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The Differential Leucocyte Count in Chronic Periapical Dental Infection1
THE DIFFERENTIAL LEUCOCYTE COUNT IN CHRONIC PERIAPICAL DENTAL INFECTION1 By RUSSELL L. HADEN, M.D., Kansas City, Missouri
A
T T H E present time the radio indicating the proper procedure to follow graph is necessarily the main de with pulpless teeth. Such teeth may be pendence in the diagnosis of negative in the radiograph and yet be in chronic periapical dental infection. fected since there must be many bacteria Clinicians and dentists agree that pa present before sufficient bone destruction tients suffering from systemic disease of takes place to show in the x-ray. On focal origin should have removed all the other hand teeth around which there teeth which may be a source of infection. is evident bone destruction may have There is a great difference of opinion, become sterile and thus be harmless from however, as to what should be done a s)stemic standpoint. with pulpless teeth which are negative in Attempts have been made to determine the radiograph, and even with teeth toxin absorption from infected foci by which show evidence of infection, in the complement fixation method. Mixed the absence of systemic disease. The cultures or organisms isolated from peri problem is of great concern to both the apical infection are used as an antigen. physician and dentist. It is of special Such procedures have yielded little in interest to the dentist since the patient formation of value. A study of leuco presenting himself to him is so often not cytes of the blood would seem to be a suffering from systemic disease, while more promising method of approach, the reverse is true of a patient coming to since the white corpuscles may respond the physician. quite rapidly when bacteria or products The criteria of systemic disease are of bacterial activity are absorbed by the relatively crude and the physical signs blood. relatively gross. Great damage may be Hecker states that he has observed done to body tissues before the changes tinctorial changes in the leucocytes in are serious enough to be recognized by the presence of dental infection (1). the usual clinical methods. It is ap Logan found a leucocytosis in 47 out of parent that foci which are causing gen 52 cases of periapical infection (2). eral damage should be removed early as Goadby thinks that there is constantly a preventive measure. Some diagnostic an increase in mononuclears in pyorrhea sign which would enable us to determine and systemic disease (3). Daland con whether absorption is taking place from cludes that “small cell lymphocytosis infected areas in the absence of systemic with a corresponding decrease in the disease would be of the greatest value in polymorphonuclear cells is an important diagnostic sign of periapical dental in ’From the Deaner Institute. 596 Jour. A .D . A., July, 1923
Haden— The Differential Leucocyte Count fection, the, value of which is increased when leucopenia exists” (4). This ob server considers that lymphocytosis (38 per cent or more of lymphocytes) indi cates that toxins or streptococci or both are entering the blood stream. He states that he found a lymphocytosis only twice in 100 cases of chronic disease where no focal infection existed. Toren claims to have found a certain type of leucocyte in the blood indicative of infection about the teeth (5). This cell, he thinks, origi nates in the lymph glands draining the infected area. To determine whether we could utilize the findings described by others as a diagnostic measure in chronic periapical dental infection I have made a differen tial leucocyte count on blood films from 200 patients. The films have in every instance been made on cover glasses, a procedure which allows the drop of blood to spread spontaneously and evenly. It is very doubtful whether it is possible to get a true differential blood count where films are made on slides. No films have been used unless there was a uniform spread of the cells with the red cells one cell thick over an area covering at least eight low power fields of the microscope. On each film 500 cells have been counted, hence the study includes a count of 100,000 cells. I have made all counts. The films have been made on seveneighths inch cover slips and stained with W right’s stain as follows: Eight drops of stain are run on the film and left for one minute, eight drops of a phosphate buffer solution of P h 6.4 are then added and left for four minutes. The film is washed with distilled water, dried and mounted film side down in balsam. We have found that the addition of the buf fer solution instead of distilled water to the stain gives remarkably uniform preparations and differentiates very sharply the various types of white cells.
597
The granules of the granular cells are brought out especially brilliantly in films prepared in this manner. In such a study it is apparent that the basis of classification of the leucocytes should be plainly stated. This is not clear in many published reports. Daland, for instance (4), appears to have divided the cells only into 1) mphoc)'tes and polymorphonuclears. Toren in claiming that there is a peculiar type of cell in infec tion about the mouth evidently uses a different classification from other hema tologists, since he finds in normal indi viduals only one-half per cent large mononuclears while others agree on sixtenths per cent. From the standpoint of origin there are three different types of white cells in the blood : ( 1 ) polymorphonuclears coming from the bone marrow, (2) lym phocytes, large and small arising in the lymph glands and (3) true monocytes which include both the large mononu clears and transitionals. The origin of the latter is in dispute but the consensus of opinion is that they are of endotheloid origin (6). The identification of the polymorphonuclears is simple. The same may be said of the small lympho cytes. There is a great deal of con fusion, however, concerning the relation and differentiation of large lymphocytes and large mononuclear cells. In films stained by the technic described above, the mononuclear cells are sharply dif ferentiated. The large lymphocytes have dark blue nuclei and the protoplasm is clear or diffusely blue. The protoplasm may contain azurophile granules, which are a very dark purple color, are usually few in number and show a great varia tion in size. The true large mononu clears, cn the other hand, have relatively larger nuclei which may be round, in dented or saddle bag shaped and usu ally take a lighter stain than the nucleus
598
The Journal of the American Dental Association
of the lymphocytes. The protoplasm has a ground glass appearance due to the uni formly distributed light purplish blue granules which are very fine and of uni form size. The granular appearance has been ascribed as due to nodosities in the reticulum of the protoplasm but seems more likely due to the presence of true granules. The classification we have used has the added value that it can be compared with the very complete study of the normal differential leucocyte counts made by Miller (7). Miller includes the large lymphocytes with the large mononu clears and makes separate classification of the transitionals. The lymphocyte group is thus smaller and the large mononuclear group larger than would be when the cells are classified on the basis of origin. Patients have been grouped as follows: Group I includes 134 patients who showed evidence of alveolar abscess in the dental radiograph. Since we have proven by culture that many such ab scesses are sterile it does not necessarily follow that all the individuals of this group really have periapical infection. Group II includes 66 patients who showed no definite evidence of infection in a radiograph of the teeth. Of the 66 patients in this group 28 had one or more pulpless teeth. Many pulpless teeth which show no radiographic evidence of infection are really infected, so here again the grouping is rather artificial. Group III comprises 47 patients who showed, on careful physical exam ination, definite evidence of systemic dis ease of focal origin. The diseases in cluded are arthritis, neuritis, iritis, pyelonephritis, duodenal ulcer, encephal itis and endocarditis. All patients had pulpless teeth and 36 had periapical abscesses. Group IV includes 53 patients who
were thoroughly examined and found to have no evidence of systemic disease. Of this group 29 had pulpless teeth and 17 had periapical abscesses. Group V comprises 23 patients all of which were proven by cultures to have infected teeth. In every case rabbits were injected and the lesion from which the patient suffered reproduced in the animal. There is every reason to be lieve that the dental infection was the source of the systemic disease. If the differential blood count shows anything typical in focal infection it should cer tainly be evident in this group. The results of the differential counts are shown in Table I. The average white cell count in Group I is 8311 per c. m. m .; Group II, 7800; Group III, 8763; Group IV, 7714 and Group V, 8838. The differential count is re markably alike in the five groups. The average polymorphonuclear neutrophile is 62.2 per cent in Group II and 66.2 per cent in Group V. These are the two groups which one would expect to show the greatest difference. The eosinophiles show much the same variation, being highest in Group V. The basophiles show no change. The lymphocytes show practically the same average throughout the five groups. The average is 26.6 per cent in these patients showing un doubted evidence of disease of focal origin (Group V) and 28.5 per cent in those showing no evidence of infection in the radiograph (Group II). The large mononuclear cells show equally lit tle variation. D is c u s s io n
The results in this series of counts indicate that the patient with alveolar abscesses will have a slightly higher total white count than one who shows no radiographic evidence of infection. If systemic disease of focal origin is pres ent the difference is somewhat more
Haden— The Differential Leucocyte Count TABLE I. GROUP Total Number of Counts Average Total White Blood Cell Count
Distribution of Counts
Polymorphonuclear Neutrophiles
Distribution of Counts
Polymorphonuclear Eosinophiles
Distribution of Counts
Polymorphonuclear Basophiles
Distribution of Counts
Lymphocytes (large and small)
Distribution of Counts
Large Mononuclears and Transitionals (Monocytes)
Distribution of Counts
Over 10,000 8,000-10,000 6,000-8,000 4,000-6,000 Average Over 80% 70-80% 60-70% 50-60% 40-50% Average Over 5% 4-5% 3-4% 2-3% 1-2% Under 1% Average Over 1% 0.4-1% Under 0.4% Average Over 30% 25-30% 20-25% 10-20% Under 10% Average Over 10%
8-10% 6-8%
599
I II III V IV 134 66 47 53 25 8311 7800 8783 7714 8838 % % % % % 11.8 7.5 27.6 9.5 24.0 42.2 33.3 36.2 30.3 44.0 .38.5 52.8 29.8 45.5 20.0 7.5 6.1 6.4 15.2 12.0 64.4% 62.2% 63.9% 64.6% 66.2% % % % % % 2.2 1.5 2.5 0 0 23.9 4.2 12.7 40.0 16.0 47.9 34.8 63.8 32.1 60.0 23.9 36.4 19.2 22.7 24.0 2.2 3.0 2.0 5.2 0.0 1.7% 2.0% 2.3% 1.6% 2.5% % % % % % 3.0 3.0 6.3 0 8.0 3.0 3.0 6.3 8.0 0 8.2 6.1 15.0 9.4 8.0 20.2 30.3 27.7 24.5 36.0 44.8 31.8 25.5 41.5 16.0 20.8 25.7 19.2 24.5 ■ 24.0 0.5% 0.4% 0.4% 0.4% 0.5% % % % % % 3.8 6.0 10.6 16.9 16.0 73.1 72.7 59.5 37.7 28.0 23.1 21.3 29.9 45.5 56.0 27.1% 28.5% 26.0% 27.5% 26.6% % % % % % 29.9 45.5 23.4 35.9 28.0 31.3 24.2 25.5 17.0 40.0 21.6 18.2 38.3 24.5 16.0 16.4 12.1 12.8 22.6 16.0 0.8 0 0 0 0
6.2% %
4.5 5.9 14.2
6.5% %
6.0 12.1 21.2
6.5% %
10.6 23.4 23.4
5.9%
6.3%
%
%
7.5 9.4 15.1
8.0 24.0 16.0
67.2 53.0 19.2 54.7 4-6% 24.0 Under 4% 8.2 7.6 23.4 13.3 28.0 Group I. Patients showing in radiograph definite evidence of one or more infected teeth. Group II. Patients showing in radiograph no evidence of infected teeth. Group III. Patients with infected teeth and systemic disease of focal origin. Group IV. Patients with no evidence of systemic disease of focal origin (17 showed definite areas of rarefaction in dental radiograph, 28 had no pulpless teeth, and 18 had pulpless teeth showing no evidence of infection). Group V. Patients with systemic disease of focal origin which was reproduced in rabbits by bacteria isolated from periapical foci.
600
The Journal of the American Dental Association
marked. This difference is not great enough, however, to be of any definite value in diagnosis and decision as to treatment. A study of the differential counts shows that the increase in white cells ob served is due to a general increase in all types of cells although there is a slight relative increase in the polymorphonu clear cells. There is no relative increase in the lymphocytes and large mononu clear cells. We have found no evidence of any type of cell which is peculiar to focal infection. There is no sufficient clear-cut increase in any one type of cell to make the differential leucocyte count of definite value in the diagnosis of ab sorption from areas of infection. In fact, the study has demonstrated to us that the differential leucocyte count is cf little value in our problem. Sum mary
than those having no abscesses. The difference is somewhat more marked in those patients suffering from systemic disease of focal origin. The increase is, for the most part, in the polymorphonuclears although all types show some increase. Patients suffering from chronic peri apical dental infection do not show typically a lymphocytosis. We have found no evidence of an un usual type of white cell or tinctorial re action in chronic dental infection. The differential count is of little prac tical value in determining whether a patient is absorbing toxins or bacteria from possible foci of infection about pulpless teeth. R eferen ces 1. H
Science. 2.
ecker,
F.
American Journal Medical
L ogan, W. H . G. Journal Allied D en
tal Society,
1916. The results of the stud}' of the white 3. G o a d b y11,, K156, e n n e t h . Journal American cell count and differential count in 200 Dental Association, 9 , 3 7 3 , 5 0 4 , 19 2 2 . patients is presented, 100,000 white cells 4 . D a l a n d , J u d s o n . Journal American having been counted. Medical Association, 77, 1 30 8 , 19 2 1 . Patients with periapical abscesses 5. T o k e n , J u l i u s A . Dental Cosmos, 64, show a slightly higher total white count 9 1 7 , 1 9 2 2 .
A
T T H E present time the radio indicating the proper procedure to follow graph is necessarily the main de with pulpless teeth. Such teeth may be pendence in the diagnosis of negative in the radiograph and yet be in chronic periapical dental infection. fected since there must be many bacteria Clinicians and dentists agree that pa present before sufficient bone destruction tients suffering from systemic disease of takes place to show in the x-ray. On focal origin should have removed all the other hand teeth around which there teeth which may be a source of infection. is evident bone destruction may have There is a great difference of opinion, become sterile and thus be harmless from however, as to what should be done a s)stemic standpoint. with pulpless teeth which are negative in Attempts have been made to determine the radiograph, and even with teeth toxin absorption from infected foci by which show evidence of infection, in the complement fixation method. Mixed the absence of systemic disease. The cultures or organisms isolated from peri problem is of great concern to both the apical infection are used as an antigen. physician and dentist. It is of special Such procedures have yielded little in interest to the dentist since the patient formation of value. A study of leuco presenting himself to him is so often not cytes of the blood would seem to be a suffering from systemic disease, while more promising method of approach, the reverse is true of a patient coming to since the white corpuscles may respond the physician. quite rapidly when bacteria or products The criteria of systemic disease are of bacterial activity are absorbed by the relatively crude and the physical signs blood. relatively gross. Great damage may be Hecker states that he has observed done to body tissues before the changes tinctorial changes in the leucocytes in are serious enough to be recognized by the presence of dental infection (1). the usual clinical methods. It is ap Logan found a leucocytosis in 47 out of parent that foci which are causing gen 52 cases of periapical infection (2). eral damage should be removed early as Goadby thinks that there is constantly a preventive measure. Some diagnostic an increase in mononuclears in pyorrhea sign which would enable us to determine and systemic disease (3). Daland con whether absorption is taking place from cludes that “small cell lymphocytosis infected areas in the absence of systemic with a corresponding decrease in the disease would be of the greatest value in polymorphonuclear cells is an important diagnostic sign of periapical dental in ’From the Deaner Institute. 596 Jour. A .D . A., July, 1923
Haden— The Differential Leucocyte Count fection, the, value of which is increased when leucopenia exists” (4). This ob server considers that lymphocytosis (38 per cent or more of lymphocytes) indi cates that toxins or streptococci or both are entering the blood stream. He states that he found a lymphocytosis only twice in 100 cases of chronic disease where no focal infection existed. Toren claims to have found a certain type of leucocyte in the blood indicative of infection about the teeth (5). This cell, he thinks, origi nates in the lymph glands draining the infected area. To determine whether we could utilize the findings described by others as a diagnostic measure in chronic periapical dental infection I have made a differen tial leucocyte count on blood films from 200 patients. The films have in every instance been made on cover glasses, a procedure which allows the drop of blood to spread spontaneously and evenly. It is very doubtful whether it is possible to get a true differential blood count where films are made on slides. No films have been used unless there was a uniform spread of the cells with the red cells one cell thick over an area covering at least eight low power fields of the microscope. On each film 500 cells have been counted, hence the study includes a count of 100,000 cells. I have made all counts. The films have been made on seveneighths inch cover slips and stained with W right’s stain as follows: Eight drops of stain are run on the film and left for one minute, eight drops of a phosphate buffer solution of P h 6.4 are then added and left for four minutes. The film is washed with distilled water, dried and mounted film side down in balsam. We have found that the addition of the buf fer solution instead of distilled water to the stain gives remarkably uniform preparations and differentiates very sharply the various types of white cells.
597
The granules of the granular cells are brought out especially brilliantly in films prepared in this manner. In such a study it is apparent that the basis of classification of the leucocytes should be plainly stated. This is not clear in many published reports. Daland, for instance (4), appears to have divided the cells only into 1) mphoc)'tes and polymorphonuclears. Toren in claiming that there is a peculiar type of cell in infec tion about the mouth evidently uses a different classification from other hema tologists, since he finds in normal indi viduals only one-half per cent large mononuclears while others agree on sixtenths per cent. From the standpoint of origin there are three different types of white cells in the blood : ( 1 ) polymorphonuclears coming from the bone marrow, (2) lym phocytes, large and small arising in the lymph glands and (3) true monocytes which include both the large mononu clears and transitionals. The origin of the latter is in dispute but the consensus of opinion is that they are of endotheloid origin (6). The identification of the polymorphonuclears is simple. The same may be said of the small lympho cytes. There is a great deal of con fusion, however, concerning the relation and differentiation of large lymphocytes and large mononuclear cells. In films stained by the technic described above, the mononuclear cells are sharply dif ferentiated. The large lymphocytes have dark blue nuclei and the protoplasm is clear or diffusely blue. The protoplasm may contain azurophile granules, which are a very dark purple color, are usually few in number and show a great varia tion in size. The true large mononu clears, cn the other hand, have relatively larger nuclei which may be round, in dented or saddle bag shaped and usu ally take a lighter stain than the nucleus
598
The Journal of the American Dental Association
of the lymphocytes. The protoplasm has a ground glass appearance due to the uni formly distributed light purplish blue granules which are very fine and of uni form size. The granular appearance has been ascribed as due to nodosities in the reticulum of the protoplasm but seems more likely due to the presence of true granules. The classification we have used has the added value that it can be compared with the very complete study of the normal differential leucocyte counts made by Miller (7). Miller includes the large lymphocytes with the large mononu clears and makes separate classification of the transitionals. The lymphocyte group is thus smaller and the large mononuclear group larger than would be when the cells are classified on the basis of origin. Patients have been grouped as follows: Group I includes 134 patients who showed evidence of alveolar abscess in the dental radiograph. Since we have proven by culture that many such ab scesses are sterile it does not necessarily follow that all the individuals of this group really have periapical infection. Group II includes 66 patients who showed no definite evidence of infection in a radiograph of the teeth. Of the 66 patients in this group 28 had one or more pulpless teeth. Many pulpless teeth which show no radiographic evidence of infection are really infected, so here again the grouping is rather artificial. Group III comprises 47 patients who showed, on careful physical exam ination, definite evidence of systemic dis ease of focal origin. The diseases in cluded are arthritis, neuritis, iritis, pyelonephritis, duodenal ulcer, encephal itis and endocarditis. All patients had pulpless teeth and 36 had periapical abscesses. Group IV includes 53 patients who
were thoroughly examined and found to have no evidence of systemic disease. Of this group 29 had pulpless teeth and 17 had periapical abscesses. Group V comprises 23 patients all of which were proven by cultures to have infected teeth. In every case rabbits were injected and the lesion from which the patient suffered reproduced in the animal. There is every reason to be lieve that the dental infection was the source of the systemic disease. If the differential blood count shows anything typical in focal infection it should cer tainly be evident in this group. The results of the differential counts are shown in Table I. The average white cell count in Group I is 8311 per c. m. m .; Group II, 7800; Group III, 8763; Group IV, 7714 and Group V, 8838. The differential count is re markably alike in the five groups. The average polymorphonuclear neutrophile is 62.2 per cent in Group II and 66.2 per cent in Group V. These are the two groups which one would expect to show the greatest difference. The eosinophiles show much the same variation, being highest in Group V. The basophiles show no change. The lymphocytes show practically the same average throughout the five groups. The average is 26.6 per cent in these patients showing un doubted evidence of disease of focal origin (Group V) and 28.5 per cent in those showing no evidence of infection in the radiograph (Group II). The large mononuclear cells show equally lit tle variation. D is c u s s io n
The results in this series of counts indicate that the patient with alveolar abscesses will have a slightly higher total white count than one who shows no radiographic evidence of infection. If systemic disease of focal origin is pres ent the difference is somewhat more
Haden— The Differential Leucocyte Count TABLE I. GROUP Total Number of Counts Average Total White Blood Cell Count
Distribution of Counts
Polymorphonuclear Neutrophiles
Distribution of Counts
Polymorphonuclear Eosinophiles
Distribution of Counts
Polymorphonuclear Basophiles
Distribution of Counts
Lymphocytes (large and small)
Distribution of Counts
Large Mononuclears and Transitionals (Monocytes)
Distribution of Counts
Over 10,000 8,000-10,000 6,000-8,000 4,000-6,000 Average Over 80% 70-80% 60-70% 50-60% 40-50% Average Over 5% 4-5% 3-4% 2-3% 1-2% Under 1% Average Over 1% 0.4-1% Under 0.4% Average Over 30% 25-30% 20-25% 10-20% Under 10% Average Over 10%
8-10% 6-8%
599
I II III V IV 134 66 47 53 25 8311 7800 8783 7714 8838 % % % % % 11.8 7.5 27.6 9.5 24.0 42.2 33.3 36.2 30.3 44.0 .38.5 52.8 29.8 45.5 20.0 7.5 6.1 6.4 15.2 12.0 64.4% 62.2% 63.9% 64.6% 66.2% % % % % % 2.2 1.5 2.5 0 0 23.9 4.2 12.7 40.0 16.0 47.9 34.8 63.8 32.1 60.0 23.9 36.4 19.2 22.7 24.0 2.2 3.0 2.0 5.2 0.0 1.7% 2.0% 2.3% 1.6% 2.5% % % % % % 3.0 3.0 6.3 0 8.0 3.0 3.0 6.3 8.0 0 8.2 6.1 15.0 9.4 8.0 20.2 30.3 27.7 24.5 36.0 44.8 31.8 25.5 41.5 16.0 20.8 25.7 19.2 24.5 ■ 24.0 0.5% 0.4% 0.4% 0.4% 0.5% % % % % % 3.8 6.0 10.6 16.9 16.0 73.1 72.7 59.5 37.7 28.0 23.1 21.3 29.9 45.5 56.0 27.1% 28.5% 26.0% 27.5% 26.6% % % % % % 29.9 45.5 23.4 35.9 28.0 31.3 24.2 25.5 17.0 40.0 21.6 18.2 38.3 24.5 16.0 16.4 12.1 12.8 22.6 16.0 0.8 0 0 0 0
6.2% %
4.5 5.9 14.2
6.5% %
6.0 12.1 21.2
6.5% %
10.6 23.4 23.4
5.9%
6.3%
%
%
7.5 9.4 15.1
8.0 24.0 16.0
67.2 53.0 19.2 54.7 4-6% 24.0 Under 4% 8.2 7.6 23.4 13.3 28.0 Group I. Patients showing in radiograph definite evidence of one or more infected teeth. Group II. Patients showing in radiograph no evidence of infected teeth. Group III. Patients with infected teeth and systemic disease of focal origin. Group IV. Patients with no evidence of systemic disease of focal origin (17 showed definite areas of rarefaction in dental radiograph, 28 had no pulpless teeth, and 18 had pulpless teeth showing no evidence of infection). Group V. Patients with systemic disease of focal origin which was reproduced in rabbits by bacteria isolated from periapical foci.
600
The Journal of the American Dental Association
marked. This difference is not great enough, however, to be of any definite value in diagnosis and decision as to treatment. A study of the differential counts shows that the increase in white cells ob served is due to a general increase in all types of cells although there is a slight relative increase in the polymorphonu clear cells. There is no relative increase in the lymphocytes and large mononu clear cells. We have found no evidence of any type of cell which is peculiar to focal infection. There is no sufficient clear-cut increase in any one type of cell to make the differential leucocyte count of definite value in the diagnosis of ab sorption from areas of infection. In fact, the study has demonstrated to us that the differential leucocyte count is cf little value in our problem. Sum mary
than those having no abscesses. The difference is somewhat more marked in those patients suffering from systemic disease of focal origin. The increase is, for the most part, in the polymorphonuclears although all types show some increase. Patients suffering from chronic peri apical dental infection do not show typically a lymphocytosis. We have found no evidence of an un usual type of white cell or tinctorial re action in chronic dental infection. The differential count is of little prac tical value in determining whether a patient is absorbing toxins or bacteria from possible foci of infection about pulpless teeth. R eferen ces 1. H
Science. 2.
ecker,
F.
American Journal Medical
L ogan, W. H . G. Journal Allied D en
tal Society,
1916. The results of the stud}' of the white 3. G o a d b y11,, K156, e n n e t h . Journal American cell count and differential count in 200 Dental Association, 9 , 3 7 3 , 5 0 4 , 19 2 2 . patients is presented, 100,000 white cells 4 . D a l a n d , J u d s o n . Journal American having been counted. Medical Association, 77, 1 30 8 , 19 2 1 . Patients with periapical abscesses 5. T o k e n , J u l i u s A . Dental Cosmos, 64, show a slightly higher total white count 9 1 7 , 1 9 2 2 .