sensitization in Humans . . 93 Comparison Between Protein Sensitization as Seen Clinically and

Experimentally 95

Oral Sepsis as a Cause of Protein Sensitization and Intoxication . . . 95

Chronic Mild Anaphylaxis 95

Vaughan's Theory 96

Tolerance of Alien Proteins 97

Clinical Symptoms Attributable to Protein Sensitization or Anaphylaxis 98

The Relative Importance of Anaphylaxis as a Cause of Systemic Disorder 98

Anaphylaxis as a Cause of Functional Disorder 99

Symptoms Frequently Relieved by the Removal of Sources of Chronic

Intoxication 99

General symptoms 99

Diseases of the skin 100

Functional disorders and neuroses 100

Disorders of the vegetative nervous system 100

Functional disturbance due in part to organic disease 100

Symptoms due in part to other infections 100

Chapter VII Headache As Related To Oral Sepsis

Oral Sepsis as a Primary and as a Contributing Cause of Headache . 102

Oral Sepsis as a Source of Arthritis in Cervical Spine, etc P'2

Oral Sepsis as a Source of Neuralgia or Neuritis in Facial Nerve . . 10-1

Headache as a Referred Pain fmm a Diseased Tooth 104

Headache Caused by Antrum Infection Due Primarily to Oral Sepsis . 105

CHAPTER VIII Frequent Occurrence of Oral Sepsis 10(1

Statistics Showing the Comparison Between the Occurrence of Oral

Sepsis and That of Other Chronic Infections 106

Limitation of Conclusions Drawn from Clinical Observations .... 107 Statistics Showing the Frequency with which Oral Sepsis and Other

Chronic Infections Coexist 107

Conclusions Concerning the Importance of Oral Sepsis as a Cause of

Systemic Disorder 10!)

Conclusions Concerning the Various Ways in Which Oral Sepsis May

Cause III Health 109

Results Which Follow the Eradication of Oral Sepsis 109

Treatment of Oral Sepsis . 110

ILLUSTRATIONS

FIG. PAGE

1-4. Illustrations showing a normal condition of roots and alveolar

process 25

5-6 Illustrations showing erosion of alveolar process 26

7-10. Case of pyorrhea alveolaris of long standing 27

11-14. Illustrations of cases in Avhich the alveolar process has been so destroyed by infection that some of the teeth are held in

place by soft tissues alone 28

15-16. Pyorrheal abscesses 29

17. Abscess at the root apex of a vital tooth 29

18-21. Showing ill effect upon the alveolar process of careless dental

work 30

22-24. Showing the ill effect upon the alveolar process of careless

dental work 31

25-30. Illustrations showing deposits on necks of roots 33

31-36. Case of chronic recurrent pyorrhea alveolaris 35

37-41. Illustrations of large alveolar abscesses 38

42-43. Osteomyelitis of the jaw derived from an infection at the

roots of a molar tooth . 39

44-49. Illustration of the less active type of periapical infection . . 40 50-55. Typical example of oral sepsis in a patient with a great deal

of dental work 41

56-59. Example of the occurrence of numerous large abscesses ... 42 60-65. Example of an individual having a great deal of dental work,

who shows relatively little periapical sepsis 43

66-71. Illustration of the commonest source of periapical infection; namely, devitalized teeth with incompletely filled root

canals 44

72-74. Illustration of abscesses due to perforation of root by pins . . 45

75-77. Apical sepsis due to infection of the pulp by decay 46

78-83. Examples of root remnants which are the site of infection . . 47 84-89. Examples of infection at the apices of filled teeth whose pulp

was not intentionally destroyed 48

90-91. Examples of infection at the root apices of unerupted teeth . 49 92. Example of periapical infection of teeth whose pulp was destroyed by severe trauma 50

93-97. Example of periapical infections of crowned teeth whose pulp

was not purposely devitalized 51

98-99. Examples of periapical infection of untreated teeth .... 52

14 ILLUSTRATIONS

PIG. PAGE

LOO L02. Absorption of the tips of the rool apices and rosis of

the apex 5.3

103 L06. Several teeth showing one or more completely necrosed roots 51 107-113. Illustrations of shadows indicating areas of increased density in the alveolar process as a result of healing of infected areas 55

114-116. Illustrations of radiopaque areas which simulate the healed

abscesses shown in Figs. 107-113 56

117. Roentgenogram showing hone of increased density 57

118-120. Examples of root remnants which have apparently become

encysted 57

1.1. Roentgenogram taken immediately after drainage and rilling of

the root canal 60

122. Roentgenogram of the same tooth as in Fig. 121 approximately

one year later 60

123. Roentgenogram taken just before drainage and tilling of the

root canal 60

12 1. Roentgenogram of the same tooth as in Fig. 123 two months later 60

125. Roentgenogram showing small area of apical sepsis 61

126. Roentgenogram of same tooth taken approximately six months

after its treatment 61

127. Roentgenogram showing small area of sepsis 61

12^. Roentgenogram showing same tooth approximately three months

after its treatment 61

120. Roentgenogram showing apical infection 02

130. Roentgenogram taken shortly after the filling of the rout canal . 62

131. Roentgenogram taken approximately eight months after that shown

132. Roentgenogram showing an abscess at the root of a crowned left

upper incisor 63

133. Roentgenogram taken three months after irrigation through the

root canal of the left incisor followed by filling 6f the root canal 63

134. Roentgenogram taken six months after treatment 63

L35. Roentgenogram showing apical infection at the root of a lower

molar tooth 64

136. Roentgenogram taken approximately s'; months after drainage

and filling of the root canal 64

L37-139. Roentgenograms showing sepsis at the apices of two lower

molar teeth before, during, and after treatment ... 61 140-142. Roentgenograms showing large alveolar abscess before and

after treatment 65

113-146. Roentgenograms showing abscesses at the roots of two lower

incisor teeth lie fore, during, and after treatment ... 65

ILLUSTRATIONS 15

FIG. PAGE

147-148. Boentgenograms showing large discharging alveolar abscess at the apex of a lower incisor tooth before and after treatment 66

149-150. Boentgenograms showing an abscess at the root of an upper

bicuspid tooth before and after treatment . ... . . 66

151-152. Boentgenograms showing an abscessed lower molar tooth before and after treatment . 66

153-161. Examples of careful root canal work 67-70

162. Case of chronic migratory polyarthritis of several months' dura-

tion which was completely relieved by extraction of tooth shown in illustration . 76

163. Case of multiple neuritis relieved by extraction of tooth ... 76

164. Case of recurrent pain in gall bladder region associated with

jaundice relieved by extraction of tooth 76

165. Case of staphylococcus septicemia SO

166-167. Boentgenograms showing broaches which had been introduced

with ease through the root canal and alveolar process practically as far down as the dental nerve 103

168. Case of severe headache due to cervical arthritis and myostitis

relieved by extraction of tooth 104

169. Case of severe facial neuralgia relieved by extraction of a tooth . 104

170. Case of headache due to antrum infection, the source of which was

an abscess at the root of a bicuspid tooth 104

ORAL SEPSIS IN ITS RELATIONSHIP TO SYSTEMIC DISEASE

Chapter I Introduction

The discovery of a relationship between ill health and defective teeth is by no means recent. It has received casual mention in the older literature and has been independently recognized, perhaps for centuries, by practitioners of medicine and dentistry. The subject has not received the prominence it deserves, however, previous to the past decade. We wish to quote in toto an article published by Benjamin Rush, one of the signers of the Declaration of Independence, and one of America's most noted physicians, on observations commenced by him in 1801. This remarkable article, written before the discovery of bacteria and when our knowledge of pathology was meager indeed, harmonizes in- its essentials with the more popular views of the present day. I have taken the liberty of italicizing several striking sentences.

Medical Inquiries and Observations* By Benjamin Rush, M.D.

Professor of the Institute and Practice of Medicine and Clinical Practice in the University of Pennsylvania

"Some time in the month of October, 1801, I attended Miss A. C. with rheumatism in her hip joint, which yielded for a while, to the several remedies for that dis-

*Vol. I, p. 199, published in 1818 bv M. Carey & Son, Philadelphia. This article was found by Mrs. Rose M. Hibbard of the Kansas City Medical Library in the private collection of Dr. A. E. Hertzler. It has also been referred to by George N. Kreider, A. D. Black, and David Riesman.

18 ORAT, SEPSIS

case. In the month of November it returned with great violence, accompanied with a severe toothache. Suspecting the rheumatic affection was excited by the pain in her tooth, which was decayed, I directed it to be extracted. The rheumatism immediately left her hip, and she recovered in a few days. She has continued ever since to be free from it.

"Soon after this I was consulted by Mrs. J. R. who had been affected for several weeks witli dyspepsia and toothache. Her tooth, though no mark of decay appeared in it, was drawn by my advice. The next day she was relieved from her distressing stomach complaint, and has continued ever since to enjoy good health. From the soundness of the external part of the tooth, and the adjoining gum, there ivas no reason to suspect a discharge of matter from it had produced the disease in her stomach.

"Some time in the year 1801 I was consulted by the father of a young gentleman in Baltimore, who had been affected with epilepsy. I inquired into the state of his teeth, and was informed that several of them in his upper jaw were decayed. I directed them to be extracted, and advised him after to lose a few ounces of blood, at any time when he felt the premonitory symptoms of a recurrence of his fits. He followed my advice, in consequence of which I had lately the pleasure of hearing from his brother that he was perfectly cured.

"I have been made happy by discovering that I have only added to the observations of other physicians, in pointing out a connection behveen the extraction of decayed and diseased teetli and the cure of general diseases. Several cases of efficacy of that remedy in relieving headache and vertigo are mentioned by Dr. Darwin. Dr. Gater relates that Mr. Petit, a celebrated French surgeon, had often cured intermitting fevers, which had resisted the bark for months, and even years, by this prescription ; and he quotes from his works two cases, the one of

INTRODUCTION" 19

consumption, the other of vertigo, both of long continuance, Avhich were suddenly cured by the extraction of two decayed teeth in the former, and of two supernumerary teeth in the latter case.

"In the second number of a late work, entitled Bibliotheque Germanique Medico Chirurgicale, published in Paris, by Dr. Bluver and Dr. Delaroche, there is an account, by Dr. Siebold, of a young woman who had been affected for several months with great inflammation, pain, and ulcers, in her right upper and lower jaws, at the usual time of the appearance of the catamenia, which at that period were always deficient in quantity. Upon inspecting the seat of those morbid affections, the doctor discovered several of the molars in both jaws to be decayed. He directed them to be drawn, in consequence of which the woman was relieved of the monthly disease in her mouth, and afterwards had a regular discharge of her catamenia.

'''These facts, though but little attended to, should not surprise us, when tve recollect hoiv often the most distressing general diseases are brought on by very inconsiderable inlets of morbid excitement into the system. A small tumor, concealed in the fleshy part of the leg, has been known to bring on epilepsy. A trifling wound with a splinter or a nail, even after it has healed, has often produced a fatal tetanus. Worms in the bowels have produced internal dropsy of the brain, and a stone in the kidney has excited the most violent commotions in every part of the system. Many hundred facts of a similar nature are to be met with in the records of medicine.

"When ive consider hoiv often the teeth, when decayed, are exposed to irritation from hot and cold drinks and aliments, from pressure by mastication, and from the cold air, and hoiv intimate the connection of the mouth is with the whole system, I am disposed to believe they are often the unsuspected causes of general, and particularly of nervous diseases. When we add to the list of those diseases the morbid effects of the acrid and putrid matters, which are sometimes discharged from the carious teeth, or from the ulcers in the gums created by them, also the influence which both have in preventing perfect mastication, and the connection of that animal function with good health, I can not help thinking that our success in the treatment of all chronic diseases would be vert/ much promoted, by directing our inquiries into the state of the teeth in sick people, and by advising their extraction in every case in which they are decayed. It is not necessary that they should be attended with pain, in order to produce diseases, for splinters, tumors, and other irritants before mentioned, often bring on disease and death, when they give no pain, and are unsuspected causes of them. This translation of sensation and motion into parts remote from the place where impressions are made, appears in many instances, and seems to depend upon an original law of the animal economy. ' '

The following generalizations are recognized by many who have interested themselves in the bearing which the teeth have upon health. Very few men of fifty years or over who show advanced stages of dental sepsis are normal physically. The vast majority have chronic disease. There are, of course, notable exceptions to this. Conversely, adults of fifty or over who have perfect teeth free from sepsis are often remarkably free from chronic disease (inflammatory in origin) and are usually well preserved. Striking examples of individuals seventy to ninety years of age with nearly perfect teeth and splendid health impress one with the reality of a relationship between the two. Men of advanced age who have worn false teeth for a number of vears have better health as

INTRODUCTION 21

a rule than the average of their age who have retained defective teeth.

In earlier years the relationship between ill health and defective teeth was attributed to caries. It was very apparent that this rendered teeth unfit for mastication and that the lack of this function might be a source of digestive disturbance. Infection of food by carious teeth during the process of chewing seemed a factor as also did the swallowing of putrid matter from carious teeth and of pus from infected gums.

It is not unlikely that the swallowing of poorly masticated food, the swallowing of pus, putrid material, etc., has some slight untoward influence upon digestion. It does not seem probable, however, that it has an important bearing upon the many systemic ills for which the teeth are now thought to be remotely responsible. The fact is that the mucous membrane of the gastrointestinal tract when in healthy condition can tolerate a great deal of abuse. It can tolerate poorly masticated food, and, as a rule, can destroy septic material when swallowed. The serious effect of oral sepsis is rarely through this channel in individuals who are otherwise normal.

Pyorrhea is mentioned as a possible factor in the etiology of anemias, joint troubles, etc., in some of the older textbooks. Its importance, however, as a frequent source of chronic infection distributed by the blood to remote organs is a recent suggestion. The discovery of the frequency of alveolar abscesses and granulomata and their importance as a source of ill health is of still more recent date and has been brought to light through dental roentgenology. The fact that alveolar abscesses are of greater pathologic import, so far as general health is concerned, than pyorrhea seems at once evident. Alveolar abscesses lack drainage. In pyorrhea drainage is often good. Not only are alveolar abscesses blind, but their localization in bony tissue renders them a more serious detriment to health than septic foci of equal size in soft tissues such as the gums where expansion is possible. Apical sepsis would appear a greater factor than pyorrhea in the causation of disease for another important reason; namely, pyorrhea gives rise to symptoms which usually attract the attention of both patient and dentist. Alveolar abscesses do not give rise, as a rule, to a single disagreeable symptom by which cither patient or dentist is led to suspect their existence. Consequently, many individuals have been subject to the effect of sepsis in the alveolar process for years even though they have paid scrupulous attention to their teeth and visited the dentist frequently. The frequent failure of alveolar abscesses to cause pain or other local evidence of trouble often makes it difficult to convince patients that their teeth need attention; in fact, dentists themselves occasionally refuse to believe that certain teetli are diseased, even when the fact can be clearly demonstrated in dental roentgenograms. This frequently leads to controversies and unfortunate situations.

The incidence of infection in the gums and alveola r process is astonishingly great. It is not frequently found in individuals of less than twenty years, but is found in the vast majority of adults. It is found oftener and in greater extent as age advances, and in late adult life few escape it entirely.

One of the greatest sources of dental sepsis aside from decay, tartar, and gross neglect, is dental work. It is not altogether fair to the dentists to say defective dental work, for the same is very frequently true even of dental work carried out according to the more approved methods of the past decade. As a broad, general rule it can be said of individuals whose teeth have received careful attention that the amount of oral sepsis at a given age varies largely with the amount of dental work and that few individuals with a considerable amount of

INTRODUCTION 23

dental work are free from it. It is generally stated by dentists who have interested themselves in the septic conditions of the mouth that fifty per cent or more of devitalized teeth show roentgen shadows at the root apices which are indicative of chronic sepsis and that a very large proportion of crowns, fillings, and bridges project at the gum margin enough to irritate the gum and leave pockets in which food material can lodge and putrify and lead almost inevitably to pyorrhea.

Dentists have been wonderfully successful in preserving the visible portion of the teeth and in making restorations which look well and serve well for purposes of mastication, but very few have given the attention to sepsis which it now appears to deserve. Fillings, crowns, and bridges have not been constructed in the past with a paramount purpose of avoiding sepsis, and have often been attached to teeth so badly infected that a sanitary result could not have been hoped for. The sins of commission have been no greater than the sins of omission, for many of the most skilled dentists even at the present day allow patients to leave their offices looking lightly upon a degree of sepsis which may be not only detrimental to their physical welfare, but may also lead eventually to the loss of more teeth. In mentioning this, we do not wish to question the skill of dentists, but rather to emphasize the fact that unanimity of opinion between physicians and dentists concerning the diagnosis of dental sepsis and concerning the remote effect of the same is urgently needed, as is also hearty cooperation in its treatment. In the past the practice of dentistry has been directed toward the preservation of the teeth almost solely for mechanical and cosmetic purposes. In the future it appears, it is destined to have as one of its chief aims the prevention and cure of disease.

Chapter II

Pyorrhea alveolaris is rarely due to one cause alone. In an overwhelming majority of cases it is due to one chief cause and several important contributing causes. The more important causes are mechanical conditions which expose the gums repeatedly to injury or to the irritating effects of putrefying food material, secretions, etc.; systemic or local conditions which increase the susceptibility of the gums to infection and finally infection itself. The successful treatment of pyorrhea depends upon the removal of each abnormal condition which takes part in its etiology.

Causes of Pyorrhea Alveolaris

1. Microorganisms; streptococcus group, pneumococcus group, staphylococcus group, amebae, spirochete, and fusiform bacilli of Vincent's angina, bacilli of many types, putrefactive organisms, etc.

2. Chronic irritation or trauma, such as that caused by tartar, decay, malocclusion, defective dental work, and, perhaps, in rare instances, by the improper use of toothpicks, toothbrushes, etc.

3. Unsanitary conditions, such as may be caused by pockets and irregularities of the teeth which make possible the lodgement and putrefaction of secretions, food materials, etc. Such may occur as a result of defective dental work, tartar, decay, irregularity of the teeth, etc.

4. Conditions ivhich prevent the normal massage of the gums and cleaning of the teeth by the excursion of food, the tongue, and cheeks during the process of mastication ;

namely, malocclusion, irregularity of the teeth, and defective dental work.

5. Constitutional conditions which increase the susceptibility of the gums to infection; namely, diabetes, pregnancy, lactation, alcoholism, lead poisoning, the use of mercury and potassium iodide in therapy, chronic debilitating diseases, blood diseases, anemia, etc., diseases of the ductless glands, scurvy, acute infectious diseases,

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Figs. 1-4. — Illustrations showing a normal condition of roots and alveolar process. Figs. 1 and 2, in adult life. Figs. 3 and 4, before eruption of second teeth.

chronic infections, such as infected tonsils, alveolar abscesses, infected nasal sinuses, chronic appendicitis, cholecystitis, etc.

The above factors vary in their relative importance, and each factor varies in its degree of importance. Several factors play a part in the majority of cases. When this is the case, relatively unimportant factors may play important roles. For example, acute trauma, such as that brought about by injury or by the use of toothpicks, stiff toothbrushes, etc., seldom or never causes pyorrhea in normal individuals with normal teeth, in Tact, stiff brushes are used in prophylaxis against pyorrhea. In a patient with diabetes, however, or in pregnant women, acute trauma may initiate an infection of the gums, especially if, in addition to this, the patient has tartar or defective dental work. Likewise, the irritating effect of defective dental work which might be well tolerated by a normal individual might be a source of severe pyorrhea in an individual taking intensive doses of mercury or potassium iodide, or in an individual with irregular teeth having accumulations of tartar, etc.