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Osteomyelitis of the Jaws*
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records. These records are checked, and corrected if necessary. W ith the aid of very thin carbon paper, any existing high spots are located and removed with small mounted stones. T h e operator should locate and eliminate errors in one relation at a time, beginning with centric relation and follow ing with any necessary correction in the lateral relations. T h e teeth are then milled with fine abrasive paste to perfect the occlusion, and the dentures placed in the mouth and checked for accuracy o f relationship. Subsequent checking of the various relationships w ill provide the maximum of denture com fort and efficiency.
C O N C L U S IO N
A fter careful observation and inquiry, I have found that those in our profession w ho are considered leaders and authori ties on full denture problems are not necessarily dentists who limit their prac tice to fu ll denture construction but, in general, are individuals who assume the responsibility of acquainting themselves with the best literature and ideas on the subject and apply precision and exactness to every detail involved in denture con struction. T his is my answer to the ques tion : H o w can the general practitioner be assisted in the solution of his full denture problems? 209 East T w en ty-T h ird Street.
OSTEOMYELITIS OF THE JAWS* ALBERT D. DAVIS, D.D.S., B.Sc., M.D., San Francisco, Cal.i. , as defined by M cC allum , is “ a destructive proc ess affecting the periosteum, the cortex and the m arrow .” Disagreement by various authors as to the correct term to be applied to that type o f infection resulting in bony dissolution or destruc tion of the maxilla or mandible has led to a thorough investigation o f the word and its true meaning. Particular em phasis has been placed on the w ord “ myelin,” which is used as the body of the word osteo-myel-itis, with the suffix and the prefix well understood (if such nomenclature is applicable). As myelin is not a true synonym for bone marrow, but refers, according to W hiting, and s t e o m y e l it is
O
*Read before the Oakland Dental Club, M ay 31, 1928. *From the department o f Plastic Surgery, Leland Stanford M edical School. Jour. A . D . A ., August, IÇ2Ç
also to Stimson, to any 'soft part on which the integrity o f the bone wholly depends, or to all the soft parts which contribute to the nourishment o f the bones, this disagreement is without foun dation. W hiting even goes so far as to state that every bone in the body contains marrow or endosteum, but that there are many bones which contain but few myelin cells in the immature, and in adults none. M yelin is a substance which, contrary to the accepted teach ings, plays no part in the nourishment of the bones, but acts purely as a blood producing element or organ. Infectious osteomyelitis, occurring as it does in the soft tissue o f any bone, causes a destructive inflammation with suppuration. W ere the myelin cells con fined in the marrow, osteomyelitis could be found only in the long bones which
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D avis— Osteom yelitis of the Jaws
house the marrow. However, these cells are found in as large numbers in flat bones as in the bones which contain mar row. T h e flat bones have the same gen eral characteristics as the long bones, the soft tissue content replacing the marrow, and containing, as above stated, myelin cells. It is therefore considered perfectly
Blair,1 o f St. Louis, found thirty-three cases affecting the low er jaw , eight af fecting the upper jaw , and one which in volved both jaws. T h e proportions in relation to age were two-thirds in adults to one-third in children. T h e same rela tive proportions occurred in respect to males and females, the males predomi nating.
Fig. 1.— Acute osteomyelitis of the mandible, involving the area from cuspid to first bicuspid o f the opposite side. T he sequestrum has been definitely w alled off from the healthy bone with lines of demarcation clearly visible. T h e bone involved has a worm-eaten appear ance and there is characteristic thinning-out of the necrosed area. In this case, there was a high degree o f toxicity with general weakness, pyrexia, enlargement of the lymph glands and marked discharge of pus. Exfoliation was complete on the sixtieth day of the disease.
correct to apply the term “ osteomyelitis,” instead of “ osteitis,” “ periostitis” or other names to the acute suppurative in flammation of the soft tissues of the max illa and mandible. OCCURRENCE
In
an analysis o f cases, Vilray
P.
E T IO L O G Y
T h e etiology o f osteomyelitis o f the jaws in the majority o f cases may be traced to a lighting up o f some latent in I. Blair, V. P., and Brown, J. B .: Personal Observations on Osteomyelitis of Jaws, Internat. J. Orthodontia, 12:52-68 (Jan.) 1926.
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fection, principally by an extension of the infection around a carious tooth, the presence o f a gangrenous pulp, postex traction neglect or any infection in a wound which reaches the bone or peri osteum. Other causes include those of hematogenous origin, trauma, chemical poisoning, syphilis and extremes o f tem perature. Osteomyelitis of hematogenous origin usually occurs a few weeks after some acute infectious disease, such as scarlet fever, influenza, measles, typhoid fever,
ing the long bones) is a definite entity and that pure cultures o f typhoid bacilli have been isolated from the sinuses, even in old bone sinus cases. In these cases, the location is in the diaphysis of the bone and the periosteal involvement is much greater than the bone reaction. Careful histories, laboratory tests and the roentgenogram will aid the surgeon in a differentiation. Smallpox complicated by an osteo myelitis usually attacks the epiphyseal line of the long bones and is rapid in on-
Fig. 2.— Acute osteomyelitis with involvement of the lingual plate of the mandible. Se questration is incomplete. Duration of disease was six weeks. T he infection was of the low grade type without marked symptoms. There was a small amount of discharge and very little toxicity present. The patient was ambulatory and seemingly had a high degree of resistance to the invading organisms. Clarity was obtained by various angulations of the “ cracker-bite” exposures.
diphtheria and chickenpox. This type of osteomyelitis naturally is found, in the majority of cases at least, in children. W hether or not the specific infection is directly responsible or the general low ered resistance of the individual, due to the infection, plays the major role in the etiology of osteomyelitis follow ing acute infectious disease is at present a debated question. It is a well known fact that typhoid bone infection (usually involv-
set, causing' widespread symmetrical dis semination and little or no suppuration. M ention is made o f these two types of os teomyelitis because of their more com mon occurrence. It must be borne in mind that a child may develop an osteo myelitis around an apparently healthy tooth or even one which is vital and noncarious. In these cases, the etiologic fac tor is o f hematogenous origin. On the other hand, the child may develop an os
D avis— O steom yelitis of the Jaws
teomyelitis follow ing the extraction of an infected tooth. I f a history of an acute infectious disease o f recent date is also obtained, the question arises as to the true etiologic factor— the preexisting periapical infection, the specific organ isms of the disease, the lowered resistance caused by the disease, or the combination of all. In any event, the symptomatology, progress and treatment remain the same when osteomyelitis develops in the jaws.
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bearing in mind the anatomic and histo logic structure o f the parts involved. It must be remembered that the soft parts of the bone, consisting of a stroma of connective tissue enclosing blood vessels, nerves, lymphatic bone cells and fat, are found, not only outside and within the bone, but in the haversian canals as well. As destructive inflammation involves the soft tissues of the bone, and is designated as acute infectious osteomyelitis, it is well to recall the location of the soft parts in-
Fig. 3.— An old chronic case of osteomyelitis with involvement of most of the mandible. There was a history o f acute osteomyelitis follow in g extraction o f a tooth eight years perviously. T he patient was confined to the hospital fo r a period o f eight months, during which time many sequestra were exfoliated. T he condition after three months’ treatment and surgical rem oval o f all infectious foci is shown. There is “ filling-in” of the cancellous bone around the teeth. A ll symptoms have ceased and the patient is rapidly gaining in weight. The roentgenographic evidence is important. Ramifications of the disease must be obtained by repeated experiments from every angle and type of exposure. W here extensive edema is present, extra-oral plates, preferably stereoscopic, are made and supplemented by a series of “ cracker-bite” exposures made sublingually. As soon as the edema subsides, a series of intra-oral dental films are made to bring out in more detail the ramifications of the disease. Later exposures used as check-ups on the course o f the disease should be made, at as nearly the same angle and with the same roentgenographic technic as was used before.
PATHOLOGY
It is difficult to understand the path ologic processes that are associated with an acute osteomyelitis without constantly
volved. Infection occurs in two w ays: through the blood stream or directly by means o f some break in the continuity of the soft parts. T h e organisms involved
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are principally the staphylococcus, strep tococcus, pneumonococcus and mixed bacteria. A ny pathogenic organism cap able of being transported in the blood stream may be deposited in the bone and produce suppuration. T h e invasion of the cancellous bone may occur before the symptoms become manifest. O n the other hand, the periosteum alone may be involved at first, in which case symptoms of pain and swelling appear at the on set. T h e organisms increase in number, phagocytosis occurs and sepsis results.
SYM PTO M S
W here primary bone invasion has oc curred, pain is extreme at the onset even though the cause may be unrecognized. Edema occurs and pus localizes in the region involved. T he infection spreads rather rapidly, this depending on the virulence of the organism and the re sistance of the individual. A low grade infection may assume a high degree of virulence, if the resistance of the indi vidual is well below par. Overw ork, systemic disease, shock, chill, exposure, malnutrition, pregnancy or even a severe cold may lower the resistance o f the host to such a degree that the bacterial inva sion may be fatal. Sinuses may form at points quite re moved from the original site of the in fection. T h e periosteum is stripped from the bone, which is exposed and has the characteristic “ worm-eaten” appearance. If this condition is allowed to continue, the bone becomes exfoliated after ne crosis is complete.
Fig. 4.— An extra-oral plate showing a large area of osteomyelitis involving the ante rior part of the mandible. T h e theory of extension of the disease by way of the mandibular canal, as held by some authors, seems unsound, as in this case there is in volvement around and including the mental foramen without extension at the angle.
Liquefaction or breaking down of the bone follow ed by complete or partial ne crosis and sequestration occurs as an endresult. T here are cases in which no se questration occurs. The usual period of necrosis with exfoliation o f sequestra and formation of the involucrum is about ninety days.
T h e patient becomes quite toxic in the early stages of the disease, and general weakness, fever and loss of appetite are marked. T h e breath is fetid and there is an enlargement of the lymph glands, which become quite sensitive to palpa tion. I f the lingual plate of the mandible is involved, there is a characteristic thick ness o f speech due to swelling of the sub mental region, and a consequent lack of mobility of the tongue. Trismus is usually present if the mus cles of mastication are near the diseased area and are involved in any way. There is an increase in the white cell count. Severe local and referred pain, due to pressure on sensory filaments within the periosteum and bone, may cause great distress. It is well to remember that the roentgenogram may show no bony
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of the infection, perhaps breaking down and suppurating. 2. Metastasis may occur, whereby the COURSE heart, kidneys or other vital organs may Osteomyelitis of the jaws usually runs become involved in the general infection. a more or less prolonged course, lasting Other bones may be affected by infected from four to eighteen months or longer. material being carried through the blood From the onset to the exfoliation of se* stream. questra and formation of the involucrum, 3. Pathologic fracture often occurs in the usual time is about ninety days. By cases in which there is a large amount of this time, the involucrum w ill be o f suffi bone involvement or the disease in the cient strength so that removal of the se mandible literally cuts through the bone questrum is permissible. from the teeth to the external plate. Subsequent areas may develop or sev Even after apparent healing and freedom eral segments in the same jaw may be in from discharge, I have had tw o cases various stages of the disease. Cases have in which fracture resulted when the pa been reported which have persisted for a tient yawned. number of years. 4. Fistulous tracts leading from the original focus to the skin, which may ap P R O G N O S IS parently heal, only to break down Again, in the prognosis, we encounter months later, are present in old chronic virulence and resistance. There are also cases. Contraction of these old tracts re to be considered the amount o f involve sults in a characteristic dimpling o f the ment, the location o f the disease and the skin. type o f bacterial organisms present. F or 5. Ulcerative stomatitis in localized tunately, few cases o f osteomyelitis o f the areas, usually in and about the third jaws are fatal, if properly treated. T h e molar region, may occur, owing to the patient should be warned during the ini presence of virulent organisms in the tial stage of the disease that there may be mouth and the lowered vitality o f the serious complications and sequelae, if tissues surrounding an erupting third strict conform ity to rules of hygiene and molar. treatment are not follow ed. H e should 6. Peritonsillar and pharyngeal ab also be told something o f the length of scesses may result from the conditions time usually necessary to obtain a cure. given above. There w ill be certain periods when the 7. L udw ig’s angina, although rare, symptoms tend to flare up anew, then may occur in spite o f extensive drainage, decrease, only to flare up again. This medication, etc., and, once established, knowledge w ill tend to carry him over carries with it a high mortality. In these the “ rough spots” of his treatment, and cases, a very small amount o f pus, if any, if he is told in advance what he may ex is found when incision is made, and, in pect, he w ill have greater confidence and stead, a turbid, foul serous fluid, often respect for the surgeon. containing gas bacilli, is present. 8. Throm bosis o f the cavernous sinus C O M P L IC A T IO N S is an occasional complication and a very 1. A n y one or all of the salivary serious one. Protrusion o f the eyeball, glands may become involved in the spread extreme prostration, edema o f the orbit
changes during the first week or ten days of the disease.
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and eyelids with other symptoms rela tive to disturbance in vision, etc., should indicate the involvement o f the caver nous sinus. D IF F E R E N T IA L
D IA G N O S IS
Diagnosis of osteomyelitis is compara tively simple as a rule. T h e history, the roentgen-ray findings and the nature of the discharge all tend toward an early diagnosis. Sarcoma.— T his condition, especially where both extra-oral and intra-oral swelling and softness of the tissues are present, may be confused with osteomye litis. T h e teeth may be loose in their sockets and present other characteristics o f osteomyelitis. T h e history, roentgeno gram and discharge w ill eliminate the confusion in the diagnosis. Actinomycosis. — M icroscopic exami nation, secondary skin involvement with repeated breaking down into fistulous tracts should make differentiation from actinomycosis an easy matter. T h e chronicity, history, living conditions, includ ing locality, and the finding of distinct yellowish masses of the ray fungus in the purulent matter, which when rubbed between the fingers gives a gritty and sandlike sensation, are distinctive fea tures of actinomycosis. T h e bone en larges and becomes painful. Edema, soft ening and infiltration of adjacent parts, with secondary purulent fistulous tracts to the skin, and late involvement o f the lymph glands, should differentiate acti nomycosis from osteomyelitis. Tuberculosis.— T his may occur as a distinct entity as tuberculous osteomye litis, or as a secondary infection superim posed on an ordinary osteomyelitis. T h e roentgen-ray and laboratory findings and the microscopic examination are impor tant. T h e point of predilection is the infra-orbital border o f the maxilla. T h e
chronicity and mildness o f the infection, together with the concomitant signs of tuberculosis elsewhere, may obviate er rors in diagnosis. Syphilis.— T ertiary syphilis of the jaw bones, although quite rare, is to be con sidered. Generally attacking the max illa, it may be confused with tubercu lous osteomyelitis. Negative W assermann reactions are the rule in about 15 per cent of cases o f syphilitic bone le sions. Provocative Wassermann tests and spinal fluid examinations should be insti tuted in suspected cases. Specific treat ment instituted as soon as diagnosis is confirmed leads to early improvement. Treatm ent.— The treatment of osteo myelitis of the jaws depends on one fac tor, which must always be constant ; that is, conservation. In order to be safe, go slowly. T im e is a great healer, and the treatment which is safe and sure requires all the patience at your command. T he old proverb, “ Haste makes waste” was never so truly applicable as in a case of acute osteomyelitis of the jaws. Spontaneous drainage is usually es tablished in most cases of osteomyelitis o f the jaws. Pus exudes from 'around the teeth and is more marked at the site of the greatest involvement. T his may or may not be in the region of the original infection. I f there is drainage, it must be con tinued. I f not, it must be established early with the least possible trauma. This is a disease in which the overzealous op erator must substitute judgment for in strumentation, patience for zeal, treat ment for operation, and caution for haste. T h e terrible deformities which result from ill-advised surgery in osteomyelitis o f the jaws are a direct end-result of misunderstanding and lack of knowl edge.
Davis— Osteomyelitis of the Jaws As soon as drainage is thoroughly es tablished, hot irrigations of some bland solution, such as physiologic sodium chlorid, compound solution o f cresol, 15 drops to 2 quarts of water, or any non irritating drug, are instituted. I prefer some deodorant, such as the cresol solu tion, in order to clear up as quickly as possible the foul odors. These irriga tions consist of 2 full quarts of solution, not a half a glass nor yet a few spurts from the spray bottle, but a generous and complete healing lavage twice a day, with instructions to the patient that the continuation of such treatments at home w ill aid in cleaning up the mouth and lowering the virulence of the infectious organism. Complete debridement o f spiculae o f sequestrated bone and granulomatous tissue is instituted superficially. T h e area is irrigated until the virulence o f the in fection has subsided. Just how much time this w ill take depends again on the type o f organism and the resistance of the individual to the infection. D uring this period, a diet high in nourishing value is prescribed. T o o much importance cannot be placed on the medical care o f these cases. As lowered resistance plays such an im portant role in the development and progress o f the disease, a diet planned to build up this resistance is indicated. M ilk , eggs, fruit juices, stewed fruits, cereals, cooked vegetables, etc., are the mainstay in such a diet. M edically, codliver oil emulsions, bitter tonics, such as tincture o f gentian compound, phosphomuriate o f quinin, iron, quinin and strychnin or something equally effica cious is prescribed. Blood transfusion is often of great value. Sun baths or ultraviolet ray treat ments are aids not to be overlooked.
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W h en the patient is ambulatory, fresh air and sunshine are insisted on. W h ere pain is severe, the follow ing prescription has been found to give re lie f: amidopyrin and acetylsalicylic acid, 5 grains each, mixed and made into twelve powders, and one powder taken every tw o hours, for pain if needed. W h en the patient gains weight in spite of the infection present and the constant discharge o f pus, the prognosis is good. The subsidence o f the acute symptoms, together with a gain in weight, is usually the turning point of the infection. Nevertheless, the irriga tions are just as important at this time as ever. Localization of the infection, to prevent a général septicemia and metastasis, together with the building up of a patient’s resistance to the invading organism, constitutes the greatest safe guard against complications which may arise if these factors are neglected. Rest is essential especially in the initial stages o f the disease. W h en a patient is suffering from an infection, such as is present in an osteomyelitis o f the jaws, his tissues are utilizing more energy than is required for daily labor. I f such extra exertion is added, the disease may be very slow in progress and may develop into a chronic osteomyelitis, with years, instead o f months, elapsing before a cure is effected. Hospitalization is the ideal, but often is unnecessary. Ambulatory cases, especially after the first severe symptoms are safely past, seem to do well, if properly treated. I cannot emphasize the dietary re quirements for these cases too strongly. M ost important are those foods high in vitamins C and A . Cod-liver oil and whole raw milk in abundance w ill sup ply vitamins A and D . Tom atoes and oranges, lemons, limes and all the other citrus fruits provide vitamins and tend
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to reduce acidosis. Lima beans, either in soups, served as a vegetable or ground into flour and made into bread, are high in value as an antacid. Cod-liver oil contains vitamin D , which is necessary for building bone. Vitamin D is also developed in the skin by the action of ultraviolet rays, either in sunshine or the mercury-quartz lamp. Calcium lactate in 5-grain doses has some apparent value in offsetting the cal cium deficiency. Operative interference after thorough drainage is established and until the formation of sequestra is absolutely contraindicated. Superficial curettage after the exfoliation o f the sequestrum is permissible, but such curettage should be delicately and care fully done. Packing or dressings are to be con demned. As drainage is the object sought for, any type o f dressing only tends to dam up the pus and prevent its exit. Application of external heat or of ichthyol, antiphlogistin and other drugs in the same category are dangerous. Ice packs are indicated instead, even though the patient takes kindly to dry heat or poultices. C old not only reduces the inflammation present, but also decreases the rapidity o f growth of bacteria. T h e only exception to this rule is that, after all other means have failed and the in evitable “ pointing” externally has oc curred, continuously applied hot fomen tations may aid in the localization of the pus externally to a point where extra-oral incision may be made to avoid important structures such as the parotid gland, seventh nerve, etc. I f in this paper nothing else is learned but to avoid placing hot fomen tations to the face and jaws in virulent infections, it has accomplished a great purpose. T h e laity as a whole, and even
a great many physicians and dentists are too often influenced by the appeals o f the patient for greater comfort, and, as a result, heat is used where cold is indi cated. A ll of us have been offenders, but one case o f the avoidance of a dis seminated infection by the substitution of ice for heat is worth all the grateful words of a pleased patient for the use of a warm poultice. Vaccines, antitoxins and serums may aid, in selected cases, to destroy the micro-organisms. Autogenous vaccines are, as a rule, the most efficacious, al though good results have been obtained in the use of stock vaccines and serums. T h e greatest value from their use is to be obtained early in the course of the disease. T h e removal of the sequestra is usually quite simple. T h e important factor is patience until the sequestra are ready to be exfoliated. A n incision is necessary in some cases in order that the involucrum may not be injured. T h e removal should be accomplished with the least possible injury to adjacent tissues, unless the sequestrum is buried in hard bone. In the latter case, one wall of the involucrum may be chiseled away in order to permit deliv.ery. Clinical experience is the only criterion offered as to the time to remove a seques trum. Spontaneous exfoliation is the rule, but even though one end may still be at tached, it is often better to remove it than to wait. Roentgenograms taken at inter vals in the course o f the disease may be of great aid in determining the proper time for sequestrectomy. W h en, as often hap pens, the tissues overlying the bone break down and the bone is exposed as a dry, hard, nonsensitive. mass, a large round bur is useful in removing the external plate and exposing the cancellous, bleed ing bone. Sometimes, the immediate re sponse is astounding in that, whereas
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broth is used as wet dressings applied over the affected part. G reat claims are made for the cures effected by this form of treatment, especially in old chronic cases. In 1925, M a x T h orek ,2 o f Chicago, brought to the attention o f surgeons a new method o f treatment of chronic sup purations, especially o f bones. His method was based on his observations in the meat preserving industry, in which brine containing nitrate of potassium is used as the oxidizing agent. In his first cases, he tried using po tassium nitrate alone, in an endeavor to create antibodies by means o f which the natural processes within the host tend to eliminate the invading organism. A l though quite successful end-results were obtained, great irritation and sloughing occurred after ten days, the action of the deformity. potassium nitrate seeming to be cumu A fter the removal of the sequestra, the irrigation should be continued at less lative. A fter repeated tests, many failures frequent intervals until the case is finally and a great deal o f research, it was found dismissed. In cases in which deformities that the potassium nitrate when com may occur after removal o f bone bined with aluminum nitrate seemed to prior to sequestration, immediate steps inhibit the pain without decreasing the should be taken to prevent deformity by oxidizing properties o f the potassium the orthodontist. Other forms o f treatment in vogue are salt. T h e combination failed when used in high aqueous solutions, owing to the those in which application is made to the falling apart o f the tw o salts, maceration skin of medium tending toward absorp tion through the tissues and affecting the o f the tissues being again caused by the action of the potassium nitrate. R e bone beneath. O ne o f these is the use o f cultures newed efforts in research resulted in the formation o f a stabilized compound from made from the discharging pus. T h e or concentrated nitric acid which did not ganisms are cultured in broth until decause hydrolysis of the aluminum nitrate. vitilization occurs from autointoxication. Definite proportions are necessary to ob In other words, the bacteria are allowed tain this result, and I can best quote D r. to g row and multiply in the same me Thorek. dium until they are no longer able to The quantity of aluminum nitrate and po live in their own toxins. T h e medium tassium nitrate used should be in proportion is filtered and the bacteria are placed in new mediums and allowed again to reach 2. Thorek, M a x : N ew M ethod of T rea t ment o f Chronic Suppurations, Internat. the same end-result. T h is is repeated until Clin., 1:137-168 (M arch) 1925. no further growth appears. T h e n the
before there existed a large area of ex posed bone, to all intents and purposes the beginning o f a definite large seques trum, there is an immediate formation o f new fibrous mucoperiosteum and the bone again becomes covered. T h e ex posed surface should be cut away in all directions up to and slightly beneath the healthy mucoperiosteum, but should stop when bleeding bone is reached. In some cases, this can be accomplished without the use o f anesthetics, and if care is used to avoid the sensitive membranes cover ing the bone, the extent o f necessary cut ting is easily recognized. In one of my cases, this operation cleared up the fo r mation o f a large sequestrum in a very short time, where watchful waiting might have resulted in the loss o f a large segment o f the mandible, with a ghastly
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of the molecular weight of one molecule of o f aluminum nitrate to three times the molec ular weight of one molecule of potassium nitrate. For example, 375 grains of aluminum nitrate and 303 grains o f potassium nitrate in sufficient hot concentrated nitric acid to dissolve the substance w ill produce a solu tion from which the double salt A1 (N 3) s 3KNO0IOH2O w ill crystallize out on cooling and after drying the product it contains ap proximately 31% aluminum nitrate, 44% potassium nitrate and 25% water of crystal lization. About 500 c.c. of concentrated nit ric acid, kept hot by means of the water bath, is a suitable quantity of acid in which to dis solve one kilo o f aluminum nitrate and po tassium nitrate mixed in the proportions in dicated. T h e described salt crystallizes from the concentrated nitric acid solution in the form o f colorless rhombic and monoclinic crystals, which ^re readily soluble in cold or warm water in substantially all proportions. T h ey possess an astringent, slightly metallic taste. This product is further diluted with nine parts of potassium nitrate, and the re sultant mixture is incorporated in the dress ing used in the treatment.
0
Investigations to determine the germi cidal index of the aluminum-potassium nitrate compound resulted in the finding that, when added to culture mediums, this compound assisted and intensified bacterial growth. Anim al tests proved it to be nontoxic, intravenously, subcutaneously, intraperitoneally and orally. “ T h e technic of application consists in applying a plastic dressing directly over the affected area, made up o f a vehicle in which the compound is incorporated.” Ordinary rolled oats, sterilized for tw o hours in an autoclave to prevent sour ing, and heated in an ordinary oven for from twenty to thirty minutes, w ill do. F ifty cubic centimeters o f boiling water to each ounce of rolled oats, stirred until a uniform mass is obtained, with 13 grains of the aluminum-potassium nitrate compound to each ounce o f oats used, produces the, best results. T his dressing is applied about one-eighth inch thick directly to the skin. It extends well
beyond the affected area, and is covered over with waterproofing material such as wax paper or guttapercha. “ T h e dressing should remain in absolute contact with the skin continuously and should be changed as often as it becomes saturated with secretions, and in any case should be changed at least once in thirty-six hours. N o gauze should be interposed between the dressing and the skin.” D r. T horek claims that a simple gauze pack substituted for the plastic vehicle does not produce any of the typical reac tions or effects. T h e effects produced a re: (1 ) erythema in forty-eight h ours; ( 2 ) vesicles and pustules, a few days later, continuing as long as infection per sists in the underlying tissues; ( 3 ) re cession o f the area of reaction when in fection clears in underlying tissues. His theory is that nascent oxygen is liberated from the nitrate ion in its pas sage through the skin into the deeper tissues. Reaction beyond the area of disease w ill not occur, which shows that the compound evidently has a selective affin ity for the point o f infiltration. “ In the case of a small area of osteo myelitis in the middle third of the femur, a dressing applied over the entire fe m ur’s length w ill not produce a typical reaction on the skin throughout the length o f the area covered by the dress ing.” Rapid autolysis at the point of infec tion and increased propagation of bac teria, local leukocytosis and phagocyto sis are the results claimed. T h e virulence o f the organisms decreases rapidly. T h e systemic condition o f the patient im proves and pain soon subsides. T horek advises starting with small doses, gradually increasing until the ni trate tolerance o f the individual is ob tained. O ne hundred and sixteen cases
W a ite—-Practitioner o f Dentistry were reported, including bone tubercu losis, osteomyelitis, postoperative wound infections and some forms of gangrene. T h e results reported are worthy o f consideration, and as several ja w cases are reported in his series, this form of treatment should be tried out at some time to determine its value over our pres ent methods. RESU M E
1. Osteomylitis o f the jaws is a serious disease, characterized by inflammation of the soft parts of the bone and adjacent tissues, liquefaction o f the bone and fo r mation of pus, and, if untreated or im properly treated, may result in deformity. 2. It runs a rather definite course, with periods of subsidence and recru
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descence and generaljy a fair prognosis. 3. T h e etiology is generally traceable to a “ lighting up” o f an old infection in or around a carious tooth or other infec tion ; hence, the importance of the den tist in prevention. 4. T h e micro-organisms most com monly found are staphylococcus, strep tococcus, pneumococcus, Bacillus pyocyaneus, mixed bacteria, etc. 5. Treatm ent is divided into stages o f : (a ) removal of causative factor; (b ) establishment of drainage; ( c ) building up the resistance of the patient; ( d ) hot irrigations; (e ) application of cold ex ternally; ( f ) removal o f sequestrums; (g ) prevention of deformities. 209 Post Street.
THE PRACTITIONER OF DENTISTRY AND DENTAL EDUCATION AND RESEARCH* By FREDERICK C. WAITE,IPh.D., Cleveland, Ohio
N the United States, dentistry, the child of medicine, in the exuberance of infancy left the maternal domicile and declared its independence.
I
W hatever may be its present or future relation to medicine, in its historical re lation, it is a part of medicine, and since a child inherits not only the benefits but also, to a certain extent, the obligations of its parent, American dentistry cannot escape certain historical obligations in herent to its coincidence with medicine through many centuries. *A bridged from a paper read before the annual meeting o f the Ohio State Dental Association, Cleveland, Dec. 7, 1927. Re ceived fo r publication Jan. 14, 1929. Jour. A . D . A ., August, IQ2Q
T h e advancement of knowledge is one o f the m ajor functions historically as sumed by medicine and inherited by den tistry. Hence, the dental practitioner has definite historical responsibility to the promotion of learning. R E S P O N S IB IL IT IE S
OF
TH E
IN D IV ID U A L
Each adult individual in normal men tal condition has a series o f personal re sponsibilities. These responsibilities en tail certain duties to fam ily; to the local community of which he is a p a rt; to the larger community, the state, o f which he is a citizen; and to his country. These responsibilities arise either through vol untary contract, as in the fam ily; through
T h e Journal o f the Am erican D en ta l Association
records. These records are checked, and corrected if necessary. W ith the aid of very thin carbon paper, any existing high spots are located and removed with small mounted stones. T h e operator should locate and eliminate errors in one relation at a time, beginning with centric relation and follow ing with any necessary correction in the lateral relations. T h e teeth are then milled with fine abrasive paste to perfect the occlusion, and the dentures placed in the mouth and checked for accuracy o f relationship. Subsequent checking of the various relationships w ill provide the maximum of denture com fort and efficiency.
C O N C L U S IO N
A fter careful observation and inquiry, I have found that those in our profession w ho are considered leaders and authori ties on full denture problems are not necessarily dentists who limit their prac tice to fu ll denture construction but, in general, are individuals who assume the responsibility of acquainting themselves with the best literature and ideas on the subject and apply precision and exactness to every detail involved in denture con struction. T his is my answer to the ques tion : H o w can the general practitioner be assisted in the solution of his full denture problems? 209 East T w en ty-T h ird Street.
OSTEOMYELITIS OF THE JAWS* ALBERT D. DAVIS, D.D.S., B.Sc., M.D., San Francisco, Cal.i. , as defined by M cC allum , is “ a destructive proc ess affecting the periosteum, the cortex and the m arrow .” Disagreement by various authors as to the correct term to be applied to that type o f infection resulting in bony dissolution or destruc tion of the maxilla or mandible has led to a thorough investigation o f the word and its true meaning. Particular em phasis has been placed on the w ord “ myelin,” which is used as the body of the word osteo-myel-itis, with the suffix and the prefix well understood (if such nomenclature is applicable). As myelin is not a true synonym for bone marrow, but refers, according to W hiting, and s t e o m y e l it is
O
*Read before the Oakland Dental Club, M ay 31, 1928. *From the department o f Plastic Surgery, Leland Stanford M edical School. Jour. A . D . A ., August, IÇ2Ç
also to Stimson, to any 'soft part on which the integrity o f the bone wholly depends, or to all the soft parts which contribute to the nourishment o f the bones, this disagreement is without foun dation. W hiting even goes so far as to state that every bone in the body contains marrow or endosteum, but that there are many bones which contain but few myelin cells in the immature, and in adults none. M yelin is a substance which, contrary to the accepted teach ings, plays no part in the nourishment of the bones, but acts purely as a blood producing element or organ. Infectious osteomyelitis, occurring as it does in the soft tissue o f any bone, causes a destructive inflammation with suppuration. W ere the myelin cells con fined in the marrow, osteomyelitis could be found only in the long bones which
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D avis— Osteom yelitis of the Jaws
house the marrow. However, these cells are found in as large numbers in flat bones as in the bones which contain mar row. T h e flat bones have the same gen eral characteristics as the long bones, the soft tissue content replacing the marrow, and containing, as above stated, myelin cells. It is therefore considered perfectly
Blair,1 o f St. Louis, found thirty-three cases affecting the low er jaw , eight af fecting the upper jaw , and one which in volved both jaws. T h e proportions in relation to age were two-thirds in adults to one-third in children. T h e same rela tive proportions occurred in respect to males and females, the males predomi nating.
Fig. 1.— Acute osteomyelitis of the mandible, involving the area from cuspid to first bicuspid o f the opposite side. T he sequestrum has been definitely w alled off from the healthy bone with lines of demarcation clearly visible. T h e bone involved has a worm-eaten appear ance and there is characteristic thinning-out of the necrosed area. In this case, there was a high degree o f toxicity with general weakness, pyrexia, enlargement of the lymph glands and marked discharge of pus. Exfoliation was complete on the sixtieth day of the disease.
correct to apply the term “ osteomyelitis,” instead of “ osteitis,” “ periostitis” or other names to the acute suppurative in flammation of the soft tissues of the max illa and mandible. OCCURRENCE
In
an analysis o f cases, Vilray
P.
E T IO L O G Y
T h e etiology o f osteomyelitis o f the jaws in the majority o f cases may be traced to a lighting up o f some latent in I. Blair, V. P., and Brown, J. B .: Personal Observations on Osteomyelitis of Jaws, Internat. J. Orthodontia, 12:52-68 (Jan.) 1926.
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fection, principally by an extension of the infection around a carious tooth, the presence o f a gangrenous pulp, postex traction neglect or any infection in a wound which reaches the bone or peri osteum. Other causes include those of hematogenous origin, trauma, chemical poisoning, syphilis and extremes o f tem perature. Osteomyelitis of hematogenous origin usually occurs a few weeks after some acute infectious disease, such as scarlet fever, influenza, measles, typhoid fever,
ing the long bones) is a definite entity and that pure cultures o f typhoid bacilli have been isolated from the sinuses, even in old bone sinus cases. In these cases, the location is in the diaphysis of the bone and the periosteal involvement is much greater than the bone reaction. Careful histories, laboratory tests and the roentgenogram will aid the surgeon in a differentiation. Smallpox complicated by an osteo myelitis usually attacks the epiphyseal line of the long bones and is rapid in on-
Fig. 2.— Acute osteomyelitis with involvement of the lingual plate of the mandible. Se questration is incomplete. Duration of disease was six weeks. T he infection was of the low grade type without marked symptoms. There was a small amount of discharge and very little toxicity present. The patient was ambulatory and seemingly had a high degree of resistance to the invading organisms. Clarity was obtained by various angulations of the “ cracker-bite” exposures.
diphtheria and chickenpox. This type of osteomyelitis naturally is found, in the majority of cases at least, in children. W hether or not the specific infection is directly responsible or the general low ered resistance of the individual, due to the infection, plays the major role in the etiology of osteomyelitis follow ing acute infectious disease is at present a debated question. It is a well known fact that typhoid bone infection (usually involv-
set, causing' widespread symmetrical dis semination and little or no suppuration. M ention is made o f these two types of os teomyelitis because of their more com mon occurrence. It must be borne in mind that a child may develop an osteo myelitis around an apparently healthy tooth or even one which is vital and noncarious. In these cases, the etiologic fac tor is o f hematogenous origin. On the other hand, the child may develop an os
D avis— O steom yelitis of the Jaws
teomyelitis follow ing the extraction of an infected tooth. I f a history of an acute infectious disease o f recent date is also obtained, the question arises as to the true etiologic factor— the preexisting periapical infection, the specific organ isms of the disease, the lowered resistance caused by the disease, or the combination of all. In any event, the symptomatology, progress and treatment remain the same when osteomyelitis develops in the jaws.
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bearing in mind the anatomic and histo logic structure o f the parts involved. It must be remembered that the soft parts of the bone, consisting of a stroma of connective tissue enclosing blood vessels, nerves, lymphatic bone cells and fat, are found, not only outside and within the bone, but in the haversian canals as well. As destructive inflammation involves the soft tissues of the bone, and is designated as acute infectious osteomyelitis, it is well to recall the location of the soft parts in-
Fig. 3.— An old chronic case of osteomyelitis with involvement of most of the mandible. There was a history o f acute osteomyelitis follow in g extraction o f a tooth eight years perviously. T he patient was confined to the hospital fo r a period o f eight months, during which time many sequestra were exfoliated. T he condition after three months’ treatment and surgical rem oval o f all infectious foci is shown. There is “ filling-in” of the cancellous bone around the teeth. A ll symptoms have ceased and the patient is rapidly gaining in weight. The roentgenographic evidence is important. Ramifications of the disease must be obtained by repeated experiments from every angle and type of exposure. W here extensive edema is present, extra-oral plates, preferably stereoscopic, are made and supplemented by a series of “ cracker-bite” exposures made sublingually. As soon as the edema subsides, a series of intra-oral dental films are made to bring out in more detail the ramifications of the disease. Later exposures used as check-ups on the course o f the disease should be made, at as nearly the same angle and with the same roentgenographic technic as was used before.
PATHOLOGY
It is difficult to understand the path ologic processes that are associated with an acute osteomyelitis without constantly
volved. Infection occurs in two w ays: through the blood stream or directly by means o f some break in the continuity of the soft parts. T h e organisms involved
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are principally the staphylococcus, strep tococcus, pneumonococcus and mixed bacteria. A ny pathogenic organism cap able of being transported in the blood stream may be deposited in the bone and produce suppuration. T h e invasion of the cancellous bone may occur before the symptoms become manifest. O n the other hand, the periosteum alone may be involved at first, in which case symptoms of pain and swelling appear at the on set. T h e organisms increase in number, phagocytosis occurs and sepsis results.
SYM PTO M S
W here primary bone invasion has oc curred, pain is extreme at the onset even though the cause may be unrecognized. Edema occurs and pus localizes in the region involved. T he infection spreads rather rapidly, this depending on the virulence of the organism and the re sistance of the individual. A low grade infection may assume a high degree of virulence, if the resistance of the indi vidual is well below par. Overw ork, systemic disease, shock, chill, exposure, malnutrition, pregnancy or even a severe cold may lower the resistance o f the host to such a degree that the bacterial inva sion may be fatal. Sinuses may form at points quite re moved from the original site of the in fection. T h e periosteum is stripped from the bone, which is exposed and has the characteristic “ worm-eaten” appearance. If this condition is allowed to continue, the bone becomes exfoliated after ne crosis is complete.
Fig. 4.— An extra-oral plate showing a large area of osteomyelitis involving the ante rior part of the mandible. T h e theory of extension of the disease by way of the mandibular canal, as held by some authors, seems unsound, as in this case there is in volvement around and including the mental foramen without extension at the angle.
Liquefaction or breaking down of the bone follow ed by complete or partial ne crosis and sequestration occurs as an endresult. T here are cases in which no se questration occurs. The usual period of necrosis with exfoliation o f sequestra and formation of the involucrum is about ninety days.
T h e patient becomes quite toxic in the early stages of the disease, and general weakness, fever and loss of appetite are marked. T h e breath is fetid and there is an enlargement of the lymph glands, which become quite sensitive to palpa tion. I f the lingual plate of the mandible is involved, there is a characteristic thick ness o f speech due to swelling of the sub mental region, and a consequent lack of mobility of the tongue. Trismus is usually present if the mus cles of mastication are near the diseased area and are involved in any way. There is an increase in the white cell count. Severe local and referred pain, due to pressure on sensory filaments within the periosteum and bone, may cause great distress. It is well to remember that the roentgenogram may show no bony
Davis— Osteomyelitis o f the Jaws
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of the infection, perhaps breaking down and suppurating. 2. Metastasis may occur, whereby the COURSE heart, kidneys or other vital organs may Osteomyelitis of the jaws usually runs become involved in the general infection. a more or less prolonged course, lasting Other bones may be affected by infected from four to eighteen months or longer. material being carried through the blood From the onset to the exfoliation of se* stream. questra and formation of the involucrum, 3. Pathologic fracture often occurs in the usual time is about ninety days. By cases in which there is a large amount of this time, the involucrum w ill be o f suffi bone involvement or the disease in the cient strength so that removal of the se mandible literally cuts through the bone questrum is permissible. from the teeth to the external plate. Subsequent areas may develop or sev Even after apparent healing and freedom eral segments in the same jaw may be in from discharge, I have had tw o cases various stages of the disease. Cases have in which fracture resulted when the pa been reported which have persisted for a tient yawned. number of years. 4. Fistulous tracts leading from the original focus to the skin, which may ap P R O G N O S IS parently heal, only to break down Again, in the prognosis, we encounter months later, are present in old chronic virulence and resistance. There are also cases. Contraction of these old tracts re to be considered the amount o f involve sults in a characteristic dimpling o f the ment, the location o f the disease and the skin. type o f bacterial organisms present. F or 5. Ulcerative stomatitis in localized tunately, few cases o f osteomyelitis o f the areas, usually in and about the third jaws are fatal, if properly treated. T h e molar region, may occur, owing to the patient should be warned during the ini presence of virulent organisms in the tial stage of the disease that there may be mouth and the lowered vitality o f the serious complications and sequelae, if tissues surrounding an erupting third strict conform ity to rules of hygiene and molar. treatment are not follow ed. H e should 6. Peritonsillar and pharyngeal ab also be told something o f the length of scesses may result from the conditions time usually necessary to obtain a cure. given above. There w ill be certain periods when the 7. L udw ig’s angina, although rare, symptoms tend to flare up anew, then may occur in spite o f extensive drainage, decrease, only to flare up again. This medication, etc., and, once established, knowledge w ill tend to carry him over carries with it a high mortality. In these the “ rough spots” of his treatment, and cases, a very small amount o f pus, if any, if he is told in advance what he may ex is found when incision is made, and, in pect, he w ill have greater confidence and stead, a turbid, foul serous fluid, often respect for the surgeon. containing gas bacilli, is present. 8. Throm bosis o f the cavernous sinus C O M P L IC A T IO N S is an occasional complication and a very 1. A n y one or all of the salivary serious one. Protrusion o f the eyeball, glands may become involved in the spread extreme prostration, edema o f the orbit
changes during the first week or ten days of the disease.
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and eyelids with other symptoms rela tive to disturbance in vision, etc., should indicate the involvement o f the caver nous sinus. D IF F E R E N T IA L
D IA G N O S IS
Diagnosis of osteomyelitis is compara tively simple as a rule. T h e history, the roentgen-ray findings and the nature of the discharge all tend toward an early diagnosis. Sarcoma.— T his condition, especially where both extra-oral and intra-oral swelling and softness of the tissues are present, may be confused with osteomye litis. T h e teeth may be loose in their sockets and present other characteristics o f osteomyelitis. T h e history, roentgeno gram and discharge w ill eliminate the confusion in the diagnosis. Actinomycosis. — M icroscopic exami nation, secondary skin involvement with repeated breaking down into fistulous tracts should make differentiation from actinomycosis an easy matter. T h e chronicity, history, living conditions, includ ing locality, and the finding of distinct yellowish masses of the ray fungus in the purulent matter, which when rubbed between the fingers gives a gritty and sandlike sensation, are distinctive fea tures of actinomycosis. T h e bone en larges and becomes painful. Edema, soft ening and infiltration of adjacent parts, with secondary purulent fistulous tracts to the skin, and late involvement o f the lymph glands, should differentiate acti nomycosis from osteomyelitis. Tuberculosis.— T his may occur as a distinct entity as tuberculous osteomye litis, or as a secondary infection superim posed on an ordinary osteomyelitis. T h e roentgen-ray and laboratory findings and the microscopic examination are impor tant. T h e point of predilection is the infra-orbital border o f the maxilla. T h e
chronicity and mildness o f the infection, together with the concomitant signs of tuberculosis elsewhere, may obviate er rors in diagnosis. Syphilis.— T ertiary syphilis of the jaw bones, although quite rare, is to be con sidered. Generally attacking the max illa, it may be confused with tubercu lous osteomyelitis. Negative W assermann reactions are the rule in about 15 per cent of cases o f syphilitic bone le sions. Provocative Wassermann tests and spinal fluid examinations should be insti tuted in suspected cases. Specific treat ment instituted as soon as diagnosis is confirmed leads to early improvement. Treatm ent.— The treatment of osteo myelitis of the jaws depends on one fac tor, which must always be constant ; that is, conservation. In order to be safe, go slowly. T im e is a great healer, and the treatment which is safe and sure requires all the patience at your command. T he old proverb, “ Haste makes waste” was never so truly applicable as in a case of acute osteomyelitis of the jaws. Spontaneous drainage is usually es tablished in most cases of osteomyelitis o f the jaws. Pus exudes from 'around the teeth and is more marked at the site of the greatest involvement. T his may or may not be in the region of the original infection. I f there is drainage, it must be con tinued. I f not, it must be established early with the least possible trauma. This is a disease in which the overzealous op erator must substitute judgment for in strumentation, patience for zeal, treat ment for operation, and caution for haste. T h e terrible deformities which result from ill-advised surgery in osteomyelitis o f the jaws are a direct end-result of misunderstanding and lack of knowl edge.
Davis— Osteomyelitis of the Jaws As soon as drainage is thoroughly es tablished, hot irrigations of some bland solution, such as physiologic sodium chlorid, compound solution o f cresol, 15 drops to 2 quarts of water, or any non irritating drug, are instituted. I prefer some deodorant, such as the cresol solu tion, in order to clear up as quickly as possible the foul odors. These irriga tions consist of 2 full quarts of solution, not a half a glass nor yet a few spurts from the spray bottle, but a generous and complete healing lavage twice a day, with instructions to the patient that the continuation of such treatments at home w ill aid in cleaning up the mouth and lowering the virulence of the infectious organism. Complete debridement o f spiculae o f sequestrated bone and granulomatous tissue is instituted superficially. T h e area is irrigated until the virulence o f the in fection has subsided. Just how much time this w ill take depends again on the type o f organism and the resistance of the individual to the infection. D uring this period, a diet high in nourishing value is prescribed. T o o much importance cannot be placed on the medical care o f these cases. As lowered resistance plays such an im portant role in the development and progress o f the disease, a diet planned to build up this resistance is indicated. M ilk , eggs, fruit juices, stewed fruits, cereals, cooked vegetables, etc., are the mainstay in such a diet. M edically, codliver oil emulsions, bitter tonics, such as tincture o f gentian compound, phosphomuriate o f quinin, iron, quinin and strychnin or something equally effica cious is prescribed. Blood transfusion is often of great value. Sun baths or ultraviolet ray treat ments are aids not to be overlooked.
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W h en the patient is ambulatory, fresh air and sunshine are insisted on. W h ere pain is severe, the follow ing prescription has been found to give re lie f: amidopyrin and acetylsalicylic acid, 5 grains each, mixed and made into twelve powders, and one powder taken every tw o hours, for pain if needed. W h en the patient gains weight in spite of the infection present and the constant discharge o f pus, the prognosis is good. The subsidence o f the acute symptoms, together with a gain in weight, is usually the turning point of the infection. Nevertheless, the irriga tions are just as important at this time as ever. Localization of the infection, to prevent a général septicemia and metastasis, together with the building up of a patient’s resistance to the invading organism, constitutes the greatest safe guard against complications which may arise if these factors are neglected. Rest is essential especially in the initial stages o f the disease. W h en a patient is suffering from an infection, such as is present in an osteomyelitis o f the jaws, his tissues are utilizing more energy than is required for daily labor. I f such extra exertion is added, the disease may be very slow in progress and may develop into a chronic osteomyelitis, with years, instead o f months, elapsing before a cure is effected. Hospitalization is the ideal, but often is unnecessary. Ambulatory cases, especially after the first severe symptoms are safely past, seem to do well, if properly treated. I cannot emphasize the dietary re quirements for these cases too strongly. M ost important are those foods high in vitamins C and A . Cod-liver oil and whole raw milk in abundance w ill sup ply vitamins A and D . Tom atoes and oranges, lemons, limes and all the other citrus fruits provide vitamins and tend
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to reduce acidosis. Lima beans, either in soups, served as a vegetable or ground into flour and made into bread, are high in value as an antacid. Cod-liver oil contains vitamin D , which is necessary for building bone. Vitamin D is also developed in the skin by the action of ultraviolet rays, either in sunshine or the mercury-quartz lamp. Calcium lactate in 5-grain doses has some apparent value in offsetting the cal cium deficiency. Operative interference after thorough drainage is established and until the formation of sequestra is absolutely contraindicated. Superficial curettage after the exfoliation o f the sequestrum is permissible, but such curettage should be delicately and care fully done. Packing or dressings are to be con demned. As drainage is the object sought for, any type o f dressing only tends to dam up the pus and prevent its exit. Application of external heat or of ichthyol, antiphlogistin and other drugs in the same category are dangerous. Ice packs are indicated instead, even though the patient takes kindly to dry heat or poultices. C old not only reduces the inflammation present, but also decreases the rapidity o f growth of bacteria. T h e only exception to this rule is that, after all other means have failed and the in evitable “ pointing” externally has oc curred, continuously applied hot fomen tations may aid in the localization of the pus externally to a point where extra-oral incision may be made to avoid important structures such as the parotid gland, seventh nerve, etc. I f in this paper nothing else is learned but to avoid placing hot fomen tations to the face and jaws in virulent infections, it has accomplished a great purpose. T h e laity as a whole, and even
a great many physicians and dentists are too often influenced by the appeals o f the patient for greater comfort, and, as a result, heat is used where cold is indi cated. A ll of us have been offenders, but one case o f the avoidance of a dis seminated infection by the substitution of ice for heat is worth all the grateful words of a pleased patient for the use of a warm poultice. Vaccines, antitoxins and serums may aid, in selected cases, to destroy the micro-organisms. Autogenous vaccines are, as a rule, the most efficacious, al though good results have been obtained in the use of stock vaccines and serums. T h e greatest value from their use is to be obtained early in the course of the disease. T h e removal of the sequestra is usually quite simple. T h e important factor is patience until the sequestra are ready to be exfoliated. A n incision is necessary in some cases in order that the involucrum may not be injured. T h e removal should be accomplished with the least possible injury to adjacent tissues, unless the sequestrum is buried in hard bone. In the latter case, one wall of the involucrum may be chiseled away in order to permit deliv.ery. Clinical experience is the only criterion offered as to the time to remove a seques trum. Spontaneous exfoliation is the rule, but even though one end may still be at tached, it is often better to remove it than to wait. Roentgenograms taken at inter vals in the course o f the disease may be of great aid in determining the proper time for sequestrectomy. W h en, as often hap pens, the tissues overlying the bone break down and the bone is exposed as a dry, hard, nonsensitive. mass, a large round bur is useful in removing the external plate and exposing the cancellous, bleed ing bone. Sometimes, the immediate re sponse is astounding in that, whereas
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broth is used as wet dressings applied over the affected part. G reat claims are made for the cures effected by this form of treatment, especially in old chronic cases. In 1925, M a x T h orek ,2 o f Chicago, brought to the attention o f surgeons a new method o f treatment of chronic sup purations, especially o f bones. His method was based on his observations in the meat preserving industry, in which brine containing nitrate of potassium is used as the oxidizing agent. In his first cases, he tried using po tassium nitrate alone, in an endeavor to create antibodies by means o f which the natural processes within the host tend to eliminate the invading organism. A l though quite successful end-results were obtained, great irritation and sloughing occurred after ten days, the action of the deformity. potassium nitrate seeming to be cumu A fter the removal of the sequestra, the irrigation should be continued at less lative. A fter repeated tests, many failures frequent intervals until the case is finally and a great deal o f research, it was found dismissed. In cases in which deformities that the potassium nitrate when com may occur after removal o f bone bined with aluminum nitrate seemed to prior to sequestration, immediate steps inhibit the pain without decreasing the should be taken to prevent deformity by oxidizing properties o f the potassium the orthodontist. Other forms o f treatment in vogue are salt. T h e combination failed when used in high aqueous solutions, owing to the those in which application is made to the falling apart o f the tw o salts, maceration skin of medium tending toward absorp tion through the tissues and affecting the o f the tissues being again caused by the action of the potassium nitrate. R e bone beneath. O ne o f these is the use o f cultures newed efforts in research resulted in the formation o f a stabilized compound from made from the discharging pus. T h e or concentrated nitric acid which did not ganisms are cultured in broth until decause hydrolysis of the aluminum nitrate. vitilization occurs from autointoxication. Definite proportions are necessary to ob In other words, the bacteria are allowed tain this result, and I can best quote D r. to g row and multiply in the same me Thorek. dium until they are no longer able to The quantity of aluminum nitrate and po live in their own toxins. T h e medium tassium nitrate used should be in proportion is filtered and the bacteria are placed in new mediums and allowed again to reach 2. Thorek, M a x : N ew M ethod of T rea t ment o f Chronic Suppurations, Internat. the same end-result. T h is is repeated until Clin., 1:137-168 (M arch) 1925. no further growth appears. T h e n the
before there existed a large area of ex posed bone, to all intents and purposes the beginning o f a definite large seques trum, there is an immediate formation o f new fibrous mucoperiosteum and the bone again becomes covered. T h e ex posed surface should be cut away in all directions up to and slightly beneath the healthy mucoperiosteum, but should stop when bleeding bone is reached. In some cases, this can be accomplished without the use o f anesthetics, and if care is used to avoid the sensitive membranes cover ing the bone, the extent o f necessary cut ting is easily recognized. In one of my cases, this operation cleared up the fo r mation o f a large sequestrum in a very short time, where watchful waiting might have resulted in the loss o f a large segment o f the mandible, with a ghastly
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of the molecular weight of one molecule of o f aluminum nitrate to three times the molec ular weight of one molecule of potassium nitrate. For example, 375 grains of aluminum nitrate and 303 grains o f potassium nitrate in sufficient hot concentrated nitric acid to dissolve the substance w ill produce a solu tion from which the double salt A1 (N 3) s 3KNO0IOH2O w ill crystallize out on cooling and after drying the product it contains ap proximately 31% aluminum nitrate, 44% potassium nitrate and 25% water of crystal lization. About 500 c.c. of concentrated nit ric acid, kept hot by means of the water bath, is a suitable quantity of acid in which to dis solve one kilo o f aluminum nitrate and po tassium nitrate mixed in the proportions in dicated. T h e described salt crystallizes from the concentrated nitric acid solution in the form o f colorless rhombic and monoclinic crystals, which ^re readily soluble in cold or warm water in substantially all proportions. T h ey possess an astringent, slightly metallic taste. This product is further diluted with nine parts of potassium nitrate, and the re sultant mixture is incorporated in the dress ing used in the treatment.
0
Investigations to determine the germi cidal index of the aluminum-potassium nitrate compound resulted in the finding that, when added to culture mediums, this compound assisted and intensified bacterial growth. Anim al tests proved it to be nontoxic, intravenously, subcutaneously, intraperitoneally and orally. “ T h e technic of application consists in applying a plastic dressing directly over the affected area, made up o f a vehicle in which the compound is incorporated.” Ordinary rolled oats, sterilized for tw o hours in an autoclave to prevent sour ing, and heated in an ordinary oven for from twenty to thirty minutes, w ill do. F ifty cubic centimeters o f boiling water to each ounce of rolled oats, stirred until a uniform mass is obtained, with 13 grains of the aluminum-potassium nitrate compound to each ounce o f oats used, produces the, best results. T his dressing is applied about one-eighth inch thick directly to the skin. It extends well
beyond the affected area, and is covered over with waterproofing material such as wax paper or guttapercha. “ T h e dressing should remain in absolute contact with the skin continuously and should be changed as often as it becomes saturated with secretions, and in any case should be changed at least once in thirty-six hours. N o gauze should be interposed between the dressing and the skin.” D r. T horek claims that a simple gauze pack substituted for the plastic vehicle does not produce any of the typical reac tions or effects. T h e effects produced a re: (1 ) erythema in forty-eight h ours; ( 2 ) vesicles and pustules, a few days later, continuing as long as infection per sists in the underlying tissues; ( 3 ) re cession o f the area of reaction when in fection clears in underlying tissues. His theory is that nascent oxygen is liberated from the nitrate ion in its pas sage through the skin into the deeper tissues. Reaction beyond the area of disease w ill not occur, which shows that the compound evidently has a selective affin ity for the point o f infiltration. “ In the case of a small area of osteo myelitis in the middle third of the femur, a dressing applied over the entire fe m ur’s length w ill not produce a typical reaction on the skin throughout the length o f the area covered by the dress ing.” Rapid autolysis at the point of infec tion and increased propagation of bac teria, local leukocytosis and phagocyto sis are the results claimed. T h e virulence o f the organisms decreases rapidly. T h e systemic condition o f the patient im proves and pain soon subsides. T horek advises starting with small doses, gradually increasing until the ni trate tolerance o f the individual is ob tained. O ne hundred and sixteen cases
W a ite—-Practitioner o f Dentistry were reported, including bone tubercu losis, osteomyelitis, postoperative wound infections and some forms of gangrene. T h e results reported are worthy o f consideration, and as several ja w cases are reported in his series, this form of treatment should be tried out at some time to determine its value over our pres ent methods. RESU M E
1. Osteomylitis o f the jaws is a serious disease, characterized by inflammation of the soft parts of the bone and adjacent tissues, liquefaction o f the bone and fo r mation of pus, and, if untreated or im properly treated, may result in deformity. 2. It runs a rather definite course, with periods of subsidence and recru
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descence and generaljy a fair prognosis. 3. T h e etiology is generally traceable to a “ lighting up” o f an old infection in or around a carious tooth or other infec tion ; hence, the importance of the den tist in prevention. 4. T h e micro-organisms most com monly found are staphylococcus, strep tococcus, pneumococcus, Bacillus pyocyaneus, mixed bacteria, etc. 5. Treatm ent is divided into stages o f : (a ) removal of causative factor; (b ) establishment of drainage; ( c ) building up the resistance of the patient; ( d ) hot irrigations; (e ) application of cold ex ternally; ( f ) removal o f sequestrums; (g ) prevention of deformities. 209 Post Street.
THE PRACTITIONER OF DENTISTRY AND DENTAL EDUCATION AND RESEARCH* By FREDERICK C. WAITE,IPh.D., Cleveland, Ohio
N the United States, dentistry, the child of medicine, in the exuberance of infancy left the maternal domicile and declared its independence.
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W hatever may be its present or future relation to medicine, in its historical re lation, it is a part of medicine, and since a child inherits not only the benefits but also, to a certain extent, the obligations of its parent, American dentistry cannot escape certain historical obligations in herent to its coincidence with medicine through many centuries. *A bridged from a paper read before the annual meeting o f the Ohio State Dental Association, Cleveland, Dec. 7, 1927. Re ceived fo r publication Jan. 14, 1929. Jour. A . D . A ., August, IQ2Q
T h e advancement of knowledge is one o f the m ajor functions historically as sumed by medicine and inherited by den tistry. Hence, the dental practitioner has definite historical responsibility to the promotion of learning. R E S P O N S IB IL IT IE S
OF
TH E
IN D IV ID U A L
Each adult individual in normal men tal condition has a series o f personal re sponsibilities. These responsibilities en tail certain duties to fam ily; to the local community of which he is a p a rt; to the larger community, the state, o f which he is a citizen; and to his country. These responsibilities arise either through vol untary contract, as in the fam ily; through