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Healing of Tooth Sockets Following Tooth Extraction in Dogs*
2156
The Journal of the American Dental Association
o f the ductless glands, arthritis, nephritis, neuritis, pancreatitis, so-called nervous dis eases, may all be caused by bacterial invasion from infective fo c i; consequently, the phy sician wants the fo ci eradicated now. He is not interested in any theory of reattachment of soft tissue to cementum. He knows his tology well enough to know that it w ill not happen. I challenge any champion o f the reattachment theory to show one case in which any soft tissue has reattached where a pyorrhea pocket has once existed. M y chal lenge is issued after investigation in thou sands of cases has not revealed a single so-called reattachment. In answer to the ques tion as to what I consider the proper method o f treating teeth where bone is lost in the bifurcations: I consider it safest, fo r the patient, to extract teeth so badly infected, especially the upper molars. Sometimes, low er molars with long wide spreading roots can be successfully operated on. Alw ays, when ever successfully operated on, the mesial and distal alveolar process must be shortened un til it is as low or low er than the bone in the bifurcations. In reply to Dr. H irschfeld, I am assured by no less an authority than Dr. M oody that I am correct in my statement that
bone destruction in a pyorrhea pocket is true bone caries. Dr. H irschfeld asks how I know when we remove the caries that we have re m oved all infection. I know just as well as any surgeon knows when he operates on any septic wound. W herever possible, surgeons are doing a debridement that is cutting w ide ly into healthy tissues. This is one o f the most important lessons taught by the late war. Thousands o f lives were saved by this pro cedure in shrapnel, bullet and other wounds. Gas gangrene septicemia was prevented in thousands of cases. T h is has become common practice now, and such a dreadful thing as a carbuncle is innocent enough when the sur geon cuts far enough into healthy tissue. T he United States Arm y M edical Department has named the pyorrhea eradication operation gingiva alveolus debridement. In this opera tion, we remove enough to feel reasonably sure that we are in uninfected tissue, and Nature is usually very kind. Sometimes, the cancellous bone in the approximal spaces is low er than the cortical plates. In these con ditions, I remove enough of the plates so that the lowest point is level with or a little higher than the external bone.
HEALING OF TOOTH SOCKETS FOLLOWING TOOTH EXTRACTION IN DOGS* By WARREN S. SCHRAM, D.D.S., St. Paul, Minn. H IS is a preliminary report o f a series of studies made at N orth western University during the past year with the hope o f obtaining some definite information regarding the proc ess of repair follow ing surgical inter ference with the maxillary bones. T h e literature on general bone regen eration, which dates back to the early
T
*Read before the Section on Histology, Physiology, Pathology, Bacteriology and Chemistry (Research) at the Seventieth A n nual Session of the Am erican Dental A sso ciation, Minneapolis, Minn., Aug. 22, 1928. Jour. A . D. A ., N ovem ber, 1928
part o f the eighteenth century, is volum inous. Practically all of the w ork was done on the long bones. T h e object of the various experiments made was to determine which of the cellular elements o f bone, such as bone marrow, the can cellous bone or periosteum, was most active in bone formation, and whether any o f them could be definitely excluded from the bone form ing process. Arthur Keith1 sums up the varying opinions o f these men as follow s: “ And 1.
Keith, A rthur: Brit. J. Surg., 1919.
Schram— Healing of Tooth Sockets in Dogs
2157
o f my work closely parallels and agrees in general with his. Several dogs with sound teeth were selected. T h e upper and low er bicuspids were removed with simple extraction on one side and with surgical extraction on the other. T h e differences, if any, which w ould be found in the healing process were to be noted, the w ork being done with the same care in regard to technic and asepsis as w ould be used in human cases. A t varying intervals, the dogs were killed, and sections from the opera tive areas were studied microscopically. O ur w ork deals primarily with the W e were unfortunate in obtaining regeneration taking place in the alveolar material from the wounds produced by process. In reviewing the English litera surgical removal. T hrou gh accident, we ture, we find that men writing on the lost the material for the 8-day, 2-week subject of regeneration taking place in and 3-week specimens. It is evident from the maxillary bones have based their our slides o f simple extraction that these opinions on the findings reported from would have been most interesting. One long bone experiments. slide o f a surgical removal o f 3 weeks H. W . M a cM illa n 2 says, “ Dental became infected, ow ing to the loss o f the literature abounds with terms which de suture before initial healing had taken scribe the alveolar process as transitory place, thereby exposing the alveolar bone and unlike true bone.” And he states to the fluids o f the mouth. that, in his opinion, this tissue is true (In this slide, there is evidence of the bone, differing only from the other bones epithelium dipping down between the of the body because of the demand of alveolar bone and the gum flap, thus function. I refer to this controversy seriously interfering with the healing because o f the direct affect which it process. T h e entire area o f exposed bone might have on the problem o f regenera is necrotic, and it is o f interest to note tion in these tissues follow ing injury. that the destructive process has pro T h e work which I have done consists gressed to the pericemental membrane of the microscopic study o f the process and dentin o f the adjoining tooth, de o f regeneration taking place in the maxil stroying small areas in the cementum.) lary bones of dogs at varying intervals This, o f course, is a condition which after tooth removal both by simple ex might occur in surgical removal or wher traction and by surgical methods. ever the alveolar bone is left unprotected D r. Euler3 made a similar study o f by a blood clot and exposed to the fluids simple extraction wounds in 1923. Part o f the mouth.
here we are in the twentieth century still with the same tw o groups, those who regard periosteum as the chief osteogenetic element o f the human skeleton, and those who regard bone itself as that element.” W h ere is the truth? As in most cases o f this kind, there is truth on both sides. But the greater share is on M acew n’s, whose conclusions are that periosteum has no osteogenetic function in itself but acts as a confining and de limiting membrane for the cells which are active in bone formation.
2. M acM illan, H. W . : J. Dent. Res., 6: 251, 1924-1926. 3. E uler: Deutsch. Monatschr. f. Zahnheilk., December, 1923.
From the w ork which we have done, I believe that we have been able to study fairly accurately the regenerative proc ess taking place after simple extraction,
2158
The Journal of the American Dental Association
and our w ork corresponds almost en tirely to that done by D r. Euler. W e have seen disease which may occur after the exposure of the alveolar bone to the
oral fluids. As yet we are not prepared to make definite statements regarding repair follow in g surgical removal of teeth. W e hope to complete this work.
TREATM ENT TO ENLARGE ABNORMALLY SMALL M OUTH FOR FULL DENTURE PROSTHESIS: REPORT OF CASE By B. S. BURKS, D.D.S., Crewe, Va. B O U T three years ago, a patient came to my office for an extraction. On ex amination, I found the mouth to be greatly drawn, as were the hands and fing ers. T h e extraction was done with a great deal of difficulty, ow ing to the smallness of the mouth.
A
The patient stated that, nine years previously, she was affected with a disease which caused draw ing o f the muscles of the mouth, hands and fingers. H er physician was puzzled, but said that the condition was due to some nerve trouble. Treatment gave no great amount of relief. On questioning the patient further, I found that the case was congenital to a certain extent. She left my office without my obtaining any further his tory. In about a year, she returned suffering with odontalgia. On examination, I found a pyrroheic condition and so advised extraction of the few remaining teeth. A fter a time, the patient came in to have a denture made. Now the real problem faced me. H ow was I to get into patient’s mouth an impression tray which w ould be large enough to fit the inside of the mouth? A No. 4 impression tray could not be gotten in, and even if we had been able to insert it, it would have been too small fo r the arch. D ay after day, I studied the case and finally sent the patient to Rich mond to G. W . H olliday fo r an examination. A fe w days later, Dr. H olliday wrote me that it was the most extreme case that he had ever seen and he did not see how it would be possible to make a denture for the patient in Jour. A . D. A ., N ovem ber, 1928
her present condition. He suggested some me chanical device to enlarge the mouth by stretching the muscles. I had the patient try a large marble, a bottle and several other devices, but with no success. I then determined to attempt enlargement of the mouth by h aving the patient use her fingers to stretch the muscles. She was there fore instructed to put her fingers in the cor ners of her mouth and pull against the muscles for one hour and twenty minutes each day. M ay 5, 1927, this procedure was begun, and the patient was instructed to report to my office every tw o weeks fo r examination. Soon I noticed the muscles had begun to relax just a little, and I felt greatly encouraged. In three months, there was a marked change, the expansion being very noticeable. T he patient was as greatly delighted as I was when we realized that our goal was in sight. Th ree months later, the mouth had been ex panded to such an extent that impressions of compound and plaster were successfully taken. T h e follow in g is an extract from patient’s letter. “ I have had my teeth for five months and can eat anything. I w ill always be more than grateful to Dr. Burks for his work and w ill be glad fo r any visiting dentist w ho comes to Crewe to examine my mouth.” I fully realize that had I been able to ob tain a more complete history of the case, it would have been more interesting. But to have perform ed this service for a cooperative and appreciative patient was a source of great satisfaction.
The Journal of the American Dental Association
o f the ductless glands, arthritis, nephritis, neuritis, pancreatitis, so-called nervous dis eases, may all be caused by bacterial invasion from infective fo c i; consequently, the phy sician wants the fo ci eradicated now. He is not interested in any theory of reattachment of soft tissue to cementum. He knows his tology well enough to know that it w ill not happen. I challenge any champion o f the reattachment theory to show one case in which any soft tissue has reattached where a pyorrhea pocket has once existed. M y chal lenge is issued after investigation in thou sands of cases has not revealed a single so-called reattachment. In answer to the ques tion as to what I consider the proper method o f treating teeth where bone is lost in the bifurcations: I consider it safest, fo r the patient, to extract teeth so badly infected, especially the upper molars. Sometimes, low er molars with long wide spreading roots can be successfully operated on. Alw ays, when ever successfully operated on, the mesial and distal alveolar process must be shortened un til it is as low or low er than the bone in the bifurcations. In reply to Dr. H irschfeld, I am assured by no less an authority than Dr. M oody that I am correct in my statement that
bone destruction in a pyorrhea pocket is true bone caries. Dr. H irschfeld asks how I know when we remove the caries that we have re m oved all infection. I know just as well as any surgeon knows when he operates on any septic wound. W herever possible, surgeons are doing a debridement that is cutting w ide ly into healthy tissues. This is one o f the most important lessons taught by the late war. Thousands o f lives were saved by this pro cedure in shrapnel, bullet and other wounds. Gas gangrene septicemia was prevented in thousands of cases. T h is has become common practice now, and such a dreadful thing as a carbuncle is innocent enough when the sur geon cuts far enough into healthy tissue. T he United States Arm y M edical Department has named the pyorrhea eradication operation gingiva alveolus debridement. In this opera tion, we remove enough to feel reasonably sure that we are in uninfected tissue, and Nature is usually very kind. Sometimes, the cancellous bone in the approximal spaces is low er than the cortical plates. In these con ditions, I remove enough of the plates so that the lowest point is level with or a little higher than the external bone.
HEALING OF TOOTH SOCKETS FOLLOWING TOOTH EXTRACTION IN DOGS* By WARREN S. SCHRAM, D.D.S., St. Paul, Minn. H IS is a preliminary report o f a series of studies made at N orth western University during the past year with the hope o f obtaining some definite information regarding the proc ess of repair follow ing surgical inter ference with the maxillary bones. T h e literature on general bone regen eration, which dates back to the early
T
*Read before the Section on Histology, Physiology, Pathology, Bacteriology and Chemistry (Research) at the Seventieth A n nual Session of the Am erican Dental A sso ciation, Minneapolis, Minn., Aug. 22, 1928. Jour. A . D. A ., N ovem ber, 1928
part o f the eighteenth century, is volum inous. Practically all of the w ork was done on the long bones. T h e object of the various experiments made was to determine which of the cellular elements o f bone, such as bone marrow, the can cellous bone or periosteum, was most active in bone formation, and whether any o f them could be definitely excluded from the bone form ing process. Arthur Keith1 sums up the varying opinions o f these men as follow s: “ And 1.
Keith, A rthur: Brit. J. Surg., 1919.
Schram— Healing of Tooth Sockets in Dogs
2157
o f my work closely parallels and agrees in general with his. Several dogs with sound teeth were selected. T h e upper and low er bicuspids were removed with simple extraction on one side and with surgical extraction on the other. T h e differences, if any, which w ould be found in the healing process were to be noted, the w ork being done with the same care in regard to technic and asepsis as w ould be used in human cases. A t varying intervals, the dogs were killed, and sections from the opera tive areas were studied microscopically. O ur w ork deals primarily with the W e were unfortunate in obtaining regeneration taking place in the alveolar material from the wounds produced by process. In reviewing the English litera surgical removal. T hrou gh accident, we ture, we find that men writing on the lost the material for the 8-day, 2-week subject of regeneration taking place in and 3-week specimens. It is evident from the maxillary bones have based their our slides o f simple extraction that these opinions on the findings reported from would have been most interesting. One long bone experiments. slide o f a surgical removal o f 3 weeks H. W . M a cM illa n 2 says, “ Dental became infected, ow ing to the loss o f the literature abounds with terms which de suture before initial healing had taken scribe the alveolar process as transitory place, thereby exposing the alveolar bone and unlike true bone.” And he states to the fluids o f the mouth. that, in his opinion, this tissue is true (In this slide, there is evidence of the bone, differing only from the other bones epithelium dipping down between the of the body because of the demand of alveolar bone and the gum flap, thus function. I refer to this controversy seriously interfering with the healing because o f the direct affect which it process. T h e entire area o f exposed bone might have on the problem o f regenera is necrotic, and it is o f interest to note tion in these tissues follow ing injury. that the destructive process has pro T h e work which I have done consists gressed to the pericemental membrane of the microscopic study o f the process and dentin o f the adjoining tooth, de o f regeneration taking place in the maxil stroying small areas in the cementum.) lary bones of dogs at varying intervals This, o f course, is a condition which after tooth removal both by simple ex might occur in surgical removal or wher traction and by surgical methods. ever the alveolar bone is left unprotected D r. Euler3 made a similar study o f by a blood clot and exposed to the fluids simple extraction wounds in 1923. Part o f the mouth.
here we are in the twentieth century still with the same tw o groups, those who regard periosteum as the chief osteogenetic element o f the human skeleton, and those who regard bone itself as that element.” W h ere is the truth? As in most cases o f this kind, there is truth on both sides. But the greater share is on M acew n’s, whose conclusions are that periosteum has no osteogenetic function in itself but acts as a confining and de limiting membrane for the cells which are active in bone formation.
2. M acM illan, H. W . : J. Dent. Res., 6: 251, 1924-1926. 3. E uler: Deutsch. Monatschr. f. Zahnheilk., December, 1923.
From the w ork which we have done, I believe that we have been able to study fairly accurately the regenerative proc ess taking place after simple extraction,
2158
The Journal of the American Dental Association
and our w ork corresponds almost en tirely to that done by D r. Euler. W e have seen disease which may occur after the exposure of the alveolar bone to the
oral fluids. As yet we are not prepared to make definite statements regarding repair follow in g surgical removal of teeth. W e hope to complete this work.
TREATM ENT TO ENLARGE ABNORMALLY SMALL M OUTH FOR FULL DENTURE PROSTHESIS: REPORT OF CASE By B. S. BURKS, D.D.S., Crewe, Va. B O U T three years ago, a patient came to my office for an extraction. On ex amination, I found the mouth to be greatly drawn, as were the hands and fing ers. T h e extraction was done with a great deal of difficulty, ow ing to the smallness of the mouth.
A
The patient stated that, nine years previously, she was affected with a disease which caused draw ing o f the muscles of the mouth, hands and fingers. H er physician was puzzled, but said that the condition was due to some nerve trouble. Treatment gave no great amount of relief. On questioning the patient further, I found that the case was congenital to a certain extent. She left my office without my obtaining any further his tory. In about a year, she returned suffering with odontalgia. On examination, I found a pyrroheic condition and so advised extraction of the few remaining teeth. A fter a time, the patient came in to have a denture made. Now the real problem faced me. H ow was I to get into patient’s mouth an impression tray which w ould be large enough to fit the inside of the mouth? A No. 4 impression tray could not be gotten in, and even if we had been able to insert it, it would have been too small fo r the arch. D ay after day, I studied the case and finally sent the patient to Rich mond to G. W . H olliday fo r an examination. A fe w days later, Dr. H olliday wrote me that it was the most extreme case that he had ever seen and he did not see how it would be possible to make a denture for the patient in Jour. A . D. A ., N ovem ber, 1928
her present condition. He suggested some me chanical device to enlarge the mouth by stretching the muscles. I had the patient try a large marble, a bottle and several other devices, but with no success. I then determined to attempt enlargement of the mouth by h aving the patient use her fingers to stretch the muscles. She was there fore instructed to put her fingers in the cor ners of her mouth and pull against the muscles for one hour and twenty minutes each day. M ay 5, 1927, this procedure was begun, and the patient was instructed to report to my office every tw o weeks fo r examination. Soon I noticed the muscles had begun to relax just a little, and I felt greatly encouraged. In three months, there was a marked change, the expansion being very noticeable. T he patient was as greatly delighted as I was when we realized that our goal was in sight. Th ree months later, the mouth had been ex panded to such an extent that impressions of compound and plaster were successfully taken. T h e follow in g is an extract from patient’s letter. “ I have had my teeth for five months and can eat anything. I w ill always be more than grateful to Dr. Burks for his work and w ill be glad fo r any visiting dentist w ho comes to Crewe to examine my mouth.” I fully realize that had I been able to ob tain a more complete history of the case, it would have been more interesting. But to have perform ed this service for a cooperative and appreciative patient was a source of great satisfaction.