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Dental Infection as a Cause of Systemic Disease*
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tunity and pleasure of hearing two essay ists. One on “Drug Reform, Medical and Dental,” by Dr. Paul Nicholas Leech, a subject which is engaging the attention of the profession today; the other on “Fundamental Economic Factors in Den tistry,” by Dr. Henry L. Banzhaf, who has a well worth while message on this subject, dealing with a problem of vital interest to the profession. Rest assured, you cannot afford to miss this meeting. On Wednesday evening, you will have the pleasure of hearing Prof. Willis G.
Sutton, and I assure you that you will miss a very enjoyable and profitable evening if you fail to attend. With the setting of the stage complete, with the essayists and clinicians ready for the curtains to rise, with a loyal member ship ready to attend and cooperate, I declare the Seventy-Second Session of the American Dental Association convened and ready to resume its labors in the interest of professional attainments and advancement and for the benefit of those whom we serve.
D ENTAL IN FEC T IO N AS A CAUSE OF SYSTEMIC DISEASE* By JO SEPH L. MILLER, M.D., Chicrgo, 111.
S
INCE I discussed dental infection as One of the crying needs in medicine is a a cause of systemic disease with the follow-up system which will give us in Chicago Dental Society three or four formation on what has happened to a years ago, little progress has been made inpatient, not a few weeks after a certain determining the role of dental infection treatment has been carried out, but after in the etiology of disease. My observa a lapse of years. This applies not only tions would lead me to believe that more to chronic arthritis, but also to exoph and more dental surgeons are joining the thalmic goiter following subtotal thy ranks of the conservative group. No roidectomy, and to peptic ulcer after sur carefully compiled statistics, to the best gical or medical treatment; I shall confine my discussion largely to of my knowledge, have been published showing the effect on chronic arthritis chronic arthritis, as this is the disease of removal of “foci.” W e have reports, around which has largely centered the for instance, on the effect of surgical pro discussion on the role of dental infections. cedures on the intestine, for the purpose Its importance in a group of other dis of relieving stasis, with reported improve eases, such as peptic ulcer and acute and ment in the patient’s condition. No par chronic nephritis, is certainly on the Every physician sees patients for ticulars are given regarding the degree wane. whom a has recommended rad of improvement or the period over ical toothcolleague extraction for hypertension, which the patient has been observed. myocardial disease, angina pectoris, ex ophthalmic goiter and all types of *Read before the Illinois State D ental neurasthenia. Society, D ecatur, III., M a y 14, 1930. Jour. A . D. A ., September, 1930
M i l l e r — D e n t a l Infection
Before undertaking the discussion, I might mention the results of tonsillec tomy in the prevention of recurrent acute arthritis or recurrent chorea in children. A considerable number of children are subject to recurrent attacks of these two closely related diseases. Both of these ailments are frequently preceded by sore throat. There is now abundant evidence that removal of tonsils has no eifect in preventing these recurrences, largely be cause their removal does not prevent throat infections; it only prevents further attacks of tonsillitis. As for animal experimental work go ing to prove that root abscesses are the cause of chronic arthritis, only a little thought is required to show that such evidence is of little value. The patient with a chronic root abscess has probably developed a degree of immunity to the rrticro-organism, which has also lost some of its virulence. To inject a massive bouillon culture from such a tooth into the vein of a nonimmune rabbit and to have an acute polyarthritis develop is not evidence that this micro-organism is responsible for the patient’s chronic ar thritis. However, this is the proof we are as'ced to accept. The only acceptable evidence that re moval of teeth is beneficial in chronic arthritis is what happens to the patient after such treatment. Failure to improve, however, does not prove that the dental infection may not have been the source of the primary infection. The germs, having reached the joint, may find here a suitable soil for their multiplication and further dissemination. It is impossible, at least at present, to rule out such a sequence of events, except that we can say that certainly not all chronic ar thritis is of dental origin, as we see many patients with this disease who are tooth-
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le’.s for years before the appearance of the joint disturbance. Recent studies have resulted in a rather definite classification of chronic arthritis into two types with different clinical iranifestations and apparently of differ ent etiology. These types are designated as atrophic and osteo-arthritic. The atrophic form is sometimes called rheuma toid arthritis or infectious arthritis. It most frequently appears before the fourth decade and is the only type of chronic arthritis found in children. It most fre quently begins in fingers or toes and only later appears in the larger joints. In the fingers, it usually appears in the middle pha'angeal articulation and quickly gives rise to the characteristic spindle-shaped deformity of the joint. Spontaneous re covery may take place, the deformity remaining. Its usual course is one of remissions and exacerbations, finally re sulting in a high degree of atrophy, de formity and crippling. Streptococcus viridans can be cultured from the joint, the adjacent lymph glands and the blood during the period of ex acerbation. Hence, the term “infectious” arthritis is frequently employed for this type. The streptococci in the blood may come from the original focus of infection or, probably, the micro-organism from the joints gains access to the blood stream. Which of these views is correct has not been determined. It is not improbable that they reach the blood stream from the joints. If this is true, removal of the primary focus after the disease had been acquired would be of little avail. Re moval of the focus of infection would then be of value as a preventive but not as a curative measure. W e will return to a discussion of this question after a brief review of the second type of chronic arthritis, osteo-arthritis.
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Osteo-arthritis has been defined by Timbrell Fisher, an English orthopedic surgeon and a recognized authority on chronic arthritis, as not a disease sui generis but a physiologic response to irri tation either mechanical or toxic. Blood and joint cultures in this type up to date have been negative. Clinically, it is char acterized by spur formation. Heberden’s nodes are a common finding in osteo arthritis. The most frequent location of osteophytes is the spine. They are not infrequent in the knees of fat women. The nodes on the fingers are at most only moderately painful. When the knees are involved, on account of weight bearing, there is often considerable pain on walk ing. The spinal osteophytes give rise to pressure root pains. This type of arthritis is rarely found before the third decade and increases in frequency with advancing years. Osteo phytes are present in the spine in at least 70 per cent of people past 50. Only a small percentage of these have symptoms or, at most, insignificant root pains. A mechanical condition, either trauma or overuse, is an important factor in the etiology. In every occupation, the index finger is used more than the other fingers, and most frequently we find Heberden’s nodes first appearing here. Osteo-arthritis of the knees is very common in fat women but is rare in thin persons. It has been observed that workmen employed at a machine which demands the excessive use of one arm frequently develop osteophytes in the wrist, elbow or shoulder of this arm; or if one leg is used to excess, osteo phytes will appear in the knee. There is abundant evidence that overuse is an im portant factor in the etiology of this type of arthritis. Few believe that direct invasion by bacteria plays a role. Fisher is of the opinion that bacterial toxin absorbed
from some distant focus may be a second ary etiologic factor. He asserts, although he does not present any evidence to sup port his belief, that intestinal toxins may be an etiologic factor. Patients with osteo-arthritis most fre quently complain of root pains thought to be due to osteophytes in the foramen of the exit of the nerve. These pains are not continuous, but have a marked ten dency to recur. The patient with brachial neuralgia due to cervical osteo-arthritis is prone to have recurrent attacks of pain in the shoulder and arm. Attention has been called to the im portance of a mechanical factor in the production of the osteophyte. Assuming that infection may play an important etiologic role, we could not eliminate these osteophytes by removing an infected focus. Yet 1 have seen more than one patient state that such root pains had disappeared after removal of an infected tooth. However, they usually came to see me later because the pain had re turned. Just recently, a woman with a mild type of lumbar discomfort which had been diagnosed as arthritis related that, after extraction of a tooth, one month previous, the pain had entirely dis appeared, to return immediately after she had read an account in the newspaper of a death from arthritis. The chronic in valid is easily affected through psycho therapy. Some of you may recall the throwing away of crutches and canes by the John Alexander Dowie converts. It is my practice in these cases to ex plain to the patient the nature of his trouble and to assure him that this type of chronic arthritis is very rarely disabling and will probably disappear and later re turn; that we cannot remove the spurs on the spine; that acetylsalicylic acid will make him more comfortable while wait ing for Nature to relieve the condition.
M i l l e r — D e n t a l In fection
Frequently, patients will reply that since they know the disease is not crippling, they can easily tolerate the discomfort. I also advise them not to spend their money in treatments or in visiting the various springs recommended for the treatment of rheumatism. To return to the atrophic or infectious type of chronic arthritis: This form is frequently, but not always, disabling. Rarely is there steady progression except in children. Most frequently, the disease is characterized by remissions, with an occasional case terminating spontaneous ly. This tendency to spontaneous remis sion may mislead the optimistic therapist. After the infection has reached the joint, its dissemination to other joints may come, not from the primary focus, but from the primarily infected joint. The chronicity of the disease would then be due to the chronicity of the joint in fections. If this is true, removal of the focus after the disease has developed would merely be locking the door after the horse had been stolen. Eventually, this mooted point may be settled. At present, we can only observe whether the patient is definitely benefited after re moval of foci. If it can be definitely shown that removal of foci relieves these patients, we must conclude that the chronicity of the disease is due to repeated reinfections from some distant focus. When we search the literature for evi dence that removal of foci has resulted in definite improvement of the patient, we find much confusion. In most pa tients, a number of foci have been re moved or treated, such as teeth, tonsils, sinuses, gallbladder and appendix, and it is impossible to determine in case of improvement the particular focus respon sible for the infection. Our difficulties do not end here, as usually a number of different measures are carried on at the
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same time, such as heat, catharsis, vaccine or foreign protein therapy and various orthopedic measures. Furthermore, we meet with such statements as “slightly improved,” and “greatly improved.” When we recall the fluctuating course of the untreated disease, such statements are of little value. In none of the reported series have I been able to find evidence of a suitable follow-up, and it is very im portant to learn how the patient is getting along one, two, or three years later. It appears probable that indefinite evi dence such as the foregoing has estab lished the belief that chronic foci of in fection are responsible for chronic arthritis, rather than what appears more probable, that acute upper respiratory tract focal infections, such as sore throats, pharyngitis, rhinitis, laryngitis, sinusitis and bronchitis, are responsible. W e say upper respiratory tract because this region is the abode of the streptococcus. Goldthwait and his Boston school of ortho pedists believe that the intestinal tract is the most frequent source of the strep tococcus responsible for chronic arthritis. Schottmuller, the German authority on sepsis, states positively that chronic root infections are innocuous. The host does not have an immunity to the invaders responsible for acute infections, nor is the virulence of the micro-organism im paired by long abode in the same soil. The sufferers from chronic arthritis whom I see have long before had many or all of the teeth extracted. A common remark is, “I had all my teeth extracted, but I am no better” ; or, frequently, “I noticed a short period of improvement following extraction of my teeth.” One would surmise that, in the course of years, a physician should see at least one patient who called for some other ail ment, who presented the characteristic deformity of the fingers that persists after
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recovery from a chronic infectious arthri tis and who ascribed his recovery to re moval of infected teeth, but I have yet to see my first case. The patient with a chronic disease fortunately harbors the belief that some thing can be done to relieve him of his disability. This optimism furnishes a fertile soil for psychotherapy. The phy sician imbued with the belief that root abscesses are responsible for many of the ills of mankind, and the physician rather than the dental surgeon is responsible for the many unfulfilled promises, may so impress the patient with his belief that faith induces the patient to say that he is better. Much of the confusion and dif ferences of opinion in regard to various therapeutic measures in many diseases can be accounted for by the role played by psychotherapy. A magnetic personality obtains results by the use of a certain remedy when a different type of physician would fail; for, after all, very frequently the treatment of disease consists in keep ing the patient satisfied while Nature heals. A distinguished physician who was in terested in the study of chronic arthritis told me that it had been his practice to send the patient to the hospital for the purpose of removing a lymph gland ad jacent to one of the involved joints in order to make cultures. The patient was not informed of the object of this minor operation. He would tell the surgeon a few days later that since the operation, he was freer from pain than he had been for months and, in verification, would demonstrate how freely he could use the affected joint. Recently, the Mayos have been cutting the lumbar and cervical sympathetic nerve, in selected cases of chronic infec tious arthritis, with decided improvement in the patient’s condition. Recently, I
gave a clinic on chronic arthritis in a neighboring city. One of the patients chosen for the clinic had recently had a lumbar sympathectomy. She was enthusi astic about her improvement and said, “Just see how I can wave my arms!” I believe teeth with abscessed roots should be removed, but I do not believe we should promise the patients that it will cure them of their complaints. I do not believe that a tooth which is merely pulpless should be extracted. It may be a very serious matter to impair the masti cating surface of undernourished or enfeebled elderly patients by extracting teeth, even if some of them should show small root abscesses. Such a procedure may destroy their limited reserve and have disastrous consequences. I recently saw an elderly man, a streetcar conduc tor, who had had all his teeth extracted on account of indigestion. After the lapse of a year, he had been unable, for financial reasons, to obtain a plate. Needless to say, his digestion had not improved. It is not my intention to leave the im pression that root abscesses cannot be a menace to health, but rather to attempt to show that it has not been proved that they are responsible for systemic diseases, and such proof must be obtained by the clinician and not from animal experi mentation. DISCUSSION E d w a rd H . H a tto n , C hicago, 111.: D r. M iller said th a t little progress had been m ade in th is subject since he la st re ad a p a p er on it, sev eral y ears ago. A nd I should like to em phasize th a t the m ovem ent th a t has oc c u rre d w ithin the groups involved has been in the sam e direction. C e rta in groups still m ain tain th a t the foundation for this theory depends upon anim al experim en tatio n ; and a nother group, w ith w hich I have g re a t sym pathy, is inclined to believe that, a fte r all, the proof is to be found in the clinic, and th a t statem ent is am plified by D r. M ille r w hen he says th a t results a re de
M i l l e r — D e n t a l In fection term ined by w h a t happens a fte r the e x tra c tion of the teeth. Now as he w ent on to explain, he does not m ean w h a t happens to the patien t tom orrow or next week, but w h at happens eventually and perm anently. T h e cure th a t is claim ed im m ediately is not a cure, but as he delig h tfu lly explained, is psychologic. People th a t are im proved in this w ay belong to th a t g roup w hich m any of us discovered, to our sorrow , as w e practiced m edicine. T h e y a re “ re p ea te rs.” A nd I use th a t term advisedly. I think every surgeon has a g ro u p of p atien ts w ho eventually be come to him a sort of pest, because, although little by little, o r piecem eal, if you please, he has rem oved every piece of th e ir anatom y th a t is rem ovable, usually w ith im m ediate and g re a t beneficial effect, they continue to re tu rn to him fo r a n o th er a n d yet a nother operation, follow ed by a n o th er period of im provem ent, and he only gives them up w hen all the a v ailab le structures a re gone. Next, I should like to call y our a ttention to and em phasize D r. M ille r’s statem ent th a t a l though, in his own m ind, the case w as not yet proved, fo r focal infection, this is no excuse (I shall in te rp re t this statem en t freely ) fo r the d entist o r the physician, the dentist chiefly, I think, to allow m outh infection to persist, because although it cannot be proved th a t this is definitely a cause of systemic trouble, it m ay be. T h is p a p er has d ealt a l m ost solely w ith the subject of a rth ritis. T h e title, perhaps, m ight be better stated as the “Role of Focal Infection in the Etiology and T re a tm e n t of A rth ritis.” A rth ritis has alw ays been a ra th e r difficult disease to treat, and if any new id ea seems to offer a possibility fo r the im provem ent of th erap eu tics in the trea tm e n t of a rth ritis, there a re alw ays g re at num bers of in d iv id u a l clinicians w ho g ra sp a t it m ore o r less as a d ro w n in g m an grasps a t a stra w . H e has long since run through the th erap eu tic possibilities of trea tm e n t of a rth ritis, and a new m ethod is to him a g re a t boon. A rth ritis p erh ap s is a most difficult subject to discuss from the standpoint of d em o n stratin g the valu e of the focal infec tion theory. I am sure th a t th ere a re other diseases in w hich a study of the theory of focal infection has contributed m ore to th e r a peutics th a n p erhaps it has in a rth ritis. I h av e the feeling th a t in the case of iritis, the theory of focal infection is m uch m ore p lau si ble. A t least, we w ill h ave to adm it th a t the
theory of focal infection, if not beneficial,
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and I certain ly believe th a t it is, as a w o rk ing theory in the trea tm e n t of iritis, has been a g re a t benefit to the m oral stan d in g of the in d iv id u a l who had iritis, because in the p ast syphilis w as the most common etiologic factor. A t least it gives the patien t an op p o rtunity of com ing through w ith clean skirts. T h e focal infection theory is still a w orking hypothesis in the trea tm e n t of disease. P e rso n ally, I believe it is m ore th a n th at. P e rh a p s I am m ore optim istic th an D r. M iller, p rob ably because I h a v e seen few er patients th an he has seen. I observe th a t m any of the m en a t least who are enthusiastic devotees of the theory of focal infection are either lab o ra to ry experim enters or m en w ho profit larg e ly by application of the theory of focal infection. Y et I cannot divorce m yself from the opinion th a t th ere is som ething w o rth w hile in this theo ry ; and although D r. M iller says it is on the w ane, it is, I believe, still a useful tool, w hich should not be discarded. N eith er should we allow ourselves to be convinced th a t there is any reason fo r leav in g vestiges of dental infection w ith in the m outh, w hen it is w ithin our pow er to rem ove them. H e rb e rt A . P o tts, C hicago, III,: T h is sub ject is so broad th a t it is im possible to try to cover it in detail, and I hope that, from w h a t I h ave to say, you w ill not think th a t I am in fa v o r of re ta in in g these sources of infection w ithin the m outh, but I w ill m ake a plea for the serious consideration of the p a tie n t’s condition, from the standpoint of the m edical m an, the p a tie n t him self and the dentist. In other w ords, if the rem edy is going to be w orse fo r the patient, we had better consider the p a tie n t’s w e lfa re and allow him to keep some of these teeth w hich possibly a re in fected but w hich show little or no absorption of bone, re su lta n t on the infection. I f such teeth, even pulpless teeth, are ruthlessly con dem ned even in the w ell ind iv id u al, w hen the roentgenogram show s no bony absorption at all, as a prophylactic m easure a n d fo r fe a r th a t the patien t w ill h av e a rth ritis w ith in the next tw enty years, I deprecate it. Since H unter, and la te r M ayo, suggested the m outh’s being the source of m any of o u r ills, physicians and dentists have jum ped to the conclusion th a t pulpless teeth should be taken out, no m atter w h eth er the patien t is suffer ing from m ental aberratio n , indigestion o r some o ther condition not associated w ith pathogenic m icro-organism s. W ith o u t doubt,
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people generally are in a better physical state ow ing to better care of th eir m ouths because th e ir attention has been forcibly directed to the m outh as a possible source of trouble, and they them selves h ave given th e ir m ouths more care th a n before and h a v e v isited th e ir d e n tists m ore reg u larly and m ore frequently. It is tru e th a t m ore diseases are m anifested in the m outh th an in any other region of the body, but it is not true th a t the m outh is responsible for all the ills from w hich the other regions of the body suffer. Let us try to reason a little. W e all agree th a t m odern san itatio n has saved m any lives. W hy not apply some of the sam e principles to the hum an m outh; and this I assum e to be the first duty of the dentist. It is his duty to clean and scale the teeth properly, keeping them free from cal culus. O v erh an g in g m arg in s of fillings are abom inations and should be rem oved w hen ever found. U l-fittings crow ns create cess pools and should be rem oved and m ay be re placed, m any tim es, by fillings or in lay s; w hich w ill rem edy the condition and restore the gum s to a healthy state. It is probable th a t p y orrhea begins w ith g in g iv itis; conse quently, it is logical to suppose th a t if the foregoing c ausative states, i. e., the presence of calculus, o v e rh an g in g fillings and ill-fitting crow ns, be elim inated and prevented, w e w ill have less p y orrhea and th ere fo re a h e alth ie r m outh. W h a t m ight be expected as a result of p y o rrh ea ? F irst, pyorrhea is a destructive inflam m ation of the p e rid e n ta l m em brane accom panied by m ore or less pus and bac teria. From the standpoint of general health, it surely cannot be wholesom e to be constantly sw allow ing pus and bacteria. I think it w as P a ste u r w ho said th a t pus itself w as not the prim e facto r in disease, but it w as the fe rm e n tation or putrefaction of it w hich gave rise to deleterious substances. T h e re w e h a v e two factors, one the b a cteria a n d the o ther the products of b acterial grow th. T h ese m ust be considered separately. W h a t becomes of the poisons a fte r they h ave been sw allow ed? P ro b ab ly some of them a re absorbed by the m ucous m em brane of the mouth. T h e rest are undoubtedly absorbed by the g astro-intestinal trac t, and the result is the sam e as th a t w hich follow s the absorption of other poisons taken in sm all quantities. It is obvious th a t we should avoid all absorption po ssib le; conse quently, it is the d en tist’s duty to avoid or p re v en t p y orrhea as f a r as he can by p re v e n t ing gin g iv itis due to the th ree causes a lre ad y
m entioned. All m ouths c ontain bacteria, most of them tra n sie n t visitors, but some m ouths are filthy, w hile some are com paratively clean. T h ese b a cteria a re sw allow ed, but w h at becomes of them ? A fa v o rite w ay of disposing of them is to say th a t they are destroyed by the g a stric ju ic e ; but some stom achs h ave no g a stric juice, others have little and, in all events, it is poured into the stom ach only at in te rv als. W e have instances of b acteria, such as tubercle bacilli, being a b sorbed o r taken into the lymph system from the g astro -in testin al tra c t. W hy not any or all kinds of b a cteria ? I f this is true, and it seems th a t it is tru e in some instances, why not elim inate as best w e can the in v a d e r at the p o rtal? In g en eral surgery, we recognize the signs and sym ptoms of the presence of confined pus and bacteria, but as the usual pyorrheic condition presents no such signs of active inflam m ation, I am inclined to believe th a t there is only a sm all am ount of toxin and b acteria en terin g the lym ph stream through the pocket itself. W hen it does occur, we h ave at once local signs as w ell— fever, pain and leukocytosis. T h e other most p re v a lent infection at w hose door the cause of m any ills is laid is the one revealed in most instances by the roentgenogram and by it alone. In the v a st m a jo rity of cases, these infections a re hem olytic streptococci, greenproducing streptococci, e ith e r in pure culture or g ro w in g together. A nyone w ho has had any technical experience in bacteriology knows how difficult it is to grow a pure cul tu re and how im possible it w ould be to in tro duce such a pure culture, either of one or the o ther o r both organism s, d u rin g the process of root canal trea tm e n t of root filling. C on sequently, we m ust com m end the dentist who sterilizes, as he does, m ost roots, and fills them w ithout the introduction of b a c te r ia ; but, at tim es, he does not succeed and it is evidenced by an acute abscess, due to in tro duction of pus-producing germ s. T hese be fore m entioned streptococci do not form pus, and w hen we h ave an acute abscess or even a subacute abscess, the cause is a m ixed culture of b acteria. W e h ave been lax in our nom en c lature in speaking of these a reas shown in the roentgenogram as a d a rk spot. T h ey are, in the m ajo rity of cases, not abscesses, because they contain no pus. T h ey are usually m asses of g ra n u la tio n tissue, containing bac teria, it is true, but also c o ntaining leukocytes, w hich a re alive and actively engaged in de-
Schour — M a x i m o w ’s Research on In fla m m a to r y Reaction stroying the bacteria. T h ese m asses of g ra n u lalion tissue are re p ara tiv e , and if the c ausative factor, the tooth, is extracted, new bone ra p id ly replaces the g ra n u la tio n tissue and healing pursues a norm al course. R esidual infection, w hen com pared w ith the occurrence of norm al re p a ir follow ing sim ple extraction, is ra re indeed. I h ave thought fo r a long tim e th a t these streptococcic infections about root apices occur subsequently to the root canal filling, weeks, m onths o r m aybe years befo re; and as w e have show ers of vario u s b acteria w ith in the blood stream a t tim es, it is probable th a t they a re c a rrie d to these places, w hich, from the loss of the pulp w ith its circulation, present a localized a re a of lessened resistance and there find conditions fa v o ra b le for th e ir grow th. Does it not seem reasonable th a t our vario u s ills m ight be in cident to these show ers w hich infect the apical a rea s ra th e r th an being due to the secondary focus about the teeth? F urth erm o re, we are justified only in ascribing to the apical infec tion as the p rim a ry focus these pathologic conditions w hich a re due to the sam e o rg a n isms found in the apical infection. D r. M iller has told us th a t no streptococci h ave been cultured from or about the joints of these chronic a rth ritic s. Consequently, w e h av e no rig h t to ascribe the o steo -arth ritis to the teeth. I have talked recently w ith an em inent m an who sees larg e num bers of cases of osteo a rth ritis and he tells me th a t he has seen no
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cases w hich have been benefited by the e x tra c tion of infected teeth. U ndoubtedly, some pathologic conditions a re at times due d irec t ly to these chronically infected teeth, such as the infections of the choroid and in te rio r of the eye. Possibly some of the infections be hind a u re te ra l strictu re m a y .b e of dental origin, and possibly some of the cases of p ro g ressive m yocarditis m ay h ave a c o ntributing cause in the teeth, but, as yet, w e cannot be sure of it, and until w e are reasonably sure w e a re not justified in rem oving useful teeth w hen, in the case a t hand, it is doubtful th a t such rem oval w ill influence the disease from w hich the p a tie n t is suffering. In my p ra c tice, I try to go v ern m y judgm ent and p ro cedure by the severity of the p a tie n t’s illness. If the loss of eyesight is th reaten ed and no o ther cause can be found, I even rem ove pulpless teeth, although the roentgenogram is n e g a tiv e ; but I do not rem ove pulpless teeth as a prophylactic m easure fe arin g th a t the p a tient m ay a t some tim e in the future develop an iritis. N eith er do I allow a tooth or teeth b e a rin g a larg e a rea of bony destruction to rem ain, but, g iv en an in d iv id u a l not se ri ously ill, suffering from some condition w hich bears no pathologic relation to the organism s found in these g ranulom as, and h a v in g some useful pulpless teeth w hich, though infected, h av e only a sm all am ount of bony absorption about the apices, I em phatically advise ag ain st th eir rem oval.
A REVIEW OF M A X IM O W ’S RESEARCH O N INFLAM M ATORY REACTION* By ISAAC SCHOUR, B.S., D.D.S., M.S., Chicago, III.
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HE purpose of this paper is to pre standing contributions, details of which sent before the dental profession a are found in the papers referred to in the brief report of Maximow’s researches footnotes. Because of the limitation of time, it is not possible to discuss here in on the cytology of inflammation. The scope of this paper is limited to his out detail all of the controversial points in this field. * D ep artm en t of Histology, College of D enThe scientific conception of dentistry, tistry, U n iv ersity of Illinois, C hicago, 111. as contrasted with the purely mechanical *Read before the Section on O ra l P athology aspects of this art, is continuously becom at the M id w in ter C linic of the C hicago D en ing more widespread. Dental research tal Society, Ja n . 14, 1930. Jour. A . D. A ., September, 1930
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tunity and pleasure of hearing two essay ists. One on “Drug Reform, Medical and Dental,” by Dr. Paul Nicholas Leech, a subject which is engaging the attention of the profession today; the other on “Fundamental Economic Factors in Den tistry,” by Dr. Henry L. Banzhaf, who has a well worth while message on this subject, dealing with a problem of vital interest to the profession. Rest assured, you cannot afford to miss this meeting. On Wednesday evening, you will have the pleasure of hearing Prof. Willis G.
Sutton, and I assure you that you will miss a very enjoyable and profitable evening if you fail to attend. With the setting of the stage complete, with the essayists and clinicians ready for the curtains to rise, with a loyal member ship ready to attend and cooperate, I declare the Seventy-Second Session of the American Dental Association convened and ready to resume its labors in the interest of professional attainments and advancement and for the benefit of those whom we serve.
D ENTAL IN FEC T IO N AS A CAUSE OF SYSTEMIC DISEASE* By JO SEPH L. MILLER, M.D., Chicrgo, 111.
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INCE I discussed dental infection as One of the crying needs in medicine is a a cause of systemic disease with the follow-up system which will give us in Chicago Dental Society three or four formation on what has happened to a years ago, little progress has been made inpatient, not a few weeks after a certain determining the role of dental infection treatment has been carried out, but after in the etiology of disease. My observa a lapse of years. This applies not only tions would lead me to believe that more to chronic arthritis, but also to exoph and more dental surgeons are joining the thalmic goiter following subtotal thy ranks of the conservative group. No roidectomy, and to peptic ulcer after sur carefully compiled statistics, to the best gical or medical treatment; I shall confine my discussion largely to of my knowledge, have been published showing the effect on chronic arthritis chronic arthritis, as this is the disease of removal of “foci.” W e have reports, around which has largely centered the for instance, on the effect of surgical pro discussion on the role of dental infections. cedures on the intestine, for the purpose Its importance in a group of other dis of relieving stasis, with reported improve eases, such as peptic ulcer and acute and ment in the patient’s condition. No par chronic nephritis, is certainly on the Every physician sees patients for ticulars are given regarding the degree wane. whom a has recommended rad of improvement or the period over ical toothcolleague extraction for hypertension, which the patient has been observed. myocardial disease, angina pectoris, ex ophthalmic goiter and all types of *Read before the Illinois State D ental neurasthenia. Society, D ecatur, III., M a y 14, 1930. Jour. A . D. A ., September, 1930
M i l l e r — D e n t a l Infection
Before undertaking the discussion, I might mention the results of tonsillec tomy in the prevention of recurrent acute arthritis or recurrent chorea in children. A considerable number of children are subject to recurrent attacks of these two closely related diseases. Both of these ailments are frequently preceded by sore throat. There is now abundant evidence that removal of tonsils has no eifect in preventing these recurrences, largely be cause their removal does not prevent throat infections; it only prevents further attacks of tonsillitis. As for animal experimental work go ing to prove that root abscesses are the cause of chronic arthritis, only a little thought is required to show that such evidence is of little value. The patient with a chronic root abscess has probably developed a degree of immunity to the rrticro-organism, which has also lost some of its virulence. To inject a massive bouillon culture from such a tooth into the vein of a nonimmune rabbit and to have an acute polyarthritis develop is not evidence that this micro-organism is responsible for the patient’s chronic ar thritis. However, this is the proof we are as'ced to accept. The only acceptable evidence that re moval of teeth is beneficial in chronic arthritis is what happens to the patient after such treatment. Failure to improve, however, does not prove that the dental infection may not have been the source of the primary infection. The germs, having reached the joint, may find here a suitable soil for their multiplication and further dissemination. It is impossible, at least at present, to rule out such a sequence of events, except that we can say that certainly not all chronic ar thritis is of dental origin, as we see many patients with this disease who are tooth-
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le’.s for years before the appearance of the joint disturbance. Recent studies have resulted in a rather definite classification of chronic arthritis into two types with different clinical iranifestations and apparently of differ ent etiology. These types are designated as atrophic and osteo-arthritic. The atrophic form is sometimes called rheuma toid arthritis or infectious arthritis. It most frequently appears before the fourth decade and is the only type of chronic arthritis found in children. It most fre quently begins in fingers or toes and only later appears in the larger joints. In the fingers, it usually appears in the middle pha'angeal articulation and quickly gives rise to the characteristic spindle-shaped deformity of the joint. Spontaneous re covery may take place, the deformity remaining. Its usual course is one of remissions and exacerbations, finally re sulting in a high degree of atrophy, de formity and crippling. Streptococcus viridans can be cultured from the joint, the adjacent lymph glands and the blood during the period of ex acerbation. Hence, the term “infectious” arthritis is frequently employed for this type. The streptococci in the blood may come from the original focus of infection or, probably, the micro-organism from the joints gains access to the blood stream. Which of these views is correct has not been determined. It is not improbable that they reach the blood stream from the joints. If this is true, removal of the primary focus after the disease had been acquired would be of little avail. Re moval of the focus of infection would then be of value as a preventive but not as a curative measure. W e will return to a discussion of this question after a brief review of the second type of chronic arthritis, osteo-arthritis.
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Osteo-arthritis has been defined by Timbrell Fisher, an English orthopedic surgeon and a recognized authority on chronic arthritis, as not a disease sui generis but a physiologic response to irri tation either mechanical or toxic. Blood and joint cultures in this type up to date have been negative. Clinically, it is char acterized by spur formation. Heberden’s nodes are a common finding in osteo arthritis. The most frequent location of osteophytes is the spine. They are not infrequent in the knees of fat women. The nodes on the fingers are at most only moderately painful. When the knees are involved, on account of weight bearing, there is often considerable pain on walk ing. The spinal osteophytes give rise to pressure root pains. This type of arthritis is rarely found before the third decade and increases in frequency with advancing years. Osteo phytes are present in the spine in at least 70 per cent of people past 50. Only a small percentage of these have symptoms or, at most, insignificant root pains. A mechanical condition, either trauma or overuse, is an important factor in the etiology. In every occupation, the index finger is used more than the other fingers, and most frequently we find Heberden’s nodes first appearing here. Osteo-arthritis of the knees is very common in fat women but is rare in thin persons. It has been observed that workmen employed at a machine which demands the excessive use of one arm frequently develop osteophytes in the wrist, elbow or shoulder of this arm; or if one leg is used to excess, osteo phytes will appear in the knee. There is abundant evidence that overuse is an im portant factor in the etiology of this type of arthritis. Few believe that direct invasion by bacteria plays a role. Fisher is of the opinion that bacterial toxin absorbed
from some distant focus may be a second ary etiologic factor. He asserts, although he does not present any evidence to sup port his belief, that intestinal toxins may be an etiologic factor. Patients with osteo-arthritis most fre quently complain of root pains thought to be due to osteophytes in the foramen of the exit of the nerve. These pains are not continuous, but have a marked ten dency to recur. The patient with brachial neuralgia due to cervical osteo-arthritis is prone to have recurrent attacks of pain in the shoulder and arm. Attention has been called to the im portance of a mechanical factor in the production of the osteophyte. Assuming that infection may play an important etiologic role, we could not eliminate these osteophytes by removing an infected focus. Yet 1 have seen more than one patient state that such root pains had disappeared after removal of an infected tooth. However, they usually came to see me later because the pain had re turned. Just recently, a woman with a mild type of lumbar discomfort which had been diagnosed as arthritis related that, after extraction of a tooth, one month previous, the pain had entirely dis appeared, to return immediately after she had read an account in the newspaper of a death from arthritis. The chronic in valid is easily affected through psycho therapy. Some of you may recall the throwing away of crutches and canes by the John Alexander Dowie converts. It is my practice in these cases to ex plain to the patient the nature of his trouble and to assure him that this type of chronic arthritis is very rarely disabling and will probably disappear and later re turn; that we cannot remove the spurs on the spine; that acetylsalicylic acid will make him more comfortable while wait ing for Nature to relieve the condition.
M i l l e r — D e n t a l In fection
Frequently, patients will reply that since they know the disease is not crippling, they can easily tolerate the discomfort. I also advise them not to spend their money in treatments or in visiting the various springs recommended for the treatment of rheumatism. To return to the atrophic or infectious type of chronic arthritis: This form is frequently, but not always, disabling. Rarely is there steady progression except in children. Most frequently, the disease is characterized by remissions, with an occasional case terminating spontaneous ly. This tendency to spontaneous remis sion may mislead the optimistic therapist. After the infection has reached the joint, its dissemination to other joints may come, not from the primary focus, but from the primarily infected joint. The chronicity of the disease would then be due to the chronicity of the joint in fections. If this is true, removal of the focus after the disease has developed would merely be locking the door after the horse had been stolen. Eventually, this mooted point may be settled. At present, we can only observe whether the patient is definitely benefited after re moval of foci. If it can be definitely shown that removal of foci relieves these patients, we must conclude that the chronicity of the disease is due to repeated reinfections from some distant focus. When we search the literature for evi dence that removal of foci has resulted in definite improvement of the patient, we find much confusion. In most pa tients, a number of foci have been re moved or treated, such as teeth, tonsils, sinuses, gallbladder and appendix, and it is impossible to determine in case of improvement the particular focus respon sible for the infection. Our difficulties do not end here, as usually a number of different measures are carried on at the
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same time, such as heat, catharsis, vaccine or foreign protein therapy and various orthopedic measures. Furthermore, we meet with such statements as “slightly improved,” and “greatly improved.” When we recall the fluctuating course of the untreated disease, such statements are of little value. In none of the reported series have I been able to find evidence of a suitable follow-up, and it is very im portant to learn how the patient is getting along one, two, or three years later. It appears probable that indefinite evi dence such as the foregoing has estab lished the belief that chronic foci of in fection are responsible for chronic arthritis, rather than what appears more probable, that acute upper respiratory tract focal infections, such as sore throats, pharyngitis, rhinitis, laryngitis, sinusitis and bronchitis, are responsible. W e say upper respiratory tract because this region is the abode of the streptococcus. Goldthwait and his Boston school of ortho pedists believe that the intestinal tract is the most frequent source of the strep tococcus responsible for chronic arthritis. Schottmuller, the German authority on sepsis, states positively that chronic root infections are innocuous. The host does not have an immunity to the invaders responsible for acute infections, nor is the virulence of the micro-organism im paired by long abode in the same soil. The sufferers from chronic arthritis whom I see have long before had many or all of the teeth extracted. A common remark is, “I had all my teeth extracted, but I am no better” ; or, frequently, “I noticed a short period of improvement following extraction of my teeth.” One would surmise that, in the course of years, a physician should see at least one patient who called for some other ail ment, who presented the characteristic deformity of the fingers that persists after
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recovery from a chronic infectious arthri tis and who ascribed his recovery to re moval of infected teeth, but I have yet to see my first case. The patient with a chronic disease fortunately harbors the belief that some thing can be done to relieve him of his disability. This optimism furnishes a fertile soil for psychotherapy. The phy sician imbued with the belief that root abscesses are responsible for many of the ills of mankind, and the physician rather than the dental surgeon is responsible for the many unfulfilled promises, may so impress the patient with his belief that faith induces the patient to say that he is better. Much of the confusion and dif ferences of opinion in regard to various therapeutic measures in many diseases can be accounted for by the role played by psychotherapy. A magnetic personality obtains results by the use of a certain remedy when a different type of physician would fail; for, after all, very frequently the treatment of disease consists in keep ing the patient satisfied while Nature heals. A distinguished physician who was in terested in the study of chronic arthritis told me that it had been his practice to send the patient to the hospital for the purpose of removing a lymph gland ad jacent to one of the involved joints in order to make cultures. The patient was not informed of the object of this minor operation. He would tell the surgeon a few days later that since the operation, he was freer from pain than he had been for months and, in verification, would demonstrate how freely he could use the affected joint. Recently, the Mayos have been cutting the lumbar and cervical sympathetic nerve, in selected cases of chronic infec tious arthritis, with decided improvement in the patient’s condition. Recently, I
gave a clinic on chronic arthritis in a neighboring city. One of the patients chosen for the clinic had recently had a lumbar sympathectomy. She was enthusi astic about her improvement and said, “Just see how I can wave my arms!” I believe teeth with abscessed roots should be removed, but I do not believe we should promise the patients that it will cure them of their complaints. I do not believe that a tooth which is merely pulpless should be extracted. It may be a very serious matter to impair the masti cating surface of undernourished or enfeebled elderly patients by extracting teeth, even if some of them should show small root abscesses. Such a procedure may destroy their limited reserve and have disastrous consequences. I recently saw an elderly man, a streetcar conduc tor, who had had all his teeth extracted on account of indigestion. After the lapse of a year, he had been unable, for financial reasons, to obtain a plate. Needless to say, his digestion had not improved. It is not my intention to leave the im pression that root abscesses cannot be a menace to health, but rather to attempt to show that it has not been proved that they are responsible for systemic diseases, and such proof must be obtained by the clinician and not from animal experi mentation. DISCUSSION E d w a rd H . H a tto n , C hicago, 111.: D r. M iller said th a t little progress had been m ade in th is subject since he la st re ad a p a p er on it, sev eral y ears ago. A nd I should like to em phasize th a t the m ovem ent th a t has oc c u rre d w ithin the groups involved has been in the sam e direction. C e rta in groups still m ain tain th a t the foundation for this theory depends upon anim al experim en tatio n ; and a nother group, w ith w hich I have g re a t sym pathy, is inclined to believe that, a fte r all, the proof is to be found in the clinic, and th a t statem ent is am plified by D r. M ille r w hen he says th a t results a re de
M i l l e r — D e n t a l In fection term ined by w h a t happens a fte r the e x tra c tion of the teeth. Now as he w ent on to explain, he does not m ean w h a t happens to the patien t tom orrow or next week, but w h at happens eventually and perm anently. T h e cure th a t is claim ed im m ediately is not a cure, but as he delig h tfu lly explained, is psychologic. People th a t are im proved in this w ay belong to th a t g roup w hich m any of us discovered, to our sorrow , as w e practiced m edicine. T h e y a re “ re p ea te rs.” A nd I use th a t term advisedly. I think every surgeon has a g ro u p of p atien ts w ho eventually be come to him a sort of pest, because, although little by little, o r piecem eal, if you please, he has rem oved every piece of th e ir anatom y th a t is rem ovable, usually w ith im m ediate and g re a t beneficial effect, they continue to re tu rn to him fo r a n o th er a n d yet a nother operation, follow ed by a n o th er period of im provem ent, and he only gives them up w hen all the a v ailab le structures a re gone. Next, I should like to call y our a ttention to and em phasize D r. M ille r’s statem ent th a t a l though, in his own m ind, the case w as not yet proved, fo r focal infection, this is no excuse (I shall in te rp re t this statem en t freely ) fo r the d entist o r the physician, the dentist chiefly, I think, to allow m outh infection to persist, because although it cannot be proved th a t this is definitely a cause of systemic trouble, it m ay be. T h is p a p er has d ealt a l m ost solely w ith the subject of a rth ritis. T h e title, perhaps, m ight be better stated as the “Role of Focal Infection in the Etiology and T re a tm e n t of A rth ritis.” A rth ritis has alw ays been a ra th e r difficult disease to treat, and if any new id ea seems to offer a possibility fo r the im provem ent of th erap eu tics in the trea tm e n t of a rth ritis, there a re alw ays g re at num bers of in d iv id u a l clinicians w ho g ra sp a t it m ore o r less as a d ro w n in g m an grasps a t a stra w . H e has long since run through the th erap eu tic possibilities of trea tm e n t of a rth ritis, and a new m ethod is to him a g re a t boon. A rth ritis p erh ap s is a most difficult subject to discuss from the standpoint of d em o n stratin g the valu e of the focal infec tion theory. I am sure th a t th ere a re other diseases in w hich a study of the theory of focal infection has contributed m ore to th e r a peutics th a n p erhaps it has in a rth ritis. I h av e the feeling th a t in the case of iritis, the theory of focal infection is m uch m ore p lau si ble. A t least, we w ill h ave to adm it th a t the
theory of focal infection, if not beneficial,
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and I certain ly believe th a t it is, as a w o rk ing theory in the trea tm e n t of iritis, has been a g re a t benefit to the m oral stan d in g of the in d iv id u a l who had iritis, because in the p ast syphilis w as the most common etiologic factor. A t least it gives the patien t an op p o rtunity of com ing through w ith clean skirts. T h e focal infection theory is still a w orking hypothesis in the trea tm e n t of disease. P e rso n ally, I believe it is m ore th a n th at. P e rh a p s I am m ore optim istic th an D r. M iller, p rob ably because I h a v e seen few er patients th an he has seen. I observe th a t m any of the m en a t least who are enthusiastic devotees of the theory of focal infection are either lab o ra to ry experim enters or m en w ho profit larg e ly by application of the theory of focal infection. Y et I cannot divorce m yself from the opinion th a t th ere is som ething w o rth w hile in this theo ry ; and although D r. M iller says it is on the w ane, it is, I believe, still a useful tool, w hich should not be discarded. N eith er should we allow ourselves to be convinced th a t there is any reason fo r leav in g vestiges of dental infection w ith in the m outh, w hen it is w ithin our pow er to rem ove them. H e rb e rt A . P o tts, C hicago, III,: T h is sub ject is so broad th a t it is im possible to try to cover it in detail, and I hope that, from w h a t I h ave to say, you w ill not think th a t I am in fa v o r of re ta in in g these sources of infection w ithin the m outh, but I w ill m ake a plea for the serious consideration of the p a tie n t’s condition, from the standpoint of the m edical m an, the p a tie n t him self and the dentist. In other w ords, if the rem edy is going to be w orse fo r the patient, we had better consider the p a tie n t’s w e lfa re and allow him to keep some of these teeth w hich possibly a re in fected but w hich show little or no absorption of bone, re su lta n t on the infection. I f such teeth, even pulpless teeth, are ruthlessly con dem ned even in the w ell ind iv id u al, w hen the roentgenogram show s no bony absorption at all, as a prophylactic m easure a n d fo r fe a r th a t the patien t w ill h av e a rth ritis w ith in the next tw enty years, I deprecate it. Since H unter, and la te r M ayo, suggested the m outh’s being the source of m any of o u r ills, physicians and dentists have jum ped to the conclusion th a t pulpless teeth should be taken out, no m atter w h eth er the patien t is suffer ing from m ental aberratio n , indigestion o r some o ther condition not associated w ith pathogenic m icro-organism s. W ith o u t doubt,
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people generally are in a better physical state ow ing to better care of th eir m ouths because th e ir attention has been forcibly directed to the m outh as a possible source of trouble, and they them selves h ave given th e ir m ouths more care th a n before and h a v e v isited th e ir d e n tists m ore reg u larly and m ore frequently. It is tru e th a t m ore diseases are m anifested in the m outh th an in any other region of the body, but it is not true th a t the m outh is responsible for all the ills from w hich the other regions of the body suffer. Let us try to reason a little. W e all agree th a t m odern san itatio n has saved m any lives. W hy not apply some of the sam e principles to the hum an m outh; and this I assum e to be the first duty of the dentist. It is his duty to clean and scale the teeth properly, keeping them free from cal culus. O v erh an g in g m arg in s of fillings are abom inations and should be rem oved w hen ever found. U l-fittings crow ns create cess pools and should be rem oved and m ay be re placed, m any tim es, by fillings or in lay s; w hich w ill rem edy the condition and restore the gum s to a healthy state. It is probable th a t p y orrhea begins w ith g in g iv itis; conse quently, it is logical to suppose th a t if the foregoing c ausative states, i. e., the presence of calculus, o v e rh an g in g fillings and ill-fitting crow ns, be elim inated and prevented, w e w ill have less p y orrhea and th ere fo re a h e alth ie r m outh. W h a t m ight be expected as a result of p y o rrh ea ? F irst, pyorrhea is a destructive inflam m ation of the p e rid e n ta l m em brane accom panied by m ore or less pus and bac teria. From the standpoint of general health, it surely cannot be wholesom e to be constantly sw allow ing pus and bacteria. I think it w as P a ste u r w ho said th a t pus itself w as not the prim e facto r in disease, but it w as the fe rm e n tation or putrefaction of it w hich gave rise to deleterious substances. T h e re w e h a v e two factors, one the b a cteria a n d the o ther the products of b acterial grow th. T h ese m ust be considered separately. W h a t becomes of the poisons a fte r they h ave been sw allow ed? P ro b ab ly some of them a re absorbed by the m ucous m em brane of the mouth. T h e rest are undoubtedly absorbed by the g astro-intestinal trac t, and the result is the sam e as th a t w hich follow s the absorption of other poisons taken in sm all quantities. It is obvious th a t we should avoid all absorption po ssib le; conse quently, it is the d en tist’s duty to avoid or p re v en t p y orrhea as f a r as he can by p re v e n t ing gin g iv itis due to the th ree causes a lre ad y
m entioned. All m ouths c ontain bacteria, most of them tra n sie n t visitors, but some m ouths are filthy, w hile some are com paratively clean. T h ese b a cteria a re sw allow ed, but w h at becomes of them ? A fa v o rite w ay of disposing of them is to say th a t they are destroyed by the g a stric ju ic e ; but some stom achs h ave no g a stric juice, others have little and, in all events, it is poured into the stom ach only at in te rv als. W e have instances of b acteria, such as tubercle bacilli, being a b sorbed o r taken into the lymph system from the g astro -in testin al tra c t. W hy not any or all kinds of b a cteria ? I f this is true, and it seems th a t it is tru e in some instances, why not elim inate as best w e can the in v a d e r at the p o rtal? In g en eral surgery, we recognize the signs and sym ptoms of the presence of confined pus and bacteria, but as the usual pyorrheic condition presents no such signs of active inflam m ation, I am inclined to believe th a t there is only a sm all am ount of toxin and b acteria en terin g the lym ph stream through the pocket itself. W hen it does occur, we h ave at once local signs as w ell— fever, pain and leukocytosis. T h e other most p re v a lent infection at w hose door the cause of m any ills is laid is the one revealed in most instances by the roentgenogram and by it alone. In the v a st m a jo rity of cases, these infections a re hem olytic streptococci, greenproducing streptococci, e ith e r in pure culture or g ro w in g together. A nyone w ho has had any technical experience in bacteriology knows how difficult it is to grow a pure cul tu re and how im possible it w ould be to in tro duce such a pure culture, either of one or the o ther o r both organism s, d u rin g the process of root canal trea tm e n t of root filling. C on sequently, we m ust com m end the dentist who sterilizes, as he does, m ost roots, and fills them w ithout the introduction of b a c te r ia ; but, at tim es, he does not succeed and it is evidenced by an acute abscess, due to in tro duction of pus-producing germ s. T hese be fore m entioned streptococci do not form pus, and w hen we h ave an acute abscess or even a subacute abscess, the cause is a m ixed culture of b acteria. W e h ave been lax in our nom en c lature in speaking of these a reas shown in the roentgenogram as a d a rk spot. T h ey are, in the m ajo rity of cases, not abscesses, because they contain no pus. T h ey are usually m asses of g ra n u la tio n tissue, containing bac teria, it is true, but also c o ntaining leukocytes, w hich a re alive and actively engaged in de-
Schour — M a x i m o w ’s Research on In fla m m a to r y Reaction stroying the bacteria. T h ese m asses of g ra n u lalion tissue are re p ara tiv e , and if the c ausative factor, the tooth, is extracted, new bone ra p id ly replaces the g ra n u la tio n tissue and healing pursues a norm al course. R esidual infection, w hen com pared w ith the occurrence of norm al re p a ir follow ing sim ple extraction, is ra re indeed. I h ave thought fo r a long tim e th a t these streptococcic infections about root apices occur subsequently to the root canal filling, weeks, m onths o r m aybe years befo re; and as w e have show ers of vario u s b acteria w ith in the blood stream a t tim es, it is probable th a t they a re c a rrie d to these places, w hich, from the loss of the pulp w ith its circulation, present a localized a re a of lessened resistance and there find conditions fa v o ra b le for th e ir grow th. Does it not seem reasonable th a t our vario u s ills m ight be in cident to these show ers w hich infect the apical a rea s ra th e r th an being due to the secondary focus about the teeth? F urth erm o re, we are justified only in ascribing to the apical infec tion as the p rim a ry focus these pathologic conditions w hich a re due to the sam e o rg a n isms found in the apical infection. D r. M iller has told us th a t no streptococci h ave been cultured from or about the joints of these chronic a rth ritic s. Consequently, w e h av e no rig h t to ascribe the o steo -arth ritis to the teeth. I have talked recently w ith an em inent m an who sees larg e num bers of cases of osteo a rth ritis and he tells me th a t he has seen no
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cases w hich have been benefited by the e x tra c tion of infected teeth. U ndoubtedly, some pathologic conditions a re at times due d irec t ly to these chronically infected teeth, such as the infections of the choroid and in te rio r of the eye. Possibly some of the infections be hind a u re te ra l strictu re m a y .b e of dental origin, and possibly some of the cases of p ro g ressive m yocarditis m ay h ave a c o ntributing cause in the teeth, but, as yet, w e cannot be sure of it, and until w e are reasonably sure w e a re not justified in rem oving useful teeth w hen, in the case a t hand, it is doubtful th a t such rem oval w ill influence the disease from w hich the p a tie n t is suffering. In my p ra c tice, I try to go v ern m y judgm ent and p ro cedure by the severity of the p a tie n t’s illness. If the loss of eyesight is th reaten ed and no o ther cause can be found, I even rem ove pulpless teeth, although the roentgenogram is n e g a tiv e ; but I do not rem ove pulpless teeth as a prophylactic m easure fe arin g th a t the p a tient m ay a t some tim e in the future develop an iritis. N eith er do I allow a tooth or teeth b e a rin g a larg e a rea of bony destruction to rem ain, but, g iv en an in d iv id u a l not se ri ously ill, suffering from some condition w hich bears no pathologic relation to the organism s found in these g ranulom as, and h a v in g some useful pulpless teeth w hich, though infected, h av e only a sm all am ount of bony absorption about the apices, I em phatically advise ag ain st th eir rem oval.
A REVIEW OF M A X IM O W ’S RESEARCH O N INFLAM M ATORY REACTION* By ISAAC SCHOUR, B.S., D.D.S., M.S., Chicago, III.
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HE purpose of this paper is to pre standing contributions, details of which sent before the dental profession a are found in the papers referred to in the brief report of Maximow’s researches footnotes. Because of the limitation of time, it is not possible to discuss here in on the cytology of inflammation. The scope of this paper is limited to his out detail all of the controversial points in this field. * D ep artm en t of Histology, College of D enThe scientific conception of dentistry, tistry, U n iv ersity of Illinois, C hicago, 111. as contrasted with the purely mechanical *Read before the Section on O ra l P athology aspects of this art, is continuously becom at the M id w in ter C linic of the C hicago D en ing more widespread. Dental research tal Society, Ja n . 14, 1930. Jour. A . D. A ., September, 1930