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Importance of Early Recognition and Treatment of Periodontoclasia*
IM P O R T A N C E O F E A R L Y R E C O G N IT IO N A N D T R E A T M E N T O F P E R IO D O N T O C L A S IA * B y R O B E R T L. D E M E N T , D .D .S ., A tla n ta , G a.
T
H E importance of the early recogni tion and treatment of periodonto clasia is a subject which has been and still is sadly neglected by the dental pro fession as a whole, for no other reason, it seems, than carelessness or, shall we say, ignorance. W e hesitate to say that this neglect is due to ignorance, but when we continue to have patients come in for examination and diagnosis with the state ment that “ D r. Blank says that I have pyorrhea and there is nothing to do ex cept remove the teeth— he doesn’t believe in pyorrhea treatment,” what other opin ion are we to form ? A t a meeting of the American Acad emy of Periodontology, held in New York City, in M ay, 1 9 2 1 ,1 heard Arthur H . M erritt read a paper entitled “ A Brief History of Periodontology,” in which he made the following statement: Diseases of the periodontium are as old as recorded history. Frequent mention is made by ancient writers of “loose teeth,” “ shaking teeth,” “hemorrhage of the gums.” In the Ebers papyrus, which dates from the thirty-seventh century, B. C., cer tain remedies are prescribed “to strengthen the gums.” T h e dental profession has made won derful strides, particularly in recent years, but judging from what we see in the mouths of patients from day to day, the progress made by some of the mem *R e a d before the Section on Periodontia at the Seventy-Sixth Annual Session of the Am erican Dental Association, St. Paul, Minn., Aug. 7, 1934. Jour. A .D .A ., V ol. 22, A u g u st, 1935
bers of our profession has been very slight, or nil, along the line of periodon tology. For the past seventeen years, I have been devoting my entire time to the prac tice of periodontia, and the thought grows stronger each day that the great est service we can render our patients is to recognize the symptoms of periodonto clasia early and institute treatment im mediately, before the normal contour of the supporting tissues has been changed and, perhaps, the teeth themselves are lost, to say nothing of the patients’ health becoming impaired on account of the focus of infection in the periodon tium. THOROUGH EXAMINATION OF MOUTH
In examining the oral cavity, it is a natural tendency to center our attention on the things that particularly interest us. In other words, if we enjoy inlay work, we look for cavities in which to place in lays, and, if we are peculiarly adept at bridgework, we look for places to insert a bridge. Those who practice periodon tia naturally observe the supporting structure of the teeth. A thorough ex amination should be made, taking the mouth as a unit, and each defect noted on a suitable chart, in order that we may have a complete record of the condition of the oral cavity and also may formulate a systematic plan on which to proceed in our endeavor to place the mouth in a healthy, sanitary and comfortable condi
1307
1308
The Journal of the American Dental Association
STUDY CASTS tion. In this way, we render the patient a much more efficient and complete health Study casts are advocated by many service. periodontists in every case treated; but A s a routine in examination, I would unless we are to do restorative work or suggest the following procedure, after a the bite is to be opened and the whole cursory macroscopic examination of the occlusal relation changed, I have never mouth: felt it necessary or very helpful in my 1. A complete roentgenographic reown work. In adjusting the occlusal re view of the teeth and supporting struc lation, I have always depended on my tures, being careful of angulation in order knowledge of the occlusal relation, to show clearly the interproximal spaces, mechanical ability and patience and per crowns and root apices, without elonga severance. I do not find it necessary to tion or foreshortening. In some cases, change the occlusal relation in every extraoral plates should be made in third case; but when it is necessary, the grind molar areas and also, at different angles, ing is done slowly and cautiously, then of some of the pulpless or suspicious teeth. checked and rechecked, until, as nearly 2. Study casts, if necessary. 3. Vitality as possible, there is an equal distribution tests of all suspicious teeth. 4. Clinical of stress, if possible in line with the long examination along with roentgenograms. axis of the tooth. 5. A case history. 6. Prognosis. VITALITY TESTS
ROENTGENOGRAMS
In years gone by, it was my misfortune to encounter trouble because of failure to take complete roentgenograms before beginning treatment of oral conditions. Until we develop fluoroscopic eyes, we cannot always detect rarefied areas at the apices of teeth, although it is possible to detect some of these areas by digital pal pation. W e also need the roentgenogram in locating broken off roots, residual areas, interproximal cavities, cysts, un erupted teeth and periodontal lesions ; determining the course of roots and the character of alveolar bone and as an aid in detecting traumatic occlusion, as well as other details. O f course, the taking of roentgenograms causes a little additional expense to the patient, but it makes for a much more complete and thorough health service, which, after all, is what the pa tient expects, and should receive. W ith out a complete roentgenographic review of every case, we are sure to overlook many pathologic conditions which would otherwise be found.
Some dentists advocate a vitality test for each tooth in the mouth. I do not see the necessity of testing every tooth, but would suggest testing the vitality of every tooth holding a bridge which has been placed in close proximity to the pulp chamber or which looks at all suspicious. In other words, a tooth which raises a question in your mind as to its vitality should be looked on as a menace to health until proved healthy. M any times, teeth may be saved by root canal therapy if devitalization is detected before the cementum around the apex has been nicked by absorption and even before granulomatous areas appear. I am not a member of the so-called “ 100 per cent club,” the group which believes in the removal of every pulpless tooth, since I have never been able to make myself be lieve that every pulpless tooth carries ac tive infection. On the other hand, it is my opinion that much trouble has been started by the useless removal of teeth, breaking the arch and permitting the re maining teeth to drift into an inharmoni
Dement— Early Treatment of Periodontoclasia ous relationship with their antagonists of the opposing jaw and thus producing traumatic occlusion with its sequelae. • CLINICAL EXAMINATION
A fter making the necessary vitality tests, with the roentgenogram before us, we proceed to examine the oral cavity, starting with the tonsils and examining the soft tissues throughout. W e next ex amine the teeth and periodontium, noting missing teeth, cavities, imperfect restora tions (fillings and bridges), imbedded teeth, unerupted teeth, devitalized teeth and teeth which have drifted or are ro tated or leaning. W e then check the oc clusal relation to see whether trauma ex ists, and the possibility of its relief, taking into consideration the anatomic relation as well as the amount of alveolar support remaining. Then with suitable explorers (I would suggest thin, flat explorers, not over 2 mm. in width), we probe around in the gingival crevice, noting its depth and particularly noting the depth of peri odontal lesions found. If the crevice meas ures more than the normal, which is about 1.5 mm., it is outlined on the chart for special attention in treatment and obser vation. Each lesion and its depth is out lined on the chart. W e also note the color and character of the gingival tis sue, whether congested, hypertrophied, spongy, hard or anemic. W e also note gingival recession, which is always ac companied by alveolar resorption. When we feel it necessary, we make bactério logie slides. W e started several years ago to make bacterial tests in every case, but soon came to the conclusion that it was unnecessary, since practically the same organisms were found in every case, these being streptococci, staphylococci, colon bacillus, diplococci, Vincent’s spirochete and others. In my early days of specializing in per iodontia, I acquired the habit, as no
1309
doubt others have, of examining the gin gival tissue macroscopically; and, if there were no visible evidences of pathologic change, I would, through negligence, and I suppose ignorance, give a negative diag nosis of periodontoclasia. In many cases, I would not even take roentgenograms. Perhaps there would be slight evidence of gingivitis. In such cases, I would recom mend prophylactic treatment and instruc tion in mouth care and, with an applica tion of aconite and iodine, dismiss the pa tient as having all the treatment neces sary. As time went on and my knowledge increased, I began to take more time and pains in examinations, with the result that few patients leave my office now without having a positive diagnosis of periodontoclasia in some form. I soon learned that macroscopically I could not know what was going on in the gingival crevice, and while good, clear roentgeno grams were wonderful aids in diagnosis, they could not be fully depended on to tell the whole truth, so I began, on these seemingly perfect supporting structures around the teeth, to probe with small blunt explorers the gingival crevice, and I know now that I overlooked many pathologic conditions. Now, before a pa tient leaves my office with a negative diagnosis, the gingival crevice all around each tooth has been explored thoroughly. T his can be done rapidly, but at the same time thoroughly, after a little prac tice. Since the normal gingival crevice is about 1.5 mm. in depth, if the explorer passes to a greater depth, there is no doubt that a pathologic change is taking place and treatment should be instituted at this time. CASE HISTORY
In treating any disease process, a thor ough knowledge of a patient’s age, gen eral health and habits is of inestimable value. It is natural to assume that an
1310
The Journal of the American D ental Association
advanced case of periodontoclasia exist ing in the mouth of one who has reached the age of 50 or 60 years, and who has a history of poor general health, would not respond So well as a case in a young person of strong vitality. If the patient has developed such conditions as iritis, nephritis, arthritis, myocarditis, endo carditis, pericarditis or neuritis or any of the many other secondary conditions, we cannot afford to take as much chance in advanced cases as we would otherwise. PROGNOSIS
A fter a thorough study of the case, it matters not how much we would like to retain certain teeth on account of their strategic importance, we must remember that even if all of the teeth have to be removed in order to eradicate all foci of infection, it is better to have a healthy mouth with artificial dentures than jeopardize the general health by leaving a pathologic condition. In older people, on account of the difficulty in learning to use artificial dentures, it is important to maintain as many teeth as possible to act as stays to partial dentures or removable bridges, if these teeth can be placed and maintained in a healthy condition. There is one grave mistake being made by many men in the dental profession which I would bring to your attention, and that is the habit of looking for signs of perio dontoclasia in only those who have reached adult life. O f course, the per centage of those affected grows with ad vancing years, but it is surprising how many cases are found in the mouths of persons still in their teens or even younger. By placing a finger on the lin gual and another on the labial aspect, with pressure, a small amount of pus and blood, which is a forerunner of much more serious trouble, can so often be ex uded from the gingival crevice in the in-
terproximal spaces, as well as from the labial and lingual aspects. A t this stage, prophylactic treatment alone is not enough. T he periodontal lesion is de veloping and periodontal treatment is in dicated. T he greatest service the dental pro fession can render humanity is in the field of prevention. Even though the arrest of so-called pyorrhea alveolaris is a very worth while service, if we use every means at our disposal for the early recog nition and treatment of incipient perio dontoclasia, think of the advantage accru ing to the patient. When the gingival tissues lose their normal contour, the teeth and gums be come less self-cleansing and, in many cases, are more difficult to clean by arti ficial means. T he appearance is less pleas ing in that the esthetic value of normal gingival tissue has been lost to a certain degree. In treating incipient periodonto clasia, there is much less pain, time and expense, as a rule. By treating the condi tion in its incipiency, the possibility of in volvement of the general health through development of a focus of infection, loss of the teeth and impairment of mastica tion is avoided. O f course, the ideal would be to pre vent even the incipient cases of perio dontoclasia, but until we understand more of endocrinology and the food re quirements of the body, and can regulate habits of life, we cannot, I fear, reach such a utopia. By taking more time and exercising more patience and perseverance in teaching our younger patients home care of the mouth and impressing on them its importance; we can accomplish much in the way of prevention of gingi val disturbances as well as caries, thus guarding the general health of our pa tients to a marked degree. 923 D octors’ B u ild in g .
T
H E importance of the early recogni tion and treatment of periodonto clasia is a subject which has been and still is sadly neglected by the dental pro fession as a whole, for no other reason, it seems, than carelessness or, shall we say, ignorance. W e hesitate to say that this neglect is due to ignorance, but when we continue to have patients come in for examination and diagnosis with the state ment that “ D r. Blank says that I have pyorrhea and there is nothing to do ex cept remove the teeth— he doesn’t believe in pyorrhea treatment,” what other opin ion are we to form ? A t a meeting of the American Acad emy of Periodontology, held in New York City, in M ay, 1 9 2 1 ,1 heard Arthur H . M erritt read a paper entitled “ A Brief History of Periodontology,” in which he made the following statement: Diseases of the periodontium are as old as recorded history. Frequent mention is made by ancient writers of “loose teeth,” “ shaking teeth,” “hemorrhage of the gums.” In the Ebers papyrus, which dates from the thirty-seventh century, B. C., cer tain remedies are prescribed “to strengthen the gums.” T h e dental profession has made won derful strides, particularly in recent years, but judging from what we see in the mouths of patients from day to day, the progress made by some of the mem *R e a d before the Section on Periodontia at the Seventy-Sixth Annual Session of the Am erican Dental Association, St. Paul, Minn., Aug. 7, 1934. Jour. A .D .A ., V ol. 22, A u g u st, 1935
bers of our profession has been very slight, or nil, along the line of periodon tology. For the past seventeen years, I have been devoting my entire time to the prac tice of periodontia, and the thought grows stronger each day that the great est service we can render our patients is to recognize the symptoms of periodonto clasia early and institute treatment im mediately, before the normal contour of the supporting tissues has been changed and, perhaps, the teeth themselves are lost, to say nothing of the patients’ health becoming impaired on account of the focus of infection in the periodon tium. THOROUGH EXAMINATION OF MOUTH
In examining the oral cavity, it is a natural tendency to center our attention on the things that particularly interest us. In other words, if we enjoy inlay work, we look for cavities in which to place in lays, and, if we are peculiarly adept at bridgework, we look for places to insert a bridge. Those who practice periodon tia naturally observe the supporting structure of the teeth. A thorough ex amination should be made, taking the mouth as a unit, and each defect noted on a suitable chart, in order that we may have a complete record of the condition of the oral cavity and also may formulate a systematic plan on which to proceed in our endeavor to place the mouth in a healthy, sanitary and comfortable condi
1307
1308
The Journal of the American Dental Association
STUDY CASTS tion. In this way, we render the patient a much more efficient and complete health Study casts are advocated by many service. periodontists in every case treated; but A s a routine in examination, I would unless we are to do restorative work or suggest the following procedure, after a the bite is to be opened and the whole cursory macroscopic examination of the occlusal relation changed, I have never mouth: felt it necessary or very helpful in my 1. A complete roentgenographic reown work. In adjusting the occlusal re view of the teeth and supporting struc lation, I have always depended on my tures, being careful of angulation in order knowledge of the occlusal relation, to show clearly the interproximal spaces, mechanical ability and patience and per crowns and root apices, without elonga severance. I do not find it necessary to tion or foreshortening. In some cases, change the occlusal relation in every extraoral plates should be made in third case; but when it is necessary, the grind molar areas and also, at different angles, ing is done slowly and cautiously, then of some of the pulpless or suspicious teeth. checked and rechecked, until, as nearly 2. Study casts, if necessary. 3. Vitality as possible, there is an equal distribution tests of all suspicious teeth. 4. Clinical of stress, if possible in line with the long examination along with roentgenograms. axis of the tooth. 5. A case history. 6. Prognosis. VITALITY TESTS
ROENTGENOGRAMS
In years gone by, it was my misfortune to encounter trouble because of failure to take complete roentgenograms before beginning treatment of oral conditions. Until we develop fluoroscopic eyes, we cannot always detect rarefied areas at the apices of teeth, although it is possible to detect some of these areas by digital pal pation. W e also need the roentgenogram in locating broken off roots, residual areas, interproximal cavities, cysts, un erupted teeth and periodontal lesions ; determining the course of roots and the character of alveolar bone and as an aid in detecting traumatic occlusion, as well as other details. O f course, the taking of roentgenograms causes a little additional expense to the patient, but it makes for a much more complete and thorough health service, which, after all, is what the pa tient expects, and should receive. W ith out a complete roentgenographic review of every case, we are sure to overlook many pathologic conditions which would otherwise be found.
Some dentists advocate a vitality test for each tooth in the mouth. I do not see the necessity of testing every tooth, but would suggest testing the vitality of every tooth holding a bridge which has been placed in close proximity to the pulp chamber or which looks at all suspicious. In other words, a tooth which raises a question in your mind as to its vitality should be looked on as a menace to health until proved healthy. M any times, teeth may be saved by root canal therapy if devitalization is detected before the cementum around the apex has been nicked by absorption and even before granulomatous areas appear. I am not a member of the so-called “ 100 per cent club,” the group which believes in the removal of every pulpless tooth, since I have never been able to make myself be lieve that every pulpless tooth carries ac tive infection. On the other hand, it is my opinion that much trouble has been started by the useless removal of teeth, breaking the arch and permitting the re maining teeth to drift into an inharmoni
Dement— Early Treatment of Periodontoclasia ous relationship with their antagonists of the opposing jaw and thus producing traumatic occlusion with its sequelae. • CLINICAL EXAMINATION
A fter making the necessary vitality tests, with the roentgenogram before us, we proceed to examine the oral cavity, starting with the tonsils and examining the soft tissues throughout. W e next ex amine the teeth and periodontium, noting missing teeth, cavities, imperfect restora tions (fillings and bridges), imbedded teeth, unerupted teeth, devitalized teeth and teeth which have drifted or are ro tated or leaning. W e then check the oc clusal relation to see whether trauma ex ists, and the possibility of its relief, taking into consideration the anatomic relation as well as the amount of alveolar support remaining. Then with suitable explorers (I would suggest thin, flat explorers, not over 2 mm. in width), we probe around in the gingival crevice, noting its depth and particularly noting the depth of peri odontal lesions found. If the crevice meas ures more than the normal, which is about 1.5 mm., it is outlined on the chart for special attention in treatment and obser vation. Each lesion and its depth is out lined on the chart. W e also note the color and character of the gingival tis sue, whether congested, hypertrophied, spongy, hard or anemic. W e also note gingival recession, which is always ac companied by alveolar resorption. When we feel it necessary, we make bactério logie slides. W e started several years ago to make bacterial tests in every case, but soon came to the conclusion that it was unnecessary, since practically the same organisms were found in every case, these being streptococci, staphylococci, colon bacillus, diplococci, Vincent’s spirochete and others. In my early days of specializing in per iodontia, I acquired the habit, as no
1309
doubt others have, of examining the gin gival tissue macroscopically; and, if there were no visible evidences of pathologic change, I would, through negligence, and I suppose ignorance, give a negative diag nosis of periodontoclasia. In many cases, I would not even take roentgenograms. Perhaps there would be slight evidence of gingivitis. In such cases, I would recom mend prophylactic treatment and instruc tion in mouth care and, with an applica tion of aconite and iodine, dismiss the pa tient as having all the treatment neces sary. As time went on and my knowledge increased, I began to take more time and pains in examinations, with the result that few patients leave my office now without having a positive diagnosis of periodontoclasia in some form. I soon learned that macroscopically I could not know what was going on in the gingival crevice, and while good, clear roentgeno grams were wonderful aids in diagnosis, they could not be fully depended on to tell the whole truth, so I began, on these seemingly perfect supporting structures around the teeth, to probe with small blunt explorers the gingival crevice, and I know now that I overlooked many pathologic conditions. Now, before a pa tient leaves my office with a negative diagnosis, the gingival crevice all around each tooth has been explored thoroughly. T his can be done rapidly, but at the same time thoroughly, after a little prac tice. Since the normal gingival crevice is about 1.5 mm. in depth, if the explorer passes to a greater depth, there is no doubt that a pathologic change is taking place and treatment should be instituted at this time. CASE HISTORY
In treating any disease process, a thor ough knowledge of a patient’s age, gen eral health and habits is of inestimable value. It is natural to assume that an
1310
The Journal of the American D ental Association
advanced case of periodontoclasia exist ing in the mouth of one who has reached the age of 50 or 60 years, and who has a history of poor general health, would not respond So well as a case in a young person of strong vitality. If the patient has developed such conditions as iritis, nephritis, arthritis, myocarditis, endo carditis, pericarditis or neuritis or any of the many other secondary conditions, we cannot afford to take as much chance in advanced cases as we would otherwise. PROGNOSIS
A fter a thorough study of the case, it matters not how much we would like to retain certain teeth on account of their strategic importance, we must remember that even if all of the teeth have to be removed in order to eradicate all foci of infection, it is better to have a healthy mouth with artificial dentures than jeopardize the general health by leaving a pathologic condition. In older people, on account of the difficulty in learning to use artificial dentures, it is important to maintain as many teeth as possible to act as stays to partial dentures or removable bridges, if these teeth can be placed and maintained in a healthy condition. There is one grave mistake being made by many men in the dental profession which I would bring to your attention, and that is the habit of looking for signs of perio dontoclasia in only those who have reached adult life. O f course, the per centage of those affected grows with ad vancing years, but it is surprising how many cases are found in the mouths of persons still in their teens or even younger. By placing a finger on the lin gual and another on the labial aspect, with pressure, a small amount of pus and blood, which is a forerunner of much more serious trouble, can so often be ex uded from the gingival crevice in the in-
terproximal spaces, as well as from the labial and lingual aspects. A t this stage, prophylactic treatment alone is not enough. T he periodontal lesion is de veloping and periodontal treatment is in dicated. T he greatest service the dental pro fession can render humanity is in the field of prevention. Even though the arrest of so-called pyorrhea alveolaris is a very worth while service, if we use every means at our disposal for the early recog nition and treatment of incipient perio dontoclasia, think of the advantage accru ing to the patient. When the gingival tissues lose their normal contour, the teeth and gums be come less self-cleansing and, in many cases, are more difficult to clean by arti ficial means. T he appearance is less pleas ing in that the esthetic value of normal gingival tissue has been lost to a certain degree. In treating incipient periodonto clasia, there is much less pain, time and expense, as a rule. By treating the condi tion in its incipiency, the possibility of in volvement of the general health through development of a focus of infection, loss of the teeth and impairment of mastica tion is avoided. O f course, the ideal would be to pre vent even the incipient cases of perio dontoclasia, but until we understand more of endocrinology and the food re quirements of the body, and can regulate habits of life, we cannot, I fear, reach such a utopia. By taking more time and exercising more patience and perseverance in teaching our younger patients home care of the mouth and impressing on them its importance; we can accomplish much in the way of prevention of gingi val disturbances as well as caries, thus guarding the general health of our pa tients to a marked degree. 923 D octors’ B u ild in g .