Periodontal Sepsis in Relationship to Systemic Disease

PERIODONTAL SEPSIS IN RELATIONSHIP TO SYSTEMIC DISEASE By R u s s e l l A. S a n d , D.D.S., Fargo, N. D.

H E increased attendance at the sessions of the Section on Perio­ dontia the past several years is very significant, since it reflects the way in which members of the dental pro­ fession are meeting their responsibilities. Dqntistry, a com paratively young pro­ fession, has made almost unbelievable strides in its first century o f existence as a profession largely because its mem­ bers have met the challenge o f increas­ ing demands. As members of this profession, we can be proud of the perfection that restor­ ative technics have reached and o f the developments that are taking place each day in that field. H aving attained a high degree o f perfection in the restoration of lost teeth and tooth structure, modern dentistry is turning more and more to the prevention o f this loss. A patient, although grateful to a surgeon for the skilful removal o f a limb and the subse­ quent provision for a functioning pros­ thesis, would be far more grateful to him could he have saved the lost member. The same holds true for the dentist who can save teeth the retention of which will not prove injurious to the patient’s health. One of the most fertile fields in tooth preservation is that of the pre­ vention and eradication o f disease o f the investing tissues. Probably, as m any teeth are lost today through periodontoclasia as from caries, even though caries is often called the most nearly universal

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Read before the Section on Periodontia at the Eighty-Second Annual Meeting of the American Dental Association, Cleveland, Ohio, September 10, 1940. Jour. A.D.A., Vol. 28, May 1941

disease known to mankind. This being true, there is little wonder that interest in periodontia is constantly increasing. T he relationship o f oral sepsis to sys­ temic disease has undoubtedly more than any other single factor been responsible for elevating the profession o f dentistry to its rightfully deserved place among the healing arts. W hen the theory of focal infection was proved, the dentist emerged from the class o f technician or artisan to become the physician and sur­ geon of the mouth. Study o f the pulpless tooth made the dentist more con­ scious o f the importance o f diagnosis and more careful as to what teeth he allowed to remain in a patient’s mouth. It shall be m y endeavor to show that disease of the investing tissue is of as great impor­ tance as or of greater importance than the pulpless tooth focus. The pulpless tooth is the menace which first enters our mind in thinking of dental foci, and sometimes we over­ look periodontal sepsis in an oral diag­ nosis. In m y opinion, this periodontal sepsis is one of the most vicious foci with which we, as dentists, deal. The very nature o f the disease, a pain­ less, chronic, seemingly innocent condi­ tion, almost brands it menace number one. Should we grant that every pulpless tooth is not infected, we must assume that every tooth affected periodontally is theoretically infected and must be treated or removed to eradicate the ex­ isting infection. W ithout attention, every periodontal lesion remains as a poten­ tial focus and, as such, its importance must not be underestimated in an oral 710

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diagnosis in the search for possible foci. Just as it is easier for the physician to diagnose an acute appendicitis than a low-grade chronic one, it is easier for the dentist to diagnose an acute abscess of a tooth than a hidden chronic condi­ tion involving the supporting structures of the teeth. M ost systemic diseases which might be caused or amplified by a dental focus are traceable to chronic, but active symptomless foci, since the acute, readily apparent foci are usually eradi­ cated because o f the discomfort that they cause locally. Thus, it behooves us in our diagnosis to be especially diligent in evaluating such obscure sources of in­ fection. In dealing with oral foci, m any au ­ thors state that alveolar abscesses (usu­ ally referring to periapical abscesses) are o f greater pathologic importance than periodontal lesions. T o this state­ ment, I take exception, chiefly on the basis of clinical experience, but con­ sidering laboratory theory as well. T h e chief arguments given are that periapical abscesses lack d rain age; are usually symptomless, and therefore often over­ looked ; are subject to the pressure of mastication, which forces their bacterial inhabitants into the blood stream more readily, and, lastly, are blind and local­ ized, and hence a more serious menace than those including soft tissue where expansion is possible. Referring to these arguments: Peri­ odontal lesions are both of the type that lacks drainage and the type that does not. Hence, transmission o f septic m a­ terial can take place ( i ) metastatically, (2) by direct extension through swallow­ ing and (3) by transmission along mucous and serous surfaces. Considering that the gastro-intestinal membranes are merely a continuation of the oral mem­ branes, we must place no little impor­ tance on the condition o f the latter. Furthermore, since periodontal lesions are not walled off as are most periapical

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abscesses, infectious products are readily absorbed into the system. T h e conten­ tion that the alveolar abscess is less symp­ tomatic and more readily overlooked by the patient seems a trifle absurd in con­ sideration o f the high percentage of patients who must be told by their den­ tist that they are suffering from peri­ odontoclasia as compared with those who do not know that they have pulpless infected teeth. In consideration of the pressure of mastication, periodontally in­ fected teeth are, if anything, of greater importance as foci, since the teeth thus affected are usually looser and therefore can mechanically pump more septic m a­ terial into the circulation. T h e argument that periapical abscesses are blind and localized and therefore more severe than one that can expand seems slightly illogi­ cal, since an expanding area continually increases the area o f absorption. Bacteriologically, the periodontal le­ sion seems to present evidence o f being as important a focus as we know. Superficial lesions show streptococci, staphylococci, pneumococci, diplococci, bacilli and amebae. O verlapping gingival disease often causes an association of fusiform bacilli and the spirochete of Vincent. Deeper areas disclose Strepto­ coccus viridans and S. hemolyticus, Staphylococcus aureus and Staph, albus and amebae. T o judge from the types of bacteria isolated from organs and tissue proved to be affected by remote areas of infection, it appears that gingival and periodontal lesions harbor an abundant crop of these same organisms. In general, periodontal lesions m ay harbor nearly all organisms found in the mouth normally, the difference being that, in such a con­ dition of disease, these organisms have a much more fertile field in which to work and become more virulent. Locations of foci usually given are the teeth and their investing tissues, the ton­ sils, the sinuses, the prostate gland and the cervix uteri. O f these, only the

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periapical abscess has less drainage than the periodontal lesion. As the importance of the other possible foci is unques­ tioned, in all our studies and the prac­ tice o f periodontia, the first and fore­ most consideration should b e : Is the lesion affecting the health of the patient? I f it could be, treatment should be gov­ erned accordingly. . For the present, then, let us assume that periodontal sepsis, at least theo­ retically, m ay be a factor in dealing with systemic disease. As a more practical approach to the question, I should like to give m y own impression o f observa­ tions from a ten-year association with a group o f physicians in a private medical clinic. A follow-up o f medical case his­ tories o f patients indicates that the fol­ lowing systemic ailments have been im­ proved or eliminated by the removal of oral fo c i : 1. Chronic physical exhaustion, with characteristic malaise, weakness, nervous exhaustion and prostration on the slight­ est exertion; a generalized feeling that “ the brakes are on at all times.” 2. V ague chronic non-specific gastro­ intestinal disturbances, which have ap­ peared to be the commonest conditions responding to the eradication o f peri­ odontal sepsis. 3. Low-grade, mild appendicitis, chole­ cystitis, glomerulonephritis, chronic diar­ rhea and spastic constipation, which have responded well to the clearing up o f periodontal disease. 4. Cases of arthritis, bursitis, myositis and dermatoses, such as acne. 5. Cases o f subacute bacterial endo­ carditis and other heart lesions, traced to disease o f the investing tissue. 6. Headaches o f certain types. These cases have shown definite improvement after the elimination o f periodontal sepsis and have probably been one of the best controls because, in most cases, no other treatment was instituted during the elimination o f the foci except pal­

liative sedatives. M any theories and ar­ guments might be advanced as to how the elimination o f sepsis could improve headaches. Several influences seem factual, how ever; i.e., in headaches aris­ ing from areas directly affected by oral sepsis, such as sinus, nasal and orbital areas. Another indirect effect o f oral sepsis on headaches is arthritic involve­ ment o f vertebral structures, with asso­ ciated myositis and bursitis. These con­ ditions, which m ay cause pain at the base o f the skull radiating upward along the skull, are m any times due to oral sepsis, the removal of which often elim­ inates or immeasurably improves the symptoms. Auto-intoxication from intes­ tinal stasis and other gastro-intestinal disturbances often causes headaches which can be overcome by the elimina­ tion of oral sepsis. In m y experience, periodontal sepsis is more important than periapical sepsis in this regard. In addition to those conditions already mentioned, we believe, from clinical ex­ perience in our group, that m any other conditions are more or less directly due to chronic oral sepsis and that all non­ specific diseases respond better to treat­ ment when existing sepsis is eliminated. It is virtually impossible, in a private institution, to use patients as controls, but it has been possible in enough cases for us to prove that the elimination of oral sepsis alone will clear up some cases o f systemic disease. Neither has it been possible always to segregate purely peri­ odontal from periapical sepsis, but we have been able to do so in enough cases out of several hundred to at least con­ vince ourselves of its importance. T h e procedure followed was to re­ move still vital, hopeless periodontally involved teeth, and to follow with the removal of non-vital infected teeth after determining a result from the first pro­ cedure. O nly those cases were used in which overlapping medical treatment was negligible or not used at all. The

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results of long-drawn-out periodontal treatment are harder to prove than the results of removal of hopelessly involved teeth because of the greater possibility for other treatment factors to confuse results. Case histories are an effective means o f illustrating the subject matter o f any paper and proving one’s point. I have dozens of histories on file to demonstrate w hat the removal of foci can accomplish in the conditions mentioned. In the handling of any case o f oral sepsis when the systemic condition of the patient is believed to be involved, several factors are extremely important in the eradication of such foci. Among the factors to be remembered are (1) age, (2) sex, (3) history o f previous attacks, (4) duration and character of the disease, (5) heredity, (6) diet, cli­ mate and other extraneous conditions and (7) the last but the most important factor, the systemic tolerance and re­ sistance of the patient. In general, we should proceed slowly in the elimination of focal infection. If removal o f teeth is necessary, only a few should be extracted at one time, the num­ ber depending on the severity o f the local infection. Four is about the maximum. A postoperative flare-up of symptoms indi­ cates the necessity for a longer intervening period before further extractions. W hen­ ever possible, the sepsis is eliminated in one area, either m axillary or mandibular, right or left, at a time. I have found that removal of four teeth from one area, the lower right, for example, pro­ duces less shock than removal of two or three teeth in different areas. The best procedure is first to remove one tooth or treat one area until the patient’s reac­ tion to such treatment has been noted. W hen the resistance is low, it is best to build it up to a reasonable level before elimination of any chronic sepsis is at­ tempted. In cases o f acute disease, with a few exceptions, no attempts at elim­

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ination of sepsis should be made until the acute symptoms have subsided. I f the local pain is intolerable, early elim­ ination of the focus is essential. When acute pericoronal abscesses develop around third molars, there is much less systemic reaction, and a speedier recov­ ery with fewer complications, if these teeth are removed promptly. W e thus establish adequate drainage quickly, rather than employing the common, less effective method of incision over the af­ fected area. I have seen more osteo­ myelitis and septicemia with high tem­ peratures, pulse rate and leukocyte count when incisions have been made into acutely abscessed areas than in those cases where tooth removal provided rapid and complete drainage. These prin­ ciples that I have mentioned apply to any oral focus as well as to those of a purely periodontal nature. In dealing with periodontal sepsis ex­ clusively, we must, more than with any hopeless periapical infection, be very selective in our treatment. When it ap­ pears evident that periodontal sepsis m ay be wholly or partially responsible for an existing systemic condition, the dentist, in consultation with the physician, should determine what method should be used in eliminating the focus. W e have all noted the flare-up o f constitu­ tional symptoms following removal o f an infected tooth. It is short lived in most cases, since the patient’s defenses come to the rescue rapidly and liberation of micro-organisms comes from one in­ sult. Successive curettage of deep periodon­ tal pockets, however, produces a shock at each operation, somewhat the same as if these toxins were injected directly into the system. I have observed several cases in which each periodontal treat­ ment instituted to save questionable teeth caused a flare-up of symptoms over a long period o f time. The rule that I follow in eliminating periodontal

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sepsis in individuals suffering from sys­ temic disease which m ay be due to this focus is th is: When there is suppura­ tion present in well advanced lesions and the prognosis is at best questionable, the patient with little resistance is advised to have the teeth thus affected removed rather than take the risk o f irreparable damage from repeated stirring U p o f in­ fected areas. c o n c l u s io n

I should like to say that it has not been m y intention necessarily to weigh periapical sepsis against periodontal sep­ sis as an important focus, since both are potential foci. However, I cannot too strongly urge that the septic peri­

odontal lesion not be underestimated as a focus of infection. Neither do I wish to seem radical in advising removal of teeth affected periodontally. T h e choice o f a conservative or a radical procedure should be determined by our individual judgment. I f lesions about the teeth can be successfully treated, instead of remov­ ing the teeth, by all means let them be treated. A t all times, we must bear in mind that we are dealing with a tinder box of infection waiting to be touched off by the spark of lowered resistance. T h e science of periodontia blazed the trail in the pioneering venture o f saving teeth. L et it continue this mission in re­ storing health and saving lives. 807 Broadway.

DENTISTRY’S CONTRIBUTION TO INTERAMERICAN RELATIONS By

H a r r y H . P ie r s o n ,

A

Y E A R ago, my present chief, Mr. Charles A. Thomson, addressed this group of scientists. Let me hark back for a moment to what he said in order to give our thought some continuity. Y ou m ay recall that he directed your attention to the grow­ ing feeling throughout Am erica that careful attention should be given to New W orld ties— a mutual desire to draw closer together politically, economically and culturally. Events o f this year have heightened our belief that the course described is the wisest one to follow. Y ou will also recall that, in fostering From the Division of Cultural Relations, Department of State. Read at the annual meeting of the Pan American Odontological Association, New York, N. Y ., December 4, 1940.

Jour. A.D.A., Vol. 28, May 1941

Washington, D . C.

this movement, the Department o f State and responsible private organizations in the field have sought to emphasize three thin gs: education for basic understand­ ing, reciprocity and cooperation. L et us look first at the item of rec­ iprocity ; that is, the mutual recogni­ tion that each culture, north and south, has much to receive and much to give. No one today really knows how much the other American republics have to offer to us of the United States cultur­ ally. I do not believe that a complete study of the subject has ever been made and set down in popular or learned form. Prejudices and misconceptions must first be cleared away and an ob­ jective and receptive attitude must take their place. We must not think that merely be-