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Mottled Enamel
1701
Fossum— M o ttled Enamel be p laced that w ill perm an ently restore fu n c tion and tooth fo r m throughou t the p e rio d o f their use, w ith ou t e n d a n g e rin g the p u lp ? H a v e these men m astered the tech nic o f p ro tecting u n occu pied spaces in thé d ecid u ou s arch w h ich h ave been le ft through the p re m ature loss o f d ecid u ou s m olars, thus p la c in g a check on m esial and distal m igra tion o f p erm anent teeth, as w e ll as on m any other
ill-effects that fo llo w the prem ature loss o f d ecid u ou s m o la r s ?
I f this has been a ccom
p lished in the p riv ate p ra ctice o f these men, they h a v e h elp ed to fill a y a w n in g g a p in dental serv ice and, in the process o f their serv in g , h ave done m ore f o r the preven tion o f m a locclu sion than m a n y orth odon tists ac com p lish in its correction .
MOTTLED ENAMEL By CARL FOSSUM, D.D.S., Aberdeen, S. D. «
O T T L E D enamel in its various macroscopic forms and tints no doubt antedates history, yet little progress has been made towards com bating this annoying condition up to the present time. I wish to present some new ideas for consideration, as a result of years of ob servation in this community, known as an endemic area. I trust that they may in a measure stimulate further investi gation dealing with this sad state o f af fairs. M y ideas may differ somewhat from the accepted general line of thought, yet I believe that I am justified in making the follow ing statements. In choosing a subject for considera tion, we like to be guided, to a consider able extent, by requests that come to us from our patients, and judging from the number received relative to mottled teeth, w e may rest assured that w e as dentists should devote considerable time and study and prepare ourselves to meet this deplorable situation. T his disease known as mottled enam el, brown stain, or streaking of the enamel, of both deciduous and perma nent teeth, particularly permanent, is one
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Jour. A. D. A., Sept., ipz8
which, so far, exists in defiance of either the dental or the medical profession. M an y years ago, when I began prac ticing, I was annoyed in finding so many patients with pitted enamel, and being unable to meet the situation, I naturally wondered why I had not received in structions at college dealing with this condition. I remembered studying the socalled Hutchinson teeth, but this did not explain the situation at all. In my dilem ma, I therefore sought all available in formation through current literature, both dental and medical, and also through the aid o f research laboratories, and the scarcity o f information easily explained why the college offered so little on this subject. I thought that if I could find its cause, I might produce a remedy, but it seemed that this was not to be. In 1910, while in charge of the program o f the dental clinic here, I made an attempt to get papers on this matter, by both den tists and physicians. T h e subject was, “ T h e Deleterious Effects o f Skin D is eases upon the Development o f T eeth D uring the P friod o f Eruption.” T h e papers were good, but the subject as signed was evaded because there seemed
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T h e Journal of the American D ental Association
to be little to say aside from its appear ance. Being forcibly impressed with the fact that little was known relative to this disease and that my findings, as sub stantiated by case histories, were new, I naturally took a keener interest in the subject, and the more I investigated, or rather observed, the facts at my dis posal, the more I was certain that I was right. M any years ago, our Society enter tained a prominent dentist from C olo rado who presented this subject, and I believe that he attributed these condi tions to malnutrition, artesian water and heredity, but principally to artesian water. Years ago, Hutchinson first called attention to malformation of the anterior teeth, particularly the incisors, and ascribed this to congenital syphilis, or hereditary causes. H e says, “ It has been noted that not all children who are victims of hereditary syphilis present these dental appearances, and again, ap pearances said to be identical with them are observed in children said not to be syphilitic.” It seem eda little confusing, but threw some light on the subject. Located as we are in the heart o f a so-called endemic area, everything gets its share of blame, from artesian water to lack of moisture in the air, and as a consequence, much confusion exists. One feels that something should be done; for how often we see an otherwise beau tiful set of teeth marred by this mottled discoloration and the life o f the indi vidual seriously handicapped thereby. M an y authors claim that this disease is prevalent in certain regions more than others, notably in Texas, Virginia, South and North Dakota, California and O re gon, also in the Bahamas and Cape Verde Islands, and in many other places as well. Sometimes, this disease appears
under a different name, such as brown or black stained teeth, notably in Italy and Asiatic countries, but the endemic areas are the same and fully as impor tant. Black, M cK a y and others who have made investigations have found that a percentage as high as 87.5 per cent of the inhabitants who are native born are affected in these areas. Bampton, in 1914, described tw o cases o f brown pig ment and pitted teeth and said that the condition was seen in the deciduous and the permanent dentition and that these cases were hereditary. (T h is seems to be a positive statement.) Black, who be gan investigation in 1908, states that the dark brown spots or streaks usually oc cur in pigmentation or mottling of the incisors. H e arrived at the conclusion that there was a failure o f normally oc curring cementum, between the enamel rods in the outer one-fourth to onethird o f the surface o f the enamel and the coloring matter takes the space of the normal cementing substance between the enamel rods. H e further states that the more o f this brown stain there is, the darker w ill be the color and the weaker the teeth; that Nasmyth’s mem brane is always normal, and the prob able result is failure o f proper develop ment of the tissues. D ick thinks that the brown staining alluded to by Black is due to malnutrition and that, in an ex amination o f school children, he found 40 per cent to be affected. Black found the brown pigment to be coincidental with freckles, but he asserted that this mottled condition was due to dystrophia or faulty nutrition. Grieves thinks that it is due to thyroid disturbances or at least to some defect in endocrine secretion. M c Kay, who has made the most thorough and extensive investigation of the dis ease, visiting nearly every affected area
Fossum— M o ttle d Enamel in the United States, asserts that the damage is wrought by some influence which acts either in an inhibitory or in a destructive way on the enamel, during or immediately after the building period, and that the condition is established prior to eruption. T w o prominent Italian dentists who have written on the subject o f mottled teeth come to the conclusion that there
U p per central in cisor (f r o m patient o v e r 40 years o f a g e ), sh o w in g the effects o f m easles at 7J4 y e a rs and ch icken p ox at 9 y e a r s; fin din gs w h ich w e re confirm ed by the patient. T h e w h ite effect o f the enam el is not natural but the result o f the e n g r a v in g process. E xcept f o r the enam el blem ishes, the tooth is perfect.
is a minimum content of normal salt in general and o f the salts of calcium in particular. T his minimal content of cal cium salts is the cause o f the condition which produces mottled teeth. M cK ay says further that whatever the cause is— if it is the water supply, which ap pears very probable-— it has not as yet been discovered. Gies thinks the brown coloring may come from the blood, dur ing the enamel-forming period. M any of our local dentists have attrib uted the mottling o f the teeth to our artesian water, to malnutrition and even to heredity. T h e schoolnurse, who fo l lows a similar line of thought, from con tact with the profession, informs the school children and their parents o f this theory.
1703
T h e situation is confusing and unsat isfactory, and the causes are numerous and varied, with no remedy available at this time. Various theories have been submitted in explanation o f mottled teeth. T h e diet has been given as the cause, but malnutrition and the water used, especially if artesian water, seem to be the chief enemy. Again, some say that the condition may be due to a dis turbance during the formative period. A ll these and more are suggested; but one thing we know : it affects practi cally all races alike, for I have seen it in the mouths o f Indians and Negroes, as well as in the white race. I am in no way associated with a re search laboratory, but I have access to them as has any one, and while I have nothing original to offer, I do find, after carefully reviewing the situation and elaborating on the findings o f others, that I can, with an encouraging degree of success, prove my conclusions with the facts at hand, and it is with this posi tive diagnostic sign and other signs at our disposal that I am able to determine the nature and apparent cause o f mottled teeth. I f we know the etiology positively, we may be able to combat the disease, and especially so, if we succeed in learning the direct cause, for treatment then be comes only a matter of detail. Let us review a little. W h a t is the difference between the hard and soft tissues of the body? T h e difference is the calcification of the one and the non calcification of the other. W h a t is cal cification? It is the impregnation, in a tissue, of calcium salts. W here do the calcium salts come from that produce this change? A t this point, a mistake is often made in considering the embry ology o f these tissues. T h e calcium salts with which a soft tissue, any formative
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T h e Journal of the American D en tal Association
tissue, is impregnated, must always come from organic sources. It is a law o f na ture that no animal organism can or ganize inorganic matter. From where, then, are the calcium salts with which the soft, formative tissue is impreg nated obtained ? T h e y must come from organic sources, and therefore all the hard tissues always have their origin from organic sources. T h e lime salts cannot be taken into the body for build ing into the teeth or bones: nature must elaborate its own from the pabulum, the food which the animal takes in and which is digested. T h e calcium taken in with the oxygen and whatever else goes to form these lime salts must be de rived from external sources and elab orated in the body. It is a law of the constructive system that it cannot take its own bricks ready-made, but must form and prepare them on the spot and build them in with the other tissues. T here are two ways in which the lime salts may be organized into the tissues. T h ey may be impregnated in a forma tive matrix, infiltrated therein, which is usually cartilaginous in character. T his formative matrix is the embryonal ma terial into which the lime salts may be incorporated according to the law of their development. O r they may be or ganized through a membrane. It is this latter way that shells are formed, by a membrane having in connection with it certain cells whose function it is to or ganize the calcium salts and build them into hard structures. I f the body cannot organize inorganic matter, there is no use trying to cure by administering lime salts a disease which is the result of a lack o f these salts. A cure can be effected only by stimulating the nutritive forces so that their func tion w ill be sufficiently active to do the work and elaborate the material which
is . to be built into tissues, and the vita mins may be the stimulating force that is needed; yet how often we see it attempted. Lime salts may be held in solution in water or any inorganic medium, and if for any reason they are precipitated through the neutralization o f the acid which holds them in solution, they will fall in an amorphous form , that is with out organization; simply dropping down as separate particles without regularity, without structure. T h a t is the condi tion obtained when the precipitation takes place in an inorganic material, or inorganic fluid. Let there be an organic fluid o f albuminous or gelatinous char acter, or other organic matter holding the lime salts in the same way, and when they are precipitated, it is in a very dif ferent form . T h ey change their whole character and method of their organiza tion, becoming lam inated; that is, they are super-imposed laminae o f the par tially organized lime salts, and cohesion binds them together. In the teeth, calcification is within a cartilaginous matrix and not from a membrane. In this matrix the lime salts w ill be held in solution. It is an or ganic solution, and as already stated, when the lime salts are precipitated, it is always in an organized form or struc ture. T h e differentiation and growth of the tooth structure I am not attempt ing to dwell on, but I am trying to show that the tooth substance is the result of crystallization o f lime salts, in the pres ence o f an albuminous medium. T here is no other way to obtain tooth structure than by crystallization, and the crystal lization o f an element or a compound is always the same for that particular sub stance or material. O ne w ill either get the crystal or nothing; there is no modi fication of it, when formed.
Fossum— M o ttle d Enamel A snow crystal or ice crystal, as an example, is a naturally produced angu lar solid of definite form , whether it is formed in South Dakota or F lorida; whether it is formed slow ly or rapidly; and when form ed, it is always the same in hardness, but may be of a different color or hue and macroscopic appear ance, this depending on the solution and formative influences or tissues. T h e beautiful crystals of ice and snow, in their myriad forms, are always hexag onal in outline. Y ou w ill get either the six sided crystal or nothing, regardless of whether it is zero or 40 degrees be low . I f for any reason the water can not get room to accommodate its crys tallization arrangement, even at 40 degrees below, it w ill not freeze, but w ill remain liquid. T here is no midway or modification o f this law o f nature: we either get the predetermined crystal lization of the substance or nothing, and if for any reason the crystal is altered, this must take place after it was formed. Immediately after the crystallization of a substance, then, w e must have a uniformity o f arrangement and hard ness. Alteration, or mutilation o f an ice crystal, is brought about by heat, and tooth substance, which is the crystalliza tion o f lime salts in an albuminous me dium, by an acid. A tooth, then, which is the result of a crystallization, must either be devel oped microscopically structurally, or else not developed at all, and this, according to the laws o f nature. Hence, there can be no part form ation; but we can and do get varied shapes and colors. T h e modification o f the tooth structure must take place after the tooth is formed, from some source foreign to its development, an outside influence. T h e enamel, being completed before eruption, must then be perfect in struc
1705
ture prior to its entry into the oral cavi ty, and being about 98 per cent mineral matter, absolutely dead and fully formed before eruption, it stands to reason that anything one eats or drinks, or does, must act directly on it, or be passive to it, and in this respect about all that could hap pen is a surface discoloration. T his elaboration shows the folly of attributing destruction o f the enamel, such as in mottled teeth, to hereditary causes, to prenatal influence, to malnu trition affecting formative disturbance and allied attributes. If, for any reason, there is still a doubt, the very fact that all teeth are not equally affected, with reference to the same enamel develop ment, throughout the dentition, must confirm it. Furthermore, could any de velopment or disturbance affect the one and not the other when they are equal dependents? I think not. In the process of elimination, then, we find that all teeth are created the same in hardness o f structure, and the same in the arrange ment o f its formative structure; in other words, as we should find the crowns o f all unerupted teeth practically the same in the foregoing respects, we must attribute the mottled tooth condition as something occurring from the eruptive period on. T h e composition o f a tooth chemi cally shows that the only thing which could cause the loss o f tooth structure must be an acid, as only acid substances can dissolve it. T h e enamel must play a passive part in the disease process, being cut off, at the completion o f its formation, from all sources of nutrition, besides being de prived o f all defensive mechanism against agencies which may threaten its destruction. A s it is nonvital, construc tive or retrogressive metamorphosis can not take place. A s it is an inert chemical
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T h e Journal of the American D en tal Association
substance, the acid destructive agencies are apart from the tooth itself. W ater, being neutral or alkaline, need not even be considered, notwithstanding the artesian water “ scare.” A s further proof of the fallacy o f this theory, I have a tooth which has been immersed in re newed artesian water weekly for about fifteen years, and, if anything, it looks much better than teeth I have had lay ing about in boxes for a similar period of time. T h e food theory must be aban doned because ( 1 ) the agency must be an acid; ( 2 ) all teeth w ou ld be affected; (3 ) all teeth w ould be affected on all surfaces, and ( 4 ) the phenomena would always be the same. Again, it would no doubt be more or less prevalent in all families o f a certain district and all members o f the same family. So we find that water and food, and malnutrition during the formative period, and the preeruptive factors must all be classified as nonconducive to the cause o f mottling of the enamel. Even oral prophylaxis must be a negative contributing factor, because only a few teeth may be affected, only one o f several children may be afflicted, and adults are never affected. Hence, w e must look elsewhere for the acid and acid cause or causes other than the tooth decay theory. T h e fact that enamel mottling takes place in an individual tooth while an adjacent one is free from mottling de fects proves it to be due to an acid secre tion from the gums. T h e fact that it affects one tooth and not another proves that it mottled the tooth at the gum line during the period o f eruption only. T h e fact that it did not affect all of the affected tooth shows that the acid des truction was of a certain duration only. T h e fact that all the teeth which were partly erupted were equally affected at the gum line at the time shows that the
acid was .general upon the gums in both jaws. T h e fact that the unerupted tooth, or even part o f the unerupted, affected tooth, is free from destructive agencies shows that the acid was upon the gum surface only and not within the gum tissue. T h e fact that the portion o f the erupted tooth extending beyond the gums and into the oral cavity remained unmottled shows that the acid was very attentive to the gum line only, and that the saliva may have been neutral or al kaline ; and as the deciduous teeth are af fected in a similar way, and no tooth mottling takes place after complete den tition, it is evident that the acid form ing process manifests itself during the tooth eruptive period only, and that the permanent m ottling disfigurement period must therefore be from 6 to 20 years of age, with the greatest damage period between the ages o f 6 and 14. I have on several occasions expressed an opinion as to the cause o f mottled teeth to some of my local professional brethren, and as their findings are in ac cord with mine, I shall endeavor to give good and sufficient proof o f my conclu sions. I hope that much good w ill come of this discussion, and that the immedi ate future w ill give us the necessary preventive measures. T h e normal mouth secretions are al kaline, but conditions can and do alter the situation. A ny disturbance o f the skin, throat, lungs, alimentary tract or any epithelial tissue area immediately causes acidosis. Acidosis is, according to research laboratories, one of the com monest conditions that are met with, re sulting from any type of malnutrition, as a result o f febrile disturbance; and this is manifested in the mouth, not through the salivary glands, but through what is known histologically as the mu cous follicles, which are situated in the
Fossum— M o ttle d Enamel gums, labiobuccally mostly, also on the inner side o f lips, opposite the necks of the teeth. T h ey are similar to the seba ceous glands o f the skin, both being em phatically excretory and not secretory. In a healthy mouth and skin, both are inactive and invisible to the naked eye; but just as night sweats are symptomatic of tuberculosis, so are the mucous follicles actively symptomatic, especially, o f dis eases accompanied by intermittent fever; in other words, the mucous follicles be come pathologically active during an epithelial disturbance. I have recognized hundreds of cases of intermittent fever by examining the teeth o f the patients, regardless o f the patient’s age, at the time of the examina tion, and the proof of my conclusions were usually verified by the case history. One is not only able to recognize the kind of disease which brought about the disturbance, but is able also to tell, with in a few months, how old the patient was, when he or she had the disease, and, furthermore, what other diseases he or she has had, and the patient’s age, within a few months, according to the case his tory. A nd not only that, but one cansoon tell about how long the disease lasted. F or instance, a girl, aged 20 years, who came to me, had some badly disfigured teeth, the condition being due to measles, chickenpox and some other condition which I was not so sure o f; but I was sure that the last mentioned condition took place between the years o f 11 and 13, and caused illness. W hen I so stated this to the patient, she told me that she had had the influenza or some similar illness during that period, because she was just able to be about for tw o years, commencing at the time that she was 11. I was able to tell ex actly how old she was when she had the other tw o diseases, and also what the
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diseases were, and my statements were verified by both the young woman and her mother. I f a patient who is around 30 years of age has more or less pronounced mottling of the teeth, and w e can say: “ Y ou had measles when you were 7 years old and scarlet fever when you were 11 years o ld ,” and then find that we are right, to within a few months. I believe that there is proof o f a relationship. I find that if I go over the different markings carefully, I can invariably tell, within a few months, when the patient was sick with the febrile disease, regard less o f how long standing and regard less of its severity. I have diagnosed many a mild case, which was confirmed by the mother, only after reflection. She perhaps recalled that the child stayed out of school, because he was not feeling well, and possibly because o f the mild ness of the condition, the child escaped being quarantined for measles or what ever the disease was. I f mottling o f the teeth is due to in termittent diseases, as I have tried to show, naturally one w ill find it among the whites, Indians, Negroes and all other races, in direct proportion to the race susceptibility toward these diseases and regional influence (endemic areas). T his explains all the confusion referred to at the beginning of this paper. W ith the history o f a case, including the age o f the child at the period of the disease, and an examination of the po sitions o f the defects on the tooth, the age w ill serve as an indication as to whether there has been any connection between the eruptive fever and the mot tling on the tooth. Further, if certain macroscopic peculiarities and colorings are always in evidence with relation to certain diseases, it is evident that the disease has brought them about. For
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T h e Journal o f the American D en tal Association
example, if pits have been caused by an eruptive fever, between the ages o f 7 and 8, they should occupy the circular labial area, about half-way or midway between the incisal edge and the gum o f the fully erupted upper central incisors; but if the disease occurred at the age o f 6 years, or 6 years and 3 months, the per manent teeth are unharmed, with the exception o f the occlusal surfaces, and a part of the gingival portion o f all the first permanent molars. In other words, the pitting takes place at the gum line only, of all erupted teeth, and the pit ting or mottling continues throughout the period o f the disease; therefore, if a tooth erupted a quarter of an inch dur ing this period, the m ottling would spread over the enamel surface to that extent only and naturally w ould affect all erupting teeth, deciduous or per manent. It must be evident that the enamel already above the gum line, as well as below, could not be affected.
formation is the cause o f tooth erosion in adult life, possibly through a siege of malnutrition brought on by auto intoxication, or something of a similar na ture. T his acid formation, which has nothing to do with bacterial agencies, is simply the result o f inefficient nutrition.
T h e general cause o f the devastating diseases of a febrile nature that impair or alter the nutritional condition of the blood supply leaves an effect on the gum tissue primarily, because o f the un usual capillary circulation. It is the long est capillary system in the body and has an unusual anastomosis as w e ll; hence anything affecting the body nutrition leaves its imprint in this capillary circula tion first. Defects in nutritional condi tions, leaving their imprint on the gums, vary in their macroscopic appearance ac cording to the nature of the disease, and if the disease lasts, a general body acidosis sooner or later makes its appearance. In the mouth, this acidity comes through the
N o w how can we tell whether the patient has had measles, typhoid fever or a bad case o f tonsilitis, etc. ? This can be detected by the macroscopic enamel dissolution, combined with its pigmentation.
M alnutrition means suboxidation, and this manifestation is greatest in the capillary circulation o f the gums. Sub oxidation o f course, accompanied by the retention o f carbon dioxid in the cells, makes for acid reaction. Cell-waste is acid in reaction. W e find, then, that accompanying an intermittent disease we have destruction, or mottling o f the enamel, at the gum line, opposite the ori fices o f the mucus glands, and this affects all erupting teeth alike, at that time, regardless o f whether they are de ciduous or permanent, and whether the possessor is white or black, or whether its owner lives in the region o f the ar tesian basin or not.
mucous follicles o f the gums, which are found quite freely therein along the line of tooth eruption, buccolabially. T his acid has a decalcifying effect on
I have never been able to determine why the gum acid causes a pit in measles and leaves a yellow streak in whooping cough or a partially opaque streaked area in tonsilitis. N o doubt, the gumacid is altered by bacteria o f a chromogenic and a nonchromogenic nature, which first changes the physical nature o f the acid, allowing it to remain in the form o f a droplet, on the one hand, and, on the other hand permitting it to flow freely around the tooth. These bacteria leave the tooth enamel bleached or show ing varying shades o f discoloration, usually o f a yellowish hue, in the enamel
the enamel and I believe that this acid
dissolved base through the proteins or
Fossum— M o ttle d Enamel organic matrix, largely by pyogenic or ganisms, giving o ff end-products as indol, a blue crystalline by-product, or skatol, another colored crystalline by-product. It seems that, in gum acidity, the readily diffusible and alkaline salts, so dium phosphate, o f the cells, and the ex cess carbon dioxid, existing as carbonic acid, forms on reaction an acid (acid sodium phosphate), and, in all probabil ity this is the acid which attacks the cal cium salts of the enamel. A t any rate, it has been demonstrated by Brubaker that a tooth immersed for a week in a solution of acid sodium phosphate, and daily sub jected to brushing, did at the end of a week produce spots and grooves. Treatment w ould seem to be indi cated between 6 and 18 years of age, with particular attention between the years o f 6 and 12. T h e remedy, aside from preventing the disease, would seem to be local and general in its scope; lo cally, for the neutralization of the gumacid, and by tooth protection, such as a tooth acid resisting varnish, and the gen eral treatment, aside from the regular prescribed course by the physician, should be an immediate attempt to check gum acidosis. I am not prepared to state how this should be accomplished but I do believe that it should be foremost in the remedial effort. I firmly believe that electrotherapeu tics w ill help solve the problem, because the body fluids are largely composed of water, and therefore contain oxygen and hydrogen; and, in the process o f electro lysis, the form er is electronegative and collects around the positive pole, and the latter toward the negative pole, and it is this affinity that gives the two poles an exactly opposite therapeutic effect. Oxygen is an acid m aker; consequently, the tissues adjacent to the positive pole are rendered acid in reaction, and tissue
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destructive in character, yet sedative in nature. Hydrogen is an alkali maker, and therefore collects around the nega tive pole, and the tissues are rendered alkaline, in the immediate vicinity. T his creates a condition o f overstimulation, or irritation; but one can see the possi bilities, as a remedial adjunct. SUMMARY
T o o th mottling is due entirely to an acid produced by the mucous follicles, which are quite numerous from the cen ter o f the gum ridge line, labiobuccally, but less numerous lingually. Further, this acid is liberated at the gum margin, in modified form, according to the indi rect cause, which seems to be a disease of the intermittent-fever type, a throat and lung affection or an alimentary dis turbance, such as typhoid fever; in other words, any disturbance of the mucous membrane. T his acid formation, which seems to take place regardless o f the severity of the disease continues throughout the period o f disturbance. T h e affected sur face o f a tooth is in direct proportion to the duration of the disease, and the progress of its eruption within that space o f time. It affects all teeth in the act o f eruption from visibility on, and this regardless of whether the teeth are de ciduous or permanent, whether its owner is white or black and whether the person was born in an endemic area or not. T h e fact that a tooth has been af fected by one febrile disease does not pre vent it from being again affected by some other disease, o f this nature; there fore, we may find one tooth giving the appearance of passing through several disease periods, while an adjacent one may reveal a different number, this de pending upon whether or not it was ex-
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T h e Journal of the American D en tal Association
posed to conditions in the oral cavity, for the same length of time or not. Roughly speaking, measles displays a band of pits, chickenpox, a pale yellow band, whoopingcough, a darker yellow band, typhoid fever, a very dark yel low band, tonsillitis and sore throat, a faint broken white ban d; influenza, a less broken and a more decided white band; pneumonia, a plain white band; and so on. Remember this: A disease of a week’s duration may leave only a very narrow line because the tooth did not erupt very much during that tim e; whereas, if a patient had more or less sore throat and tonsillitis, from 7 years of age on, say to 12, the whole o f the upper central incisor would be more or less covered on its labial surface, with white parallel streaks, more or less broken. I f the child were (y1 /^ years of age, and if this child’s teeth were erupt ing at the accepted standard, normal time, and he had an average case of measles and then came to you when he
was 20, you w ould find, all o f the sur face o f the first permanent molars, on the occlusal and about one-sixteenth to one-quarter inch toward the gingival margin, badly pitted, as if some volcanic disturbance had taken place, and natur ally the low er teeth would be a little more affected, because the eruption of the low er precedes that o f the upper teeth. A typhoid fever band is usually about a quarter o f an inch wide, owing to the length of its duration, which al lows more time for the tooth to eru p t; but o f course all typhoid cases do not cause yellow banding o f the teeth, as the fever and the eruption must be in unison. I hope that good may develop from my efforts and that further investiga tion may be stimulated along this line, as I believe that the remedy is near at hand. W e may perhaps cooperate to advantage with the general practitioner and also with the board o f health. W e lls B lock.
TH E PARTIAL DENTURE AS RELATED TO FULL DENTURE CONSTRUCTION* By CLYDE H. SCHUYLER, D.D.S., New York City H E preservation of the teeth and the supporting structures should be the first precept o f every prac ticing dentist; yet it appears that many dentists have considered the partial restoration as merely a stepping-stone to the full restoration. T h e great value of functional efficiency, esthetics and com fort, and lastly, the preservation of the
T
alveolar ridges have not been sufficiently realized. Fortunately, we are now approaching an era when greater interest and thought are being directed toward prevention in all branches of dental science. Such men as Box, Stillman, M cC a ll and Bricker1 have taught us the signifi cance of functional occlusion to the
*P resented as a clin ic at the Sixty-N inth A n n u al Session o f the A m e rica n D en tal A s sociation, D e tro it, M ich ., Oct. 27, 1927.
1. B ricker, F. A . : D ia g n o sis and C o r re c tion o f T ra u m a tic O cclu sion , J .A .D .A ., 11: 697 (A u g .) 1924.
Jour. A . D. A., Sept., 1928
Fossum— M o ttled Enamel be p laced that w ill perm an ently restore fu n c tion and tooth fo r m throughou t the p e rio d o f their use, w ith ou t e n d a n g e rin g the p u lp ? H a v e these men m astered the tech nic o f p ro tecting u n occu pied spaces in thé d ecid u ou s arch w h ich h ave been le ft through the p re m ature loss o f d ecid u ou s m olars, thus p la c in g a check on m esial and distal m igra tion o f p erm anent teeth, as w e ll as on m any other
ill-effects that fo llo w the prem ature loss o f d ecid u ou s m o la r s ?
I f this has been a ccom
p lished in the p riv ate p ra ctice o f these men, they h a v e h elp ed to fill a y a w n in g g a p in dental serv ice and, in the process o f their serv in g , h ave done m ore f o r the preven tion o f m a locclu sion than m a n y orth odon tists ac com p lish in its correction .
MOTTLED ENAMEL By CARL FOSSUM, D.D.S., Aberdeen, S. D. «
O T T L E D enamel in its various macroscopic forms and tints no doubt antedates history, yet little progress has been made towards com bating this annoying condition up to the present time. I wish to present some new ideas for consideration, as a result of years of ob servation in this community, known as an endemic area. I trust that they may in a measure stimulate further investi gation dealing with this sad state o f af fairs. M y ideas may differ somewhat from the accepted general line of thought, yet I believe that I am justified in making the follow ing statements. In choosing a subject for considera tion, we like to be guided, to a consider able extent, by requests that come to us from our patients, and judging from the number received relative to mottled teeth, w e may rest assured that w e as dentists should devote considerable time and study and prepare ourselves to meet this deplorable situation. T his disease known as mottled enam el, brown stain, or streaking of the enamel, of both deciduous and perma nent teeth, particularly permanent, is one
M
Jour. A. D. A., Sept., ipz8
which, so far, exists in defiance of either the dental or the medical profession. M an y years ago, when I began prac ticing, I was annoyed in finding so many patients with pitted enamel, and being unable to meet the situation, I naturally wondered why I had not received in structions at college dealing with this condition. I remembered studying the socalled Hutchinson teeth, but this did not explain the situation at all. In my dilem ma, I therefore sought all available in formation through current literature, both dental and medical, and also through the aid o f research laboratories, and the scarcity o f information easily explained why the college offered so little on this subject. I thought that if I could find its cause, I might produce a remedy, but it seemed that this was not to be. In 1910, while in charge of the program o f the dental clinic here, I made an attempt to get papers on this matter, by both den tists and physicians. T h e subject was, “ T h e Deleterious Effects o f Skin D is eases upon the Development o f T eeth D uring the P friod o f Eruption.” T h e papers were good, but the subject as signed was evaded because there seemed
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to be little to say aside from its appear ance. Being forcibly impressed with the fact that little was known relative to this disease and that my findings, as sub stantiated by case histories, were new, I naturally took a keener interest in the subject, and the more I investigated, or rather observed, the facts at my dis posal, the more I was certain that I was right. M any years ago, our Society enter tained a prominent dentist from C olo rado who presented this subject, and I believe that he attributed these condi tions to malnutrition, artesian water and heredity, but principally to artesian water. Years ago, Hutchinson first called attention to malformation of the anterior teeth, particularly the incisors, and ascribed this to congenital syphilis, or hereditary causes. H e says, “ It has been noted that not all children who are victims of hereditary syphilis present these dental appearances, and again, ap pearances said to be identical with them are observed in children said not to be syphilitic.” It seem eda little confusing, but threw some light on the subject. Located as we are in the heart o f a so-called endemic area, everything gets its share of blame, from artesian water to lack of moisture in the air, and as a consequence, much confusion exists. One feels that something should be done; for how often we see an otherwise beau tiful set of teeth marred by this mottled discoloration and the life o f the indi vidual seriously handicapped thereby. M an y authors claim that this disease is prevalent in certain regions more than others, notably in Texas, Virginia, South and North Dakota, California and O re gon, also in the Bahamas and Cape Verde Islands, and in many other places as well. Sometimes, this disease appears
under a different name, such as brown or black stained teeth, notably in Italy and Asiatic countries, but the endemic areas are the same and fully as impor tant. Black, M cK a y and others who have made investigations have found that a percentage as high as 87.5 per cent of the inhabitants who are native born are affected in these areas. Bampton, in 1914, described tw o cases o f brown pig ment and pitted teeth and said that the condition was seen in the deciduous and the permanent dentition and that these cases were hereditary. (T h is seems to be a positive statement.) Black, who be gan investigation in 1908, states that the dark brown spots or streaks usually oc cur in pigmentation or mottling of the incisors. H e arrived at the conclusion that there was a failure o f normally oc curring cementum, between the enamel rods in the outer one-fourth to onethird o f the surface o f the enamel and the coloring matter takes the space of the normal cementing substance between the enamel rods. H e further states that the more o f this brown stain there is, the darker w ill be the color and the weaker the teeth; that Nasmyth’s mem brane is always normal, and the prob able result is failure o f proper develop ment of the tissues. D ick thinks that the brown staining alluded to by Black is due to malnutrition and that, in an ex amination o f school children, he found 40 per cent to be affected. Black found the brown pigment to be coincidental with freckles, but he asserted that this mottled condition was due to dystrophia or faulty nutrition. Grieves thinks that it is due to thyroid disturbances or at least to some defect in endocrine secretion. M c Kay, who has made the most thorough and extensive investigation of the dis ease, visiting nearly every affected area
Fossum— M o ttle d Enamel in the United States, asserts that the damage is wrought by some influence which acts either in an inhibitory or in a destructive way on the enamel, during or immediately after the building period, and that the condition is established prior to eruption. T w o prominent Italian dentists who have written on the subject o f mottled teeth come to the conclusion that there
U p per central in cisor (f r o m patient o v e r 40 years o f a g e ), sh o w in g the effects o f m easles at 7J4 y e a rs and ch icken p ox at 9 y e a r s; fin din gs w h ich w e re confirm ed by the patient. T h e w h ite effect o f the enam el is not natural but the result o f the e n g r a v in g process. E xcept f o r the enam el blem ishes, the tooth is perfect.
is a minimum content of normal salt in general and o f the salts of calcium in particular. T his minimal content of cal cium salts is the cause o f the condition which produces mottled teeth. M cK ay says further that whatever the cause is— if it is the water supply, which ap pears very probable-— it has not as yet been discovered. Gies thinks the brown coloring may come from the blood, dur ing the enamel-forming period. M any of our local dentists have attrib uted the mottling o f the teeth to our artesian water, to malnutrition and even to heredity. T h e schoolnurse, who fo l lows a similar line of thought, from con tact with the profession, informs the school children and their parents o f this theory.
1703
T h e situation is confusing and unsat isfactory, and the causes are numerous and varied, with no remedy available at this time. Various theories have been submitted in explanation o f mottled teeth. T h e diet has been given as the cause, but malnutrition and the water used, especially if artesian water, seem to be the chief enemy. Again, some say that the condition may be due to a dis turbance during the formative period. A ll these and more are suggested; but one thing we know : it affects practi cally all races alike, for I have seen it in the mouths o f Indians and Negroes, as well as in the white race. I am in no way associated with a re search laboratory, but I have access to them as has any one, and while I have nothing original to offer, I do find, after carefully reviewing the situation and elaborating on the findings o f others, that I can, with an encouraging degree of success, prove my conclusions with the facts at hand, and it is with this posi tive diagnostic sign and other signs at our disposal that I am able to determine the nature and apparent cause o f mottled teeth. I f we know the etiology positively, we may be able to combat the disease, and especially so, if we succeed in learning the direct cause, for treatment then be comes only a matter of detail. Let us review a little. W h a t is the difference between the hard and soft tissues of the body? T h e difference is the calcification of the one and the non calcification of the other. W h a t is cal cification? It is the impregnation, in a tissue, of calcium salts. W here do the calcium salts come from that produce this change? A t this point, a mistake is often made in considering the embry ology o f these tissues. T h e calcium salts with which a soft tissue, any formative
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tissue, is impregnated, must always come from organic sources. It is a law o f na ture that no animal organism can or ganize inorganic matter. From where, then, are the calcium salts with which the soft, formative tissue is impreg nated obtained ? T h e y must come from organic sources, and therefore all the hard tissues always have their origin from organic sources. T h e lime salts cannot be taken into the body for build ing into the teeth or bones: nature must elaborate its own from the pabulum, the food which the animal takes in and which is digested. T h e calcium taken in with the oxygen and whatever else goes to form these lime salts must be de rived from external sources and elab orated in the body. It is a law of the constructive system that it cannot take its own bricks ready-made, but must form and prepare them on the spot and build them in with the other tissues. T here are two ways in which the lime salts may be organized into the tissues. T h ey may be impregnated in a forma tive matrix, infiltrated therein, which is usually cartilaginous in character. T his formative matrix is the embryonal ma terial into which the lime salts may be incorporated according to the law of their development. O r they may be or ganized through a membrane. It is this latter way that shells are formed, by a membrane having in connection with it certain cells whose function it is to or ganize the calcium salts and build them into hard structures. I f the body cannot organize inorganic matter, there is no use trying to cure by administering lime salts a disease which is the result of a lack o f these salts. A cure can be effected only by stimulating the nutritive forces so that their func tion w ill be sufficiently active to do the work and elaborate the material which
is . to be built into tissues, and the vita mins may be the stimulating force that is needed; yet how often we see it attempted. Lime salts may be held in solution in water or any inorganic medium, and if for any reason they are precipitated through the neutralization o f the acid which holds them in solution, they will fall in an amorphous form , that is with out organization; simply dropping down as separate particles without regularity, without structure. T h a t is the condi tion obtained when the precipitation takes place in an inorganic material, or inorganic fluid. Let there be an organic fluid o f albuminous or gelatinous char acter, or other organic matter holding the lime salts in the same way, and when they are precipitated, it is in a very dif ferent form . T h ey change their whole character and method of their organiza tion, becoming lam inated; that is, they are super-imposed laminae o f the par tially organized lime salts, and cohesion binds them together. In the teeth, calcification is within a cartilaginous matrix and not from a membrane. In this matrix the lime salts w ill be held in solution. It is an or ganic solution, and as already stated, when the lime salts are precipitated, it is always in an organized form or struc ture. T h e differentiation and growth of the tooth structure I am not attempt ing to dwell on, but I am trying to show that the tooth substance is the result of crystallization o f lime salts, in the pres ence o f an albuminous medium. T here is no other way to obtain tooth structure than by crystallization, and the crystal lization o f an element or a compound is always the same for that particular sub stance or material. O ne w ill either get the crystal or nothing; there is no modi fication of it, when formed.
Fossum— M o ttle d Enamel A snow crystal or ice crystal, as an example, is a naturally produced angu lar solid of definite form , whether it is formed in South Dakota or F lorida; whether it is formed slow ly or rapidly; and when form ed, it is always the same in hardness, but may be of a different color or hue and macroscopic appear ance, this depending on the solution and formative influences or tissues. T h e beautiful crystals of ice and snow, in their myriad forms, are always hexag onal in outline. Y ou w ill get either the six sided crystal or nothing, regardless of whether it is zero or 40 degrees be low . I f for any reason the water can not get room to accommodate its crys tallization arrangement, even at 40 degrees below, it w ill not freeze, but w ill remain liquid. T here is no midway or modification o f this law o f nature: we either get the predetermined crystal lization of the substance or nothing, and if for any reason the crystal is altered, this must take place after it was formed. Immediately after the crystallization of a substance, then, w e must have a uniformity o f arrangement and hard ness. Alteration, or mutilation o f an ice crystal, is brought about by heat, and tooth substance, which is the crystalliza tion o f lime salts in an albuminous me dium, by an acid. A tooth, then, which is the result of a crystallization, must either be devel oped microscopically structurally, or else not developed at all, and this, according to the laws o f nature. Hence, there can be no part form ation; but we can and do get varied shapes and colors. T h e modification o f the tooth structure must take place after the tooth is formed, from some source foreign to its development, an outside influence. T h e enamel, being completed before eruption, must then be perfect in struc
1705
ture prior to its entry into the oral cavi ty, and being about 98 per cent mineral matter, absolutely dead and fully formed before eruption, it stands to reason that anything one eats or drinks, or does, must act directly on it, or be passive to it, and in this respect about all that could hap pen is a surface discoloration. T his elaboration shows the folly of attributing destruction o f the enamel, such as in mottled teeth, to hereditary causes, to prenatal influence, to malnu trition affecting formative disturbance and allied attributes. If, for any reason, there is still a doubt, the very fact that all teeth are not equally affected, with reference to the same enamel develop ment, throughout the dentition, must confirm it. Furthermore, could any de velopment or disturbance affect the one and not the other when they are equal dependents? I think not. In the process of elimination, then, we find that all teeth are created the same in hardness o f structure, and the same in the arrange ment o f its formative structure; in other words, as we should find the crowns o f all unerupted teeth practically the same in the foregoing respects, we must attribute the mottled tooth condition as something occurring from the eruptive period on. T h e composition o f a tooth chemi cally shows that the only thing which could cause the loss o f tooth structure must be an acid, as only acid substances can dissolve it. T h e enamel must play a passive part in the disease process, being cut off, at the completion o f its formation, from all sources of nutrition, besides being de prived o f all defensive mechanism against agencies which may threaten its destruction. A s it is nonvital, construc tive or retrogressive metamorphosis can not take place. A s it is an inert chemical
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T h e Journal of the American D en tal Association
substance, the acid destructive agencies are apart from the tooth itself. W ater, being neutral or alkaline, need not even be considered, notwithstanding the artesian water “ scare.” A s further proof of the fallacy o f this theory, I have a tooth which has been immersed in re newed artesian water weekly for about fifteen years, and, if anything, it looks much better than teeth I have had lay ing about in boxes for a similar period of time. T h e food theory must be aban doned because ( 1 ) the agency must be an acid; ( 2 ) all teeth w ou ld be affected; (3 ) all teeth w ould be affected on all surfaces, and ( 4 ) the phenomena would always be the same. Again, it would no doubt be more or less prevalent in all families o f a certain district and all members o f the same family. So we find that water and food, and malnutrition during the formative period, and the preeruptive factors must all be classified as nonconducive to the cause o f mottling of the enamel. Even oral prophylaxis must be a negative contributing factor, because only a few teeth may be affected, only one o f several children may be afflicted, and adults are never affected. Hence, w e must look elsewhere for the acid and acid cause or causes other than the tooth decay theory. T h e fact that enamel mottling takes place in an individual tooth while an adjacent one is free from mottling de fects proves it to be due to an acid secre tion from the gums. T h e fact that it affects one tooth and not another proves that it mottled the tooth at the gum line during the period o f eruption only. T h e fact that it did not affect all of the affected tooth shows that the acid des truction was of a certain duration only. T h e fact that all the teeth which were partly erupted were equally affected at the gum line at the time shows that the
acid was .general upon the gums in both jaws. T h e fact that the unerupted tooth, or even part o f the unerupted, affected tooth, is free from destructive agencies shows that the acid was upon the gum surface only and not within the gum tissue. T h e fact that the portion o f the erupted tooth extending beyond the gums and into the oral cavity remained unmottled shows that the acid was very attentive to the gum line only, and that the saliva may have been neutral or al kaline ; and as the deciduous teeth are af fected in a similar way, and no tooth mottling takes place after complete den tition, it is evident that the acid form ing process manifests itself during the tooth eruptive period only, and that the permanent m ottling disfigurement period must therefore be from 6 to 20 years of age, with the greatest damage period between the ages o f 6 and 14. I have on several occasions expressed an opinion as to the cause o f mottled teeth to some of my local professional brethren, and as their findings are in ac cord with mine, I shall endeavor to give good and sufficient proof o f my conclu sions. I hope that much good w ill come of this discussion, and that the immedi ate future w ill give us the necessary preventive measures. T h e normal mouth secretions are al kaline, but conditions can and do alter the situation. A ny disturbance o f the skin, throat, lungs, alimentary tract or any epithelial tissue area immediately causes acidosis. Acidosis is, according to research laboratories, one of the com monest conditions that are met with, re sulting from any type of malnutrition, as a result o f febrile disturbance; and this is manifested in the mouth, not through the salivary glands, but through what is known histologically as the mu cous follicles, which are situated in the
Fossum— M o ttle d Enamel gums, labiobuccally mostly, also on the inner side o f lips, opposite the necks of the teeth. T h ey are similar to the seba ceous glands o f the skin, both being em phatically excretory and not secretory. In a healthy mouth and skin, both are inactive and invisible to the naked eye; but just as night sweats are symptomatic of tuberculosis, so are the mucous follicles actively symptomatic, especially, o f dis eases accompanied by intermittent fever; in other words, the mucous follicles be come pathologically active during an epithelial disturbance. I have recognized hundreds of cases of intermittent fever by examining the teeth o f the patients, regardless o f the patient’s age, at the time of the examina tion, and the proof of my conclusions were usually verified by the case history. One is not only able to recognize the kind of disease which brought about the disturbance, but is able also to tell, with in a few months, how old the patient was, when he or she had the disease, and, furthermore, what other diseases he or she has had, and the patient’s age, within a few months, according to the case his tory. A nd not only that, but one cansoon tell about how long the disease lasted. F or instance, a girl, aged 20 years, who came to me, had some badly disfigured teeth, the condition being due to measles, chickenpox and some other condition which I was not so sure o f; but I was sure that the last mentioned condition took place between the years o f 11 and 13, and caused illness. W hen I so stated this to the patient, she told me that she had had the influenza or some similar illness during that period, because she was just able to be about for tw o years, commencing at the time that she was 11. I was able to tell ex actly how old she was when she had the other tw o diseases, and also what the
1707
diseases were, and my statements were verified by both the young woman and her mother. I f a patient who is around 30 years of age has more or less pronounced mottling of the teeth, and w e can say: “ Y ou had measles when you were 7 years old and scarlet fever when you were 11 years o ld ,” and then find that we are right, to within a few months. I believe that there is proof o f a relationship. I find that if I go over the different markings carefully, I can invariably tell, within a few months, when the patient was sick with the febrile disease, regard less o f how long standing and regard less of its severity. I have diagnosed many a mild case, which was confirmed by the mother, only after reflection. She perhaps recalled that the child stayed out of school, because he was not feeling well, and possibly because o f the mild ness of the condition, the child escaped being quarantined for measles or what ever the disease was. I f mottling o f the teeth is due to in termittent diseases, as I have tried to show, naturally one w ill find it among the whites, Indians, Negroes and all other races, in direct proportion to the race susceptibility toward these diseases and regional influence (endemic areas). T his explains all the confusion referred to at the beginning of this paper. W ith the history o f a case, including the age o f the child at the period of the disease, and an examination of the po sitions o f the defects on the tooth, the age w ill serve as an indication as to whether there has been any connection between the eruptive fever and the mot tling on the tooth. Further, if certain macroscopic peculiarities and colorings are always in evidence with relation to certain diseases, it is evident that the disease has brought them about. For
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T h e Journal o f the American D en tal Association
example, if pits have been caused by an eruptive fever, between the ages o f 7 and 8, they should occupy the circular labial area, about half-way or midway between the incisal edge and the gum o f the fully erupted upper central incisors; but if the disease occurred at the age o f 6 years, or 6 years and 3 months, the per manent teeth are unharmed, with the exception o f the occlusal surfaces, and a part of the gingival portion o f all the first permanent molars. In other words, the pitting takes place at the gum line only, of all erupted teeth, and the pit ting or mottling continues throughout the period o f the disease; therefore, if a tooth erupted a quarter of an inch dur ing this period, the m ottling would spread over the enamel surface to that extent only and naturally w ould affect all erupting teeth, deciduous or per manent. It must be evident that the enamel already above the gum line, as well as below, could not be affected.
formation is the cause o f tooth erosion in adult life, possibly through a siege of malnutrition brought on by auto intoxication, or something of a similar na ture. T his acid formation, which has nothing to do with bacterial agencies, is simply the result o f inefficient nutrition.
T h e general cause o f the devastating diseases of a febrile nature that impair or alter the nutritional condition of the blood supply leaves an effect on the gum tissue primarily, because o f the un usual capillary circulation. It is the long est capillary system in the body and has an unusual anastomosis as w e ll; hence anything affecting the body nutrition leaves its imprint in this capillary circula tion first. Defects in nutritional condi tions, leaving their imprint on the gums, vary in their macroscopic appearance ac cording to the nature of the disease, and if the disease lasts, a general body acidosis sooner or later makes its appearance. In the mouth, this acidity comes through the
N o w how can we tell whether the patient has had measles, typhoid fever or a bad case o f tonsilitis, etc. ? This can be detected by the macroscopic enamel dissolution, combined with its pigmentation.
M alnutrition means suboxidation, and this manifestation is greatest in the capillary circulation o f the gums. Sub oxidation o f course, accompanied by the retention o f carbon dioxid in the cells, makes for acid reaction. Cell-waste is acid in reaction. W e find, then, that accompanying an intermittent disease we have destruction, or mottling o f the enamel, at the gum line, opposite the ori fices o f the mucus glands, and this affects all erupting teeth alike, at that time, regardless o f whether they are de ciduous or permanent, and whether the possessor is white or black, or whether its owner lives in the region o f the ar tesian basin or not.
mucous follicles o f the gums, which are found quite freely therein along the line of tooth eruption, buccolabially. T his acid has a decalcifying effect on
I have never been able to determine why the gum acid causes a pit in measles and leaves a yellow streak in whooping cough or a partially opaque streaked area in tonsilitis. N o doubt, the gumacid is altered by bacteria o f a chromogenic and a nonchromogenic nature, which first changes the physical nature o f the acid, allowing it to remain in the form o f a droplet, on the one hand, and, on the other hand permitting it to flow freely around the tooth. These bacteria leave the tooth enamel bleached or show ing varying shades o f discoloration, usually o f a yellowish hue, in the enamel
the enamel and I believe that this acid
dissolved base through the proteins or
Fossum— M o ttle d Enamel organic matrix, largely by pyogenic or ganisms, giving o ff end-products as indol, a blue crystalline by-product, or skatol, another colored crystalline by-product. It seems that, in gum acidity, the readily diffusible and alkaline salts, so dium phosphate, o f the cells, and the ex cess carbon dioxid, existing as carbonic acid, forms on reaction an acid (acid sodium phosphate), and, in all probabil ity this is the acid which attacks the cal cium salts of the enamel. A t any rate, it has been demonstrated by Brubaker that a tooth immersed for a week in a solution of acid sodium phosphate, and daily sub jected to brushing, did at the end of a week produce spots and grooves. Treatment w ould seem to be indi cated between 6 and 18 years of age, with particular attention between the years o f 6 and 12. T h e remedy, aside from preventing the disease, would seem to be local and general in its scope; lo cally, for the neutralization of the gumacid, and by tooth protection, such as a tooth acid resisting varnish, and the gen eral treatment, aside from the regular prescribed course by the physician, should be an immediate attempt to check gum acidosis. I am not prepared to state how this should be accomplished but I do believe that it should be foremost in the remedial effort. I firmly believe that electrotherapeu tics w ill help solve the problem, because the body fluids are largely composed of water, and therefore contain oxygen and hydrogen; and, in the process o f electro lysis, the form er is electronegative and collects around the positive pole, and the latter toward the negative pole, and it is this affinity that gives the two poles an exactly opposite therapeutic effect. Oxygen is an acid m aker; consequently, the tissues adjacent to the positive pole are rendered acid in reaction, and tissue
1709
destructive in character, yet sedative in nature. Hydrogen is an alkali maker, and therefore collects around the nega tive pole, and the tissues are rendered alkaline, in the immediate vicinity. T his creates a condition o f overstimulation, or irritation; but one can see the possi bilities, as a remedial adjunct. SUMMARY
T o o th mottling is due entirely to an acid produced by the mucous follicles, which are quite numerous from the cen ter o f the gum ridge line, labiobuccally, but less numerous lingually. Further, this acid is liberated at the gum margin, in modified form, according to the indi rect cause, which seems to be a disease of the intermittent-fever type, a throat and lung affection or an alimentary dis turbance, such as typhoid fever; in other words, any disturbance of the mucous membrane. T his acid formation, which seems to take place regardless o f the severity of the disease continues throughout the period o f disturbance. T h e affected sur face o f a tooth is in direct proportion to the duration of the disease, and the progress of its eruption within that space o f time. It affects all teeth in the act o f eruption from visibility on, and this regardless of whether the teeth are de ciduous or permanent, whether its owner is white or black and whether the person was born in an endemic area or not. T h e fact that a tooth has been af fected by one febrile disease does not pre vent it from being again affected by some other disease, o f this nature; there fore, we may find one tooth giving the appearance of passing through several disease periods, while an adjacent one may reveal a different number, this de pending upon whether or not it was ex-
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T h e Journal of the American D en tal Association
posed to conditions in the oral cavity, for the same length of time or not. Roughly speaking, measles displays a band of pits, chickenpox, a pale yellow band, whoopingcough, a darker yellow band, typhoid fever, a very dark yel low band, tonsillitis and sore throat, a faint broken white ban d; influenza, a less broken and a more decided white band; pneumonia, a plain white band; and so on. Remember this: A disease of a week’s duration may leave only a very narrow line because the tooth did not erupt very much during that tim e; whereas, if a patient had more or less sore throat and tonsillitis, from 7 years of age on, say to 12, the whole o f the upper central incisor would be more or less covered on its labial surface, with white parallel streaks, more or less broken. I f the child were (y1 /^ years of age, and if this child’s teeth were erupt ing at the accepted standard, normal time, and he had an average case of measles and then came to you when he
was 20, you w ould find, all o f the sur face o f the first permanent molars, on the occlusal and about one-sixteenth to one-quarter inch toward the gingival margin, badly pitted, as if some volcanic disturbance had taken place, and natur ally the low er teeth would be a little more affected, because the eruption of the low er precedes that o f the upper teeth. A typhoid fever band is usually about a quarter o f an inch wide, owing to the length of its duration, which al lows more time for the tooth to eru p t; but o f course all typhoid cases do not cause yellow banding o f the teeth, as the fever and the eruption must be in unison. I hope that good may develop from my efforts and that further investiga tion may be stimulated along this line, as I believe that the remedy is near at hand. W e may perhaps cooperate to advantage with the general practitioner and also with the board o f health. W e lls B lock.
TH E PARTIAL DENTURE AS RELATED TO FULL DENTURE CONSTRUCTION* By CLYDE H. SCHUYLER, D.D.S., New York City H E preservation of the teeth and the supporting structures should be the first precept o f every prac ticing dentist; yet it appears that many dentists have considered the partial restoration as merely a stepping-stone to the full restoration. T h e great value of functional efficiency, esthetics and com fort, and lastly, the preservation of the
T
alveolar ridges have not been sufficiently realized. Fortunately, we are now approaching an era when greater interest and thought are being directed toward prevention in all branches of dental science. Such men as Box, Stillman, M cC a ll and Bricker1 have taught us the signifi cance of functional occlusion to the
*P resented as a clin ic at the Sixty-N inth A n n u al Session o f the A m e rica n D en tal A s sociation, D e tro it, M ich ., Oct. 27, 1927.
1. B ricker, F. A . : D ia g n o sis and C o r re c tion o f T ra u m a tic O cclu sion , J .A .D .A ., 11: 697 (A u g .) 1924.
Jour. A . D. A., Sept., 1928