Pyorrhea alveolaris

Front matter

^?^yMB'A LIBRARIES OFFSITE

linflI(lffi,^i5!F.'i',?.^S STANDARD

PYOERHM AL¥H)L

Chapter I

Varieties of Pyorrhea. Page

Diabetic — Intestinal Nephritic — Infective — Gastro-intestinal Toxemic — Presenile — Senile — Resulting from Trauma — Resulting from Chemical Irritants — Resulting from Mechanical Irritants — Resulting from Thermal Irritants — Resulting from Bacteriological Irritants 17-60

Chapter VI

Pathology. Page

Preparation of Specimen for Study — Longitudinal Section of Palatine Root — Cross-Section of Palatine Root and Alveolus — Cross-Section of Anterior and Posterior Buccal Roots and Alveolus — Cross-Section of Anterior and Posterior Buccal Roots Including Alveolus — Cross-Section of Palatine Root and Alveolar Process — Cross- Section of Anterior Buccal Root and Alveolus — Cross-Section of Palatine Root and Alveolar Process — Cross-Section of Palatine Root Including Small Island of Alveolar Process — Cross- Section Near Anterior Buccal Root — Cross-Section from Near Palatine Root — Cross-Section of Anterior and Posterior Buccal Roots Including Peridental Membrane — Field Magnified One Thousand Times 94-123

CHAPTER I. Varieties of Pyorrhea

The author has for a number of years kept notes of observations made on the gums and teeth of patients afflicted with pyorrhea. In each case a history was taken, and in addition thereto the findings of an examination of the gums and the teeth. With these findings the author has classified tlie disease into the following varieties :

I. Diabetic Variety.

II. Interstitial Nephritic Variety.

III. Infective Variety.

IV. Gastro-Intestinal Toxemic Variety. V, Pre-senile Variety.

VI. Senile Variety.

VII. Variety Resulting from Trauma. VIII. Variety Resulting from Chemical Irritants.

IX. Variety Resulting from Mechanical Irritants.

X. Variety Resulting from Thermal Irritants.

XI. Variety Resulting from Bacteriological Irritants.

A complete description of the eleven varieties mentioned above is given in the followingpages :

Diabetic Vaeiety.

Etiology. — The diabetic variety of pyorrhea is a complication of diabetes. It generally manifests itself after the disease is well established, occurring between the ages of 25 and 50. The predominant number of sufferers which have come under observation were married women, and as a rule mothers. They have not been of the poorer class, but of the middle class and the rich — the greater number were among the rich. The sufferer usually is without worry, and leads a very sedentary life.

The exciting causes — trauma; chemical, mechanical, thermal and bacteriological irritants — are of great importance. The tissues around the teeth like the other tissues of the body are poor in resistance. Hence, any one of the above factors has the ability to bring about a local destruction of the gum, the peridental membrane and the alveolar process.

Pathology. — In this variety the gum around the teeth during an acute exacerbation is of a beefy-red color in contrast to the normal pink of healthy gum tissue. It is sensitive, and

VAKIETIES OF PYORRHEA 19

on gentle pressure there appears at the gum margin a thin whitish or cream colored exudate which is small in amount. If the gum is massaged a profuse hemorrhage occurs from the area thus treated. The hemorrhage is very persistent and difficult to control. In this variety of pyorrhea the painfulness of the gum is not relieved by bleeding. It is observed that the teeth are markedly affected by extreme tenderness, which in some instances is so severe that the patient constantly refrains from using them in mastication, and is very careful in conversation or at rest not to bring them into occlusion. The exacerbations come on at irregular times and vary in length of duration. One can, with little discomfort to the patient at the time of an exacerbation, pass a thin-bladed instrument for a considerable distance between the root of the tooth, the gum and the alveolar process. As the attack subsides the depth of the pocket becomes less than during the exacerbation. The depth of the pocket, as a rule, is dependent on the severity and the number of previous attacks. With each attack the pocket reappears and is increased in depth and extent around the root of the tooth. The diseased condition of the gum, the peridental membrane and

20 PYORBHEA ALVEOLAEIS

the alveolus is progressively worse with each exacerbation. The teeth, because of the loss of tissue, become greatly loosened, in some instances so loose that extraction is necessary.

Bacteriology. — In the diabetic variety there are, as a rule, a variety of organisms, with one of the staphylococci predominating.

Diagnosis.- — The diagnosis of the disease is made on the history or urinary findings of diabetes. This fact is generally known to the patient and if not should be confirmed by making a test for sugar. (The Fehling test can be quantitatively or qualitatively made.) The beefy-red color of the gum in contrast to the normal pink gum tissue, the acute overwhelming exacerbations, the sweet odor of the breath, and the urinary findings are sufficient to make a positive diagnosis of this variety of pyorrhea.

Differential Diagnosis. — The diabetic variety is differentiated from the Interstitial Nephritic Variety by the urinary findings which in the interstitial nephritic variety does not contain sugar, but albumin ; and by the character of the gum around the teeth involved, which is not of a beefy-red color. It is differentiated from the Infective Variety by the history and character of the onset of the attack; from the Gastro-intestinal Toxemic Variety by the sudden onset, soreness of the gum (which is quite general), malaise, nausea, and headache ; from the Exciting Varieties by the history and the presence of factors which have to do with the production of this variety; namely, traumatic, chemical, thermal, mechanical and bacteriological irritants. After the presence of any one of these, landmarks are left which cannot be confused with the diabetic variety of pyorrhea.

Symptomatology. — In the diabetic variety of pyorrhea the patient at intervals varying from three to six weeks has an exacerbation which is ushered in by malaise, irritability, nervousness, and pain which is neuralgic in character. The length of the exacerbation is from 2 to 7 days and in some cases it becomes so overwhelming that the patient goes to bed. At the commencement of the attack the gum around the teeth involved is painful on pressure. The gum is swollen, and bleeds readily, and after the hemorrhage has commenced it is rather hard to control. The teeth at the beginning of the exacerbation are not painful when brought into occlusion, but as the attack progresses they feel elongated, are loose, and painful when brought together. The height of the attack is generally

22 PYORRHEA ALVEOLABIS

reached within 48 hours. After this time the above described symptoms gradually subside, the gum and teeth involved feeling quite comfortable after the eighth day. The attack having passed off, the color of the gum again becomes approximately normal and a period of rest is established. After an indefinite period of time another exacerbation comes on involving teeth which were not attacked by the preceding exacerbation, and the teeth become so loose that they interfere with mastication and articulation. After the disease has become well established, the gum is constantly more or less hypersensitive to slight pressure and bleeds freely when brushed. As a result of these two inconveniences, the patient does not care for the teeth as faithfully as in the beginning of the disease, and consequently pockets of pus are many times present in the chronic stage of this vari ety which, if not cared for by evacuation, will cause the patient great pain and will burst on the surface of the gum. If this occurs it complicates the condition and is a hindrance in the treatment.

Prognosis. — The prognosis of the diabetic variety of pyorrhea is dependent on the age of the patient and duration of the disease. As a

VARIETIES OP PYORRHEA 23

rule a prognosis of fairly good results can be offered the patient.

Treatment. — The hygienic treatment in the diabetic variety is of great importance, and thorough prophylaxis on the part of the patient and the dentist is necessary. If the disease is characterized by the presence of pus at all times with an increased amount during an exacerbation, the first step in the treatment is for the physician to prescribe a diabetic diet and treatment, which will raise the immunity of the patient generally and especially the immunity of the tissues on which the teeth depend for their position and relation. The physician having prescribed, the next step is vaccination of the patient with an autogenous bacteeial. vaccine.

Interstitial Nephritic Variety.

Etiology. — The interstitial nephritic variety of pyorrhea is in all likelihood a complication of interstitial nephritis and occurs after the fortieth year. This variety of the disease is found most often in men, although it is sometimes observed in women. The social conditions are of no importance in this variety, for the disease is found among paupers as well as among the rich. The occupation of the afflicted person may be that of a laborer or banker.

In the modern teachings of medicine it is held that alcohol is an etiological factor in the production of nephritis. Hence, as a result of this deduction, alcoholism must first be considered as a factor of great importance in the production of this variety of pyorrhea. The next most important factor is the bacteria, for in this variety the immunity of the tissues around the teeth is very low and as a result thereof the}^ find them an excellent field for their growth. The presence of the products of bacteria diminish the local and general immunity, and if the sufferer is an alcoholic the immunity is further diminished.

The remaining exciting causes are the mechanical irritants; namely, ill-fitting plates, bridges, band or porcelain crowns, tartar that is of a soft putty consistency and of a pale yellow color at the gingival margin. Trauma, if of the contused variety, increases the diminished vital resistance of the tissues, and they are lost, either by the action of the bacteria and their products or by local necrosis. The thermal irritants such as very hot food or drinks, are capable of producing an irritation of such severity, which, if not treated, many times terminates in the destruction of a small or large amount of the gum tissue.

Pathology. — The onset of the interstitial nephritic variety and after its establishment is characterized by mild exacerbations. This variety of pyorrhea is very slow in its progress, the tooth or teeth first involved being only slightly painful on occlusion, with no looseness. As the disease progresses, the teeth gradually become loosened and the teeth on occlusion become painful. The looseness of the teeth is increased when an exacerbation comes on and remains so during it. The gum gradually recedes from the necks of the teeth, exposing the roots for a variable distance, depending on the duration of the existence of the malady. The roots of the teeth in some cases are smooth while in others they are rough, having a fine deposit on the surface that feels flinty when rubbed with an instrument. The gum during an exacerbation has a dark bluish-red color. It is swollen and painful on pressure, but if the pressure is continued the pain becomes very slight and there exudes from the gum margin a thin, white exudate which in some instances has a very foul odor. This odor is observed many times by the patient who as a result calls on the dentist, complaining of this odor and the looseness of the teeth.

Bacteriology. — In this variety of pyorrhea it is found microscopically that a variety of organisms are present, the staphylococcus pyogenes fetidis being the predominaitng one in the smear and culture.

Diagnosis. — The diagnosis is made on the character of the onset of the disease, the age, the sex, the color of the gum as compared to the normal pink of healthy gum tissue, the history of interstitial nephritis, and the slow progressive invasion of the disease to the approximal and distant teeth from the teeth first involved by the disease.

Differential Diagnosis. — This variety is differentiated from the Diabetic Variety by the character of the onset, the age, and the color of the gum. In this variety tartar is generally present, while in the diabetic variety it may or may not be present. The tartar is as a rule very hard, and is firmly attached to the root of the tooth, while in the diabetic variety the tartar is soft and does not adhere firmly to the root of the tooth. It is differentiated from the Infective Variety by the history, the character of the onset, the invasion, and the color of the gum; from the Gastro -intestinal Toxemic Variety by the character of the onset and the physical condition of the patient; from the Presenile Variety by the history, the color and texture of the gum, and the recession of the gum at the necks of the teeth involved; from the Senile Variety by the gradual recession of the gum around all of the remaining teeth ; from the Exciting Varieties by the evidence which they leave on the tissue!

Symptomatology. — The onset of the interstitial variety is insidious, the patient stating that a positive date of the first manifestation of the disease cannot be recalled. It is found that the gum and teeth involved have for some time been slightly painful, but at the time of calling on the dentist this painfulness is much increased. This is probably due to an exacerbation and if the patient is questioned it is learned that in the beginning of the disease these attacks were very mild, but that they have gradually increased as the condition became worse.

The invasion like the onset is a very gradual process. It may or may not attack the gum and tooth which is adjacent to the tooth affected by this disease. It may attack a tooth on the opposite side of the mouth, either in the lower or the upper jaw. The invasion of the disease in all probability is by way of the blood stream or by way of the cancelated portion of the alveolar process after the establishment of the disease. The course of the disease is very slow, involving one tooth and then another until all of the teeth are more or less affected.

Prognosis.— The prognosis is dependent on the duration of the existence of the disease and the severity of the nephritis. If the physical condition of the patient is fairly good a better prognosis can be offered than if it is poor.

Treatment. — The treatment of the gum and mouth should be rigid and thorough prophylaxis. The systemic condition of the patient should be looked after by the family physician. The physician should also prescribe such treatment which, when given with the autogenous BACTERIAL VACCINES, will assist them in raising the immunity of the patient.

Infective Variety.

Etiology. — The infective variety may occur at any age after puberty. It is not selective as to sexes, social conditions or occupation. Previous diseases have much to do with the prodiiction of this variety, especially if they are of that type which is debilitating, for by this action they lower the immunity of the sufferer and thus subject the gum, peridental membrane and alveolus of the patient to the action of micro-organisms and their products.

The exciting causes, like the predisposing, in all probability are factors of great importance. Trauma of the gum is produced by the use of a tooth-pick, a pin, the blade of a knife, or blunt instrument, or by a blow upon the tooth of sufficient severity to loosen it, or upon the gum tissue producing contusion. The chemical irritants by their action upon the gum tissue produce an irritation followed by swelling which forms a pocket at the gingival margin, offering an excellent place for the growth of bacteria. Mechanical irritants; namely, ill-fitting crowns and bridges, act as irritants to the gum tissue. The thermal irritants, especially hot tea or coffee and hot food, are capable of producing sufficient trauma and in many instances a destruction of the gum tissue around a tooth or teeth ensues. If this occurs inflammation of the gum results and a focus of infection is established. The local immunity is impaired and the process of destruction continues until the tissues re-establish an immunity capable of protecting the remaining tissue. The bacteriological irritants are of great importance, for by their presence they bring about such reactions on the tissues in which they are present that the function of the tissues are impaired. As a result of this impairment the resistance of the tissue is lowered, after which not only does this reaction continue, but the bacteria grow more abundantly and the adjacent tissues are attacked, the disease soon involving the gum and the adjacent teeth of the upper and the lower jaw. The chronic variety is a progressive stage of the acute variety.

Pathology. — The acute infective variety is characterized by localized inflammation of the gum at the neck of the tooth; or this inflammatory process may involve the gum tissue of all the teeth and the mucous membrane of the mouth. The swollen gum varies in color from a light to a dark bluish-red and is firm on palpation. The swelling causes the gum to loosen at the gingival margin and a pocket is established, which, if massaged, brings to the gingival margin a small bead of exudate that is whitish in color and adheres firmly to the gum. On microscopic examination it is found to be com-

VAEIETIES OP PYORRHEA 31

posed of pus cells, epithelial cells, bacteria, of one predominant variety, phagocytes and granular material. The roots of the teeth involved by the infection are denuded of the gum and the peridental membrane, which is variable in amount. A continuation of the disease is characterized by destruction of the alveolus and a recession of the gum below the focus of the infection. An examination of the root reveals no deposit, and its surface is quite smooth.

In the chronic variety the gum is not as badl}^ swollen as in the acute and on palpation feels quite spongy. The tinge of the gnim is a deeper blue than that observed in the acute variety. The pus pocket is greater in extent and on gentle massage there exudes at the gum margin a variable amount of exudate which varies in color from a white to a creamy yellow. The exposed roots of the teeth show in this variety a deposit variable in amount and density. The color of this deposit is a dark reddish-brown. It adheres to the root of the tooth very tenaciously.

Bacteriology. — In the infective variety the color of the gum around the teeth involved varies from a light to a dark bluish-red in contrast to the normal pink. At first there is a feeling of irritation of the gum, which gradually progresses until the gums around the diseased teeth become painful and the teeth involved become somewhat loose and slightly elongated. At variable times there are exacerbations, the onset of which may or may not be ushered in by a feeling of malaise and headache. These symptoms are soon afterward followed by an inflammation of the gum and the peridental membrane, producing a very uncomfortable feeling of the teeth if the disease is well advanced. The duration of the attack varies from two to five days, after which the gum and teeth rapidly return to an approximately normal state, and again feel quite comfortable.

The chronic infective variety follows the acute and is an advanced stage of it. It is characterized by a constant inflammation of the gum around the affected teeth. The swelling is slight and the feeling of irritation of the gum is constantly present. The teeth are variably loosened. The gum around the teeth feels spongy to the touch. The color is a dark reddish-blue in contrast to the normal pink. It is separated from that portion of the root of the tooth over which it lies.

Differential Diagnosis. — The acute infective

VAEIETIES OP PYORRHEA 33

variety is differentiated from the Diabetic Variety by the color of the gum, which in the diabetic is a beefy-red while in this variety it varies in color from a light to a dark bluish-red. It is differentiated from the Interstitial Nephritic Variety by the age which is generally after the fortieth year, while in this variety it generally occurs at any time after eruption of the permanent teeth. In the interstitial nephritic variety the recession of the gum is a gradual process, while in the acute infective variety it is a rapid process. At no time is the amount of swelling as great in the interstitial nephritic as is observed in this variety. The gum is slightly painful on pressure in the interstitial nephritic, while in the acute infective variety it is exceedingl}^ painful on the slightest pressure. This variety is differentiated from the Presenile Variety by the age, which is between 25 to 40 years. The pre-senile variety is a slow progressive process destroying the gum, peridental membrane and the alveolar process, which, if accompanied by suppuration, greatly increases the destruction of the tissues on which the position tooth is dependent. The gum tissue in the pre-senile variety is firm and hard, has a normal pink color, and is not painful on pressure. In the infective variety, whether acute or chronic, the gum is swollen and painful on pressure. In the pre- senile variety the exposed portion of the root presents a deposit which varies in color from a light yellow to a reddish-brown and in hardness from a soft chalky to a flinty consistency. In the Senile Variety there is a general shrinkage of the gum around all of the remaining teeth. The gum is firm to the touch, normal in color, and on massage, a small amount of exudate may or may not appear at the gingival margin. If the deposit is present it is yellow in color, and of a chalky consistency. There is a general loosening of all of the remaining teeth. The Gastro-intestinal Toxemic Variety is differentiated from the acute and chronic infective varieties by exacerbations which are characterized by headache, nausea, and intestinal disturbances. These are followed by a marked feeling of irritation of the gum and the peridental membrane, the teeth become very sensitive on occlusion and are slightly loosened. The Exciting Varieties are differentiated from the infective varieties by such evidence which presents itself as a result of trauma, chemical, mechanical, thermal, and bacteriological irritants.

VARIETIES OP PYORRHEA 35

Symptomatology. — The acute variety of this disease is characterized by a sudden feeling of irritation of the gum at the necks of the teeth affected. This feeling is soon after followed by tenderness and swelling. The gum around the teeth involved varies in color from a light to a dark bluish-red and is firm to the touch. At the neck of the tooth the gum retracts from it and forms a pocket. The teeth as a rule involved by the disease are loose, feel elongated to the patient, and are painful when brought into occlusion.

The chronic variety is a continuation of the acute stage and is characterized by an invasion of the disease to many of the teeth of the upper and the lower jaw. The gum in this stage is of a deeper blue color than observed in the acute stage, but is not as badly inflamed and feels spongy to the touch. The pockets are larger and the exposed portion of the roots show a deposit. The teeth are loose and are quite painful when brought into occlusion.

Prognosis. — The prognosis of the infective variety is as a rule very good.

Treatment. — The hygiene of the mouth is first in importance in the treatment of this variety and should consist of a good antiseptic

36 PYORRHEA A1.VE0LARIS

moutli wash wMcli is astringent. The character of the diet should be determined and if found faulty should be corrected by the physician. If the patient is poorly nourished such systemic treatment should be instituted as will improve the general health. The immunit}^ of the patient should be raised by drugs and autogenous bacteeial vaccines.

Gastro-intestinal Toxemic Variety.

Etiology. — This variety of pyorrhea may appear at any time after the eruption of the permanent teeth. The sexes are equally affected. It is found in the middle and wealthy classes, more often in the latter. It is most often found among extravagant livers who lead sedentary lives. It may, however, occur in the mouth of any one suffering with a gastro-intestinal toxema. Previous diseases which have the ability to leave behind a diminished functionating gastro-intestinal apparatus and diminished function of the organs of elimination are of importance in this variety.

Pathology. — The gum and the mucous membrane of the mouth are swollen and painful during an exacerbation. The gum at the necks of the teeth varies in color from a very bright to a very dark red as compared to the normal pink color. It is very firm on pressure and greatly increased in size as compared to tlie normal gum at this point. The swelling of the gum causes it to retract at this point and by so doing pockets are established. The exudates found in the pockets are rich in substances in which bacteria grow readily. The depth of the pockets depends on the previous number of attacks and on the extent of the infection which accompanied them. If the disease is of some standing, gentle massage of the pockets will bring to the margin an exudate which varies in color from a pale white to a yellow, and from a thin watery to a creamy consistency. When examined under the microscope it shows pus cells, fibrinous material, granular debris, and a variety of bacteria. The teeth affected by the exacerbation become very loose and are painful on occlusion. Sordes are observed on the teeth, the tongue is coated, and the breath as a rule is foul smelling.

Bacteriology. — The bacteria found in this variety are the staphylococcus pyogenes albiis, aureus, and fetidis (especially the fetidis) diplococci, spirochcvta refringens, and saplirophytes.

Diagnosis. — The diagnosis of this variety is made on the history of the onset of the exacerbation, the wide- spread inflammation of the gum and the mucous membrane, the swelling and the color of the gum, and symptomatology.

Differential Diagnosis. — This variety is differentiated from the. Diabetic Variety by the color of the gum which in the diabetic variety is a beefy red. In the diabetic variety there is a history of diabetes and the teeth affected are fewer in number. It is differentiated from the Interstitial Nephritic Variety by the history of the interstitial nephritis, the presence of albumin in the urine, the color of the gum, and the gum is not as greatly swollen; from the Presenile Variety by the gradual recession of the gum. The gum is not painful to pressure in the pre-senile variety. From the Acute and Chronic Infective Varieties it is differentiated by the history of the onset of the' disease. The gum in the infective variety is affected quite extensively and the consistency of the gum in the chronic variety is different from that found in this variety. It is differentiated from the Senile Variety by the history, the great amount of recession of the gum, the constant looseness of the teeth, the absence of teeth, and the age of the patient.

VAKIETIES OP PYORRHEA 39

Symptomatology. — The onset of this variety is usually sudden and is characterized by a feeling of soreness and pufifiness of the gum. After the onset the condition continues to become worse and after 24 hours the gum around the teeth becomes very painful on pressure and the teeth variably loosened and feel elongated to the patient. The gum bleeds readily when brushed but after the bleeding feels greatly relieved. In some instances the gum at the necks of the teeth becomes so loose that in the act of mastication of the soft foods which the patient eats, particles of the food crowd into the pockets and greatly irritate it, causing pain. The patient complains of a headache and nausea which is variable in intensity, does not care for food and feels best when lying down. The above symptoms are mild in character in the beginning of the disease, but as the disease progresses become worse at each exacerbation, and at the time of the visit to the dentist are severe in character. In some cases swelling is located at a considerable distance downward from the gum margin. Slight pressure over this point causes the patient to wince and object to repetition of the procedure. Pus appears if this point is lanced. The pain is, as a rule, instantly relieved after it is opened. The duration of the exacerbations varies from three to five days, after which the tenderness of the gum and sensitiveness of the teeth gradually subside. The inflammation disappears and the gum, teeth and mucous membrane gradually return to a stage of quiet, during which they feel quite comfortable to the patient.

Prognosis. — The prognosis of this variety is good.

Treatment. — The treatment should be rigid prophylaxis. An antiseptic mouth-wash is necessary. The diet is of paramount importance as it is in all probability the cause of the disease. A patient suffering from this variety is usually very indiscriminate and as a result is suffering from gastro-intestinal toxema, which greatly impairs the organs of elimination. After a diagnosis has been made the patient is sent to the family phj^sician with a note stating the findings and advising that he be treated for a gastro-intestinal toxema. The autogenous BACTERIAL vACCHsTES are of great value when assisted by the administration of drugs and instrumentation of the affected teeth.