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Relationship of Medicine to Dentistry*
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this solution, and though it is still on the acid side (a n eu tra l solution has a Ph. of 7 .0 ), it should approxim ate closely in clinical results the alkaline solution, pro vided the claim ed pu of 6.8 does n o t drop dow n too m uch before the operator in jects it. I t has never been ou r contention th a t the use of a stock solution in local anes thesia is contraindicated o r inadvisable. T h o u g h m any operators have preferred, and very likely alw ays w ill prefer, to use a freshly prepared solution, it is undo u b t edly tru e th a t if a stock solution is devel oped w herein all the know n advantages exist, there can be no logical scientific reason th a t it should n o t be routinely em ployed. T h e present trends in research w ould suggest th a t such a solution m ay be developed.
R E L A T IO N S H IP
O F
F ro m th e tim e E in h o rn discovered novocaine, in 1905, dow n to a few years ago, not m uch properly regulated and controlled research w as done w ith the anesthetic solution. F ran k ly , very little has been accomplished dow n to the pres e n t; b u t if this im p o rtan t problem is to develop as it m ust, it w ill be necessary for qualified institutions and properly trained persons to continue the research. I w ould make a plea to every person here today and to the d en tal profession of the country th a t th o u g h t be given to this study so th a t the tim e w ill soon come w hen there w ill be available an anesthetic solution w hich is rap id in action, effica cious, nontoxic and stable, produces su f ficiently durable anesthesia and is non irrita tin g to tissue. 180 North M ichigan Avenue.
M E D IC IN E
T O
D E N T IS T R Y *
B y E D G A R V . A L L E N , M .D ., R ochester, M in n .
T
H E physician experienced in ex am ination of the eyes know s th a t m uch can be learned fro m these stru ctu res regarding disease in other parts of th e body. T h e ancients regarded the eyes as the “m irro r of the soul,” b u t the m odern physician has dem onstrated in m any instances th a t the eyes are also the m irro r of the body, reflecting various pathologic conditions. T h e sm all aper tu res o r pupils through w hich light reaches the nerves of vision are character istically changed in syphilis of the brain *From the D ivision of M edicine, T h e M ayo Clinic. *Read before the Section on Periodontia at the Seventy-Sixth Annual Session of the American Dental Association, St. Paul, Minn., Aug. 8, 1934.
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and in poisoning from m orphine. W h e n th e physician looks th ro u g h th e pupils w ith a special instrum ent, he m ay see evidence of diabetes, chronic interstitial nephritis, high blood pressure, b rain tu m or, o r tuberculosis, o r of too m any o r too few erythrocytes in the blood. T h e experienced physician w ho ex amines the skin of patients m ay find evidences of too little secretion from the thyroid gland, of diabetes, tuberculosis, syphilis, leprosy, inadequate diet and dis eases of the tw o little glands th a t lie over the kidneys. I t is a tru ism th a t a physician w ho makes such observations w ould render a disservice to th e sick if he trea ted the local condition of th e eyes o r skin w ith o u t attem ptin g to correct th e u n d erly in g sys
A lle n — R elationship of M ed icin e to D en tistry temic condition. T h e correct in terp reta tion of the local conditions m entioned has played no sm all p a rt in elevating the specialties of ophthalm ology and der m atology to their rig h tfu l place in the care of th e sick. D en tistry should also be an integral p art of medicine. I n ac tu al practice, they should n o t be separated any m ore than, fo r example, derm atology and m edi cine. I am n o t interested here in the controversy regarding education of den tists, b u t I am interested, as every dentist and physician should be, in th e practical and u tilita ria n cooperation of these tw o branches of healing. A prim e factor in the accom plishm ent of this is the recogni tion by dentists th a t th e condition of the teeth frequently reflects th e condition of the entire body. W h e n dentists have recognized th a t the condition of the teeth, gums and jaw s m ay indicate scurvy, anemia, m alnutrition , overfunction of the parathyroid glands and sim ilar condi tions, they have ceased being m ere cra fts men and have become doctors of den tistry. I t is too m uch to expect dentists to diagnose systemic conditions about w hich they have n o t been instructed, but it is not too m uch to expect th a t they shall recognize th a t diseases of dental stru ctures m ay be due to general condi tions and n o t to local conditions alone. In any specific instance, the p atien t should be referred to a physician to determ ine the n atu re of a systemic condition. N o r should th e dentist be discouraged by oc casional m anifestations of disinterest on the p a rt of th e physician. H e is some times peculiarly possessive about w h at he considers to be his ow n dom ain, and he may be relu c tan t to accept the w ord of the dentist o r unable to find the systemic condition sought. In addition to purely dental conditions, diseases of structures w ith in the oral cavity may be observed originally by the
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dentist. I t is tru e th a t a d en tist observing a seriously ill p atien t w ith a m em brane on a tonsil w ould call a physician in order th a t possible diphtheria m ight be treated p ro m p tly ; b u t is cooperation so anxiously sought w hen the patient is n ot so seri ously ill or w hen the pathologic condition is n o t so obvious? I t is n o t so im portant th a t the dentist fail to recognize glossitis as a sign of pernicious anem ia and ulcer of the tongue as a m anifestation of car cinoma as it is fo r him to recognize th a t correction of dental disease w ill n ot cure such conditions. F a ilu re to recognize this fact may lead to paralysis from the spinalcord com plications of pernicious anemia, or to spread of the carcinom a to an in curable state ow ing to delay in treatm ent. A n o th er p itfa ll to avoid is acceptance of the w ord of patients th a t th eir ill health is due to d en tal disease. T h e laity has g reat confidence in the ex trac tion of teeth as a cure fo r diverse m ala dies. A s a resu lt of urging, dentists are sometimes led to ex tract teeth for condi tions th a t are n o t produced by dental dis ease. I t is a common belief th a t the fu ll beneficial effects of extraction of teeth are n o t m anifest fo r weeks o r m onths. In m any instances, this is tr u e ; b u t under circum stances of ill-advised extraction, carcinom a o r tuberculosis may m ake alarm ing headw ay, w hile the dental su r geon and the p atien t w a it hopefully for the anticipated im provem ent. T h is point is w orth y of emphasis. I am sure th a t dentists recognize th e im portance of lim iting trea tm e n t to diseases w hich are entirely local, unless they are cooperating w ith a physician. T h u s, they avoid the e rro r of those w ho h an g on the edge of ethical medicine. T h e chiropractor who, by his ow n statem ent, corrects a sup posedly dislocated v ertebra fo r a condi tion recognizable by a physician as tum or of the spinal cord, as an example, is guilty of violation of the confidence of the pa
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tien t in him and of obstructing procedures w hich m ight lead to cure of the condi tion. Before considering the im portance of good teeth, it may be of in terest to review some of the opinions of a prom inent an thropologist, H oo to n ,1 regarding these s tru c tu re s: Y e t our teeth have an illu striou s past; they have a serviceable present, and w ith due conservatism they w ill continue to per form an indispensable function in the fu ture o f man. B u t if hum an dentition breaks dow n, it w ill carry w ith it in its fa ll the hum an species. T h e control of fu tu re evolu tion is n ow in m an’s own hands— or perhaps rather in his teeth.
I f this is true, the dentist is responsible for the fu tu re of the hum an race in no sm all degree. I t is interesting th a t teeth decay in the m outh only du rin g life. A fte r death, they become the m ost nearly im perishable relics of the v ertebrate body. F o r ex ample, if an anim al’s teeth last until death, they w ill continue to defy the destructive action of tim e and the ele ments, sometimes for m illions of years. T h is observation alone justifies some skepticism regarding the theories of local causes of dental disease. PERIAPICAL INFECTIONS
T h e re is no doubt th a t organism s can be dissem inated from the teeth to distant points, w here they produce disease. A single exam ple serves to illu strate this point. I f the germs of a certain ulcerating condition of the bowel are placed in the root canals of the teeth of dogs, these anim als develop w ith in a period of from six to eight m onths a characteristic u l cerating disease com parable in every w ay to its cou n terp art in hum an beings. Sim ilar experim ents have been carried out
by H a r tz e ll2 and Rosenow. T h e general principles of focal infection have been subscribed to by such em inent physicians as C. H . M ayo, Russell H ad e n and the late Jo h n Shaw Billings. Some degree of disrepute has fallen on the tenets of focal infection because of the ex trav ag an t claims of its too enthusiastic protagonists. In certain instances, failure of the patien t to im prove afte r elim ination of periapical infection has led to the belief th a t the la tte r procedure is w orthless. T h is is a short-sighted view. T h e re are oth er foci of infectio n ; namely, the tonsils, prostate gland, u terin e cervix and, occasionally, the gallbladder and appendix. L ittle benefit w ill resu lt if the sources of infec tion around the apices of the teeth are elim inated, w hile infection rem ains in other areas. In this connection, th e dentist should rem em ber th a t the patien t w ho consults him fo r elim ination of dental infection because of rheum atism , fo r ex ample, should be referred to a physician for detection of other foci of infection and fo r general care. A second explanation of unsatisfactory clinical im provem ent after the elim ina tion of periapical disease is the ad vanced stage of th e secondary disease. Jo in ts badly injured by infectious a r th ritis cannot be restored to norm al. T h e pathologic process cannot be reversed and the join ts themselves may serve as second ary foci of infection. T h e prim e requisite in the care of all foci of infection resu lt ing o r appearing to resu lt in systemic disease is early eradication. I t is m uch b etter to lock the door before the horse is stolen. A lthough th e principles of focal infection are fairly generally sub scribed to, th e im portance of eradicating d ental infection w hen a systemic disease
2. Hartzell, T . B.: Practical Things Every Dentist Should Know Regarding Treatment 1. Hooton, E. A .: Apes, Men and Teeth, of Periodontoclasia, J.A.D.A., 16:1466-1474 Scientific Monthly, 38:24-34 (Jan.) 1934. (A ug.) 1929.
A lle n — Relationship of M edicine to D en tistry of possible focal origin does not exist is not ordinarily recognized. M a n y people never attain buoyant health. A s num erous conditions are responsible fo r this state, the physician should bear in m ind that the presence of infected teeth may oc casionally be responsible. I t w ould be far better if all foci of infection were eradicated before the p atient becomes sick. D oubtless, this procedure would reduce the incidence of certain diseases, b ut the p atient is relu c tan t to p a rt w ith teeth apparently causing no trouble, the dentist hesitates to urge th eir removal and all too often the physician assumes a noncom m ittal o r equivocal attitude. T h e loss of a few teeth, if they are dis eased a t the apex, is easily corrected. As long as this is true, hesitancy in eradicat ing periapical infection, even in the ab sence of any general systemic disease, impresses one as unw arran ted . A ny pa tient should accept gladly th e loss of a few teeth if this w ould possibly aid in avoiding such deadly o r incapacitating diseases as bacterial endocarditis or chronic ulcerative colitis. CARIES
Every physician should be interested in the prevention of caries, w hich is a health problem . T o be sure, caries is not a serious condition, as regards disability, b u t neither are m any other conditions encountered in medicine, such as acne, flat feet o r ringw orm . T h e y contribute to the general discom fort and unhappiness of the patient. Carious teeth are not only unsightly and a t tim es painful, b u t they may interfere w ith proper m astication of food and are potent sources of irritation to the tongue and buccal m em branes. In the la tte r instance, they m ay contribute to the incidence of m alignancy in the oral cavity. I may rem ark parenthetically th a t den tists have done the medical profession a
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great service in im proving the.appearance of m any persons. P atients, especially adolescent ones, are very ap t to develop a feeling of inferiority centering around crooked, crow ded, p rojecting or carious teeth. A corollary to this situation is ordinary acne. T h e m ental distress w hich results therefrom fa r outstrips in im por tance the actual disease, w hich ordinarily is of little consequence. P revention or correction of dental deform ity eases the p atien t’s m ind and contributes to his well-being. T e e th are very sim ilar to bone, enamel consisting of 95. per cent o r more, and dentin of 62 per cent of inorganic salts, chiefly calcium phosphate. Caries is chiefly a process of décalcification or re moval of calcium from the teeth. T h e re are three m ain theories regarding the etiology of caries : ( 1 ) the action of acidproducing bacteria, chiefly Bacillus aci dophilus, (2 ) the buffer action, alkalin ity, salt content and rate of flow of sa liva and (3 ) dietary deficiencies. I do not w a n t to en ter into the con troversy regarding the etiology of caries. T h e predom inant evidence strongly sug gests a dietary origin. T h is theory is supported directly and indirectly by ob servations th a t unerupted teeth not ex posed to the action of bacilli or saliva may become carious ; th a t acid sufficient to cause caries cannot be dem onstrated in the saliva; th a t scrupulous care of the teeth does not prevent caries ; th at many persons have profuse grow ths of B acillus acidophilus in the m outh and yet have no caries, and th a t caries can usually be arrested by a suitable diet, although w hen this is done, the organism s in the m outh may not change. A n o th er clinical ob servation of im portance is the occurrence of caries d u rin g pregnancy. As far as I am aw are, there is no change in local conditions at this tim e; yet caries is very likely to occur. I t has been dem onstrated
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th a t this condition, w hich is apparently due to w ith d raw a l by th e fetus of calcium and phosphorus from the m other, can be prevented by adequate adm inistration of m inerals and vitam ins to th e expectant m other. F ro m the experim ental and clinical evidence, it is thus quite clear th a t diet is unquestionably the chief factor in the cause and prevention of caries. T hose who are especially interested in this sub ject are referred to the articles of A r nold,3 H aw kins,4 and Boyd, Z entm ire and D ra in .5 T h e last-m entioned investi gators have show n th a t the degree of reten tion of calcium follow ing ingestion of an adequate diet is highest am ong children w ho do not have caries, next highest am ong those w ith arrested caries and low est am ong those w ho have active caries. In view of this evidence, it is im p o rtant fo r the dentist to have some know ledge of nutrition, in w hich field he m ust make some contact w ith medicine. Each diet should be reinforced w ith from a p in t to a q u art of milk, one egg, one or m ore oranges o r tomatoes, an ounce of b u tter, tw o or m ore helpings of succulent vegetables and of fruits, and cod liver oil. M ilk supplies the calciu m ; the fruits contain vitam ins B and C , and b u tte r and cod liver oil furnish vitam ins A and D , th e la tte r of w hich is im p o rtan t for the utilization of calcium. W h e n milk is secured w ith difficulty, some of the calcium salts, such as the tribasic phos phate, can be used. Irra d ia te d ergosterol o r haliver oil may be substituted fo r cod liver oil. I see no reason th a t every den tist should not instru ct patients w ith 3. Arnold, D. P.: D iet and Dental Caries, J.A.D .A., 70:1420-1423 (Aug.) 1933. 4. Hawkins, H. F .: Relation of D iet to Dental Caries, J.A.D .A., 21:630-635 (April) 1934. 5. Boyd, J. D .; Zentmire, Zelraa, and Drain, C. L.: Bacteriologic Studies in Dental Caries, J. D , Res., 13:443-452 (Dec.) 1933.
caries regarding reinforcem ent of the diet, provided, of course, th e p atien t is not receiving dietary care for some other condition. T h e foods prescribed by the dentist as reinforcem ent of the usual diet can be harm fu l in no way, and the den tist should m anifest no hesitancy in in sisting th a t they constitute a p a rt of the diet of his patients w ith caries and perio dontoclasia. I t should be remembered, of course, th a t such conditions as hyperthyroidism and hyperparathyroidism m ay cause de calcification of bone and, eventually, caries. I f caries does n ot respond satis factorily to dietary and other treatm en t, the services of a physician should be en listed in the search for some m etabolic disturbance th a t could be causal. PERIODONTOCLASIA
W ith o u t being too specific about a sub je c t w ith w hich I am little fam iliar, I w ish to state th a t there is considerable evidence th a t periodontoclasia is in large p a rt a m anifestation of systemic defi ciency. T o be sure, bacteria are very im portant, as has been dem onstrated by H a rtz e ll, b u t they may gain a foothold secondarily. T h e re exists a rough corol lary of this situation in medicine. Scurvy is due to a deficiency of v itam in C . A good description is furnished in Jo h n C olbatch’s6 “A C ollection of Facts, S ur gical and M edical in 1699” : I have frequently been told by some seamen and surgeons, th at having had long voyages at sea, especially tow ard China and the Indies, th at of a hundred men in a ship, not two of them but have been almost eaten up with the scurvy, their skin squalid and full of blotches, their gums eaten away, and their teeth ready to drop out, pains and aches all over their 6. Colbatch, John: Quoted by Hanke, M. T . : Role of Diet in Cause, Prevention and Cure of Dental Caries, J. Nutrition, 3:433-451 (Jan.) 1931.
A lle n — R elationship of M ed icin e to D en tistry bodies, and yet on landing at Cadiz, or thereabouts, where is plenty of oranges and lemons, and eating large quantities of them, in one fortnight’s time at farthest scarcely one has failed of being perfectly cured. T his is not a relation of one or two persons only, but w hat is generally agreed upon, and allowed by all to be truth.
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duce healthy cells by proper nourishment, we can often eliminate the bacteria from the infected areas and keep them outside of the confines of the tissue.
W h e th e r these im plications of the re lationship of n u tritio n to dental diseases are w holly or only p a rtly tru e is of little m om ent. E very p ractitio n er and special ist in dentistry m u st have sufficient T h e essential changes in scurvy are know ledge of n u tritio n to outline to his sw elling and degeneration of the lining patients a diet adequate in vitam ins and of th e sm all blood vessels, as a resu lt of m inerals. T o fail to do so is to disregard w hich the flow of blood is re ta rd e d ; an im portant function of the dentist as a edema, hem orrhage, and congestion oc public health officer. cur, and the tissues are inadequately sup T h e re is a com mon feeling am ong plied w ith oxygen. physicians, and perhaps they have influ T h e r e is considerable evidence th a t enced the dentists in this regard, th a t periodontoclasia is in certain aspects a pyorrheic tissue is n ot a focus of infection m ild type of scurvy due to a deficiency in general systemic diseases such as a r of vitam ins. T h u s, H o w e7 has produced th ritis and colitis. T h a t pyorrheic areas all th e dental conditions w ith w hich the are alive w ith pathogenic bacteria has dentist comes in contact by feeding m on been conclusively dem onstrated by H a rtkeys diets deficient solely in vitam in C, zell and by others, b u t physicians some and H an k e has show n th a t a d ie t rich times feel th a t it is of little m om ent be in vitam ins, particu larly in vitam in C, cause there is “ free drainage.” I am w ill n o t infrequently reduce the thickness quite certain th a t this “ free d rainage” of th e periodontal m em brane and convert does not prevent th e entran ce of bacteria spongy or soft gingival tissue into per into the general circulation. P articu late fectly norm al tissue. m atter, such as dyes, can en ter the lym H an k e has sum m arized the relation of phatic vessels of the leg th ro u g h a super diet to dental conditions as follow s: ficial scratch on th e skin. M onkeys T hese considerations justify the con acquire inflam m ation of th e brain from clusion th a t a deficiency in vitamin C may virus dropped in th e eye. In these in be a very important factor in producing stances, the “ d rain ag e” is b etter th an in pathologic changes in the pulp, in the perio pyorrhea, yet dyes and viruses gain dontal tissue and the gingival tissue. T his access to the lym ph o r blood vessels. immediately throw s a new light on dental disease and releases us from the shackles H a rtz e ll has show n th a t there are many of the rather hopeless outlook th at dental pathogenic bacteria in th e periodontal caries is a purely chemical process oc tissues. Obviously, then, th ere is not free casioned by products of bacterial ferm en drainage, and th e bacteria have ready tation and that spongy gingival tissue and access to the general circulation of the pyorrhea are primarily due to the ravages blood o r lymph. I t is probable, therefore, of bacteria that can hardly be removed th a t pyorrhea is a p o ten t source of in from the mouth. I t lays stress upon the fection and, as far as the physician is metabolism of body cells. If we can pro concerned, should be eradicated fo r the same reasons th a t periapical infections 7. Howe, P. R .: Quoted by Hanke, Footnote are. 6.
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Associated w ith pyorrhea, one often sees loss of m ineral in the m andible and m axilla, a condition recognized m edically as dem ineralization, osteoporosis, or atrophy of bone. T h is bone can be re stored to norm al, for bone w hich has been dedifferentiated into prim itive mes enchyme can be built up into bone again. In general, the form ation of norm al bone is assured in the presence of adequate cal cium, prim itive connective tissue and an adequate blood supply. I f the blood sup ply is entirely cu t off, calcification does not change. I f the blood supply is in creased, décalcification occurs. In perio dontoclasia, it is probable th a t an increase in th e blood supply results from infec tion and relative disuse. In the case of fractu re of bones, it has long been know n th a t use of the bone as soon as possible a fte r fra ctu re leads to calcification. M in o r in ju ry leads to m arked dem iner alization of bone, if the use of the ex trem ity is prohibited ; but calcification oc curs w hen the extrem ity is used in a norm al w ay. A dequate exercise, there fore, is im portant in periodontoclasia. T h is implies excessive m astication as a p a rt of trea tm e n t ; and, accordingly, foods high in roughage are im portant, in addi tion to the local treatm ent recommended by H a rtz e ll.
SUMMARY
D en ta l disease ord in arily does n o t re su lt entirely from local conditions. A s in diseases of th e eye and of the skin, dis eases of the teeth and accessory structures of m astication m ay reflect systemic disease or dietary deficiency. T h e dentist should, therefore, enlist the services of a physician in the search for systemic disease w hen such is suspected. H e should u nderstand enough about n u tritio n to prescribe a diet high in the m inerals and vitam ins necessary in the trea tm e n t of caries and periodontoclasia. T h e dentist should bear in m ind th a t patients seek rep air or extraction of teeth fo r conditions u n re lated to dentistry, and he should be on the alert to sense such situations and to cooperate w ith a physician in the care of the patient. T h e responsibility of the physician in dental disease is no less im portant. Caries, periapical infection and periodontoclasia are im p o rtan t in the general condition of the patient. T h e physician m ust be on the alert to recog nize such conditions and be quick to rec ommend the trea tm e n t of them by the dentist. C oordinated team w ork by d en tist and physician w ill redound to the cred it of both professions an d lead to increased service to the patient.
T R E A T M E N T O F T R A U M A T IC U L C E R S*
B y E D W A R D C. D O B B S , D .D .S ., B altim ore, M d.
T
H E use of silver n itrate, zinc chloride, phenol and sim ilar m edica m ents has not proved satisfactory fo r tre a tin g oral ulcers. T h is may be due *From the Department of Pharmacology and Therapeutics, University of Maryland, School of Dentistry.
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to (1 ) incorrect diagnosis of the cause of the ulcer and (2 ) th e use of one remedy for all types of ulcers. As the etiology of all oral ulcers is not the same, one remedy cannot be expected to be a cureall. B efore an oral ulcer is treated, a diagnosis should be made. T h is
T h e Journal o f th e A m erican D e n ta l Association
this solution, and though it is still on the acid side (a n eu tra l solution has a Ph. of 7 .0 ), it should approxim ate closely in clinical results the alkaline solution, pro vided the claim ed pu of 6.8 does n o t drop dow n too m uch before the operator in jects it. I t has never been ou r contention th a t the use of a stock solution in local anes thesia is contraindicated o r inadvisable. T h o u g h m any operators have preferred, and very likely alw ays w ill prefer, to use a freshly prepared solution, it is undo u b t edly tru e th a t if a stock solution is devel oped w herein all the know n advantages exist, there can be no logical scientific reason th a t it should n o t be routinely em ployed. T h e present trends in research w ould suggest th a t such a solution m ay be developed.
R E L A T IO N S H IP
O F
F ro m th e tim e E in h o rn discovered novocaine, in 1905, dow n to a few years ago, not m uch properly regulated and controlled research w as done w ith the anesthetic solution. F ran k ly , very little has been accomplished dow n to the pres e n t; b u t if this im p o rtan t problem is to develop as it m ust, it w ill be necessary for qualified institutions and properly trained persons to continue the research. I w ould make a plea to every person here today and to the d en tal profession of the country th a t th o u g h t be given to this study so th a t the tim e w ill soon come w hen there w ill be available an anesthetic solution w hich is rap id in action, effica cious, nontoxic and stable, produces su f ficiently durable anesthesia and is non irrita tin g to tissue. 180 North M ichigan Avenue.
M E D IC IN E
T O
D E N T IS T R Y *
B y E D G A R V . A L L E N , M .D ., R ochester, M in n .
T
H E physician experienced in ex am ination of the eyes know s th a t m uch can be learned fro m these stru ctu res regarding disease in other parts of th e body. T h e ancients regarded the eyes as the “m irro r of the soul,” b u t the m odern physician has dem onstrated in m any instances th a t the eyes are also the m irro r of the body, reflecting various pathologic conditions. T h e sm all aper tu res o r pupils through w hich light reaches the nerves of vision are character istically changed in syphilis of the brain *From the D ivision of M edicine, T h e M ayo Clinic. *Read before the Section on Periodontia at the Seventy-Sixth Annual Session of the American Dental Association, St. Paul, Minn., Aug. 8, 1934.
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and in poisoning from m orphine. W h e n th e physician looks th ro u g h th e pupils w ith a special instrum ent, he m ay see evidence of diabetes, chronic interstitial nephritis, high blood pressure, b rain tu m or, o r tuberculosis, o r of too m any o r too few erythrocytes in the blood. T h e experienced physician w ho ex amines the skin of patients m ay find evidences of too little secretion from the thyroid gland, of diabetes, tuberculosis, syphilis, leprosy, inadequate diet and dis eases of the tw o little glands th a t lie over the kidneys. I t is a tru ism th a t a physician w ho makes such observations w ould render a disservice to th e sick if he trea ted the local condition of th e eyes o r skin w ith o u t attem ptin g to correct th e u n d erly in g sys
A lle n — R elationship of M ed icin e to D en tistry temic condition. T h e correct in terp reta tion of the local conditions m entioned has played no sm all p a rt in elevating the specialties of ophthalm ology and der m atology to their rig h tfu l place in the care of th e sick. D en tistry should also be an integral p art of medicine. I n ac tu al practice, they should n o t be separated any m ore than, fo r example, derm atology and m edi cine. I am n o t interested here in the controversy regarding education of den tists, b u t I am interested, as every dentist and physician should be, in th e practical and u tilita ria n cooperation of these tw o branches of healing. A prim e factor in the accom plishm ent of this is the recogni tion by dentists th a t th e condition of the teeth frequently reflects th e condition of the entire body. W h e n dentists have recognized th a t the condition of the teeth, gums and jaw s m ay indicate scurvy, anemia, m alnutrition , overfunction of the parathyroid glands and sim ilar condi tions, they have ceased being m ere cra fts men and have become doctors of den tistry. I t is too m uch to expect dentists to diagnose systemic conditions about w hich they have n o t been instructed, but it is not too m uch to expect th a t they shall recognize th a t diseases of dental stru ctures m ay be due to general condi tions and n o t to local conditions alone. In any specific instance, the p atien t should be referred to a physician to determ ine the n atu re of a systemic condition. N o r should th e dentist be discouraged by oc casional m anifestations of disinterest on the p a rt of th e physician. H e is some times peculiarly possessive about w h at he considers to be his ow n dom ain, and he may be relu c tan t to accept the w ord of the dentist o r unable to find the systemic condition sought. In addition to purely dental conditions, diseases of structures w ith in the oral cavity may be observed originally by the
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dentist. I t is tru e th a t a d en tist observing a seriously ill p atien t w ith a m em brane on a tonsil w ould call a physician in order th a t possible diphtheria m ight be treated p ro m p tly ; b u t is cooperation so anxiously sought w hen the patient is n ot so seri ously ill or w hen the pathologic condition is n o t so obvious? I t is n o t so im portant th a t the dentist fail to recognize glossitis as a sign of pernicious anem ia and ulcer of the tongue as a m anifestation of car cinoma as it is fo r him to recognize th a t correction of dental disease w ill n ot cure such conditions. F a ilu re to recognize this fact may lead to paralysis from the spinalcord com plications of pernicious anemia, or to spread of the carcinom a to an in curable state ow ing to delay in treatm ent. A n o th er p itfa ll to avoid is acceptance of the w ord of patients th a t th eir ill health is due to d en tal disease. T h e laity has g reat confidence in the ex trac tion of teeth as a cure fo r diverse m ala dies. A s a resu lt of urging, dentists are sometimes led to ex tract teeth for condi tions th a t are n o t produced by dental dis ease. I t is a common belief th a t the fu ll beneficial effects of extraction of teeth are n o t m anifest fo r weeks o r m onths. In m any instances, this is tr u e ; b u t under circum stances of ill-advised extraction, carcinom a o r tuberculosis may m ake alarm ing headw ay, w hile the dental su r geon and the p atien t w a it hopefully for the anticipated im provem ent. T h is point is w orth y of emphasis. I am sure th a t dentists recognize th e im portance of lim iting trea tm e n t to diseases w hich are entirely local, unless they are cooperating w ith a physician. T h u s, they avoid the e rro r of those w ho h an g on the edge of ethical medicine. T h e chiropractor who, by his ow n statem ent, corrects a sup posedly dislocated v ertebra fo r a condi tion recognizable by a physician as tum or of the spinal cord, as an example, is guilty of violation of the confidence of the pa
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tien t in him and of obstructing procedures w hich m ight lead to cure of the condi tion. Before considering the im portance of good teeth, it may be of in terest to review some of the opinions of a prom inent an thropologist, H oo to n ,1 regarding these s tru c tu re s: Y e t our teeth have an illu striou s past; they have a serviceable present, and w ith due conservatism they w ill continue to per form an indispensable function in the fu ture o f man. B u t if hum an dentition breaks dow n, it w ill carry w ith it in its fa ll the hum an species. T h e control of fu tu re evolu tion is n ow in m an’s own hands— or perhaps rather in his teeth.
I f this is true, the dentist is responsible for the fu tu re of the hum an race in no sm all degree. I t is interesting th a t teeth decay in the m outh only du rin g life. A fte r death, they become the m ost nearly im perishable relics of the v ertebrate body. F o r ex ample, if an anim al’s teeth last until death, they w ill continue to defy the destructive action of tim e and the ele ments, sometimes for m illions of years. T h is observation alone justifies some skepticism regarding the theories of local causes of dental disease. PERIAPICAL INFECTIONS
T h e re is no doubt th a t organism s can be dissem inated from the teeth to distant points, w here they produce disease. A single exam ple serves to illu strate this point. I f the germs of a certain ulcerating condition of the bowel are placed in the root canals of the teeth of dogs, these anim als develop w ith in a period of from six to eight m onths a characteristic u l cerating disease com parable in every w ay to its cou n terp art in hum an beings. Sim ilar experim ents have been carried out
by H a r tz e ll2 and Rosenow. T h e general principles of focal infection have been subscribed to by such em inent physicians as C. H . M ayo, Russell H ad e n and the late Jo h n Shaw Billings. Some degree of disrepute has fallen on the tenets of focal infection because of the ex trav ag an t claims of its too enthusiastic protagonists. In certain instances, failure of the patien t to im prove afte r elim ination of periapical infection has led to the belief th a t the la tte r procedure is w orthless. T h is is a short-sighted view. T h e re are oth er foci of infectio n ; namely, the tonsils, prostate gland, u terin e cervix and, occasionally, the gallbladder and appendix. L ittle benefit w ill resu lt if the sources of infec tion around the apices of the teeth are elim inated, w hile infection rem ains in other areas. In this connection, th e dentist should rem em ber th a t the patien t w ho consults him fo r elim ination of dental infection because of rheum atism , fo r ex ample, should be referred to a physician for detection of other foci of infection and fo r general care. A second explanation of unsatisfactory clinical im provem ent after the elim ina tion of periapical disease is the ad vanced stage of th e secondary disease. Jo in ts badly injured by infectious a r th ritis cannot be restored to norm al. T h e pathologic process cannot be reversed and the join ts themselves may serve as second ary foci of infection. T h e prim e requisite in the care of all foci of infection resu lt ing o r appearing to resu lt in systemic disease is early eradication. I t is m uch b etter to lock the door before the horse is stolen. A lthough th e principles of focal infection are fairly generally sub scribed to, th e im portance of eradicating d ental infection w hen a systemic disease
2. Hartzell, T . B.: Practical Things Every Dentist Should Know Regarding Treatment 1. Hooton, E. A .: Apes, Men and Teeth, of Periodontoclasia, J.A.D.A., 16:1466-1474 Scientific Monthly, 38:24-34 (Jan.) 1934. (A ug.) 1929.
A lle n — Relationship of M edicine to D en tistry of possible focal origin does not exist is not ordinarily recognized. M a n y people never attain buoyant health. A s num erous conditions are responsible fo r this state, the physician should bear in m ind that the presence of infected teeth may oc casionally be responsible. I t w ould be far better if all foci of infection were eradicated before the p atient becomes sick. D oubtless, this procedure would reduce the incidence of certain diseases, b ut the p atient is relu c tan t to p a rt w ith teeth apparently causing no trouble, the dentist hesitates to urge th eir removal and all too often the physician assumes a noncom m ittal o r equivocal attitude. T h e loss of a few teeth, if they are dis eased a t the apex, is easily corrected. As long as this is true, hesitancy in eradicat ing periapical infection, even in the ab sence of any general systemic disease, impresses one as unw arran ted . A ny pa tient should accept gladly th e loss of a few teeth if this w ould possibly aid in avoiding such deadly o r incapacitating diseases as bacterial endocarditis or chronic ulcerative colitis. CARIES
Every physician should be interested in the prevention of caries, w hich is a health problem . T o be sure, caries is not a serious condition, as regards disability, b u t neither are m any other conditions encountered in medicine, such as acne, flat feet o r ringw orm . T h e y contribute to the general discom fort and unhappiness of the patient. Carious teeth are not only unsightly and a t tim es painful, b u t they may interfere w ith proper m astication of food and are potent sources of irritation to the tongue and buccal m em branes. In the la tte r instance, they m ay contribute to the incidence of m alignancy in the oral cavity. I may rem ark parenthetically th a t den tists have done the medical profession a
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great service in im proving the.appearance of m any persons. P atients, especially adolescent ones, are very ap t to develop a feeling of inferiority centering around crooked, crow ded, p rojecting or carious teeth. A corollary to this situation is ordinary acne. T h e m ental distress w hich results therefrom fa r outstrips in im por tance the actual disease, w hich ordinarily is of little consequence. P revention or correction of dental deform ity eases the p atien t’s m ind and contributes to his well-being. T e e th are very sim ilar to bone, enamel consisting of 95. per cent o r more, and dentin of 62 per cent of inorganic salts, chiefly calcium phosphate. Caries is chiefly a process of décalcification or re moval of calcium from the teeth. T h e re are three m ain theories regarding the etiology of caries : ( 1 ) the action of acidproducing bacteria, chiefly Bacillus aci dophilus, (2 ) the buffer action, alkalin ity, salt content and rate of flow of sa liva and (3 ) dietary deficiencies. I do not w a n t to en ter into the con troversy regarding the etiology of caries. T h e predom inant evidence strongly sug gests a dietary origin. T h is theory is supported directly and indirectly by ob servations th a t unerupted teeth not ex posed to the action of bacilli or saliva may become carious ; th a t acid sufficient to cause caries cannot be dem onstrated in the saliva; th a t scrupulous care of the teeth does not prevent caries ; th at many persons have profuse grow ths of B acillus acidophilus in the m outh and yet have no caries, and th a t caries can usually be arrested by a suitable diet, although w hen this is done, the organism s in the m outh may not change. A n o th er clinical ob servation of im portance is the occurrence of caries d u rin g pregnancy. As far as I am aw are, there is no change in local conditions at this tim e; yet caries is very likely to occur. I t has been dem onstrated
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th a t this condition, w hich is apparently due to w ith d raw a l by th e fetus of calcium and phosphorus from the m other, can be prevented by adequate adm inistration of m inerals and vitam ins to th e expectant m other. F ro m the experim ental and clinical evidence, it is thus quite clear th a t diet is unquestionably the chief factor in the cause and prevention of caries. T hose who are especially interested in this sub ject are referred to the articles of A r nold,3 H aw kins,4 and Boyd, Z entm ire and D ra in .5 T h e last-m entioned investi gators have show n th a t the degree of reten tion of calcium follow ing ingestion of an adequate diet is highest am ong children w ho do not have caries, next highest am ong those w ith arrested caries and low est am ong those w ho have active caries. In view of this evidence, it is im p o rtant fo r the dentist to have some know ledge of nutrition, in w hich field he m ust make some contact w ith medicine. Each diet should be reinforced w ith from a p in t to a q u art of milk, one egg, one or m ore oranges o r tomatoes, an ounce of b u tter, tw o or m ore helpings of succulent vegetables and of fruits, and cod liver oil. M ilk supplies the calciu m ; the fruits contain vitam ins B and C , and b u tte r and cod liver oil furnish vitam ins A and D , th e la tte r of w hich is im p o rtan t for the utilization of calcium. W h e n milk is secured w ith difficulty, some of the calcium salts, such as the tribasic phos phate, can be used. Irra d ia te d ergosterol o r haliver oil may be substituted fo r cod liver oil. I see no reason th a t every den tist should not instru ct patients w ith 3. Arnold, D. P.: D iet and Dental Caries, J.A.D .A., 70:1420-1423 (Aug.) 1933. 4. Hawkins, H. F .: Relation of D iet to Dental Caries, J.A.D .A., 21:630-635 (April) 1934. 5. Boyd, J. D .; Zentmire, Zelraa, and Drain, C. L.: Bacteriologic Studies in Dental Caries, J. D , Res., 13:443-452 (Dec.) 1933.
caries regarding reinforcem ent of the diet, provided, of course, th e p atien t is not receiving dietary care for some other condition. T h e foods prescribed by the dentist as reinforcem ent of the usual diet can be harm fu l in no way, and the den tist should m anifest no hesitancy in in sisting th a t they constitute a p a rt of the diet of his patients w ith caries and perio dontoclasia. I t should be remembered, of course, th a t such conditions as hyperthyroidism and hyperparathyroidism m ay cause de calcification of bone and, eventually, caries. I f caries does n ot respond satis factorily to dietary and other treatm en t, the services of a physician should be en listed in the search for some m etabolic disturbance th a t could be causal. PERIODONTOCLASIA
W ith o u t being too specific about a sub je c t w ith w hich I am little fam iliar, I w ish to state th a t there is considerable evidence th a t periodontoclasia is in large p a rt a m anifestation of systemic defi ciency. T o be sure, bacteria are very im portant, as has been dem onstrated by H a rtz e ll, b u t they may gain a foothold secondarily. T h e re exists a rough corol lary of this situation in medicine. Scurvy is due to a deficiency of v itam in C . A good description is furnished in Jo h n C olbatch’s6 “A C ollection of Facts, S ur gical and M edical in 1699” : I have frequently been told by some seamen and surgeons, th at having had long voyages at sea, especially tow ard China and the Indies, th at of a hundred men in a ship, not two of them but have been almost eaten up with the scurvy, their skin squalid and full of blotches, their gums eaten away, and their teeth ready to drop out, pains and aches all over their 6. Colbatch, John: Quoted by Hanke, M. T . : Role of Diet in Cause, Prevention and Cure of Dental Caries, J. Nutrition, 3:433-451 (Jan.) 1931.
A lle n — R elationship of M ed icin e to D en tistry bodies, and yet on landing at Cadiz, or thereabouts, where is plenty of oranges and lemons, and eating large quantities of them, in one fortnight’s time at farthest scarcely one has failed of being perfectly cured. T his is not a relation of one or two persons only, but w hat is generally agreed upon, and allowed by all to be truth.
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duce healthy cells by proper nourishment, we can often eliminate the bacteria from the infected areas and keep them outside of the confines of the tissue.
W h e th e r these im plications of the re lationship of n u tritio n to dental diseases are w holly or only p a rtly tru e is of little m om ent. E very p ractitio n er and special ist in dentistry m u st have sufficient T h e essential changes in scurvy are know ledge of n u tritio n to outline to his sw elling and degeneration of the lining patients a diet adequate in vitam ins and of th e sm all blood vessels, as a resu lt of m inerals. T o fail to do so is to disregard w hich the flow of blood is re ta rd e d ; an im portant function of the dentist as a edema, hem orrhage, and congestion oc public health officer. cur, and the tissues are inadequately sup T h e re is a com mon feeling am ong plied w ith oxygen. physicians, and perhaps they have influ T h e r e is considerable evidence th a t enced the dentists in this regard, th a t periodontoclasia is in certain aspects a pyorrheic tissue is n ot a focus of infection m ild type of scurvy due to a deficiency in general systemic diseases such as a r of vitam ins. T h u s, H o w e7 has produced th ritis and colitis. T h a t pyorrheic areas all th e dental conditions w ith w hich the are alive w ith pathogenic bacteria has dentist comes in contact by feeding m on been conclusively dem onstrated by H a rtkeys diets deficient solely in vitam in C, zell and by others, b u t physicians some and H an k e has show n th a t a d ie t rich times feel th a t it is of little m om ent be in vitam ins, particu larly in vitam in C, cause there is “ free drainage.” I am w ill n o t infrequently reduce the thickness quite certain th a t this “ free d rainage” of th e periodontal m em brane and convert does not prevent th e entran ce of bacteria spongy or soft gingival tissue into per into the general circulation. P articu late fectly norm al tissue. m atter, such as dyes, can en ter the lym H an k e has sum m arized the relation of phatic vessels of the leg th ro u g h a super diet to dental conditions as follow s: ficial scratch on th e skin. M onkeys T hese considerations justify the con acquire inflam m ation of th e brain from clusion th a t a deficiency in vitamin C may virus dropped in th e eye. In these in be a very important factor in producing stances, the “ d rain ag e” is b etter th an in pathologic changes in the pulp, in the perio pyorrhea, yet dyes and viruses gain dontal tissue and the gingival tissue. T his access to the lym ph o r blood vessels. immediately throw s a new light on dental disease and releases us from the shackles H a rtz e ll has show n th a t there are many of the rather hopeless outlook th at dental pathogenic bacteria in th e periodontal caries is a purely chemical process oc tissues. Obviously, then, th ere is not free casioned by products of bacterial ferm en drainage, and th e bacteria have ready tation and that spongy gingival tissue and access to the general circulation of the pyorrhea are primarily due to the ravages blood o r lymph. I t is probable, therefore, of bacteria that can hardly be removed th a t pyorrhea is a p o ten t source of in from the mouth. I t lays stress upon the fection and, as far as the physician is metabolism of body cells. If we can pro concerned, should be eradicated fo r the same reasons th a t periapical infections 7. Howe, P. R .: Quoted by Hanke, Footnote are. 6.
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Associated w ith pyorrhea, one often sees loss of m ineral in the m andible and m axilla, a condition recognized m edically as dem ineralization, osteoporosis, or atrophy of bone. T h is bone can be re stored to norm al, for bone w hich has been dedifferentiated into prim itive mes enchyme can be built up into bone again. In general, the form ation of norm al bone is assured in the presence of adequate cal cium, prim itive connective tissue and an adequate blood supply. I f the blood sup ply is entirely cu t off, calcification does not change. I f the blood supply is in creased, décalcification occurs. In perio dontoclasia, it is probable th a t an increase in th e blood supply results from infec tion and relative disuse. In the case of fractu re of bones, it has long been know n th a t use of the bone as soon as possible a fte r fra ctu re leads to calcification. M in o r in ju ry leads to m arked dem iner alization of bone, if the use of the ex trem ity is prohibited ; but calcification oc curs w hen the extrem ity is used in a norm al w ay. A dequate exercise, there fore, is im portant in periodontoclasia. T h is implies excessive m astication as a p a rt of trea tm e n t ; and, accordingly, foods high in roughage are im portant, in addi tion to the local treatm ent recommended by H a rtz e ll.
SUMMARY
D en ta l disease ord in arily does n o t re su lt entirely from local conditions. A s in diseases of th e eye and of the skin, dis eases of the teeth and accessory structures of m astication m ay reflect systemic disease or dietary deficiency. T h e dentist should, therefore, enlist the services of a physician in the search for systemic disease w hen such is suspected. H e should u nderstand enough about n u tritio n to prescribe a diet high in the m inerals and vitam ins necessary in the trea tm e n t of caries and periodontoclasia. T h e dentist should bear in m ind th a t patients seek rep air or extraction of teeth fo r conditions u n re lated to dentistry, and he should be on the alert to sense such situations and to cooperate w ith a physician in the care of the patient. T h e responsibility of the physician in dental disease is no less im portant. Caries, periapical infection and periodontoclasia are im p o rtan t in the general condition of the patient. T h e physician m ust be on the alert to recog nize such conditions and be quick to rec ommend the trea tm e n t of them by the dentist. C oordinated team w ork by d en tist and physician w ill redound to the cred it of both professions an d lead to increased service to the patient.
T R E A T M E N T O F T R A U M A T IC U L C E R S*
B y E D W A R D C. D O B B S , D .D .S ., B altim ore, M d.
T
H E use of silver n itrate, zinc chloride, phenol and sim ilar m edica m ents has not proved satisfactory fo r tre a tin g oral ulcers. T h is may be due *From the Department of Pharmacology and Therapeutics, University of Maryland, School of Dentistry.
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to (1 ) incorrect diagnosis of the cause of the ulcer and (2 ) th e use of one remedy for all types of ulcers. As the etiology of all oral ulcers is not the same, one remedy cannot be expected to be a cureall. B efore an oral ulcer is treated, a diagnosis should be made. T h is