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Relationship of Dentistry to Peptic Ulcer and Goiter
RELATIONSHIP OF DENTISTRY TO PEPTIC ULCER AND GOITER B y G . A r n o l d S t e v e n s , M .D ., Los A ngeles, C alif.
N first thought, it w ou ld seem som ew hat incongruous to consider jo in tly tw o such ap p aren tly u n related conditions as peptic u lcer and goiter. H ow ever, these diseases, w hen one thinks o f them fro m the aspect o f their relationship to dentistry, m anifest certain factors in com m on. T h e cause o f both conditions is unknow n, y e t cer tain predisposing etiologic factors seem to b e com m on to them . B oth h yp erth y roidism and peptic ulcer predom inate in h igh strung persons, both conditions a p pearin g to be associated w ith a disturb ance o f the sym pathetic nervous system ; and, in both conditions, fo ci o f infection, including those o f dental origin, seem to p la y a part. T h is discussion w ill be confined essen tia lly to a sum m ary o f related d en tal ab normalities. In m y practice, I h a v e been impressed w ith the freq u en cy o f dental caries and pyorrhea in patients w ith hyperthyroidism and gastric and d u o denal ulcer as com pared w ith th e in ci dence o f dental disease in patients p re senting themselves fo r treatm ent o f other conditions. T h e increased inciden ce of d ental infection in patients h a v in g goiter has b een reported in the literature, a l though the relationship has not appeared to be constant. L in tz fou n d that, o f the patients he exam ined w ith goiter, 40 per cen t had either infected or extracted te e th ; whereas, in his control series o f norm al persons, the incidence w as only 17 p er cent.
O
Read at the annual meeting of the Southern California Dental Association, October 23,
1940. Jour. A .D .A ,, Vol. 28, March 1941
H alstead, Boos, A b b o tt and others have noted a sim ilar, b u t not so m arked, rela tionship o f foci -of infection, including those o f the teeth, to goiter. G ranted, then, th a t this relationship exists, w h ich is cause and w h ich is effect? W . A . Plum m er, o f the M a y o C lin ic, a d mits the prob ab ility th a t fo ci o f in fe c tion m a y precipitate a hyperthyroidism . O n the other han d , h e believes that the presence of toxic goiter m ay m ake the patient m ore susceptible to foci. T o sub stantiate this opinion, h e presents data from clinical histories in w h ich a con siderable percentage o f patients did not present dental abnorm alities u n til after the developm ent o f goiter. O bviously, accurate deductions o f this n ature are difficult to arrive at, since one m ust d e pend entirely on the history given by the patient. It is likewise difficult to answ er the question w h y disease o f the thyroid and disease o f the teeth are so freq u en tly co existent. T h e results o f investigation in this field are som ew hat confusing. E ric Stern, o f the fa c u lty o f m edicine o f the U n iversity o f Paris, has published d ata w hich suggest th a t the relatively large num ber o f dental defects in cases o f hyperthyroidism are due to defective cap illary nutrition resulting from the altered m etabolism . A lthausen et al. state th at the ad m in istration of th yroxin doubles th e excre tion o f calcium , o w in g to increased peristalsis, and thus facilitates the d evel opm ent o f d en tal caries. O n the other hand, H ellw ig reports, in the January 1940 issue o f Archives o f Surgery, that
404
S t e v e n s — P e p t ic U l c e r a n d G o it e r
an excessive am ount of calcium chloride and calcium carbonate in the blood stream causes goiter in dogs. Bartels and H aggart, o f the L a h e y C lin ic, noted that, in addition to a tend en cy to early caries in the teeth o f h yper thyroid patients, there is a coexistent al veolar resorption. I t is conceivable, they believe, th a t a general d eca lcifyin g proc ess (osteoporosis) exists w hich , in some cases, extends to the tooth structures, re sulting in a low ered resistance to caries. T h e presence o f osteoporosis h a d been previously reported b y von R eck lin g hausen, K o ep p en and others. In contradistinction to these findings, A rn o ld O sterberg states that his chem ical investigation o f the bones o f h yp er thyroid patients yields no evidence o f osteoporosis. Likewise, S ch our believes that availab le facts do n ot establish a cor relation betw een calcium m etabolism and caries. A greater than average incidence of dental infection in patients w ith peptic ulcer is likewise supported in the litera ture. Eusterm an and Austin, o f the M a y o C lin ic, h ave cited clinical d ata suggesting the etiologic relationship o f foci to ulcer. T h e m ost unique exp eri m ental w ork along this line is th at o f Rosenow , w ho produced duodenal ulcers in dogs b y the intravenous injection o f certain strains o f streptococci obtained from the teeth. T h e organism s obtained from the ulcers w ere sim ilar in cultural characteristics to those procured from the teeth. T h e role o f vitam ins in the association o f den tal caries and diseases o f the th y roid and the stom ach has been stressed b y K eeton , o f the U n iversity o f Illinois. H e rem inds us th at 0.45 gm . o f calcium is the norm al d a ily intake requirem ent and that an y alteration o f gastric acid ity retards calcium absorption. H e states that the resultant decrease in b lood c al cium is aggravated b y a relative defi cien cy o f vitam in D in b oth toxic goiter and ulcer. In 1937, he fou n d that, in
405
hyperthyroidism , an excessive am ount o f vitam in C is used. T h is vitam in, he points out, is a catalyst in cellular o x id a tion and also regulates the colloidal con dition o f intracellular substances. V itam in C deficiency, therefore, results in sw elling and bleeding o f the gums and increased cap illa ry fragility. Since teeth require oxygen fo r life, the deficient oxidation resulting from an in ad eq u acy o f vitam in C predisposes to caries. Regardless o f w hether the relationship o f diseased teeth to p eptic ulcer and goiter is causative, resultant or both, one fa c t rem ains c le a r : neither o f these con ditions can be treated adequately i f the need fo r care o f the teeth is disregarded. T h is care can be adm inistered properly on ly b y the dentist, and, in order fo r him to hand le intelligently his part o f the case, h e should be fam iliar w ith certain general principles o f the treatm ent o f these ailm ents. T o rationalize the treatm ent o f peptic ulcer, the m anagem ent o f the two types o f this lesion, n am ely gastric and d u o denal ulcers, m ust be considered sep arately. A vaila b le d ata indicate that from 5 to 10 per cent o f ulcers o f the stom ach becom e m alignant, w hereas can cer o f the duodenum is p ractically u n heard of. A lth o u gh in all uncom plicated gastric and duodenal ulcers, m edical treatm ent should be tried before surgical measures are instituted, the m edical trea t m ent o f gastric ulcer should not be p ro longed unless there is early evidence o f im provem ent, because o f the possibility th a t the u lcer m a y be m alignant. In the latter event, surgery offers the on ly hope o f cure. O n the oth er hand, duodenal ulcer m a y be treated m ed ically for m onths, and even years, w ithou t d anger o f this com plication. In clu d ed in the m edical m anagem ent o f these lesions is the rem oval o f all fo ci o f infection. D e n tal disease should be corrected, including the extraction o f diseased teeth w hen in dicated.
The essential indications for surgery
4o6
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
o f gastric ulcer are ( i ) failu re to obtain clinical and roentgenologic cure w ithin a relatively short period o f m ed ical trea t m ent, (2) repeated hem orrhage, (3) p er foration and (4 ), occasionally, obstruc tion. A lth o u gh no one operative pro cedure applies in the treatm ent o f gastric ulcer, some form o f p artial gastrectom y w ill usually offer the highest percentage o f surgical cures. In this operation, from one-third to on e-h alf o f th e stom ach is rem oved and gastro-intestinal continuity is reestablished b y anastomosis o f the jeju n u m or the duodenum w ith the re m aining portion o f the stom ach. Indications fo r the surgical treatm ent o f duodenal u lcer are ( 1 ) failu re o f the u lcer to respond to prolonged m edical treatm ent, (2) obstruction, (3) repeated hem orrhage and (4) perforation . T h e m ost com m only perform ed operations fo r this condition are partial gastrectom y and gastro-enterostom y. T h e latter con sists o f shortcircuiting the ex it o f the stom ach contents b y establishing anas tomosis o f a loop o f jeju n u m w ith the anterior or posterior w a ll o f the stom ach. P artial gastrectom y fo r d uodenal ulcer has replaced gastro-enterostom y to a con siderable extent recently. A n d it seems rightly so, because the u lcer patien t w ith a h igh gastric a cid ity is less likely to de velop postoperative ulcer at the site o f the anastomosis a fte r gastrectom y than a fter gastro-enterostom y. H ow ever, one m ust not m inim ize the im portance o f gastro-enterostom y as a therapeu tic agent in duodenal ulcer. T h e indications fo r gastro-enterostom y in the treatm ent o f duodenal u lcer m ay be sum m arized as fo llo w s: 1. O b stru ct ing duodenal ulcers in patients over 50 years o f age. Patients o f this age group, it has been fou n d , h a ve a low er gastric acid ity than yo u n ger in d ivid uals and, therefore, are less prone to d evelop postoperative ulcers a t the site o f the anastomosis. 2. Cases in w hich, fo r m echanical reasons, the operation o f
gastrectom y cannot be perform ed. 3. Patients whose general condition does not w arran t the added surgical risk o f gas trectom y. T h e treatm ent o f goiter depends on the type o f thyroid abn orm ality present. T h e sim ple colloid goiter, occurring m ost frequ en tly in adolescent girls and you n g w om en, does n ot call fo r surgical interference. I t w ill usu ally subside u n der m edical treatm ent w ith sm all doses o f iodine. I t is safer to treat n od u lar non-toxic goiter surgically because a m aterial per centage o f these goiters w ill becom e toxic in time (P lu m m er) and 3 p er cent o f them becom e m alignant (Pem berton and others). T h e operative m ortality in these cases is on ly 0.3 per cent. T h e re fore, the chance of d yin g from m alig n an cy in this type o f goiter is ten times greater th an the chance o f d ying from the operation. I t is generally agreed that both n odular toxic goiter an d diffuse toxic goiter (exophthalm ic goiter) are best treated surgically because o f the im pend in g cardiac dam age in these cases. T h e im portance o f preoperative m edical m an agem ent cannot be overestim ated. T his includes the adm inistration o f iodine and sedatives. T h e average tim e required to prepare the patien t fo r operation is from ten to fourteen days. I t is the opinion o f some that foci of infection such as septic tonsils and teeth should be rem oved before surgery o f the thyroid is undertaken. O liv e r T . O s borne, em eritus professor o f therapeutics a t Y a le U n iversity, believes th at a th y roid gland should n ever be operated upon until dental and tonsillar foci have been rem oved. I t is true th at a t times the basal m etabolic rate is low ered and nitro gen retention is increased b y the rem oval o f these foci. E varts G rah a m and others have noted an occasional remission o f sym ptoms o f hyperthyroidism after re m oval o f dental foci.
G u l l if e r — R a d ic u l a r C y s t a n d R o o t G r a n u l o m a
H ow ever, the present consensus is that, usually, an aggravation o f the th y rotoxic sym ptom s occurs after tooth e x traction. It therefore seems safer to rem ove these foci a fte r the patien t has recovered sufficiently fro m the thyroid operation. I subscribe to this latter view . I t is m y p ractice to re fe r these patients to the dentist fo r extraction abou t six weeks a fter thyroidectom y. I f the patien t is ad equ ately prepared preoperatively, the op eration is properly executed and due consideration is given to postoperative care, th e m ortality from goiter operations is less th a n 1 per cent. A ccord in g to availab le statistics, then, thyroidectom y is safer than append ec tom y fo r acute appendicitis.
407
c o n c l u s io n s
1 . C ertain factors are com m on to goiter and peptic u lcer w ith relation to dentistry. 2 . A ll dental disease should be cor rected before operation fo r peptic ulcer is instituted. 3 . C onversely, in the case o f the goiter patient, it seems safer to extract teeth a fter the patien t has sufficiently recov ered from thyroidectom y to m ake such dental procedures safe. 4 . T h e optim um results in the treat m ent o f these conditions are obtained through cooperation o f the internist, the surgeon and the dentist. 9028 Sunset Boulevard.
THE RADICULAR CYST AND ROOT GRANULOMA B y W . H a r r y G u l l i f e r , D .M .D ., Boston, Mass.
A P P A R E N T L Y , there is some con/ "A fusion as to the differentiation betw een the root gran u lom a and the rad icu la r o r root cyst. T h e re is a tendency to call all rarefied areas as re vealed b y the x-rays cysts, w hen such areas occur abou t the roots o f teeth, and w hether th ey are sm all or large. M a n y lesions o f benign and m an y o f m alignant ch aracter h a ve a sim ilar roentgenographic appearance, but, in the present instance, on ly the root gran ulom a and rad icu lar or root cyst w ill be considered. R ad icu la r cysts and root granulom as are associated w ith eru pted teeth, roots, usually devitalized, or areas from w hich such erupted devitalized or infected teeth or roots h a v e been extracted previously. T h e causative fa cto r in granulom a is infection b y b acteria th a t h a v e invaded the p u lp through p rim ary caries, o r sec Jour. A .D .A ., Vol. 28, M arch 1941
on dary infection under fillings and in root-treated teeth, and subsequent in va sion o f the ap ical area. A pulp m a y lose its vita lity from the p roxim ity o f a fill in g or from traum a w ith subsequent gangrene, b u t m a y rem ain quiescent as to symptoms. I t is n on-vital n everthe less, giv in g rise to either the root gran ulom a or the rad icu lar cyst. O n e m ust n ot lose sight o f the fa ct that periodontal infection, subsequent to traum a o r some other predisposing condition, m a y lead to the same processes o f granu lom a or rad icu lar cyst form a tion a t a n y point along the periodontal m em brane, w ith either a vital or a nonvital p u lp in th e tooth. I t is seen, therefore, that the same causative conditions a p p ly in the tw o types o f lesions; w h ich leads logically to the question of the difference betw een the two.
N first thought, it w ou ld seem som ew hat incongruous to consider jo in tly tw o such ap p aren tly u n related conditions as peptic u lcer and goiter. H ow ever, these diseases, w hen one thinks o f them fro m the aspect o f their relationship to dentistry, m anifest certain factors in com m on. T h e cause o f both conditions is unknow n, y e t cer tain predisposing etiologic factors seem to b e com m on to them . B oth h yp erth y roidism and peptic ulcer predom inate in h igh strung persons, both conditions a p pearin g to be associated w ith a disturb ance o f the sym pathetic nervous system ; and, in both conditions, fo ci o f infection, including those o f dental origin, seem to p la y a part. T h is discussion w ill be confined essen tia lly to a sum m ary o f related d en tal ab normalities. In m y practice, I h a v e been impressed w ith the freq u en cy o f dental caries and pyorrhea in patients w ith hyperthyroidism and gastric and d u o denal ulcer as com pared w ith th e in ci dence o f dental disease in patients p re senting themselves fo r treatm ent o f other conditions. T h e increased inciden ce of d ental infection in patients h a v in g goiter has b een reported in the literature, a l though the relationship has not appeared to be constant. L in tz fou n d that, o f the patients he exam ined w ith goiter, 40 per cen t had either infected or extracted te e th ; whereas, in his control series o f norm al persons, the incidence w as only 17 p er cent.
O
Read at the annual meeting of the Southern California Dental Association, October 23,
1940. Jour. A .D .A ,, Vol. 28, March 1941
H alstead, Boos, A b b o tt and others have noted a sim ilar, b u t not so m arked, rela tionship o f foci -of infection, including those o f the teeth, to goiter. G ranted, then, th a t this relationship exists, w h ich is cause and w h ich is effect? W . A . Plum m er, o f the M a y o C lin ic, a d mits the prob ab ility th a t fo ci o f in fe c tion m a y precipitate a hyperthyroidism . O n the other han d , h e believes that the presence of toxic goiter m ay m ake the patient m ore susceptible to foci. T o sub stantiate this opinion, h e presents data from clinical histories in w h ich a con siderable percentage o f patients did not present dental abnorm alities u n til after the developm ent o f goiter. O bviously, accurate deductions o f this n ature are difficult to arrive at, since one m ust d e pend entirely on the history given by the patient. It is likewise difficult to answ er the question w h y disease o f the thyroid and disease o f the teeth are so freq u en tly co existent. T h e results o f investigation in this field are som ew hat confusing. E ric Stern, o f the fa c u lty o f m edicine o f the U n iversity o f Paris, has published d ata w hich suggest th a t the relatively large num ber o f dental defects in cases o f hyperthyroidism are due to defective cap illary nutrition resulting from the altered m etabolism . A lthausen et al. state th at the ad m in istration of th yroxin doubles th e excre tion o f calcium , o w in g to increased peristalsis, and thus facilitates the d evel opm ent o f d en tal caries. O n the other hand, H ellw ig reports, in the January 1940 issue o f Archives o f Surgery, that
404
S t e v e n s — P e p t ic U l c e r a n d G o it e r
an excessive am ount of calcium chloride and calcium carbonate in the blood stream causes goiter in dogs. Bartels and H aggart, o f the L a h e y C lin ic, noted that, in addition to a tend en cy to early caries in the teeth o f h yper thyroid patients, there is a coexistent al veolar resorption. I t is conceivable, they believe, th a t a general d eca lcifyin g proc ess (osteoporosis) exists w hich , in some cases, extends to the tooth structures, re sulting in a low ered resistance to caries. T h e presence o f osteoporosis h a d been previously reported b y von R eck lin g hausen, K o ep p en and others. In contradistinction to these findings, A rn o ld O sterberg states that his chem ical investigation o f the bones o f h yp er thyroid patients yields no evidence o f osteoporosis. Likewise, S ch our believes that availab le facts do n ot establish a cor relation betw een calcium m etabolism and caries. A greater than average incidence of dental infection in patients w ith peptic ulcer is likewise supported in the litera ture. Eusterm an and Austin, o f the M a y o C lin ic, h ave cited clinical d ata suggesting the etiologic relationship o f foci to ulcer. T h e m ost unique exp eri m ental w ork along this line is th at o f Rosenow , w ho produced duodenal ulcers in dogs b y the intravenous injection o f certain strains o f streptococci obtained from the teeth. T h e organism s obtained from the ulcers w ere sim ilar in cultural characteristics to those procured from the teeth. T h e role o f vitam ins in the association o f den tal caries and diseases o f the th y roid and the stom ach has been stressed b y K eeton , o f the U n iversity o f Illinois. H e rem inds us th at 0.45 gm . o f calcium is the norm al d a ily intake requirem ent and that an y alteration o f gastric acid ity retards calcium absorption. H e states that the resultant decrease in b lood c al cium is aggravated b y a relative defi cien cy o f vitam in D in b oth toxic goiter and ulcer. In 1937, he fou n d that, in
405
hyperthyroidism , an excessive am ount o f vitam in C is used. T h is vitam in, he points out, is a catalyst in cellular o x id a tion and also regulates the colloidal con dition o f intracellular substances. V itam in C deficiency, therefore, results in sw elling and bleeding o f the gums and increased cap illa ry fragility. Since teeth require oxygen fo r life, the deficient oxidation resulting from an in ad eq u acy o f vitam in C predisposes to caries. Regardless o f w hether the relationship o f diseased teeth to p eptic ulcer and goiter is causative, resultant or both, one fa c t rem ains c le a r : neither o f these con ditions can be treated adequately i f the need fo r care o f the teeth is disregarded. T h is care can be adm inistered properly on ly b y the dentist, and, in order fo r him to hand le intelligently his part o f the case, h e should be fam iliar w ith certain general principles o f the treatm ent o f these ailm ents. T o rationalize the treatm ent o f peptic ulcer, the m anagem ent o f the two types o f this lesion, n am ely gastric and d u o denal ulcers, m ust be considered sep arately. A vaila b le d ata indicate that from 5 to 10 per cent o f ulcers o f the stom ach becom e m alignant, w hereas can cer o f the duodenum is p ractically u n heard of. A lth o u gh in all uncom plicated gastric and duodenal ulcers, m edical treatm ent should be tried before surgical measures are instituted, the m edical trea t m ent o f gastric ulcer should not be p ro longed unless there is early evidence o f im provem ent, because o f the possibility th a t the u lcer m a y be m alignant. In the latter event, surgery offers the on ly hope o f cure. O n the oth er hand, duodenal ulcer m a y be treated m ed ically for m onths, and even years, w ithou t d anger o f this com plication. In clu d ed in the m edical m anagem ent o f these lesions is the rem oval o f all fo ci o f infection. D e n tal disease should be corrected, including the extraction o f diseased teeth w hen in dicated.
The essential indications for surgery
4o6
T h e J o u r n a l o f t h e A m e r ic a n D e n t a l A s s o c ia t io n
o f gastric ulcer are ( i ) failu re to obtain clinical and roentgenologic cure w ithin a relatively short period o f m ed ical trea t m ent, (2) repeated hem orrhage, (3) p er foration and (4 ), occasionally, obstruc tion. A lth o u gh no one operative pro cedure applies in the treatm ent o f gastric ulcer, some form o f p artial gastrectom y w ill usually offer the highest percentage o f surgical cures. In this operation, from one-third to on e-h alf o f th e stom ach is rem oved and gastro-intestinal continuity is reestablished b y anastomosis o f the jeju n u m or the duodenum w ith the re m aining portion o f the stom ach. Indications fo r the surgical treatm ent o f duodenal u lcer are ( 1 ) failu re o f the u lcer to respond to prolonged m edical treatm ent, (2) obstruction, (3) repeated hem orrhage and (4) perforation . T h e m ost com m only perform ed operations fo r this condition are partial gastrectom y and gastro-enterostom y. T h e latter con sists o f shortcircuiting the ex it o f the stom ach contents b y establishing anas tomosis o f a loop o f jeju n u m w ith the anterior or posterior w a ll o f the stom ach. P artial gastrectom y fo r d uodenal ulcer has replaced gastro-enterostom y to a con siderable extent recently. A n d it seems rightly so, because the u lcer patien t w ith a h igh gastric a cid ity is less likely to de velop postoperative ulcer at the site o f the anastomosis a fte r gastrectom y than a fter gastro-enterostom y. H ow ever, one m ust not m inim ize the im portance o f gastro-enterostom y as a therapeu tic agent in duodenal ulcer. T h e indications fo r gastro-enterostom y in the treatm ent o f duodenal u lcer m ay be sum m arized as fo llo w s: 1. O b stru ct ing duodenal ulcers in patients over 50 years o f age. Patients o f this age group, it has been fou n d , h a ve a low er gastric acid ity than yo u n ger in d ivid uals and, therefore, are less prone to d evelop postoperative ulcers a t the site o f the anastomosis. 2. Cases in w hich, fo r m echanical reasons, the operation o f
gastrectom y cannot be perform ed. 3. Patients whose general condition does not w arran t the added surgical risk o f gas trectom y. T h e treatm ent o f goiter depends on the type o f thyroid abn orm ality present. T h e sim ple colloid goiter, occurring m ost frequ en tly in adolescent girls and you n g w om en, does n ot call fo r surgical interference. I t w ill usu ally subside u n der m edical treatm ent w ith sm all doses o f iodine. I t is safer to treat n od u lar non-toxic goiter surgically because a m aterial per centage o f these goiters w ill becom e toxic in time (P lu m m er) and 3 p er cent o f them becom e m alignant (Pem berton and others). T h e operative m ortality in these cases is on ly 0.3 per cent. T h e re fore, the chance of d yin g from m alig n an cy in this type o f goiter is ten times greater th an the chance o f d ying from the operation. I t is generally agreed that both n odular toxic goiter an d diffuse toxic goiter (exophthalm ic goiter) are best treated surgically because o f the im pend in g cardiac dam age in these cases. T h e im portance o f preoperative m edical m an agem ent cannot be overestim ated. T his includes the adm inistration o f iodine and sedatives. T h e average tim e required to prepare the patien t fo r operation is from ten to fourteen days. I t is the opinion o f some that foci of infection such as septic tonsils and teeth should be rem oved before surgery o f the thyroid is undertaken. O liv e r T . O s borne, em eritus professor o f therapeutics a t Y a le U n iversity, believes th at a th y roid gland should n ever be operated upon until dental and tonsillar foci have been rem oved. I t is true th at a t times the basal m etabolic rate is low ered and nitro gen retention is increased b y the rem oval o f these foci. E varts G rah a m and others have noted an occasional remission o f sym ptoms o f hyperthyroidism after re m oval o f dental foci.
G u l l if e r — R a d ic u l a r C y s t a n d R o o t G r a n u l o m a
H ow ever, the present consensus is that, usually, an aggravation o f the th y rotoxic sym ptom s occurs after tooth e x traction. It therefore seems safer to rem ove these foci a fte r the patien t has recovered sufficiently fro m the thyroid operation. I subscribe to this latter view . I t is m y p ractice to re fe r these patients to the dentist fo r extraction abou t six weeks a fter thyroidectom y. I f the patien t is ad equ ately prepared preoperatively, the op eration is properly executed and due consideration is given to postoperative care, th e m ortality from goiter operations is less th a n 1 per cent. A ccord in g to availab le statistics, then, thyroidectom y is safer than append ec tom y fo r acute appendicitis.
407
c o n c l u s io n s
1 . C ertain factors are com m on to goiter and peptic u lcer w ith relation to dentistry. 2 . A ll dental disease should be cor rected before operation fo r peptic ulcer is instituted. 3 . C onversely, in the case o f the goiter patient, it seems safer to extract teeth a fter the patien t has sufficiently recov ered from thyroidectom y to m ake such dental procedures safe. 4 . T h e optim um results in the treat m ent o f these conditions are obtained through cooperation o f the internist, the surgeon and the dentist. 9028 Sunset Boulevard.
THE RADICULAR CYST AND ROOT GRANULOMA B y W . H a r r y G u l l i f e r , D .M .D ., Boston, Mass.
A P P A R E N T L Y , there is some con/ "A fusion as to the differentiation betw een the root gran u lom a and the rad icu la r o r root cyst. T h e re is a tendency to call all rarefied areas as re vealed b y the x-rays cysts, w hen such areas occur abou t the roots o f teeth, and w hether th ey are sm all or large. M a n y lesions o f benign and m an y o f m alignant ch aracter h a ve a sim ilar roentgenographic appearance, but, in the present instance, on ly the root gran ulom a and rad icu lar or root cyst w ill be considered. R ad icu la r cysts and root granulom as are associated w ith eru pted teeth, roots, usually devitalized, or areas from w hich such erupted devitalized or infected teeth or roots h a v e been extracted previously. T h e causative fa cto r in granulom a is infection b y b acteria th a t h a v e invaded the p u lp through p rim ary caries, o r sec Jour. A .D .A ., Vol. 28, M arch 1941
on dary infection under fillings and in root-treated teeth, and subsequent in va sion o f the ap ical area. A pulp m a y lose its vita lity from the p roxim ity o f a fill in g or from traum a w ith subsequent gangrene, b u t m a y rem ain quiescent as to symptoms. I t is n on-vital n everthe less, giv in g rise to either the root gran ulom a or the rad icu lar cyst. O n e m ust n ot lose sight o f the fa ct that periodontal infection, subsequent to traum a o r some other predisposing condition, m a y lead to the same processes o f granu lom a or rad icu lar cyst form a tion a t a n y point along the periodontal m em brane, w ith either a vital or a nonvital p u lp in th e tooth. I t is seen, therefore, that the same causative conditions a p p ly in the tw o types o f lesions; w h ich leads logically to the question of the difference betw een the two.