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Etiology of Pyorrhea Alveolaris, With a Simplified Treatment*
ETIOLOGY OF PYORRHEA ALVEOLARIS, W ITH A SIMPLIFIED TREATMENT * By T H O M A S B. HARTZELL, D .M .D ., M .D ., Minneapolis, Minn.
D IS C U S S IO N
C. W. H offer, N ashville, T erm : I agree with Dr. Hartzell that much pyorrhea is the result of the activity o f the streptococci and staphylococci which gain access to the tissues surrounding the teeth through the gingival crevice. There is no doubt in the minds of the leaders o f this specialty that debris and accumulations o f food and plaques around the necks of the teeth act as an excellent medium fo r the propagation o f bacteria, and through the series o f inflammatory changes, by the action o f both their toxins and fer ments, cause the breaking down o f the tissues; producing avenues o f ingress o f the bacteria into the deeper tissues. I have not been able to overcome these conditions when apparently traumatic occlusion has so injured the mem brane surrounding the teeth, and so lowered its vitality that inflammation has set in with an ingress o f bacteria following. By correct ing the occlusion and through surgical pro cedure, I have been able, where there has not been too much bone involvement, to bring the tissues back to normal; then, with a stimu latory technic o f brushing, I have been able to maintain a normal condition. I do find nor mal conditions o f the gum tissue with teeth out o f position, as Dr. Hartzell mentions in several o f his case reports, where I would have expected traumatic occlusion to be present. Usually, in these cases, I find that the resistance o f the patient is very high, and though teeth have moved into new positions, owing to the loss o f teeth, we may not neces sarily have a pounding or hammering o f such teeth to the extent o f trauma, due to the oc clusion being balanced. I have several such cases on record. I am glad that Dr. Hartzell is not a great believer in medicines in the treatment o f pyorrhea. It has been my ex *T h is p ap er a p p ea red in the D ecem ber issu e o f T he Journal.
Jour. A . D . A., January, 1926
perience, and the experience of the men I have followed, that the long and continued use of antiseptics and astringents has a tendency to lower rather than raise the resistance o f the tissues surrounding the teeth. I agree that we should use extreme care in removing the debris and deposits from the cementum of the teeth, and at the same time retain as much covering o f the necks of the teeth with the soft tissues as possible. But when there is considerable bone involvement and excessive granulomatous tissue in advanced pyorrheal conditions, I do believe that we are thoroughly justified in laying healthy tissue out o f the way, with perfect access to the roots, thoroughly removing both necrotic bone tissue and the granulomatous tissue from the soft tissues, laying back in position the healthy tissue, and suturing and sealing with any of the surgical dressings which are now being used in surgical pyorrhea. This in my hands has given more positive and much more satis factory results and in less time than when acids were used to dissolve or burn out the diseased and granulomatous tissue. This is followed in a very short time with a very vigorous brushing. Dr. Hartzell lays little stress on the removal o f deposits, clearing up deep pockets surgically and then cleansing, and I ask an expression o f his opinion on this point when he closes the discussion.
W eston A. P rice, C leveland, O hio : If Dr. Hartzell would consent to dropping one word from the subject o f his paper, I would find myself largely in accord with his views. I would want to take out the first word— etiology. Frankly, I do not see in pyorrhea simply an expression o f local irritation, nor do I see a local and systemic expression o f a local irritation. I see, rather, a local expres sion o f a combination o f local and systemic factors, chief o f which is a systemic factor, 112
Hartzell—Etiology of Pyorrhea Alveolaris the trigger o f the gun being the local irri tation; and just as a gun cannot be very dangerous fo r shooting without a trigger, just so the trigger alone can’t make a gun. In other words, I feel it my duty at this moment to put in this word, that we who are going out to practice have a great responsibility to our patients, but we who discuss this paper at this time, and send it out to the profession and to humanity as coming from this associa tion o f national prominence have a still larger duty, which is to carry over to the people somewhat o f the larger importance o f pyor rhea than the local irritation would have. Dr. Hartzell has referred to a number o f cases in his paper, clearly illustrating traumatic occlusion without pyorrhea. I would call
Fig. 1.— Death rate from diabetes and from all causes, New York City, 1866-1921 (Haven Emerson), showing an increase in diabetes o f over 1,400 per cent, notwithstand ing striking decrease from all causes. your attention to the fact that you a ll see not a few but many cases o f traumatic occlusion without pyorrhea. You also see many cases of pyorrhea without traumatic occlusion. We have, then, abundant evidence that a local con dition alone cannot create the condition. Let us consider another aspect : According to Haven Emerson, diabetes has increased 1,400 per cent in the last sixty years. The top curve in Figure 1, the dotted line running across the page, shows the rapid decline o f deaths from a ll causes in New York City and Man hattan, and in spite o f that great general de cline in death rate, there has been a progressive increase in the death rate as shown in the heavy, continuous dark line, which is the death rate from diabetes. W ill you not, then, agree that something is influencing diabetes greater than our influence on morbidity and
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death in general? In that connection, and i f I had time I could easily demonstrate it, I say that diabetics practically always have periodontoclasia, or pyorrhea, in some stage, and usually to a marked degree ; and, further, those o f you who are treating diabetic patients, ( if you know it when you are doing it, and I don’t suppose you always know it), w ill know that you have much less success and much less gratifying results as you treat your diabetic patients, than with nondiabetics. There is a direct relationship between the functioning o f the islands o f Langerhans and décalcification. Dr. Haven Emerson has shown (Fig. 2, lowest line) that people under 19 years o f age are not developing diabetes.
Fig. 2.— Comparison o f the increase o f diabetes in different age periods. (Haven Emerson.) Note the great in crease in the group 45 years o f age and over. They do not constitute the group that have the increase, and in the second, the dotted line, the people from 20 to 44 years o f age do not show an increase in diabetes, but the people 45 years and older show this enormous in crease, as shown by the line that projects so high and so sharply. Back o f all this, we have the fundamental fact that some great metabolic change takes place after 45 years o f age. Am I right in say ing that you see pyorrhea developing more rapidly after 45 years o f age? To what is this due? Not to calcium levels alone, but to the mechanisms that con trol those levels. For every diabetic patient, every patient with a hyperglycemia, has a disturbance o f the mechanism o f cal-
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The Journal o f the American Dental Association
cification, and it is that disturbance which is the main lesion in pyorrhea. In Figure 3, we have a dozen or fifteen
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people that never develop rheumatism, but many get diabetes and pyorrhea. They get the lesions of the decalcifying group. If they
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98 27 124 900 775 65.4 25.9 Kasai catarrh .
1.5 - 3.6 101 26 134 470 236 63.0 28.5 Hc*r normal. Had v e ry a c tiv e o a r ie s .
Fig. 3.— Typical blood pictures showing high total and high active calcium. Note that there are no cases o f extreme negative calcium balance.
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2 1 .7 3 9 .2 4 2 .3 33.1 -1 2 .6 -1 8 .5 138 32 111
320 236 5 8 .6 3 3 .0 Pyorrhea a l v e o l a r i s . 509 334 4 8 .3 4 5 .4 S evere l a s s it u d e . 833 744 5 3 .0 4 1 .0 P a r a ly s is o f eye m u s cle. 463 352 6 2 .8 3 0 .8 Reoent nervoua e x h a u s tio n .
1 1.1 2 9 .0 2 1 .9 13.6 - 1 8 .7 - 2 2 .7 104 27 128
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600 472 6 5 .6 2 7 .9 Mental d e p r e s s io n .
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740 488 6 0 .2 3 1 .4 F ain i n b a c k -
12 .5 3 8 .1 7 3 .3 33.2 ♦ 2 .1 -1 2 .5 107 22
687 584 64-. 1 2 6 .2 E x o e s s iv e c a r i e s .
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Fig. 4.— Typical blood pictures of individuals with overload. Note high normal total calcium and low active calcium. There is marked negative calcium balance in most o f these cases.
H art zell— E tiology o f Pyorrhea Alveolaris presence o f an irritation depends on many things, as do the levels o f each o f our various calcium factors of the blood. Figure 4 shows a different condition. The average in this group w ill be around 11, or over, fo r total calcium and the active calcium around 8 or 9. In those cases the patients have had good health but are breaking, and these two groups furnish 95 per cent at least o f all cases o f pyorrhea.
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has destroyed the alveolar process nearly twothirds o f the way to the apex o f the roots. This man belongs to the group who, in the presence o f an irritant, w ill tear down bone. That is part o f the mechanism o f defense against the local irritant. Here is a man who decalcified and at 61 years o f age is in a condition o f broken health, and at this time his total calcium has been reduced, as shown in thé second column,
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(W orry f o r d a u g h te r ) No o a m o la i n t . 5 1 .0 3 9 .3 E x h a u s tio n and d i g e s t iv e t r o u b le . 6 00 511 5 0 .0 4 0 .0 L a s s i t u d e an d n e u r i t i s . 752 640 6 0 .7 3 2 .2 A sth m a. S 1 . 7 2 5 .1 F a in a b o u t h e a r t . 7CU6 1 9 .5 A c u t e d e n t a l c a r i e s . 281 179 5 8 .2 3 2 .4 A r t h r i t i s , b e d r id d e n .
Fig. 5.-—Individuals with typical low total and low active calcium with typical severe overloads including dental infections. In the next group (Fig. 5) are people who have a low total calcium and a low active calcium, perhaps because they have carried an overload so long that it has dragged down both the active and the total, but in that group the total calcium is around 9, most of them under 10, and the active calcium 8 and 9. These people are always ill. They do not have active pyorrhea though they may have chronic lesions; fo r they may have been in the other group and come into this grouping. The people who normally have the low levels o f calcium may have tartar around their teeth and do not have that type o f irritation. In Figure 6, we have a typical case, the so-called horizontal pyorrhea. Décalcification
to 9. His active calcium is'down to 8.5. This man could not possibly be well in that con dition. With no other treatment than the removal o f his infected teeth (all that we felt could not be safely treated), in a little less than a month, his total calcium has come up to 1 1 and his active calcium up to 9.4, a marked increase, and with a remarkable im provement in his physical condition. Shall we, with a man who has that picture, simply treat a local condition? I f we do, we invite a break in the metabolism that w ill shorten his life materially. It may be just such a break as has already presented itself in his fam ily (a death from tuberculosis). There is a serious case o f tuberculosis now in
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The Journal of the American Dental Association
the family. When you study the chart, you see that it shows that he had a high defense, as has also the family. There are no rheu matic group diseases. Shall we then, because he does not have heart trouble and rheuma tism, think he is safe? This is the group that tends to develop cancer and diabetes and, if
have lived to be 80 or 90 years o f age are largely toothless, not because of the over activity o f the modern exodontist, but be cause o f pyorrhea; not simply because they had pyorrhea, but because they had a mechanism o f defense which in the presence o f an irritant did tear down bone. But that
Fig. 6— Typical severe physical break associated with pyorrhetic infection, with marked improvement in less than a month following elimination o f gingival and alveolar infection. Note absence o f rheumatic group lesions. they get tuberculosis, make a poor fight. Are we going to see this rising tide o f 1,400 per cent increase in diabetes in sixty-six years and not take some warning from it? Are we simply going to treat a local lesion as though the teeth were the end to be desired, or are we going to see the larger view of that man’s life and, i f necessary, let him lose some o f his teeth in order that he may have his metabolic processes in active capacity and function fo r a long period o f life? Am I not correct when I say that these people in your practice who
mechanism may disturb metabolism so that they are subject to other diseases; fo r it is the people who are never sick a day in their lives that develop cancer. It is not the people who complain with arthritis and heart in volvement who get cancer and tuberculosis. I have searched this country fa r and wide fo r one single case o f tuberculosis with prolific arthritis, and I cannot find one. You can find the other type o f arthritis, which is due to metabolism disturbances, not to den tal infection; so we have a larger problem
Hartzell— E tiology of Pyorrhea Alveolaris here than just what can we do to make this man’s teeth last just as many years as possible. Figure 7 presents a history o f a man 64 years o f age, and his total calcium is up to 13, active up to 11, with a marked tendency to décalcification. We see four cases o f tuber culosis in this family, and he has come be-
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father died at 76, a young man. His baby was then only 1 year old. He had been married three times and had had twenty-one children. In Figure 7, we have the décalci fication that takes place in pernicious anemia, a functional disease, and I want to warn you against seeing simply the constricted picture
B.
V e ry e x t e n s iv e p e r i o d o n t o o l a a i a .
C. BLOOD MORPHOLOGY H em oglobin. . 80% E r y th r o c y te s 5 ,0 6 0 ,0 0 0 L e u o o c y t e s .. 6 ,6 0 0 .C olor I n d e x ,. 0 .6 A rneth I n d e x .. 63 W alker I n d e x .. - 1 2 .4 Polym orphonuolear8 79.00% Sm all ly m p h ooy tes. 13.80% T o t a l p o ly s p oam. 5210 " s . lyms " " . 1040 la r g e ly m ph ooy tes. 1 .9 0 $ M on on u clears............ 3.40% B a s o p h ils .................. 0 .6 0 $ E o s in o p h ils ....... 1.30%
D. BLOOD CHEMISTRY A l k a l i n i t y In dex 2 9 .1 4 B lood s u g a r ..........1 31.00 I n o r g a n io p h o s .. 3 .8 5 T ota l o a . . . . . . . . 13 .1 2 Ca a o t i v e .............. . 1 1 .0 5 Ca i n x o o m b in .. 1 .7 2 Fhos-C a r a t i o . . . 1 -3 .4 1 N o n - p r o - n it .......... 18.8 3 T o t a l.p r p t e in ... 5 .7 8 T o t a l a lb u m i n ... 3 .9 4 T ota l g l o b u lin .. 1.8 8 7 E u g lo b u lin a . . . . 0 .4 1 9 " b .... 0 .4 0 6 " o .... 1.0 6 2 G lo b -A lb r a t i o . . 1 -2 .0 7
E . ABNORMAL CONDITIONS: , C hronic b r o n c h it i s w ith sputum. Normal d e fe n s e sh ou ld b o h ig h . E x te n s iv e d e n ta l i n f e c t i o n s , b o th a p io a l and g in g iv a l. , E viden ce o f h ig h o a p a c it y f o r r e a c t i o n . Reduced a l k a l i n i t y in d e x t o 2 9 . In o r e a s e d b lo o d sugar. F . INTERPRETATIONS: P a t ie n t d e v e lo p in g an a c i d o s i s and h yp erglyoem ia . C h ron ic b r o n c h it i s may b o p a r t ly s e n s i t iz a t i o n r e a c t io n . A l l c o n d it io n s demand com p le t e e r a d ic a t io n o f d e n ta l i n f e c t i o n s . 0 . IBOGNOSIS: P a tie n t in p o t e n t i a l dan ger o f d e v e lo p in g a t u b e r c u lo s is o r d ia b e t e s , o r b o t h . O ther w is e has p r o s p e c t o f an u n u s u a lly lo n g and h o a lt h f l il life .
Fig. 7.-—Typical patients with high defense breaking at late middle life. Note the alveo lar absorption, absence o f rheumatic group lesions and several cases o f tuberculosis, including patient’s suspicious bronchial symptom. cause of a chronic bronchitis as one o f his symptoms. Another factor that I have just discussed: This man has a chart that is per fectly free from rheumatic group diseases, yet a ll the members o f the fam ily have lesions appearing in diabetes, cancer and tuberculosis. His total calcium is up to 13. He said, “I can drive a golf ball as fa r as any of them even at 64.” He has a room fu ll o f golf trophies. His active calcium is up to 11. His father’s sister is still living at 90. His father died at 94, from an accident. The mother’s
of what you can do fo r each individual patient as fa r as maintaining the teeth as long as possible, if they have a tendency toward pernicious anemia, because that in itself is a décalcification process again, and comes in that same pyorrhetic group. Make the teeth last as long as possible, if you can do it without embarrassing the last ten or twenty or thirty years o f the patient’s life.
.1. P. C orley ( Sew anee, T enn.) : I would like to ask Dr. Price if his extraction o f those teeth is not really local treatment?
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The Journal of the American Dental Association
Dr. P rice: The infection about the tooth fu r nishes a toxic material, o f which Dr. Hartzell has told you, which cannot be neutralized with soap when you get it into the constitution. Dr. H artzell: Answer yes, or no. Dr. P rice: I say the extraction o f those teeth prevents the generation o f the toxic material, which has a marked effect on the parathyroid glands, so you take away one of the -injuries to metabolism by getting com pletely rid o f that tooth. Your suggestion is a good one.
Arthur H. M erritt ( N ew York C ity ) : As a clinician, there are two or three points which I should like to emphasize. The first is, trau matic occlusion should be defined as that oc clusion only which traumatizes. Teeth may be as irregular as the imagination can conceive without producing trauma, which means in jury to the supporting tissue. Also teeth that are regular may traumatize. Therefore, we should be careful in our definitions o f trau matic occlusion. Regarding bacterial in vasion, I believe that Dr. Hartzell is quite correct in the statement which he makes re garding it. In 1919, Noyes, in his study of the pathology o f the periodontal membrane, made the statement that the changes which occurred in the pericementum were caused by bacterial invasion follow ing along the line o f the lymphatics. More recently, Box has discovered “rarefying pericementitis fibrosa,” this same lesion which he ascribes to traumatic occlusion. I am inclined to think there is a sense in which both are right. Traumatic occlusion lowers resistance and thereby makes bacterial invasion possible. I should also like to call attention to the possibility that in it self this w ill produce disease. Those o f you who were here yesterday and listened to Dr. Hirschfeld’s paper on his studies o f the skulls in the American Museum o f Natural History in New York were interested to know that he finds teeth whose enamel is entirely worn off the occlusal surfaces, proving that they have been subjected to great stress, without the slightest disturbance o f the surrounding bony support o f those teeth. What was the reason? It was not because there was not great strain, nor because the supporting tissues o f the teeth were not sub ject to bacterial invasion, but because these individuals used their teeth so vigorously that they translated vigorous use into well nourished and highly resistant tissues. The
value o f Dr. Hartzell’s scouring o f the teeth in my opinion is due to the fact, not that they have been scrubbed and bacteria eliminated, though that may be helpful, but because the circulation has been stimulated and they have become more resistant. In other words, he is doing artificially with his scouring process what our prehistoric ancestors did by the use o f course and fibrous foods.
Dr. H artzell , ( clo sin g ) : In reply to Dr. Price, permit me to ask, in view of the fact that his statements regarding invasion o f bac teria have not been supported by actual in vestigation: How does he know in these in stances that bacteria are there? When the resistance, the local resistance, is kept very high, by scouring the teeth, as he approves of doing in endorsing what I have said here, the invasion is checked and is comparatively slight. The Egyptians, 4,000 years ago, suffered just exactly as we do now, and they lived a comparatively simple life so fa r as their foods were concerned. A book by Sir Marc Armand Ruffer, compiled by Dr. Moody o f Chicago, shows dental lesions confirming what I have said. Dr. M erritt stated that when weight is delivered, against the teeth, it may be de livered exactly true, and still there may be traumatic occlusion. He tells you, too, that it can be delivered sideways, and traumatic occlusion not be present. Now I leave that to you. If you believe it is so, a ll right. I don’t. I am grateful fo r the words o f appro bation. Remember, the title o f this paper is the treatment o f this disease simplified. I ain giving you this morning, and have given you, the things that have made fo r the largest pos sible success in my work, and I have done nothing else now fo r thirty years. It is simple, direct, easy o f application, and reveals a positive result. Dr. Price talked about cal cium in its relation to pyorrhea. He made assertions that would lead you to think that this disease which attacks the investing tissues o f the teeth is largely one o f old age. I saw a child two years and a half old lose every tooth by infection. They were so loose that one could pluck them out with thumb and finger, and the child made scarcely any ob jection. That is strange, indeed, but true. I saw but one case o f that sort, but I am con stantly seeing children with lesions around the necks o f the teeth. A young man, at least 21 years old, came to me last week, with
Hartzell—Etiology of Pyorrhea Alveolaris lesions one eighth inch deep between his molars. He was, apparently, on a good, nor mal diet— milk, eggs, green vegetables, fruits, and still there were these deep lesions between the teeth. I placed him under treatment, and I dismissed him a week ago, after three weeks’ treatment by the scouring process. The result was that the crevices filled with granulation and the epithelium was bridging the ulcers, and I am sure that in another week there w ill be a new, healthy, shining coat o f epithelium on the ulcers covering the space bridging over between the teeth. It is not a disease o f old age. It is a disease o f life, from the cradle to the grave, and I don’t believe that the food habits o f this country are robbing it o f the ability to gather calcium. Dr. Price w ill say that the individual who is getting a quart of fresh milk daily, and still has pyorrhea, prob ably has one o f those illusive things that pre vent him from appropriating it. Frankly, I owe much to Dr. Price. He is the man that started me to digging. Dr. Price has talked about calcium here. I hope that you w ill be willing to test the things that I have advocated, and not attempt to study the blood chemistry in order to determine whether the calcium balance is a ll right. I f you heard one o f the other papers, you w ill know that it would be quite impossible to get dead fish livers enough to activate the calcium o f the country. In the meantime, you might do something by scouring the teeth, if you tried. I am not unmindful o f the fact that Dr.
119
Price discovered the germ that caused pyor rhea in 1916. He showed in San Francisco, Seattle, Minneapolis, and other places a bacillus “X ” which he got on blood culture. In a ll his pyorrhea cases, he was equally cer tain that he was right. It was proved that bacillus “X ” was the hay bacillus, the most difficult thing to fight in keeping cultures clean. I have not heard him saying much about bacillus “X ” lately. Might it not be possible that some o f these abstract statements that he has made he w ill m odify after a while? Please do not be discouraged with this matter. I do not believe that the lack of calcium is in any proportion so important a problem as checking the local growth of bac teria on the tooth surface and adjacent to the teeth, and I do know that an effort to check this growth w ill yield a great meed of success to every individual who conscientiously puts it into operation. I am going to leave this matter right here with you now, to adopt or not, as you see fit, and if you wish to delay work on your cases and attempt to bring about normality by blood chemistry, which you do not know how to do, and which I do not know how to do (I should have to seek an expert in biologic chemistry to have it carried out) and which so fa r Dr. Price has not taught us how to do, and which such men as Dr. Albert P. Matthews, one o f the greatest biologic chemists o f this country today, is still in doubt about, I beg o f you, in the mean time, while you are settling these difficulties, adopt the regime o f cleanliness.
D IS C U S S IO N
C. W. H offer, N ashville, T erm : I agree with Dr. Hartzell that much pyorrhea is the result of the activity o f the streptococci and staphylococci which gain access to the tissues surrounding the teeth through the gingival crevice. There is no doubt in the minds of the leaders o f this specialty that debris and accumulations o f food and plaques around the necks of the teeth act as an excellent medium fo r the propagation o f bacteria, and through the series o f inflammatory changes, by the action o f both their toxins and fer ments, cause the breaking down o f the tissues; producing avenues o f ingress o f the bacteria into the deeper tissues. I have not been able to overcome these conditions when apparently traumatic occlusion has so injured the mem brane surrounding the teeth, and so lowered its vitality that inflammation has set in with an ingress o f bacteria following. By correct ing the occlusion and through surgical pro cedure, I have been able, where there has not been too much bone involvement, to bring the tissues back to normal; then, with a stimu latory technic o f brushing, I have been able to maintain a normal condition. I do find nor mal conditions o f the gum tissue with teeth out o f position, as Dr. Hartzell mentions in several o f his case reports, where I would have expected traumatic occlusion to be present. Usually, in these cases, I find that the resistance o f the patient is very high, and though teeth have moved into new positions, owing to the loss o f teeth, we may not neces sarily have a pounding or hammering o f such teeth to the extent o f trauma, due to the oc clusion being balanced. I have several such cases on record. I am glad that Dr. Hartzell is not a great believer in medicines in the treatment o f pyorrhea. It has been my ex *T h is p ap er a p p ea red in the D ecem ber issu e o f T he Journal.
Jour. A . D . A., January, 1926
perience, and the experience of the men I have followed, that the long and continued use of antiseptics and astringents has a tendency to lower rather than raise the resistance o f the tissues surrounding the teeth. I agree that we should use extreme care in removing the debris and deposits from the cementum of the teeth, and at the same time retain as much covering o f the necks of the teeth with the soft tissues as possible. But when there is considerable bone involvement and excessive granulomatous tissue in advanced pyorrheal conditions, I do believe that we are thoroughly justified in laying healthy tissue out o f the way, with perfect access to the roots, thoroughly removing both necrotic bone tissue and the granulomatous tissue from the soft tissues, laying back in position the healthy tissue, and suturing and sealing with any of the surgical dressings which are now being used in surgical pyorrhea. This in my hands has given more positive and much more satis factory results and in less time than when acids were used to dissolve or burn out the diseased and granulomatous tissue. This is followed in a very short time with a very vigorous brushing. Dr. Hartzell lays little stress on the removal o f deposits, clearing up deep pockets surgically and then cleansing, and I ask an expression o f his opinion on this point when he closes the discussion.
W eston A. P rice, C leveland, O hio : If Dr. Hartzell would consent to dropping one word from the subject o f his paper, I would find myself largely in accord with his views. I would want to take out the first word— etiology. Frankly, I do not see in pyorrhea simply an expression o f local irritation, nor do I see a local and systemic expression o f a local irritation. I see, rather, a local expres sion o f a combination o f local and systemic factors, chief o f which is a systemic factor, 112
Hartzell—Etiology of Pyorrhea Alveolaris the trigger o f the gun being the local irri tation; and just as a gun cannot be very dangerous fo r shooting without a trigger, just so the trigger alone can’t make a gun. In other words, I feel it my duty at this moment to put in this word, that we who are going out to practice have a great responsibility to our patients, but we who discuss this paper at this time, and send it out to the profession and to humanity as coming from this associa tion o f national prominence have a still larger duty, which is to carry over to the people somewhat o f the larger importance o f pyor rhea than the local irritation would have. Dr. Hartzell has referred to a number o f cases in his paper, clearly illustrating traumatic occlusion without pyorrhea. I would call
Fig. 1.— Death rate from diabetes and from all causes, New York City, 1866-1921 (Haven Emerson), showing an increase in diabetes o f over 1,400 per cent, notwithstand ing striking decrease from all causes. your attention to the fact that you a ll see not a few but many cases o f traumatic occlusion without pyorrhea. You also see many cases of pyorrhea without traumatic occlusion. We have, then, abundant evidence that a local con dition alone cannot create the condition. Let us consider another aspect : According to Haven Emerson, diabetes has increased 1,400 per cent in the last sixty years. The top curve in Figure 1, the dotted line running across the page, shows the rapid decline o f deaths from a ll causes in New York City and Man hattan, and in spite o f that great general de cline in death rate, there has been a progressive increase in the death rate as shown in the heavy, continuous dark line, which is the death rate from diabetes. W ill you not, then, agree that something is influencing diabetes greater than our influence on morbidity and
113
death in general? In that connection, and i f I had time I could easily demonstrate it, I say that diabetics practically always have periodontoclasia, or pyorrhea, in some stage, and usually to a marked degree ; and, further, those o f you who are treating diabetic patients, ( if you know it when you are doing it, and I don’t suppose you always know it), w ill know that you have much less success and much less gratifying results as you treat your diabetic patients, than with nondiabetics. There is a direct relationship between the functioning o f the islands o f Langerhans and décalcification. Dr. Haven Emerson has shown (Fig. 2, lowest line) that people under 19 years o f age are not developing diabetes.
Fig. 2.— Comparison o f the increase o f diabetes in different age periods. (Haven Emerson.) Note the great in crease in the group 45 years o f age and over. They do not constitute the group that have the increase, and in the second, the dotted line, the people from 20 to 44 years o f age do not show an increase in diabetes, but the people 45 years and older show this enormous in crease, as shown by the line that projects so high and so sharply. Back o f all this, we have the fundamental fact that some great metabolic change takes place after 45 years o f age. Am I right in say ing that you see pyorrhea developing more rapidly after 45 years o f age? To what is this due? Not to calcium levels alone, but to the mechanisms that con trol those levels. For every diabetic patient, every patient with a hyperglycemia, has a disturbance o f the mechanism o f cal-
114
The Journal o f the American Dental Association
cification, and it is that disturbance which is the main lesion in pyorrhea. In Figure 3, we have a dozen or fifteen
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people that never develop rheumatism, but many get diabetes and pyorrhea. They get the lesions of the decalcifying group. If they
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* 4 .6 - 6.1 132 iib
70.6 21.5 In d ig e s tio n .
1560 50.5 11.44 10.20 5 .2
* 2.9 - 6.9 122 56
63.8 28.4 Skin ir r i t a t i o n .
1565 29.1 13.12 11.05 5.8
«1 0 .0 « 2 .5 131 18
1569 41.3 12.64 10.57 3.1
0-.9 - 7.1
1572 39 .0 11.33 11.00 3.1
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79.0 13.8 Chronio b r o n c h itis .
97 34
60.5 29.0 Rone.
86 22 114 474 360 6 6.0 33.2 liild nervousness.
1.4 - 3.1 102 27 129 464 335 6 5.0 26.6 C old s.
1575 34.2 11.28 10.06 3.6
1612 3 1.0 12.70 10.06 3.1 36.7 “ 0.4 - 8.6 105 34 190 746 554 65.3 20.0 Hear normal, w ith h is to r y li k e angina1620 3 5.4 12.56 10.52 3.2 31.4 ♦ 0.9 - 5.8 1624 38.0 11.62 10.18 3 .5 59.5.T.Kn
98 27 124 900 775 65.4 25.9 Kasai catarrh .
1.5 - 3.6 101 26 134 470 236 63.0 28.5 Hc*r normal. Had v e ry a c tiv e o a r ie s .
Fig. 3.— Typical blood pictures showing high total and high active calcium. Note that there are no cases o f extreme negative calcium balance.
m 3 4 .4 UrCy 1268 3 2 .4 UrGn 1414 3 9 .5 UsKn 1484 3 7 .0 UsMe 1573 3 6 .7 MrHk 1580 2 8 .6 MrKr 1583 2 8 .5 UrHs 1585 3 0 .1 Ur Le 1586 3 2 .2 UrDv 1617 3 4 .5 DrDfc 1619 3 4 . b MrBr 1621 3 9 .5 DrSy 1623 3 4 .7 Chto
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get tuberculosis, they make a poor fight because they decalcify tubercles. The problem as to what occurs regarding calcium in the
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people all o f whom have high total calciums, The figures are above all 11, and their active calciums above 10, and as a group, they are
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1 1.0 6 9 .8 7 2 .8 5 2 .0 - 8 .0 -1 1 .5 125 34. 1 0 .3 7 8 .2 7 3 .6
98 1025 912 5 5 .0 3 7 .0 R ec o v e ry from n ervou a b re a k . 72 662 590 6 8 .8 2 6 .6 H eart i r r i t a b i l i t y f o l low in g c o l t e r o o e r a t io n . 81 ¿0 111 800 689 5 5 .8 2 9 .4 R e co v e r in g rrom se v e re
- 3 .0 - 9 .7 107 22
1 1.0 0 Ô.4Ô 4 .1 3 7 .2 ♦ S . i - 0 .6
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84
93 35 175
11 .4 1 8 .8 0 2 .0 3 4 .4 - 1 6 .9 -2 2 .2 127 31
89
2 1 .7 3 9 .2 4 2 .3 33.1 -1 2 .6 -1 8 .5 138 32 111
320 236 5 8 .6 3 3 .0 Pyorrhea a l v e o l a r i s . 509 334 4 8 .3 4 5 .4 S evere l a s s it u d e . 833 744 5 3 .0 4 1 .0 P a r a ly s is o f eye m u s cle. 463 352 6 2 .8 3 0 .8 Reoent nervoua e x h a u s tio n .
1 1.1 2 9 .0 2 1 .9 13.6 - 1 8 .7 - 2 2 .7 104 27 128
696 565 6 8 .3 2 4 .0 R ecen t n ervou s e x h a u s tio n .
1 1 .5 8 9.42 1 .3 33.2 - 2 6 .7 -2 7 .3 149 28 128
600 472 6 5 .6 2 7 .9 Mental d e p r e s s io n .
10 .4 2 8 .4 9 3 .3 31.8 - 5 .6 • 12.0 108 22 258
740 488 6 0 .2 3 1 .4 F ain i n b a c k -
12 .5 3 8 .1 7 3 .3 33.2 ♦ 2 .1 -1 2 .5 107 22
687 584 64-. 1 2 6 .2 E x o e s s iv e c a r i e s .
1623 3 6 .4 11 .1 2 9 .1 7 2 .6 51.1 -1 0 .9 -1 6 .0 ChUn
98 26
93
6 0 .0 3 0 .0 A p p a ren tly norm al.
Fig. 4.— Typical blood pictures of individuals with overload. Note high normal total calcium and low active calcium. There is marked negative calcium balance in most o f these cases.
H art zell— E tiology o f Pyorrhea Alveolaris presence o f an irritation depends on many things, as do the levels o f each o f our various calcium factors of the blood. Figure 4 shows a different condition. The average in this group w ill be around 11, or over, fo r total calcium and the active calcium around 8 or 9. In those cases the patients have had good health but are breaking, and these two groups furnish 95 per cent at least o f all cases o f pyorrhea.
40 2 ¿ 7 : r MsEn 589 3 9 . 0
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has destroyed the alveolar process nearly twothirds o f the way to the apex o f the roots. This man belongs to the group who, in the presence o f an irritant, w ill tear down bone. That is part o f the mechanism o f defense against the local irritant. Here is a man who decalcified and at 61 years o f age is in a condition o f broken health, and at this time his total calcium has been reduced, as shown in thé second column,
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QMCTUM METABOLISM.
115
710 6 2 4 5 0 .0 4 2 .6 A n em ia. G a l l - b l a d d e r .
UrRn 945 3 3 .4 MrHk 1124 3 5 .9 MsUr 1622 3,8.1 W«Rr
9 . 5 1 9 .2 3 15 53 3 7 .1 MrPr 9 .6 9 8 .8 4 1554 3 8 .2 Ur Jn 9 .8 1 8 .9 2 1561 3 3 .6 JAi B b 15 69 3 1 . 0 1 0 .1 3 8 .9 2 MrFr 1601 4 1 . 3 1 0 .0 9 8 .7 9 UrSd 1622 4 2 .3 9 .8 3 8 .9 6 UsUs 1624 ■38.5 8 .5 8 8 .7 8 J.K n 9 .8 4 8 .8 0 16 25 3 6 .9 Us Sd
5 .3 - 6 . 9
92 40 148 1090 842 6 3 .7 2 8 .6 P y o r r h e a t o x e m i a . 105 38
6 .1
6 7 26
2 .3
-1 7 .8 -1 8 .5
98 26
3 .1
- 9 .1 - 1 1 . 9
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2 .6
- 1 3 .9 -1 6 .2
108 28
1 .9
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89
84 26 112
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112 26
- 1 0 . 0 102 37 111
(W orry f o r d a u g h te r ) No o a m o la i n t . 5 1 .0 3 9 .3 E x h a u s tio n and d i g e s t iv e t r o u b le . 6 00 511 5 0 .0 4 0 .0 L a s s i t u d e an d n e u r i t i s . 752 640 6 0 .7 3 2 .2 A sth m a. S 1 . 7 2 5 .1 F a in a b o u t h e a r t . 7CU6 1 9 .5 A c u t e d e n t a l c a r i e s . 281 179 5 8 .2 3 2 .4 A r t h r i t i s , b e d r id d e n .
Fig. 5.-—Individuals with typical low total and low active calcium with typical severe overloads including dental infections. In the next group (Fig. 5) are people who have a low total calcium and a low active calcium, perhaps because they have carried an overload so long that it has dragged down both the active and the total, but in that group the total calcium is around 9, most of them under 10, and the active calcium 8 and 9. These people are always ill. They do not have active pyorrhea though they may have chronic lesions; fo r they may have been in the other group and come into this grouping. The people who normally have the low levels o f calcium may have tartar around their teeth and do not have that type o f irritation. In Figure 6, we have a typical case, the so-called horizontal pyorrhea. Décalcification
to 9. His active calcium is'down to 8.5. This man could not possibly be well in that con dition. With no other treatment than the removal o f his infected teeth (all that we felt could not be safely treated), in a little less than a month, his total calcium has come up to 1 1 and his active calcium up to 9.4, a marked increase, and with a remarkable im provement in his physical condition. Shall we, with a man who has that picture, simply treat a local condition? I f we do, we invite a break in the metabolism that w ill shorten his life materially. It may be just such a break as has already presented itself in his fam ily (a death from tuberculosis). There is a serious case o f tuberculosis now in
116
The Journal of the American Dental Association
the family. When you study the chart, you see that it shows that he had a high defense, as has also the family. There are no rheu matic group diseases. Shall we then, because he does not have heart trouble and rheuma tism, think he is safe? This is the group that tends to develop cancer and diabetes and, if
have lived to be 80 or 90 years o f age are largely toothless, not because of the over activity o f the modern exodontist, but be cause o f pyorrhea; not simply because they had pyorrhea, but because they had a mechanism o f defense which in the presence o f an irritant did tear down bone. But that
Fig. 6— Typical severe physical break associated with pyorrhetic infection, with marked improvement in less than a month following elimination o f gingival and alveolar infection. Note absence o f rheumatic group lesions. they get tuberculosis, make a poor fight. Are we going to see this rising tide o f 1,400 per cent increase in diabetes in sixty-six years and not take some warning from it? Are we simply going to treat a local lesion as though the teeth were the end to be desired, or are we going to see the larger view of that man’s life and, i f necessary, let him lose some o f his teeth in order that he may have his metabolic processes in active capacity and function fo r a long period o f life? Am I not correct when I say that these people in your practice who
mechanism may disturb metabolism so that they are subject to other diseases; fo r it is the people who are never sick a day in their lives that develop cancer. It is not the people who complain with arthritis and heart in volvement who get cancer and tuberculosis. I have searched this country fa r and wide fo r one single case o f tuberculosis with prolific arthritis, and I cannot find one. You can find the other type o f arthritis, which is due to metabolism disturbances, not to den tal infection; so we have a larger problem
Hartzell— E tiology of Pyorrhea Alveolaris here than just what can we do to make this man’s teeth last just as many years as possible. Figure 7 presents a history o f a man 64 years o f age, and his total calcium is up to 13, active up to 11, with a marked tendency to décalcification. We see four cases o f tuber culosis in this family, and he has come be-
117
father died at 76, a young man. His baby was then only 1 year old. He had been married three times and had had twenty-one children. In Figure 7, we have the décalci fication that takes place in pernicious anemia, a functional disease, and I want to warn you against seeing simply the constricted picture
B.
V e ry e x t e n s iv e p e r i o d o n t o o l a a i a .
C. BLOOD MORPHOLOGY H em oglobin. . 80% E r y th r o c y te s 5 ,0 6 0 ,0 0 0 L e u o o c y t e s .. 6 ,6 0 0 .C olor I n d e x ,. 0 .6 A rneth I n d e x .. 63 W alker I n d e x .. - 1 2 .4 Polym orphonuolear8 79.00% Sm all ly m p h ooy tes. 13.80% T o t a l p o ly s p oam. 5210 " s . lyms " " . 1040 la r g e ly m ph ooy tes. 1 .9 0 $ M on on u clears............ 3.40% B a s o p h ils .................. 0 .6 0 $ E o s in o p h ils ....... 1.30%
D. BLOOD CHEMISTRY A l k a l i n i t y In dex 2 9 .1 4 B lood s u g a r ..........1 31.00 I n o r g a n io p h o s .. 3 .8 5 T ota l o a . . . . . . . . 13 .1 2 Ca a o t i v e .............. . 1 1 .0 5 Ca i n x o o m b in .. 1 .7 2 Fhos-C a r a t i o . . . 1 -3 .4 1 N o n - p r o - n it .......... 18.8 3 T o t a l.p r p t e in ... 5 .7 8 T o t a l a lb u m i n ... 3 .9 4 T ota l g l o b u lin .. 1.8 8 7 E u g lo b u lin a . . . . 0 .4 1 9 " b .... 0 .4 0 6 " o .... 1.0 6 2 G lo b -A lb r a t i o . . 1 -2 .0 7
E . ABNORMAL CONDITIONS: , C hronic b r o n c h it i s w ith sputum. Normal d e fe n s e sh ou ld b o h ig h . E x te n s iv e d e n ta l i n f e c t i o n s , b o th a p io a l and g in g iv a l. , E viden ce o f h ig h o a p a c it y f o r r e a c t i o n . Reduced a l k a l i n i t y in d e x t o 2 9 . In o r e a s e d b lo o d sugar. F . INTERPRETATIONS: P a t ie n t d e v e lo p in g an a c i d o s i s and h yp erglyoem ia . C h ron ic b r o n c h it i s may b o p a r t ly s e n s i t iz a t i o n r e a c t io n . A l l c o n d it io n s demand com p le t e e r a d ic a t io n o f d e n ta l i n f e c t i o n s . 0 . IBOGNOSIS: P a tie n t in p o t e n t i a l dan ger o f d e v e lo p in g a t u b e r c u lo s is o r d ia b e t e s , o r b o t h . O ther w is e has p r o s p e c t o f an u n u s u a lly lo n g and h o a lt h f l il life .
Fig. 7.-—Typical patients with high defense breaking at late middle life. Note the alveo lar absorption, absence o f rheumatic group lesions and several cases o f tuberculosis, including patient’s suspicious bronchial symptom. cause of a chronic bronchitis as one o f his symptoms. Another factor that I have just discussed: This man has a chart that is per fectly free from rheumatic group diseases, yet a ll the members o f the fam ily have lesions appearing in diabetes, cancer and tuberculosis. His total calcium is up to 13. He said, “I can drive a golf ball as fa r as any of them even at 64.” He has a room fu ll o f golf trophies. His active calcium is up to 11. His father’s sister is still living at 90. His father died at 94, from an accident. The mother’s
of what you can do fo r each individual patient as fa r as maintaining the teeth as long as possible, if they have a tendency toward pernicious anemia, because that in itself is a décalcification process again, and comes in that same pyorrhetic group. Make the teeth last as long as possible, if you can do it without embarrassing the last ten or twenty or thirty years o f the patient’s life.
.1. P. C orley ( Sew anee, T enn.) : I would like to ask Dr. Price if his extraction o f those teeth is not really local treatment?
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Dr. P rice: The infection about the tooth fu r nishes a toxic material, o f which Dr. Hartzell has told you, which cannot be neutralized with soap when you get it into the constitution. Dr. H artzell: Answer yes, or no. Dr. P rice: I say the extraction o f those teeth prevents the generation o f the toxic material, which has a marked effect on the parathyroid glands, so you take away one of the -injuries to metabolism by getting com pletely rid o f that tooth. Your suggestion is a good one.
Arthur H. M erritt ( N ew York C ity ) : As a clinician, there are two or three points which I should like to emphasize. The first is, trau matic occlusion should be defined as that oc clusion only which traumatizes. Teeth may be as irregular as the imagination can conceive without producing trauma, which means in jury to the supporting tissue. Also teeth that are regular may traumatize. Therefore, we should be careful in our definitions o f trau matic occlusion. Regarding bacterial in vasion, I believe that Dr. Hartzell is quite correct in the statement which he makes re garding it. In 1919, Noyes, in his study of the pathology o f the periodontal membrane, made the statement that the changes which occurred in the pericementum were caused by bacterial invasion follow ing along the line o f the lymphatics. More recently, Box has discovered “rarefying pericementitis fibrosa,” this same lesion which he ascribes to traumatic occlusion. I am inclined to think there is a sense in which both are right. Traumatic occlusion lowers resistance and thereby makes bacterial invasion possible. I should also like to call attention to the possibility that in it self this w ill produce disease. Those o f you who were here yesterday and listened to Dr. Hirschfeld’s paper on his studies o f the skulls in the American Museum o f Natural History in New York were interested to know that he finds teeth whose enamel is entirely worn off the occlusal surfaces, proving that they have been subjected to great stress, without the slightest disturbance o f the surrounding bony support o f those teeth. What was the reason? It was not because there was not great strain, nor because the supporting tissues o f the teeth were not sub ject to bacterial invasion, but because these individuals used their teeth so vigorously that they translated vigorous use into well nourished and highly resistant tissues. The
value o f Dr. Hartzell’s scouring o f the teeth in my opinion is due to the fact, not that they have been scrubbed and bacteria eliminated, though that may be helpful, but because the circulation has been stimulated and they have become more resistant. In other words, he is doing artificially with his scouring process what our prehistoric ancestors did by the use o f course and fibrous foods.
Dr. H artzell , ( clo sin g ) : In reply to Dr. Price, permit me to ask, in view of the fact that his statements regarding invasion o f bac teria have not been supported by actual in vestigation: How does he know in these in stances that bacteria are there? When the resistance, the local resistance, is kept very high, by scouring the teeth, as he approves of doing in endorsing what I have said here, the invasion is checked and is comparatively slight. The Egyptians, 4,000 years ago, suffered just exactly as we do now, and they lived a comparatively simple life so fa r as their foods were concerned. A book by Sir Marc Armand Ruffer, compiled by Dr. Moody o f Chicago, shows dental lesions confirming what I have said. Dr. M erritt stated that when weight is delivered, against the teeth, it may be de livered exactly true, and still there may be traumatic occlusion. He tells you, too, that it can be delivered sideways, and traumatic occlusion not be present. Now I leave that to you. If you believe it is so, a ll right. I don’t. I am grateful fo r the words o f appro bation. Remember, the title o f this paper is the treatment o f this disease simplified. I ain giving you this morning, and have given you, the things that have made fo r the largest pos sible success in my work, and I have done nothing else now fo r thirty years. It is simple, direct, easy o f application, and reveals a positive result. Dr. Price talked about cal cium in its relation to pyorrhea. He made assertions that would lead you to think that this disease which attacks the investing tissues o f the teeth is largely one o f old age. I saw a child two years and a half old lose every tooth by infection. They were so loose that one could pluck them out with thumb and finger, and the child made scarcely any ob jection. That is strange, indeed, but true. I saw but one case o f that sort, but I am con stantly seeing children with lesions around the necks o f the teeth. A young man, at least 21 years old, came to me last week, with
Hartzell—Etiology of Pyorrhea Alveolaris lesions one eighth inch deep between his molars. He was, apparently, on a good, nor mal diet— milk, eggs, green vegetables, fruits, and still there were these deep lesions between the teeth. I placed him under treatment, and I dismissed him a week ago, after three weeks’ treatment by the scouring process. The result was that the crevices filled with granulation and the epithelium was bridging the ulcers, and I am sure that in another week there w ill be a new, healthy, shining coat o f epithelium on the ulcers covering the space bridging over between the teeth. It is not a disease o f old age. It is a disease o f life, from the cradle to the grave, and I don’t believe that the food habits o f this country are robbing it o f the ability to gather calcium. Dr. Price w ill say that the individual who is getting a quart of fresh milk daily, and still has pyorrhea, prob ably has one o f those illusive things that pre vent him from appropriating it. Frankly, I owe much to Dr. Price. He is the man that started me to digging. Dr. Price has talked about calcium here. I hope that you w ill be willing to test the things that I have advocated, and not attempt to study the blood chemistry in order to determine whether the calcium balance is a ll right. I f you heard one o f the other papers, you w ill know that it would be quite impossible to get dead fish livers enough to activate the calcium o f the country. In the meantime, you might do something by scouring the teeth, if you tried. I am not unmindful o f the fact that Dr.
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Price discovered the germ that caused pyor rhea in 1916. He showed in San Francisco, Seattle, Minneapolis, and other places a bacillus “X ” which he got on blood culture. In a ll his pyorrhea cases, he was equally cer tain that he was right. It was proved that bacillus “X ” was the hay bacillus, the most difficult thing to fight in keeping cultures clean. I have not heard him saying much about bacillus “X ” lately. Might it not be possible that some o f these abstract statements that he has made he w ill m odify after a while? Please do not be discouraged with this matter. I do not believe that the lack of calcium is in any proportion so important a problem as checking the local growth of bac teria on the tooth surface and adjacent to the teeth, and I do know that an effort to check this growth w ill yield a great meed of success to every individual who conscientiously puts it into operation. I am going to leave this matter right here with you now, to adopt or not, as you see fit, and if you wish to delay work on your cases and attempt to bring about normality by blood chemistry, which you do not know how to do, and which I do not know how to do (I should have to seek an expert in biologic chemistry to have it carried out) and which so fa r Dr. Price has not taught us how to do, and which such men as Dr. Albert P. Matthews, one o f the greatest biologic chemists o f this country today, is still in doubt about, I beg o f you, in the mean time, while you are settling these difficulties, adopt the regime o f cleanliness.