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The mouth as a focus of infection
1931.
387
PUBLIC HEALTH.
The
Mouth
as a Focus
of Infection.
By H. N. TIPLADY,L.D.S., Senior School Dental Surgeon, Swansea. This short paper, the chief aim of which, according to the author, is" to put the present position of this subject by giving a short summary of the recent findings from the investigations of the bacteriological flora found in apical infections, was read at a meeting of the Assistant 2l~redical Officers' and School Dentists' Sub-Group of the Welsh Branch, and gave rise to a useful discussion. R. D the
W I L L I A M H U N T E R , speaking at Royal Dental Hospital in 1900, on " Dental Science and Studies and their Importance in Relation to Health," stated that, in his experience as a physician from 1880-1900, he had had his attention drawn to the importance of the teeth only from the point of view of mastication. The index of the Lancet for the period 1890-1900 made three references to teeth: One on the swallowing of a dental plate, and two on the importance of the teeth as an indication of the health of the patient. The state of medical and dental opinion at that period was that general diseases preceded dental disease and were the commonest cause of the latter. Hunter began to take a keen interest in the effect of dental disease and introduced the expression " oral sepsis." His observations and studies led him to the belief that many of the general diseases owed their origin to oral sepsis and, as he says, " by a remarkable coincidence unknown to me at the time, the chief diseases and disorders which I found most frequently owing their origin to dental diseases and the septic infection underlying them were precisely those enumerated as being the antecedent causes of such dental diseases." He speaks of the daily drama of infection of the body, streptococcal infection, with the teeth and bone sockets as seats of its many pathological effects, and with a wide-spread range of medical and surgical affections in the body as the field in which are displayed the manifold activities of its poisonous effects. Since 1900, recognition of a septic infection of dental origin has gained increasing support from the dental, medical and surgical professions, and from some of the most eminent physicians and surgeons in this country and in America. In 1905, Sir William Osler gave his first public address as Regius Professor at the University of Oxford on " The Ideal of Dental Studies," and in 1927, Lord Moynihan, in his address at the Lister Centenary as President of the Royal College of Surgeons, added his surgical testimony.
In 1923, Sir William Willcox in his " Clinical, Pathological and Radiological Aspects of the Teeth and Gums " gave a clear exposition of the whole subject in an open discussion held at the Medical Society of London. He gave many facts from several hundred clinical cases and supplied conclusive evidence that, as he said, " leads one irresistibly to the conclusion that a very large amount of disease is due to dental sepsis." He drew attention to the grouping of streptococci found in mouth infections :-1.--Hcemolytic Group, causing severe toxa~mias and the anmmias resulting from dental sepsis. 2.--Viridans Group, including those streptococci associated with rheumatic infections-S. Salivarious and S. Fcecalis. These are toxic, giving general toxmmic symptoms and may give rise to arthritis, fibrositis and to cardiac lesions. They have both been associated with malignant endocarditis. 3.--Indifferent Group, which are not definitely associated with any condition. He also pointed out that an important factor in the consideration of the general effects produced by dental sepsis is the secondary intestinal infection which may of itself cause similar general disease, for, in practically every case of this kind, examination of the stool and intestinal washings shewed a marked preponderance of streptococci similar to those found in dental lesions. The clinical conditions observed were gastro-intestinal complications, cardiac lesions, eye complications, nervous diseases, altered blood conditions and rheumatic conditions. The criticism by the President of the Medical Society (Lord Dawson of Penn) had reference to the lack of very exact evidence available on this subject and need for organised team work between the radiologist, clinician and the bacteriologist. In reply it was stated that the subject was difficult, and the stage of proof had not yet been reached in regard to a number of diseases. In rheumatoid arthritis, for example, one rarely found streptococci in the joint, and,
.%s
PUBLIC
again, it was known that nephritis followed scarlet fever, but no one had found the germs in the kidneys. The same conclusions have been reached in other countries, notably in America, and a mass of clinical data showing the connection between dental lesions and degenerative diseases is available. An attempt has been made by painstaking laboratory investigations to justify these conclusions. Rosenow, speaking at the anuual meeting of the American Dental Society in April, 1930, gave a summary of a long series of experiments carried out by different workers in his laboratory over a period of fifteen years. ~ He found that the incidence of a dental focus of infection was extremely high in a study of a large number of patients suffering from systemic disease, and that the infecting organism was invariably a streptococcus. Using a pulpless dead tooth as his standard, he made cultures, zerobic and anaerobic, from the apex, guarding against contamination from the supporting structures during extraction, and injected the isolated streptococci into animals (rabbits and dogs). His results shew a very high incidence of elective localisation and, in some thousands of experiments, the percentage varies between 44 and 76. To take one instance, S. Viridans isolated from 29 cases o f sub-acute bacterial endocarditis produced arthritis in 15 per cent., endocarditis in 76 per cent., and myocarditis in 9 per cent. of 109 animals injected. These facts have been borne out by Haden and Price--all three workers in widely separated places. Price stresses the seriousness of a dental focus of infection--" The physical nature of non-vital tooth structure provides protection from the defensive elements of the body and contains food elements suitable for developing biological changes in the contained organisms. These are expressed as changes in virulence or changed affinities." The recent research carried out by Mr. Arthur Bulleid]" by means of a grant from the Medical Research Council is chiefly concerned with the organisms found in dental lesions. The work has been divided into four sections : (1) apical granulomata, (2) .chronic apical osteitis (other than granulomata), (3) acute alveolar abscess, and (4) cystic new growths. * Focal Infection (of dental origin) and Elective. Localisation, by E. C. RosENow, Mayo Foundation, Rochester. N.Y. I" Bacteriological Studies of Apical Infection. (Not yet published.)
HEALTH.
SErTE=~E~,
Group 1.---Cultures by ~erobic and amerobic methods were made with scrupulous care, and the significant fact that emerges is thb.t a member of the streptococcus group has invariably been demonstrated in all the cases of dental granutomata. Out of 80 cases, nine were S. Hcemolytici, 26 were S. Viridans and 45 were nonhzemolytic streptococci. Group 2 . - - I n 20 cases comprising either dead teeth with rarefied apical areas or live teeth with absorbed apices the corresponding proportions were two, eight and ten respectively. Group 3 . - - I n 16 cases of acute alveolar abscesses, four were S. H~ernolytici, seven were S. Viridans, and five were non-ha~molytic. S. H~emotyticus is met with far more often in these " flare ups " and suggests the possibility that exaltation of virulence may in some cases lead to the mutation of the non-h~emolytic into the hmmolytic. Mr. Bulleid states that mice were used for the animal experiments, and in all fatal cases death resulted from a general septica~mia and no evidence of a selective infective process, such as that postulated by Rosenow, was observed in any of the experimental animals.
TI-tE Right. H o n . Lord Leconfield, Lord Lieutenant of Sussex and Chairman of the \Vest Sussex County Council, has consented to act as President of the Forty-third Congress of the Royal Sanitary Institute, to be held at Brighton from July 9th to 16th, 1932.
THE Minister of Health and the Secretary of State for Scotland have appointed a Committee to inquire into the working of the law as to the con;position and description of articles of food other than milk, and to report what alterations, if any, in the law o,r its administration appear to be desirable. The members of the Committee are : - - S i r Frederick J, Willis, ~,:.B.E., C.B. (Chairman), Mrs. J. L. Adamson, Mr. W . Barratt, Mrs. E. Beck, Mr. J. N. Beckett, Mr. G. A. Birse, Mr. H . F. Carlill, Mrs. M. E. Cottrell, Mr. A. T. A. Dobson, C.J3.E., Mr. H. :E. Goodby, Mr. J. M. Hamill, O.B.E., ~.r)., D.SC., ~lrs. Jean Roberts, Mr. R . A. Robinson, T.D., Mr. H . Shaw, D.L., and Mr. G. Stubbs, C.B.E., F.I.C., F.C.S. The Secretary is Mr. ~V. J. Peete, of the Ministry of Health, to whom all communications on the subject should be addressed.
387
PUBLIC HEALTH.
The
Mouth
as a Focus
of Infection.
By H. N. TIPLADY,L.D.S., Senior School Dental Surgeon, Swansea. This short paper, the chief aim of which, according to the author, is" to put the present position of this subject by giving a short summary of the recent findings from the investigations of the bacteriological flora found in apical infections, was read at a meeting of the Assistant 2l~redical Officers' and School Dentists' Sub-Group of the Welsh Branch, and gave rise to a useful discussion. R. D the
W I L L I A M H U N T E R , speaking at Royal Dental Hospital in 1900, on " Dental Science and Studies and their Importance in Relation to Health," stated that, in his experience as a physician from 1880-1900, he had had his attention drawn to the importance of the teeth only from the point of view of mastication. The index of the Lancet for the period 1890-1900 made three references to teeth: One on the swallowing of a dental plate, and two on the importance of the teeth as an indication of the health of the patient. The state of medical and dental opinion at that period was that general diseases preceded dental disease and were the commonest cause of the latter. Hunter began to take a keen interest in the effect of dental disease and introduced the expression " oral sepsis." His observations and studies led him to the belief that many of the general diseases owed their origin to oral sepsis and, as he says, " by a remarkable coincidence unknown to me at the time, the chief diseases and disorders which I found most frequently owing their origin to dental diseases and the septic infection underlying them were precisely those enumerated as being the antecedent causes of such dental diseases." He speaks of the daily drama of infection of the body, streptococcal infection, with the teeth and bone sockets as seats of its many pathological effects, and with a wide-spread range of medical and surgical affections in the body as the field in which are displayed the manifold activities of its poisonous effects. Since 1900, recognition of a septic infection of dental origin has gained increasing support from the dental, medical and surgical professions, and from some of the most eminent physicians and surgeons in this country and in America. In 1905, Sir William Osler gave his first public address as Regius Professor at the University of Oxford on " The Ideal of Dental Studies," and in 1927, Lord Moynihan, in his address at the Lister Centenary as President of the Royal College of Surgeons, added his surgical testimony.
In 1923, Sir William Willcox in his " Clinical, Pathological and Radiological Aspects of the Teeth and Gums " gave a clear exposition of the whole subject in an open discussion held at the Medical Society of London. He gave many facts from several hundred clinical cases and supplied conclusive evidence that, as he said, " leads one irresistibly to the conclusion that a very large amount of disease is due to dental sepsis." He drew attention to the grouping of streptococci found in mouth infections :-1.--Hcemolytic Group, causing severe toxa~mias and the anmmias resulting from dental sepsis. 2.--Viridans Group, including those streptococci associated with rheumatic infections-S. Salivarious and S. Fcecalis. These are toxic, giving general toxmmic symptoms and may give rise to arthritis, fibrositis and to cardiac lesions. They have both been associated with malignant endocarditis. 3.--Indifferent Group, which are not definitely associated with any condition. He also pointed out that an important factor in the consideration of the general effects produced by dental sepsis is the secondary intestinal infection which may of itself cause similar general disease, for, in practically every case of this kind, examination of the stool and intestinal washings shewed a marked preponderance of streptococci similar to those found in dental lesions. The clinical conditions observed were gastro-intestinal complications, cardiac lesions, eye complications, nervous diseases, altered blood conditions and rheumatic conditions. The criticism by the President of the Medical Society (Lord Dawson of Penn) had reference to the lack of very exact evidence available on this subject and need for organised team work between the radiologist, clinician and the bacteriologist. In reply it was stated that the subject was difficult, and the stage of proof had not yet been reached in regard to a number of diseases. In rheumatoid arthritis, for example, one rarely found streptococci in the joint, and,
.%s
PUBLIC
again, it was known that nephritis followed scarlet fever, but no one had found the germs in the kidneys. The same conclusions have been reached in other countries, notably in America, and a mass of clinical data showing the connection between dental lesions and degenerative diseases is available. An attempt has been made by painstaking laboratory investigations to justify these conclusions. Rosenow, speaking at the anuual meeting of the American Dental Society in April, 1930, gave a summary of a long series of experiments carried out by different workers in his laboratory over a period of fifteen years. ~ He found that the incidence of a dental focus of infection was extremely high in a study of a large number of patients suffering from systemic disease, and that the infecting organism was invariably a streptococcus. Using a pulpless dead tooth as his standard, he made cultures, zerobic and anaerobic, from the apex, guarding against contamination from the supporting structures during extraction, and injected the isolated streptococci into animals (rabbits and dogs). His results shew a very high incidence of elective localisation and, in some thousands of experiments, the percentage varies between 44 and 76. To take one instance, S. Viridans isolated from 29 cases o f sub-acute bacterial endocarditis produced arthritis in 15 per cent., endocarditis in 76 per cent., and myocarditis in 9 per cent. of 109 animals injected. These facts have been borne out by Haden and Price--all three workers in widely separated places. Price stresses the seriousness of a dental focus of infection--" The physical nature of non-vital tooth structure provides protection from the defensive elements of the body and contains food elements suitable for developing biological changes in the contained organisms. These are expressed as changes in virulence or changed affinities." The recent research carried out by Mr. Arthur Bulleid]" by means of a grant from the Medical Research Council is chiefly concerned with the organisms found in dental lesions. The work has been divided into four sections : (1) apical granulomata, (2) .chronic apical osteitis (other than granulomata), (3) acute alveolar abscess, and (4) cystic new growths. * Focal Infection (of dental origin) and Elective. Localisation, by E. C. RosENow, Mayo Foundation, Rochester. N.Y. I" Bacteriological Studies of Apical Infection. (Not yet published.)
HEALTH.
SErTE=~E~,
Group 1.---Cultures by ~erobic and amerobic methods were made with scrupulous care, and the significant fact that emerges is thb.t a member of the streptococcus group has invariably been demonstrated in all the cases of dental granutomata. Out of 80 cases, nine were S. Hcemolytici, 26 were S. Viridans and 45 were nonhzemolytic streptococci. Group 2 . - - I n 20 cases comprising either dead teeth with rarefied apical areas or live teeth with absorbed apices the corresponding proportions were two, eight and ten respectively. Group 3 . - - I n 16 cases of acute alveolar abscesses, four were S. H~ernolytici, seven were S. Viridans, and five were non-ha~molytic. S. H~emotyticus is met with far more often in these " flare ups " and suggests the possibility that exaltation of virulence may in some cases lead to the mutation of the non-h~emolytic into the hmmolytic. Mr. Bulleid states that mice were used for the animal experiments, and in all fatal cases death resulted from a general septica~mia and no evidence of a selective infective process, such as that postulated by Rosenow, was observed in any of the experimental animals.
TI-tE Right. H o n . Lord Leconfield, Lord Lieutenant of Sussex and Chairman of the \Vest Sussex County Council, has consented to act as President of the Forty-third Congress of the Royal Sanitary Institute, to be held at Brighton from July 9th to 16th, 1932.
THE Minister of Health and the Secretary of State for Scotland have appointed a Committee to inquire into the working of the law as to the con;position and description of articles of food other than milk, and to report what alterations, if any, in the law o,r its administration appear to be desirable. The members of the Committee are : - - S i r Frederick J, Willis, ~,:.B.E., C.B. (Chairman), Mrs. J. L. Adamson, Mr. W . Barratt, Mrs. E. Beck, Mr. J. N. Beckett, Mr. G. A. Birse, Mr. H . F. Carlill, Mrs. M. E. Cottrell, Mr. A. T. A. Dobson, C.J3.E., Mr. H. :E. Goodby, Mr. J. M. Hamill, O.B.E., ~.r)., D.SC., ~lrs. Jean Roberts, Mr. R . A. Robinson, T.D., Mr. H . Shaw, D.L., and Mr. G. Stubbs, C.B.E., F.I.C., F.C.S. The Secretary is Mr. ~V. J. Peete, of the Ministry of Health, to whom all communications on the subject should be addressed.