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The Pulpless Tooth from a Bacteriologic and Experimental Standpoint
THE PULPLESS TOOTH FROM A BACTERIOLOGIC AND EXPERIMENTAL STANDPOINT By RUSSELL L. HADEN, M.D., Kansas City, Missouri
(R ead before the American Dental Association, Dallas, Texas, November 10-14, 1924)
H E thoughtful clinician, in eval uating the pulpless tooth as a fac tor in disease, asks three ques tions: 1. H ow frequently is the pulp less tooth infected; how far can one translate roentgenographic evidence o f infection into terms o f bacteria? 2. Are the bacteria found in areas o f dental infection able to produce dis ease; if so, with what frequency? 3. In individual cases, what experi mental proof is there that a focus o f dental infection bears a causal rela tionship to the patient’s symptoms? T h e answer to these questions must constitute 'the scientific basis fo r de termining the rôle that dental infec tion plays in the causation o f chronic infectious disease. T h e problem is largely a bacteriologic one; yet it is surprising how little data is available concerning the points mentioned. There is not in the literature a single comprehensive bacteriologic study o f dental infection by modern methods; relatively little work has been done to determine the pathogenicity o f mouth streptococci by the correct technic; very little experimental proof con cerning the causal relation o f a focus to a disease in individual cases is avail able except that o f Rosenow and co
T
Jour. A . D . A . , August, 1925
workers and o f Price.1 I have at tempted by cultures o f dental infec tion and by certain animal experi ments to obtain further facts in an swer to the questions asked. These data are presented herewith. TH E
BACTERIOLOGIC
STATUS OF THE
PULPLESS TOOTH
T o determine, if possible, the exact bacteriologic status o f the pulpless tooth, we have cultured the apices and periapical tissues o f a large number o f pulpless teeth. A quantitative tech nic has been employed by which the number o f bacteria present in the tis sues cultured can be determined. The extractions have all been performed by Dr. Charles W . Keeling and Dr. Carl D . Lucas, whose cooperation has made possible this study. T h e technic used in obtaining the culture material is as follow s: The teeth are first thoroughly scrubbed with gauze, and the gums are then painted with tinc ture o f iodin, follow ed by alcohol. The field o f operation is packed off with sterile gauze and the tooth ex tracted with sterile forceps. The apex o f the tooth is cut off with ster 1. Price, W . A . : Dental Infections, Cleveland, Penton Publishing Co., 1923.
918
y ni f , . ^ for * ?«' ftilfr H aden— The Pulpless Tooth
ile forceps directly into a sterile tube
* * '• . S f , the m edium s has been described in
containing about 1 c. c. o f salt solu
tail elsew here.2
tion and a small am ount o f sand.
the root tip in the sterile sand and salt
In tures,
m aking we
technic o f
have
the
bacteriologic
fo llo w ed
Rosenow .
closely
cul the
Each tooth has
solution
is
The
w e ll
the tissue on
.
tube containing
shaken
to
macerate
the tip o f the tooth as
com pletely as possible.
T h e mediums
are inoculated by pouring the salt so lution containing the suspended tissue into a deep tube o f glucose-brain-agar that has been heated and allow ed cool to 4 0 C .
to
T h e small am ount o f
salt solution rem aining in the tube ii then
poured
into
brain broth.
a
tube
of
glucose-
T h e inoculated tubes are
incubated at 3 7
C . fo r fro m twenty-1
fo u r to fo rty -e igh t hours.
T h e agar
tube
determine
is
em ployed
only
to
the number o f bacteria present. appearance o f is shown
in
made
fr o m
m ine
the
The*
such a positive culture F igu re
the
type
1.
broth of
Smears
tube
to
are
deter
organism, and
the
broth culture is then used fo r animal inoculation. In
the statistics to be presented,
I
have included cultures o f the incisors, cuspids
and
bicuspids
only,
since
ex
tractions o f the m olars without mouth contamination
is often
quite difficult.
T h e different steps in the technic have been
repeatedly checked
cally
to detect possible errors.
bacteriologiAs
a
further check on technic, I have con stantly Fig. 1.— A deep tube o f glucosebrain-agar used in quantitative cultures o f dental foci. T h e large number o f colonies, that are distributed through out the tube may be noted.
cultured
vital
teeth
to
deter
mine the percentage o f error. T h e results o f the cultures o f 1 3 0 7 teeth,
m ade
in
the
manner
are shown in T a b le 1.
outlined,
I have not in
cluded in the series any teeth in which
been cultured in deep tubes o f glucosebrain broth and glucose-brain-agar. These mediums afford all degrees o f oxygen tension and are thus especially favorable fo r the growth o f the strep tococci found in chronic focal lesions. T h e technic used in the preparation o f
there was a question o f contamination fr o m
saliva, lips, tongue or otherwise
at the time o f I
have
orrhea.
extraction.
excluded
teeth
Likew ise,
show ing
py
T h e teeth cultured are fairly
2. Iiaden, R. L . : Arch. Int. M ed., 32: 828 (D e c.) 1923.
920 T
The Journal of the American Dental Association 1.-— R
a b le
esu lts
o f
Q
C
u a n t it a t iv e
u ltu r e s
Number Cultured
Group
P
fr o m
e r ia p ic a l
D
Number Showing in Deep A g a r Tube One or more colonies Per Cent
T en or more colonies Per Cent
M ore than 100 colonies Per Cent
I
e n ta l
n f e c t io n
Number Sterile in Broth Per Cent
392
14
5
1
46
Pulpless teeth with negative roentgenogram
490
54
44
24
18
Pulpless teeth with positive roentgenogram
425
70
63
44
9
A ll pulpless teeth
915.
61
51
33
14
T ota l
1307
Vital
teeth
equally
divided
between
vital
teeth,
.
F o u r hundred and tw enty-five pulp
pulpless teeth with negative roentgen-
less
ographic
graphic findings are included. O f these,
with
findings
ings. vital
teeth
with
positive
roentgeno
pulpless
teeth
roentgenographic
find
7 0 per cent showed one or m ore colo
T h r e e hundred and ninety-tw o
nies in the deep agar tube; 6 3 per cent,
positive
teeth
have
and
been
cultured.
O f
ten or m ore colonies, and 4 4 per cent,
these, 14 per cent have show n one or
m ore
m ore colonies in a deep agar tube;
tube. N in e -per cent o f the broth cul
per cent, ten or m ore colonies, and per cent, m ore than
1 0 0 colonies.
5 1 It
than
100
colonies
in
the
deep
tures in this group were sterile.
The
significant
fa ct
findings here
are
the
seems reasonable to take ten or more
that 3 7 per cent o f the teeth with posi
colonies as an arbitrary num ber, as in
tive roentgenographic evidence o f in fe c
dicating
sufficient
tion showed less than ten colonies and
possible
importance
standpoint.
infection fr o m
T h ese
to a
results
be
of
systemic
9 per cent were sterile in broth.
indicate
is evident that, in m any cases, the in
It
also the percentage o f error that must
fection had run its course and healing
be a llow ed fo r in interpreting the re
had taken place as fa r as the bacteria
sults in
are concerned.
pulpless teeth.
The
positive
cultures do not all represent errors in
F o u r hundred ninety pulpless teeth
technic.
Som e o f the teeth considered
w ith
as vital
w ere
ings have
a ll
were
others
not
probably tested
had large
fo r
pulpless since vitality
cavities and
and
m igh t
negative
roentgenographic
been
cultured.
find
F i ft y -f o u r
per cent o f these have had one or more colonies
in
the
deep
agar
tube;
44
w e ll have already had in fected pulps.
per cent, ten or m ore colonies, and 2 4
O f
per
the
broth
cultures
fr o m
teeth 4 6 per cent w ere sterile.
these
cent,
Eighteen
m ore per
than
cent
100
were
colonies. sterile
in
Haden— The Pulpless Tooth broth.
I
m uch
realize
discussion
opinion
that
there
and
difference
concerning
w hat
m ay
921
be
ings,
of
lated into terms o f bacteria;
roentgeno-
w hile
of
tooth
placing teeth in this group.
graphic basis.
taken
a
conservative
w hat
is
positive
attitude
or
as
negative.
to
age
of
positive
cultures.
TH E
The
inci
be
ruled
out
on
PATHOGENICITY
The
striking thing here is the high percent
cannot be
trans
nor can
infection around the tip o f a pulpless
graphic criteria should be em ployed in W e have
aid,
a
roentgeno
OF
TH E
BAC
TERIA FROM DENTAL FOCI To pow er
determine the disease-producing of
the
bacteria
fr o m
dental
dence o f in fection is alm ost as high as
fo c i, w e have injected rabbits with the
in
original broth cultures recovered fr o m
those
graphic tooth
with
positive
findings.
with
roentgeno-
In fec tio n
negative
in
the
roentgenographic
findings is probably m ore serious fr o m the systemic standpoint than when the findings
are positive,
since little
re
sistance in the part o f the body is in dicated more ered
and rapid.
absorption The
have been
culture
or
m ixed
is
probably
organisms
streptococci with
recov in
pure
staphylococci.
O n ly rarely have other organisms been encountered.
the root tip.
rabbits have been
the
culture
fr o m
a
single
tooth
with the m ixed cultures fr o m teeth.
In
m ost instances, the anim als
I f they do not, they are killed at in tervals o f fr o m three to six days a fter the
injection,
and
the various organs
are exam ined ca refu lly fo r lesions. O th e r workers, o f course, have de the
pathogenicity
of
mouth
organisms by the injection o f cultures
tures so made show only the bactério
into anim als.
logie status at the tim e the culture is
H a r tze ll
taken.
most workers have not used, fo r
T h e y tell nothing as to what
or*
several
do not die as a result o f the injection.
term ined
I should like to emphasize that cul
Two
injected routinely with 5 c. c. each o f
Such a study is that o f
and
H en rici.3
H ow ev er, the
was there yesterday, or w h at m ight be
injection, organisms grow n under par
present
tial oxygen tension, or made the in jec
hereafter.
It
m ust
also
be
granted that some o f the negative cul
tions
tures m igh t have been positive i f
de
points are vital i f one is to determine
veloped
the
the
in
other
ways,
although
soon
true
a fte r
pathogenicity
m edium s used are the m ost favorable
isms.
know n
group dealt with
fo r
the grow th
lytic streptococci.
of
nonhem o
Several times dur
in g the past tw o years I have com piled statistics
concerning
the
cultures
when
isolation. of
the
T h ese organ
D isease-producing power in the here is quickly lost
these fun dam en tal requirements
are not m et.
and
W e have been able to reproduce in
the percentages have remained alm ost
rabbits alm ost all types o f lesions that
constant. T h ese
can be caused by the intravenous dis results
show
that
infection
semination
of
bacteria.
The
fr e
is actually present around the root tips, tell som ething about the frequency o f the in fection and give an idea o f the num ber
of
bacteria
present.
T hey
also show that roentgenographic find
3. Hartzell, T . B .; Henrici, A . T ., and Grey, W . A .: Report o f the M outh In fection Research Corps o f the. National Dental Association, J.N .D .A ., 3: 333 (N o v .) 1916.
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The Journal o f the Am erican D ental Association
I so lated
Perc entage o
2
58
34
UAL
CASES
S H IP
OF
OF
PROOF A
DENTAL
S Y S T E M IC
IN
CAUSAL
S 8
18
ii
IN D IV ID R E L A T IO N
IN F E C T IO N
p « .2
§
3
TO
DISEASE
The data so far presented give, in individual cases, no proof o f a causal relationship o f dental infection to sys temic disease. Certainly, the most convincing proof we have o f the re lation o f a focus to a disease is the reproduction in animals, with the or ganism recovered from the patient’s
D
ental
I n f e c t io n .
s Showirlg Lesioris in
24
'oV)
quency with which the main groups o f lesions occur is shown in Table 2. T h e lesion most commonly encoun tered is joint involvement; the sec ond, kidney lesions; the third, muscle; follow ed by lesions o f the endocar dium, myocardium, brain, eye, and stomach and duodenum. T h e inci dence o f involvement in the animal corresponds closely to the incidence o f lesions due to chronic foci as observed clinically in man. In addition to the lesions enumerated, many others have been observed, such as tenosynovitis, cholecystitis, enteritis, bladder involve ment and nerve lesion. The high incidence o f lesions shows clearly the great disease pro ducing power o f the bacteria from chronic foci and leaves no doubt that such organisms are capable in a high degree o f causing disease in man. E X P E R IM E N T A L
from
R a b b it s )
Endocardium
255
761
V
i/ c
Joint
Number o f Number o f Patients Animals Injected
in
9 - 0
.£ m 6
« 18
|
B a c t e r ia
of
( I n tr a v e n o u s I n j e c t io n
Stomach and Duodenum
2 .— L o c a l i z a t i o n
P
able
! > ¡ g"
T
13
focus, o f the condition from which the patient suffers. Such proof con cerns the theory o f Rosenow that bac teria tend to localize in certain tissues o f the body owing to some peculiar inherent property. The truth o f the theory has been conclusively demon strated by Rosenow and his co-work ers. I have been able to present con firmatory results in diseases o f the eye,2 the stomach,4 and the kidney,5 and in cases o f onychia.6 T h e proof seems absolute that bacteria do have such a selective tendency. Those who have questioned the theory after ex perimentation have failed to observe the necessary requirements as far as oxygen tension and rapidity o f work is concerned. The demonstration, then, that animals injected with the bacteria develop lesions similar to those o f the patient is the strongest evidence as to causal relationship and likewise evidence that, in the patient and in the animal, we are dealing with the same organism. T h e proof that, in certain cases, there is this causal relation o f 4. Haden, R. L . : Arch. Int. M ed., 35: 457 (A p r il) 1925. 5. Haden, R. L .: Am. J. M ed. Sc., 169: 407 (M a rch ) 1925. 6. Haden, R. L., and Jordan, W . H .: Arch. Dermat. and Syph., 8: 31 (J u ly ) 1923.
H aden— The Pulpless Tooth
dental infection to systemic disease is best presented by a few cases histories, with the protocols o f animal inocula tions with the organisms recovered from chronic dental foci in the pa tient. These are given herewith. R E P O R T O F CASES C ase 1.— Endocarditis and Auricular Fibrillation. H istory.— L . C . H ., a w idow , aged 60, w orking as a clerk, complained o f heart trouble. She had had chorea first
F ig. 2.— Large vegetations on the heart valves o f a rabbit produced by the intravenous injection o f culture from the teeth o f the patient in Case 1, who was suffering from auricular fibrillation and aortic insufficiency. at 12 years, with recurrent attacks f o r sev eral years. A t 14, she had had diphtheria, and at 23, scarlet fever. Eight years be fore, she had had scleritis. For several years, she had albumin and pus in the urine. A t one time, rem oval o f a kidney was con sidered on account o f the pyuria. T he patient stated she had been well up to 1912, eleven years before admission, when she had a severe attack o f influenza. T w o weeks later, she began to have arthri tis, which persisted f o r six months. She was then w ell f o r several months, after which she began to have attacks o f rapid and ir regular heart. She had to give up work
923
f o r seven weeks at this time on account o f heart symptoms. About once a year, since this initial attack, she had had an at tack o f heart trouble, incapacitating her fo r w ork f o r from six weeks to fo u r months. D uring the past year, the attacks had been occurring every fe w days, lasting a few days at a time. T h e symptoms were worse on exertion. A t times, the ankles were swollen. Recently, the patient had been to the M ayo Clinic, where a diagnosis o f par oxysmal auricular fibrillation was made. Examination.— On admission, there was a definite aortic insufficiency without de monstrable cardiac enlargement. T he heart rate was slow and regular except f o r an occasional extra systole. T he blood pres-
Fig. 3.— Pulpless teeth o f patient in Case 2, who was suffering from severe subacute arthritis. A profuse growth o f streptococci was obtained from both teeth. T he organisms on injection produced a marked arthritis in rab bits. T h e patient recovered completely after the removal o f the infection. sure was: systolic, 140; diastolic, 70. T he urine showed a fe w pus cells in clumps. There were eleven pulpless teeth, only fo u r o f which showed definite roentgen? ographic evidence o f infection. Animal Inoculations.— T h e low er right second bicuspid and first and second molars were extracted first. A ll showed a profuse grow th o f nonhemolytic streptococci. T w o rabbits were injected. One had, at necropsy, a fe w endocardial vegetations, a fe w ab scesses in the medulla o f the kidney and a small amount o f purulent fluid in the joint. T h e other rabbit showed a massive vege tative endocarditis o f the tricuspid valve (F ig . 2 ) , a fe w lesions in the myocardium, and slight involvement o f the joints. One
924
T he Journal o f the American D ental Association
rabbit was injected with the cultures from the low er le ft bicuspid and second molar. A t necropsy, a fe w vegetations on the heart valves, numerous small abscesses in the wall o f the le ft ventricle, a purulent arthritis and a fe w kidney abscesses were found. T w o rabbits were injected with the cul tures fro m the remaining teeth. One was dead the fo llo w in g day. There were many hemorrhages in the endocardium o f the left ventricle, and at the base o f the papillary muscles. There were also a fe w hemor-
and trunk fo llow ed by an arthritis o f thé right wrist. Examination.— When the patient was first seen, all the larger joints and the fin ger joints were red, painful and stiff, and he could walk only with the aid o f crutches. The eyes were injected and painful. There was a raised pink macular eruption with clearing centers over the shoulders, arms, chest and back, resembling erythema multi form e. The leukocytes numbered 13,350. The urine was negative and the Wassermann test negative.
Fig. 4.— A , brain and spinal cord o f rabbit injected with cultures from the teeth o f a patient suffering fro m acute facial paralysis. There is marked injection o f the base o f the brain and injection and hemorrhage in the caudal end o f the cord ; B, photom icrograph o f one o f the cranial nerves at the base o f the brain shown in A . T h e exudate at the base o f the brain partly encircling the nerve may be noted. rhages and small vegetations in the right auricle near the ventricle. T h e other rabbit died tw o days after in jection. A t necropsy, only early vegeta tions on the mitral and the tricuspid valves, and mural thrombi in the right auricle were found. C ase 2.— Chronic Arthritis. H istory.— R. K ., a salesman, aged 27, complained o f rheumatism. He had never been sick until the present illness. T h e tonsils had been removed in 1919, fo u r years before. The present illness had begun fo u r weeks before admission, with an eruption on the hands
There were only tw o pulpless teeth, both o f which showed a profuse growth o f green-producing streptococci (F ig . 3 ). The patient had come in on crutches. He felt better immediately after the teeth were extracted. T he fo llo w in g day, all the joint symptoms had disappeared. T w o days later, he came in again on crutches. Examina tion showed that the sockets were not drain ing, and they were opened again. The symptoms disappeared immediately and did not return. T he skin eruption also cleared up quickly. Animal Inoculations.— T w o rabbits were
H aden— T h e P ulpless Tooth injected. Both, at necropsy, had a marked purulent arthritis and kidney abscesses. The organism injected was recovered in pure culture fro m the join t and kidney lesions. C ase 3.— Acute Facial Paralysis. His tory.— L. M . H ., a plumber, aged 39, com plained o f facial paralysis. One year pre viously, he had suffered from dizzy spells, and, on examination, was fou n d to have albumin in the urine. The facial paralysis had appeared suddenly five days before without any pain. Examination.— T he right side o f the face was foun d to be completely paralyzed. No other cranial nerves were involved. The blood pressure w as: systolic, 130; diastolic, 85. There was no anemia. T he Wassermann test was negative. T h e urine exam ination showed a specific gravity o f 1.023, and albumin fo u r plus, with many granular casts. T h e phenolsulphonephthalein excre tion and the blood urea nitrogen were within the normal limits. T he dental roentgenograms showed fo u r pulpless teeth, all presenting evidence o f periapical in fec tion. Animal Inoculation.— Three rabbits were injected with the mixed cultures from the fo u r extracted teeth. One developed a paralysis o f the hind legs forty-eight hours after injection and was killed. A t necropsy, all organs were negative except the brain and spinal cord, which showed marked in jection, some exudate at the base o f the brain (F ig . 4 ) and hemorrhage in the cau dal end o f the cord. T he second rabbit showed no symptoms at any time, and, at necropsy, only some vegetations on the heart valves were found. T he third rab bit, tw o days after injection, had paralysis o f the left ear and a pericorneal injection, which gradually cleared up. When the ani mal was killed, the only lesions foun d were a purulent arthritis. C ase 4.— Recurrent Hyalitis. History.— L. P., a steam fitter, aged 25, first seen, June 25, 1920, complained o f something flying around in front o f the right eye. This was first noticed about three weeks previously, fo llo w in g an attack o f influ enza, and had become gradually worse. Examination and Course.— T he fundus was not clearly seen. No hemorrhages were present. M any fine dustlike opacities and some larger ones were floating freely
925
in the vitreous humor, also shreds o f hya loid tissue, to which were attached numer ous dustlike opacities. There was no opac ity o f any kind to be foun d in the aque ous humor or on the back o f the cornea, and no inflammation was apparent. Vision in the right eye was 2 0/100. Under treatment, the vision became bet ter, 2 0 /5 0 , and at one time 2 0 /4 0 . Be-
Fig. 5.— A , original culture tube from the tooth shown in B, the tooth o f the patient in Case 4, w ho was suffering from hyalitis; C, photomicrograph o f the organ ism in the agar tube at left. tween June, 1920, and February, 1922, the patient had fou r light attacks, and one severe one, which left the eye almost with out a reflex. These exacerbations did not come on suddenly as they w ould have if they had been recurrent hemorrhages. From the time o f his first visit, the patient was urged to have all his pulpless teeth ex tracted, but several were not removed. A general physical examination, Feb. 24, 1922, was negative. T h e tonsils had been
926
The Journal o f the Am erican D ental Association
removed. Examination o f the blood re vealed: red cells, 4 ,6 32 ,0 0 0 ; hemoglobin, 90 per cent; white cells, 7,400; differential count: polymorphonuclear neutrophils 55.5 per cent; eosinophils, 4.5 per cent; basophils, 2.0 per cent; mononuclears, small, 25.5 per cent; mononuclears, large, and transitionals, 12.5 per cent. T h e urine showed no abnormality and the Wassermann test was negative. Roentgenograms o f the teeth showed that the upper left cus pid (F ig . 4 b) and low er left second bicus pid were pulpless, had a poor canal filling and some bone absorption at the root tip. The low er left lateral incisor was a peg
veloped an exudate in the anterior cham ber and corneal opacities o f both eyes, tw enty-four hours after inoculation. The fo llo w in g day the eyeballs were extremely red (F ig . 6 a) . The right iris was dis colored all the way around and the left partly around with milkish gray exudate (F ig. 6 b ) . There were grayish deposits on the cornea. T he animal was killed. T he necropsy was negative except fo r the eye findings. T he streptococcus was recovered by smear and culture from both eyes. March 5, two more rabbits were inoculated with the streptococcus recovered from the le ft eye o f the preceding rabbit. One de-
Fig. 6.— Eye lesions in rabbits produced by the intravenous injection o f organisms from the teeth o f the patient in Case 4, who was suffering from hyalitis. A , appearance o f eye fo llo w in g the injection o f the original culture. B, eye o f second rabbit injected with the original culture. C, eye o f rabbit with complete loss o f vision due to a hyalitis fo llo w in g the intravenous injection o f the attenuated culture. T he loss o f light reflex may be noted. D , eyes o f rabbit injected one year later with the culture from another tooth o f the same patient. tooth. The root was poorly filled and there was a large alveolar abscess. The three pulpless teeth were extracted. The brain-agar cultures showed no grow th from the low er le ft lateral incisor, and only a fe w colonies fro m the low er left second bi cuspid. The culture o f the upper left cuspid showed an infinity o f colonies o f a non hemolytic streptococcus (F ig . 5 a and c.) Animal Inoculations.■—-March 1, 1922, tw o rabbits were injected with the broth culture from the upper, left cuspid. One developed numerous patches o f choroidoretinitis, and died, three weeks later. The necropsy findings were ascites and very large ;white kidneys. T h e other animal de
veloped circumcorneal injection and a choroidoretinitis, and died thirteen days later. Necropsy revealed only kidney abscesses. T he other animal developed a marked in jection o f both eyes, and died within twenty-four hours. A short chain strepto coccus was recovered, f rom the eye. Two rabbits injected with this, culture died in a fe w hours without showing any localized lesions. T w o rabbits injected with the cul ture from the right eye o f one o f the sec ond, pair o f rabbits developed patches o f choroidoretinitis, a.nd were killed six weeks later. T he other animal developed no lesions. Three weeks after the original apical
H aden— The Pulpless Tooth cultures had been made, organisms were re moved from the agar tube (F ig . 5 a) with a sterile pipet, grow n in broth fo r
927
The red reflex was lost entirely, and there was little pupillary light reflex (F ig . 6 c and 7 b) . T he animal died eight days
Fig. 7.— A , photom icrograph o f eye shown in Figure 6 A . The cellular infiltration in the choroid may be noted. B, photomicrograph o f eye shown in Figure 6 C. The cellular infiltration in the vitreous humor may be noted. twenty-four hours and injected into three rabbits. One developed a cloudy vitreous humor and died fo u r days after inocula tion. Necropsy revealed arthritis. The second animal showed a pericorneal injec tion, three days after inoculation. T he iri tis gradually cleared. The vitreous humor o f the right eye became increasingly hazy.
Fig. 8.— Bicuspid tooth o f patient in Case 5, who was suffering from an acute pyelonephritis. T h e tooth was negative in the roentgenogram, yet from the root tip a profuse growth o f streptococci was obtained.
after inoculation. Necropsy was negative except fo r the eye findings. T h e patient’s vision at the present time is 15/100. C ase 5.— Acute Pyelonephritis. His tory.— W . W ., a medical student, aged 34, stated that two weeks previously he had
Fig. 9.— Kidney o f rabbit fo llo w in g the intravenous injection o f culture from- tooth shown in Figure 8. T he abscesses in thé medulla may be noted.
928
T he Journal of the Am erican D ental Association
suffered from frequent burning urination, hematuria, chills and fever as high as 102F. T h e symptoms improved at first under medication, but the chills and fever recurred. He had had a similar attack, nine years previously. There had been no other illness. T he tonsils were cleanly removed. Examination.— T h e physical examination was negative. T h e urine showed gross blood, many pus cells and a short chain streptococcus, which was recovered by cul ture. One bicuspid tooth (F ig . 8 a) held a large inlay under which the pulp had
Fig. 10.— Photomicrograph o f lesion medulla o f kidney shown in Figure 9.
in
died. There was no area o f rarefaction at the tip. T he tooth was extracted. From the tip a pure culture o f a green-produc ing streptococcus ( Streptococcus1 fecalis) was obtained. Animal Inoculations.— -Tw o rabbits were injected with the culture o f the streptococ cus. One showed at necropsy multiple ab scesses in the pyramids and a purulent arthritis (F ig . 8 b ) . T he other showed an acute hemorrhagic nephritis and a fe w en docardial vegetations. T he urine became normal, and there have been no further symptoms. C ase 6.— Duodenal Ulcer. H istory.— H. A . A ., a business man, aged 44, had sev eral gastric hemorrhages in December, 1922. For six months previous to this, he had had indigestion, consisting principally
o f a feeling o f fulness after eating. A diagnosis o f duodenal ulcer was made. Several teeth were extracted at this time. There were no further hemorrhages, and the symptoms were largely relieved, al though the patient stated that he still had indigestion at times, f o r which he took soda. Roentgenograms taken in June, 1924, showed one tooth o f questionable vitality and one pulpless tooth with little roentgenographic evidence o f infection. A t the site o f extraction o f the upper left first bicus pid and first molar, some fillin g material remained, and the surrounding bone showed evidence o f infection (F ig . 9 c ) . T h e tw o teeth were extracted and the in fected bone curetted. Cultures in deep tubes o f glucose-brain-agar showed a short chain streptococcus in all. Animal Inoculations.— T w o rabbits were inoculated with the mixed broth cultures. One rabbit was dead the fo llo w in g morn ing and showed many hemorrhages in the duodenum. T h e second rabbit was killed. This one showed also many hemorrhages in the first third o f the duodenum without lesions elsewhere (F ig . 9 a ) . In order to determine whether the area o f infected bone might play a part in the causation o f the ulcer, one rabbit was injected with 5 c. c. o f the broth culture from this area only. A t necropsy, twenty-four hours later, the duodenum showed massive hemorrhages (F ig . 9 b ) . There were no other lesions. C a s e 7. — M ultiple Onychia. H istory.— M . K ., a housewife, aged 51, was first seen in regard to her present infection, Jan. 10, 1922. She gave no history o f the acute in fectious diseases o f childhood. Until three years before, she had led an exceedingly ac tive life on a farm . She had had palpita tion o f the heart and soreness in the chest fo r many years. A t intervals during the last twenty-three years, she had had painful swellings o f the larger joints. She had had nycturia two or three times, without pain on voiding. T w elv e years before, she began to have trouble with her finger nails. This con sisted o f swellings, redness and tenderness around the nail roots. A t times, pus could be expressed. T h e nails o f all the fingers were successively involved, as w ell as the nails o f the great toe on the left fo o t. The infection usually ended with exfoliation o f the nail. There was no history o f injury
H aden— T h e Pulpless Tooth or o f the use o f irritating substances. T he trouble had continued until five years be fore, when the patient was referred f o r den tal treatment. Four teeth were fou n d to have periapical abscesses and were extracted. One tooth, although pulpless, was negative roentgenographically, and was filled and allow ed to remain. A fter the dental treat ment, all the active nail lesions cleared up, as did the arthritis.
929
was rapid; and the sounds were distinct with a tendency to gallop rhythm. T he b lood pressure was: systolic, 110; diastolic, 65. A blood count showed 5,592,000 red blood cells, 4,950 white cells and 90 per cent hemoglobin (norm al standard). A differential count o f 500 cells showed: polymorphonuclear neutrophils, 58 per cent; eosinophils, 1 per cent; basophils, 0 ; large
Fig. 11.— A , duodenum o f rabbit injected with the mixed cultures from patient m Case 6, who had had a duodenal ulcer. T h e numerous hemorrhages in the duodenal bulb may be noted. B, duodenum o f another rabbit fo llo w in g the injection o f the culture from an area o f infected bone only from the same patient. C, area o f infected bone the culture from which produced the lesion shown in B. D , photomicrograph o f the lesion shown in A. Jan. 10, 1922, the patient returned be cause she had begun to have pain and red ness around one finger nail. She was also having palpitation o f the heart. She now had no joint symptoms. Examination.— T h e middle finger o f the le ft hand showed marked swelling and red ness around the nail root. The nail was tender on pressure. No pus could be ex pressed. There was no glandular enlarge ment. T he right tonsil was red and showed a fe w plugged crypts. T he heart action
mononuclears, 7 per cent; and lymphocytes, 34 per cent. T h e Wassermann test was negative. A roentgenogram o f the teeth revealed areas o f rarefaction around the roots o f the low er right molar. A ll other teeth were vital. There was no pyorrhea. O utcom e.— T he low er right second m olar was extracted. T he nail infection quickly subsided. A urine examination, six weeks later, showed no albumin or pus cells. T he palpitation o f the heart disappeared. T he
930
The Journal of the American Dental Association
patient was seen several months later. There had been no return o f the nail infection. Animal Inoculations.— A culture on blood-agar o f the roots o f the extracted tooth showed a profuse growth o f Strepto coccus nonhemolyticus 1 (H olm a n ). Jan uary 13, one rabbit was injected intraven ously with a broth culture o f the organ-
There was hemorrhage around the nail roots o f the other toes o f the same foot. T he other toes were normal. A drawing o f the section o f the toe that revealed grossly the most marked change is shown in F ig ure 9 b. T he nail was removed before the section was cut. T h e area o f polym or phonuclear leukocyte infiltration is evi dent (F ig . 10 c ) . The of
organism
the first
others.
recovered
rabbit
T hese
was
show ed
m uscle
a purulent
arthritis and
kidney,
no
The
but
organism
fr o m
in jected
jo in t
into
tw o
hem orrh age,
abscesses o f
in v olv em en t was
the
carried
of
the
th rou gh
the nails. tw o
m ore sets o f rabbits, w ith sim ilar results. SU M M ARY
Fig. 12.— T o e o f rabbit injected with the culture from the tooth o f patient in Case 7. T he swelling o f the toe is indicated by the arrow. ism. Four days later, a second injection was given. Eight days after the first in jection, the animal was killed. T he post mortem examination revealed hemorrhages in the lumbar muscles, a fe w small abscesses in the cortex o f the kidneys and purulent fluid in the shoulder joints. T he organism was recovered in pure culture from the joint fluid. Around the nail root o f the second toe o f the left fo re foot, there was marked swelling and injection (F ig . 10 a ) .
AND
C O N C L U S IO N S
A very high percentage of teeth that are negative roentgenographically harbor infection. The roentgenogram should thus never be depended on to eliminate a tooth as a possible focus of systemic disease. A fairly large percentage of teeth that are positive roentgenographically did not harbor any infection or suffi cient infection to be a factor in sys temic disease at the time the culture was taken. In such cases, the infec tion has probably run its course and become bacteria free, as happens in in fections elsewhere in the body. The periapical tissues of a certain percentage of pulpless teeth, either pbsitive or negative roentgenographi cally, are sterile when cultured in glucose-brain broth. This does not prove that such are really sterile since some other method of culture might reveal organisms. The findings sug gest, however, that a pulpless tooth is not necessarily infected. The bacteria concerned in chronic foci are quite pathogenic as judged by their ability to produce lesions in ani mals on intravenous injection. In selected cases, one can prove an
931
Haden— The Pulpless Tooth
Fig. 14.'— Photom icrograph o f lesion around the base o f nail. o f polymorphonuclear infiltration is indicated by the arrow.
T h e area
932
The Tournai of the American Dental Association
unmistakable tendency of bacteria from chronic foci to localize in cer tain parts of the body. These cases afford valuable experimental proof of a causal relation of a chronic focus to systemic disease. D ISCU SSIO N
W eston A . Price, Cleveland, O hio: T o start the questionnaire I w ill ask D r. Haden tw o questions. In the culturing o f teeth that have been extracted, do you feel you are pretty safe in concluding that by bathing them in iodin or alcohol or both the percentage that carried infection was re duced? D r. H aden: I think the answer to that is fou n d in the results o f the cultures o f the vital teeth, and that is the crucial part o f the entire study. In vital teeth, we get a small percentage o f positive cultures, and it is only fa ir to conclude our percentage o f contami nations w ould not be greater in pulpless than in vital teeth. D r. P rice: In your chart, you show in fec tions with ten colonies or more. W ou ld you explain again w hy you have not counted those fro m one to ten? D r. H aden: A pathologic study o f this kind should not be confused. One has to select a way o f doing things, do them that way, and then record the findings. What we all are interested in is knowing something about the numbers o f bacteria and trying to differentiate the teeth we think harbor enough bacteria to cause disease. T o me, it seems a wise thing to differentiate the way indicated from our standpoint; that is, those that had ten or more colonies and those that had more than 100, because it gives a concrete idea o f the extent o f the infection.
D r. H ert: There was 23 per cent to the eye and then something went up to 18, and I think the stomach and duodenum went up to 12 or 13. D r. H aden: I think you referred to the first chart, which included all animals in jected. In that group, including all pa tients, the incidence o f peptic ulcer was 13 per cent. T he elective ■localization chart was made by dividing the b ig group into tw o groups, namely, the animals injected with cultures from patients who did not have peptic ulcer, and those injected with cultures from patients w ho were suf ferin g from peptic ulcer. In the first group, only 7 per cent o f the animals developed peptic ulcer; in the latter, 53 per cent were similarly affected. Clifford Rudine, Salt Lake City, Utah: W hen a patient has a kidney lesion and, as fa r as physical examination is concerned, shows nothing else, and you discover an infected tooth and make an inoculation in the rabbit, does it show anything except the kidney infection? D r. H aden: Frequently such an injec tion w ill produce more than one lesion. M any o f the animals, however, have only single lesions. In the case I showed you, the animals had no lesions except the kidney lesion. One thing that I think should be emphasized is the clinical study o f the pa tients. One finds pus cells in the urine and other evidence o f kidney trouble, when the patient does not complain o f , or know that he has, a kidney infection. It is the rule to find more than one lesion in patients suffer ing from fo ca l infection.
D r. P rice: It is sometimes as important to have the question asked as to have it an swered f o r the reason that some workers, in making determinations as to whether or not localization has taken place, are reporting B. S. H ert, Rochester, N. Y .: In the that only those cases show localization that chart shown on the screen, the localization show only one lesion— the one they are look was reduced in percentage from the left ing fo r . Let me illustrate: W e inoculated hand side to the right hand side.T he last thirty rabbits from the culture o f the pulp two were on the eye, and stomach and duo o f the tooth o f a boy who was brought to denum. I understood they were incorrect. us f o r rheumatism. He had definite joint W hy were they incorrect and the others cor lesions. His physician, or at least the nurse rect? who brought him in, did not report and D r. H aden: I did not mean to say they probably didn’t know that he had heart were incorrect. These charts presented what trouble. Had we been lookin g f o r heart conditions only, we w ould have been able we found.
Haden— The Pulpless Tooth to use, on this last basis, only tw o rabbits. Tw enty-eight o f the thirty developed heart lesions and tw o o f the thirty developed joint lesions. Incidentally the boy was dead in a fe w months from endocarditis. Supposing we were making our determination on that case and threw out the twenty-eight cases o f arthritis because they also had heart in volvements, do you see h ow clearly we w ould be misinterpreting the facts in the case? D r. Rttdine: diagnosis?
W ill
that
develop
in
the
D r. H aden: T h e diagnostician should be very cautious in assuming that the patient has o r w ill have lesions similar to those foun d in the inoculated animal. S. W . W herry, Ogden, Utah: D o you find, in inoculating through the tooth and injecting a rat or rabbit, that you get more heart lesions o r kidney lesions than you do from the intravenous injection? D r. H aden: This cannot be done on rab bits and guinea-pigs, but has been done on dogs. I do not think enough w ork has been done to ju stify us in draw ing any conclu sions, except, to say that it has been shown that lesions such as these can be produced. D r. P rice: D r. Meisser gave a paper on that subject and he has the reports n ow on 100 dogs that were inoculated. He has produced lesions by inoculating the pulp chamber o f the tooth, letting the dog carry the tooth fo r months and months, and he has a high percentage o f localization. This other is also important and interesting. When he produced pulpless teeth in the dogs and they were healthy, the pulpless teeth did not become infected in afe w months unless he infected some other tooth in the same dog. Then theyalways became in fected. M em b er: Isn’ t a 5 c.c. dose o f pure cul ture an overdose f o r a rabbit w eighing, say, 1,500 gm.? D r. H aden: Th at is a very fair dose. D r. Rosenow has used up to 75 c.c., but we use on ly 5. This is a b ig dose— much more than a patient ever gets at one time, but I think it is a perfectly fair amount to use to get comparative data in the cases
933
studied. Patients are receiving small doses over a lon g period o f time instead o f a single large dose such as is given the rabbit. R. W . Bunting: T h e w ork in our school along this line has been done largely by Drs. Rickert and Lyons. However, I am much interested, and I know D r. Rickert w ill be, in this statement o f specific localiza tion from typical cases that have occurred under D r. Haden’ s observation. In an in terjectory remark made concerning one o f the early slides, he stated that he thought it possible, that such conditions might heal o f themselves. I have wondered upon what he based his opinion and i f he had any actual evidence that some o f these cases o f root-end infection, could be permanently cured especially those in which there is an incomplete fillin g and considerable space at the end o f the root o f the teeth fo r residual infection. Possibly, I misunderstood him. D r. H aden: I did make such a statement. I know little about dental tissue pathology, but I base the statement upon several facts. T h e area with granulated tissue, in itself, is evidence o f a reparatory process on the part o f the body. T he obtaining o f sterile cul tures, and other w ell recognized facts con cerning bone infection elsewhere in the body are added evidence. In chronic osteomyelitis, healing certainly takes place, even in the presence o f a great deal o f infection. This statement is true only o f the low grade in fections. D r. Bunting: I should like to have your opinion as to this particular point o f view : In all other form s o f osteomyelitis, the body defenses are able to reach the process; D r. Price says that unless the body processes ab sorb all the portions o f the tooth that are infected, they cannot reach the source, al though residual infection in unfilled por tions o f the root end may become dormant, and may be hemmed in by the scar and granulation tissue. Whenever, as D r. Price says, these protective forces decrease or whenever the organisms increase, there is a possibility that, at any time, these infections, livin g like cave-dwellers, may come out to attack the surrounding tissues. T o me, it seems that root-end affections are different from other form s o f osteomyelitis, and the only hope I can see is to treat pulpless teeth so that infection does not occur. I have no
934
The Journal of the American Dental Association
hope or confidence in any tooth that has a residual infection that cannot be reached by medicaments or cannot be removed by sur gical operation. D r. P rice: T o fo llo w up your last point: D o you deem it possible to sterilize infected cementum while the tooth is in the mouth? D r. Bunting: I was not speaking o f ce mentum because there are many infections in which the cementum is not seriously in volved. I f the cementum is extensively in volved, I w ould either amputate or extract. But when the cementum is not involved, I have reason to believe, fro m the w ork o f D r. Rickert and from bacteriologic evi dence, that such a tooth can be sterilized and can be made permanently stable as fa r as control o f an infective process within the tooth is concerned. When this is done, the body has an opportunity to take care o f whatever infective processes may be in the periapical tissues, unless there is a large amount o f periodontal tissue involved, in which case it must be treated surgically, either by amputation or b y curettage simi lar to the surgical treatment o f pyorrhea. Such an area w ill never heal spontaneously any m ore than a pyorrhea pocket w ill heal unless there is surgical interference. D r. Price: H ow large an area would you consider too large? D r. Bunting: I cannot say. I f it went over the convex surface at the end o f the root o f the tooth, I would want such a case in m y ow n mouth treated surgically. D r. H aden: As regards the point Dr. Bunting brings up, I do not believe there is
any data published that covers this point. What we need is more w ork and more con scientiously prepared data. I have no fa rreaching conclusions to draw. I have sim ply attempted to present the results o f the w ork that has been done up to the present time. •S'. H . B rock, Dallas, T exas: W ith a re construction o f the bone tissue after the granuloma, say, fou r, five or six months after the cast, is the reconstruction bone tis sue still infected? D r. Price: I w ill answer that by asking you the explanation o f this case: I w ill show you by the slide here a tooth that in April, 1923, was painfully abscessed. A woman developed the influenza. T h e tooth ceased to be sore. T h e record I made a year later showed the bone filled in, and the tooth be came seriously infected. T he woman had a nervous breakdown. M y answer is that the fillin g in o f bone around the root o f a tooth is one o f the most misleading and un certain pathologic conditions with which we have to deal. In the second place, I have drilled fo r one-fourth inch into such con ditions that had the area fo r several years, in a tooth which I had filled a number o f years before. A fter this filled in and the bones became dense right down on the tooth, the woman was in bed with arthritis. I sent f o r her and took out the tooth and took cultures from the bone, one-eighth and one-quarter inch in three directions, and got the same stress. So my judgment is, from that and many other cases, that such bone may be infected.
(R ead before the American Dental Association, Dallas, Texas, November 10-14, 1924)
H E thoughtful clinician, in eval uating the pulpless tooth as a fac tor in disease, asks three ques tions: 1. H ow frequently is the pulp less tooth infected; how far can one translate roentgenographic evidence o f infection into terms o f bacteria? 2. Are the bacteria found in areas o f dental infection able to produce dis ease; if so, with what frequency? 3. In individual cases, what experi mental proof is there that a focus o f dental infection bears a causal rela tionship to the patient’s symptoms? T h e answer to these questions must constitute 'the scientific basis fo r de termining the rôle that dental infec tion plays in the causation o f chronic infectious disease. T h e problem is largely a bacteriologic one; yet it is surprising how little data is available concerning the points mentioned. There is not in the literature a single comprehensive bacteriologic study o f dental infection by modern methods; relatively little work has been done to determine the pathogenicity o f mouth streptococci by the correct technic; very little experimental proof con cerning the causal relation o f a focus to a disease in individual cases is avail able except that o f Rosenow and co
T
Jour. A . D . A . , August, 1925
workers and o f Price.1 I have at tempted by cultures o f dental infec tion and by certain animal experi ments to obtain further facts in an swer to the questions asked. These data are presented herewith. TH E
BACTERIOLOGIC
STATUS OF THE
PULPLESS TOOTH
T o determine, if possible, the exact bacteriologic status o f the pulpless tooth, we have cultured the apices and periapical tissues o f a large number o f pulpless teeth. A quantitative tech nic has been employed by which the number o f bacteria present in the tis sues cultured can be determined. The extractions have all been performed by Dr. Charles W . Keeling and Dr. Carl D . Lucas, whose cooperation has made possible this study. T h e technic used in obtaining the culture material is as follow s: The teeth are first thoroughly scrubbed with gauze, and the gums are then painted with tinc ture o f iodin, follow ed by alcohol. The field o f operation is packed off with sterile gauze and the tooth ex tracted with sterile forceps. The apex o f the tooth is cut off with ster 1. Price, W . A . : Dental Infections, Cleveland, Penton Publishing Co., 1923.
918
y ni f , . ^ for * ?«' ftilfr H aden— The Pulpless Tooth
ile forceps directly into a sterile tube
* * '• . S f , the m edium s has been described in
containing about 1 c. c. o f salt solu
tail elsew here.2
tion and a small am ount o f sand.
the root tip in the sterile sand and salt
In tures,
m aking we
technic o f
have
the
bacteriologic
fo llo w ed
Rosenow .
closely
cul the
Each tooth has
solution
is
The
w e ll
the tissue on
.
tube containing
shaken
to
macerate
the tip o f the tooth as
com pletely as possible.
T h e mediums
are inoculated by pouring the salt so lution containing the suspended tissue into a deep tube o f glucose-brain-agar that has been heated and allow ed cool to 4 0 C .
to
T h e small am ount o f
salt solution rem aining in the tube ii then
poured
into
brain broth.
a
tube
of
glucose-
T h e inoculated tubes are
incubated at 3 7
C . fo r fro m twenty-1
fo u r to fo rty -e igh t hours.
T h e agar
tube
determine
is
em ployed
only
to
the number o f bacteria present. appearance o f is shown
in
made
fr o m
m ine
the
The*
such a positive culture F igu re
the
type
1.
broth of
Smears
tube
to
are
deter
organism, and
the
broth culture is then used fo r animal inoculation. In
the statistics to be presented,
I
have included cultures o f the incisors, cuspids
and
bicuspids
only,
since
ex
tractions o f the m olars without mouth contamination
is often
quite difficult.
T h e different steps in the technic have been
repeatedly checked
cally
to detect possible errors.
bacteriologiAs
a
further check on technic, I have con stantly Fig. 1.— A deep tube o f glucosebrain-agar used in quantitative cultures o f dental foci. T h e large number o f colonies, that are distributed through out the tube may be noted.
cultured
vital
teeth
to
deter
mine the percentage o f error. T h e results o f the cultures o f 1 3 0 7 teeth,
m ade
in
the
manner
are shown in T a b le 1.
outlined,
I have not in
cluded in the series any teeth in which
been cultured in deep tubes o f glucosebrain broth and glucose-brain-agar. These mediums afford all degrees o f oxygen tension and are thus especially favorable fo r the growth o f the strep tococci found in chronic focal lesions. T h e technic used in the preparation o f
there was a question o f contamination fr o m
saliva, lips, tongue or otherwise
at the time o f I
have
orrhea.
extraction.
excluded
teeth
Likew ise,
show ing
py
T h e teeth cultured are fairly
2. Iiaden, R. L . : Arch. Int. M ed., 32: 828 (D e c.) 1923.
920 T
The Journal of the American Dental Association 1.-— R
a b le
esu lts
o f
Q
C
u a n t it a t iv e
u ltu r e s
Number Cultured
Group
P
fr o m
e r ia p ic a l
D
Number Showing in Deep A g a r Tube One or more colonies Per Cent
T en or more colonies Per Cent
M ore than 100 colonies Per Cent
I
e n ta l
n f e c t io n
Number Sterile in Broth Per Cent
392
14
5
1
46
Pulpless teeth with negative roentgenogram
490
54
44
24
18
Pulpless teeth with positive roentgenogram
425
70
63
44
9
A ll pulpless teeth
915.
61
51
33
14
T ota l
1307
Vital
teeth
equally
divided
between
vital
teeth,
.
F o u r hundred and tw enty-five pulp
pulpless teeth with negative roentgen-
less
ographic
graphic findings are included. O f these,
with
findings
ings. vital
teeth
with
positive
roentgeno
pulpless
teeth
roentgenographic
find
7 0 per cent showed one or m ore colo
T h r e e hundred and ninety-tw o
nies in the deep agar tube; 6 3 per cent,
positive
teeth
have
and
been
cultured.
O f
ten or m ore colonies, and 4 4 per cent,
these, 14 per cent have show n one or
m ore
m ore colonies in a deep agar tube;
tube. N in e -per cent o f the broth cul
per cent, ten or m ore colonies, and per cent, m ore than
1 0 0 colonies.
5 1 It
than
100
colonies
in
the
deep
tures in this group were sterile.
The
significant
fa ct
findings here
are
the
seems reasonable to take ten or more
that 3 7 per cent o f the teeth with posi
colonies as an arbitrary num ber, as in
tive roentgenographic evidence o f in fe c
dicating
sufficient
tion showed less than ten colonies and
possible
importance
standpoint.
infection fr o m
T h ese
to a
results
be
of
systemic
9 per cent were sterile in broth.
indicate
is evident that, in m any cases, the in
It
also the percentage o f error that must
fection had run its course and healing
be a llow ed fo r in interpreting the re
had taken place as fa r as the bacteria
sults in
are concerned.
pulpless teeth.
The
positive
cultures do not all represent errors in
F o u r hundred ninety pulpless teeth
technic.
Som e o f the teeth considered
w ith
as vital
w ere
ings have
a ll
were
others
not
probably tested
had large
fo r
pulpless since vitality
cavities and
and
m igh t
negative
roentgenographic
been
cultured.
find
F i ft y -f o u r
per cent o f these have had one or more colonies
in
the
deep
agar
tube;
44
w e ll have already had in fected pulps.
per cent, ten or m ore colonies, and 2 4
O f
per
the
broth
cultures
fr o m
teeth 4 6 per cent w ere sterile.
these
cent,
Eighteen
m ore per
than
cent
100
were
colonies. sterile
in
Haden— The Pulpless Tooth broth.
I
m uch
realize
discussion
opinion
that
there
and
difference
concerning
w hat
m ay
921
be
ings,
of
lated into terms o f bacteria;
roentgeno-
w hile
of
tooth
placing teeth in this group.
graphic basis.
taken
a
conservative
w hat
is
positive
attitude
or
as
negative.
to
age
of
positive
cultures.
TH E
The
inci
be
ruled
out
on
PATHOGENICITY
The
striking thing here is the high percent
cannot be
trans
nor can
infection around the tip o f a pulpless
graphic criteria should be em ployed in W e have
aid,
a
roentgeno
OF
TH E
BAC
TERIA FROM DENTAL FOCI To pow er
determine the disease-producing of
the
bacteria
fr o m
dental
dence o f in fection is alm ost as high as
fo c i, w e have injected rabbits with the
in
original broth cultures recovered fr o m
those
graphic tooth
with
positive
findings.
with
roentgeno-
In fec tio n
negative
in
the
roentgenographic
findings is probably m ore serious fr o m the systemic standpoint than when the findings
are positive,
since little
re
sistance in the part o f the body is in dicated more ered
and rapid.
absorption The
have been
culture
or
m ixed
is
probably
organisms
streptococci with
recov in
pure
staphylococci.
O n ly rarely have other organisms been encountered.
the root tip.
rabbits have been
the
culture
fr o m
a
single
tooth
with the m ixed cultures fr o m teeth.
In
m ost instances, the anim als
I f they do not, they are killed at in tervals o f fr o m three to six days a fter the
injection,
and
the various organs
are exam ined ca refu lly fo r lesions. O th e r workers, o f course, have de the
pathogenicity
of
mouth
organisms by the injection o f cultures
tures so made show only the bactério
into anim als.
logie status at the tim e the culture is
H a r tze ll
taken.
most workers have not used, fo r
T h e y tell nothing as to what
or*
several
do not die as a result o f the injection.
term ined
I should like to emphasize that cul
Two
injected routinely with 5 c. c. each o f
Such a study is that o f
and
H en rici.3
H ow ev er, the
was there yesterday, or w h at m ight be
injection, organisms grow n under par
present
tial oxygen tension, or made the in jec
hereafter.
It
m ust
also
be
granted that some o f the negative cul
tions
tures m igh t have been positive i f
de
points are vital i f one is to determine
veloped
the
the
in
other
ways,
although
soon
true
a fte r
pathogenicity
m edium s used are the m ost favorable
isms.
know n
group dealt with
fo r
the grow th
lytic streptococci.
of
nonhem o
Several times dur
in g the past tw o years I have com piled statistics
concerning
the
cultures
when
isolation. of
the
T h ese organ
D isease-producing power in the here is quickly lost
these fun dam en tal requirements
are not m et.
and
W e have been able to reproduce in
the percentages have remained alm ost
rabbits alm ost all types o f lesions that
constant. T h ese
can be caused by the intravenous dis results
show
that
infection
semination
of
bacteria.
The
fr e
is actually present around the root tips, tell som ething about the frequency o f the in fection and give an idea o f the num ber
of
bacteria
present.
T hey
also show that roentgenographic find
3. Hartzell, T . B .; Henrici, A . T ., and Grey, W . A .: Report o f the M outh In fection Research Corps o f the. National Dental Association, J.N .D .A ., 3: 333 (N o v .) 1916.
922
The Journal o f the Am erican D ental Association
I so lated
Perc entage o
2
58
34
UAL
CASES
S H IP
OF
OF
PROOF A
DENTAL
S Y S T E M IC
IN
CAUSAL
S 8
18
ii
IN D IV ID R E L A T IO N
IN F E C T IO N
p « .2
§
3
TO
DISEASE
The data so far presented give, in individual cases, no proof o f a causal relationship o f dental infection to sys temic disease. Certainly, the most convincing proof we have o f the re lation o f a focus to a disease is the reproduction in animals, with the or ganism recovered from the patient’s
D
ental
I n f e c t io n .
s Showirlg Lesioris in
24
'oV)
quency with which the main groups o f lesions occur is shown in Table 2. T h e lesion most commonly encoun tered is joint involvement; the sec ond, kidney lesions; the third, muscle; follow ed by lesions o f the endocar dium, myocardium, brain, eye, and stomach and duodenum. T h e inci dence o f involvement in the animal corresponds closely to the incidence o f lesions due to chronic foci as observed clinically in man. In addition to the lesions enumerated, many others have been observed, such as tenosynovitis, cholecystitis, enteritis, bladder involve ment and nerve lesion. The high incidence o f lesions shows clearly the great disease pro ducing power o f the bacteria from chronic foci and leaves no doubt that such organisms are capable in a high degree o f causing disease in man. E X P E R IM E N T A L
from
R a b b it s )
Endocardium
255
761
V
i/ c
Joint
Number o f Number o f Patients Animals Injected
in
9 - 0
.£ m 6
« 18
|
B a c t e r ia
of
( I n tr a v e n o u s I n j e c t io n
Stomach and Duodenum
2 .— L o c a l i z a t i o n
P
able
! > ¡ g"
T
13
focus, o f the condition from which the patient suffers. Such proof con cerns the theory o f Rosenow that bac teria tend to localize in certain tissues o f the body owing to some peculiar inherent property. The truth o f the theory has been conclusively demon strated by Rosenow and his co-work ers. I have been able to present con firmatory results in diseases o f the eye,2 the stomach,4 and the kidney,5 and in cases o f onychia.6 T h e proof seems absolute that bacteria do have such a selective tendency. Those who have questioned the theory after ex perimentation have failed to observe the necessary requirements as far as oxygen tension and rapidity o f work is concerned. The demonstration, then, that animals injected with the bacteria develop lesions similar to those o f the patient is the strongest evidence as to causal relationship and likewise evidence that, in the patient and in the animal, we are dealing with the same organism. T h e proof that, in certain cases, there is this causal relation o f 4. Haden, R. L . : Arch. Int. M ed., 35: 457 (A p r il) 1925. 5. Haden, R. L .: Am. J. M ed. Sc., 169: 407 (M a rch ) 1925. 6. Haden, R. L., and Jordan, W . H .: Arch. Dermat. and Syph., 8: 31 (J u ly ) 1923.
H aden— The Pulpless Tooth
dental infection to systemic disease is best presented by a few cases histories, with the protocols o f animal inocula tions with the organisms recovered from chronic dental foci in the pa tient. These are given herewith. R E P O R T O F CASES C ase 1.— Endocarditis and Auricular Fibrillation. H istory.— L . C . H ., a w idow , aged 60, w orking as a clerk, complained o f heart trouble. She had had chorea first
F ig. 2.— Large vegetations on the heart valves o f a rabbit produced by the intravenous injection o f culture from the teeth o f the patient in Case 1, who was suffering from auricular fibrillation and aortic insufficiency. at 12 years, with recurrent attacks f o r sev eral years. A t 14, she had had diphtheria, and at 23, scarlet fever. Eight years be fore, she had had scleritis. For several years, she had albumin and pus in the urine. A t one time, rem oval o f a kidney was con sidered on account o f the pyuria. T he patient stated she had been well up to 1912, eleven years before admission, when she had a severe attack o f influenza. T w o weeks later, she began to have arthri tis, which persisted f o r six months. She was then w ell f o r several months, after which she began to have attacks o f rapid and ir regular heart. She had to give up work
923
f o r seven weeks at this time on account o f heart symptoms. About once a year, since this initial attack, she had had an at tack o f heart trouble, incapacitating her fo r w ork f o r from six weeks to fo u r months. D uring the past year, the attacks had been occurring every fe w days, lasting a few days at a time. T h e symptoms were worse on exertion. A t times, the ankles were swollen. Recently, the patient had been to the M ayo Clinic, where a diagnosis o f par oxysmal auricular fibrillation was made. Examination.— On admission, there was a definite aortic insufficiency without de monstrable cardiac enlargement. T he heart rate was slow and regular except f o r an occasional extra systole. T he blood pres-
Fig. 3.— Pulpless teeth o f patient in Case 2, who was suffering from severe subacute arthritis. A profuse growth o f streptococci was obtained from both teeth. T he organisms on injection produced a marked arthritis in rab bits. T h e patient recovered completely after the removal o f the infection. sure was: systolic, 140; diastolic, 70. T he urine showed a fe w pus cells in clumps. There were eleven pulpless teeth, only fo u r o f which showed definite roentgen? ographic evidence o f infection. Animal Inoculations.— T h e low er right second bicuspid and first and second molars were extracted first. A ll showed a profuse grow th o f nonhemolytic streptococci. T w o rabbits were injected. One had, at necropsy, a fe w endocardial vegetations, a fe w ab scesses in the medulla o f the kidney and a small amount o f purulent fluid in the joint. T h e other rabbit showed a massive vege tative endocarditis o f the tricuspid valve (F ig . 2 ) , a fe w lesions in the myocardium, and slight involvement o f the joints. One
924
T he Journal o f the American D ental Association
rabbit was injected with the cultures from the low er le ft bicuspid and second molar. A t necropsy, a fe w vegetations on the heart valves, numerous small abscesses in the wall o f the le ft ventricle, a purulent arthritis and a fe w kidney abscesses were found. T w o rabbits were injected with the cul tures fro m the remaining teeth. One was dead the fo llo w in g day. There were many hemorrhages in the endocardium o f the left ventricle, and at the base o f the papillary muscles. There were also a fe w hemor-
and trunk fo llow ed by an arthritis o f thé right wrist. Examination.— When the patient was first seen, all the larger joints and the fin ger joints were red, painful and stiff, and he could walk only with the aid o f crutches. The eyes were injected and painful. There was a raised pink macular eruption with clearing centers over the shoulders, arms, chest and back, resembling erythema multi form e. The leukocytes numbered 13,350. The urine was negative and the Wassermann test negative.
Fig. 4.— A , brain and spinal cord o f rabbit injected with cultures from the teeth o f a patient suffering fro m acute facial paralysis. There is marked injection o f the base o f the brain and injection and hemorrhage in the caudal end o f the cord ; B, photom icrograph o f one o f the cranial nerves at the base o f the brain shown in A . T h e exudate at the base o f the brain partly encircling the nerve may be noted. rhages and small vegetations in the right auricle near the ventricle. T h e other rabbit died tw o days after in jection. A t necropsy, only early vegeta tions on the mitral and the tricuspid valves, and mural thrombi in the right auricle were found. C ase 2.— Chronic Arthritis. H istory.— R. K ., a salesman, aged 27, complained o f rheumatism. He had never been sick until the present illness. T h e tonsils had been removed in 1919, fo u r years before. The present illness had begun fo u r weeks before admission, with an eruption on the hands
There were only tw o pulpless teeth, both o f which showed a profuse growth o f green-producing streptococci (F ig . 3 ). The patient had come in on crutches. He felt better immediately after the teeth were extracted. T he fo llo w in g day, all the joint symptoms had disappeared. T w o days later, he came in again on crutches. Examina tion showed that the sockets were not drain ing, and they were opened again. The symptoms disappeared immediately and did not return. T he skin eruption also cleared up quickly. Animal Inoculations.— T w o rabbits were
H aden— T h e P ulpless Tooth injected. Both, at necropsy, had a marked purulent arthritis and kidney abscesses. The organism injected was recovered in pure culture fro m the join t and kidney lesions. C ase 3.— Acute Facial Paralysis. His tory.— L. M . H ., a plumber, aged 39, com plained o f facial paralysis. One year pre viously, he had suffered from dizzy spells, and, on examination, was fou n d to have albumin in the urine. The facial paralysis had appeared suddenly five days before without any pain. Examination.— T he right side o f the face was foun d to be completely paralyzed. No other cranial nerves were involved. The blood pressure w as: systolic, 130; diastolic, 85. There was no anemia. T he Wassermann test was negative. T h e urine exam ination showed a specific gravity o f 1.023, and albumin fo u r plus, with many granular casts. T h e phenolsulphonephthalein excre tion and the blood urea nitrogen were within the normal limits. T he dental roentgenograms showed fo u r pulpless teeth, all presenting evidence o f periapical in fec tion. Animal Inoculation.— Three rabbits were injected with the mixed cultures from the fo u r extracted teeth. One developed a paralysis o f the hind legs forty-eight hours after injection and was killed. A t necropsy, all organs were negative except the brain and spinal cord, which showed marked in jection, some exudate at the base o f the brain (F ig . 4 ) and hemorrhage in the cau dal end o f the cord. T he second rabbit showed no symptoms at any time, and, at necropsy, only some vegetations on the heart valves were found. T he third rab bit, tw o days after injection, had paralysis o f the left ear and a pericorneal injection, which gradually cleared up. When the ani mal was killed, the only lesions foun d were a purulent arthritis. C ase 4.— Recurrent Hyalitis. History.— L. P., a steam fitter, aged 25, first seen, June 25, 1920, complained o f something flying around in front o f the right eye. This was first noticed about three weeks previously, fo llo w in g an attack o f influ enza, and had become gradually worse. Examination and Course.— T he fundus was not clearly seen. No hemorrhages were present. M any fine dustlike opacities and some larger ones were floating freely
925
in the vitreous humor, also shreds o f hya loid tissue, to which were attached numer ous dustlike opacities. There was no opac ity o f any kind to be foun d in the aque ous humor or on the back o f the cornea, and no inflammation was apparent. Vision in the right eye was 2 0/100. Under treatment, the vision became bet ter, 2 0 /5 0 , and at one time 2 0 /4 0 . Be-
Fig. 5.— A , original culture tube from the tooth shown in B, the tooth o f the patient in Case 4, w ho was suffering from hyalitis; C, photomicrograph o f the organ ism in the agar tube at left. tween June, 1920, and February, 1922, the patient had fou r light attacks, and one severe one, which left the eye almost with out a reflex. These exacerbations did not come on suddenly as they w ould have if they had been recurrent hemorrhages. From the time o f his first visit, the patient was urged to have all his pulpless teeth ex tracted, but several were not removed. A general physical examination, Feb. 24, 1922, was negative. T h e tonsils had been
926
The Journal o f the Am erican D ental Association
removed. Examination o f the blood re vealed: red cells, 4 ,6 32 ,0 0 0 ; hemoglobin, 90 per cent; white cells, 7,400; differential count: polymorphonuclear neutrophils 55.5 per cent; eosinophils, 4.5 per cent; basophils, 2.0 per cent; mononuclears, small, 25.5 per cent; mononuclears, large, and transitionals, 12.5 per cent. T h e urine showed no abnormality and the Wassermann test was negative. Roentgenograms o f the teeth showed that the upper left cus pid (F ig . 4 b) and low er left second bicus pid were pulpless, had a poor canal filling and some bone absorption at the root tip. The low er left lateral incisor was a peg
veloped an exudate in the anterior cham ber and corneal opacities o f both eyes, tw enty-four hours after inoculation. The fo llo w in g day the eyeballs were extremely red (F ig . 6 a) . The right iris was dis colored all the way around and the left partly around with milkish gray exudate (F ig. 6 b ) . There were grayish deposits on the cornea. T he animal was killed. T he necropsy was negative except fo r the eye findings. T he streptococcus was recovered by smear and culture from both eyes. March 5, two more rabbits were inoculated with the streptococcus recovered from the le ft eye o f the preceding rabbit. One de-
Fig. 6.— Eye lesions in rabbits produced by the intravenous injection o f organisms from the teeth o f the patient in Case 4, who was suffering from hyalitis. A , appearance o f eye fo llo w in g the injection o f the original culture. B, eye o f second rabbit injected with the original culture. C, eye o f rabbit with complete loss o f vision due to a hyalitis fo llo w in g the intravenous injection o f the attenuated culture. T he loss o f light reflex may be noted. D , eyes o f rabbit injected one year later with the culture from another tooth o f the same patient. tooth. The root was poorly filled and there was a large alveolar abscess. The three pulpless teeth were extracted. The brain-agar cultures showed no grow th from the low er le ft lateral incisor, and only a fe w colonies fro m the low er left second bi cuspid. The culture o f the upper left cuspid showed an infinity o f colonies o f a non hemolytic streptococcus (F ig . 5 a and c.) Animal Inoculations.■—-March 1, 1922, tw o rabbits were injected with the broth culture from the upper, left cuspid. One developed numerous patches o f choroidoretinitis, and died, three weeks later. The necropsy findings were ascites and very large ;white kidneys. T h e other animal de
veloped circumcorneal injection and a choroidoretinitis, and died thirteen days later. Necropsy revealed only kidney abscesses. T he other animal developed a marked in jection o f both eyes, and died within twenty-four hours. A short chain strepto coccus was recovered, f rom the eye. Two rabbits injected with this, culture died in a fe w hours without showing any localized lesions. T w o rabbits injected with the cul ture from the right eye o f one o f the sec ond, pair o f rabbits developed patches o f choroidoretinitis, a.nd were killed six weeks later. T he other animal developed no lesions. Three weeks after the original apical
H aden— The Pulpless Tooth cultures had been made, organisms were re moved from the agar tube (F ig . 5 a) with a sterile pipet, grow n in broth fo r
927
The red reflex was lost entirely, and there was little pupillary light reflex (F ig . 6 c and 7 b) . T he animal died eight days
Fig. 7.— A , photom icrograph o f eye shown in Figure 6 A . The cellular infiltration in the choroid may be noted. B, photomicrograph o f eye shown in Figure 6 C. The cellular infiltration in the vitreous humor may be noted. twenty-four hours and injected into three rabbits. One developed a cloudy vitreous humor and died fo u r days after inocula tion. Necropsy revealed arthritis. The second animal showed a pericorneal injec tion, three days after inoculation. T he iri tis gradually cleared. The vitreous humor o f the right eye became increasingly hazy.
Fig. 8.— Bicuspid tooth o f patient in Case 5, who was suffering from an acute pyelonephritis. T h e tooth was negative in the roentgenogram, yet from the root tip a profuse growth o f streptococci was obtained.
after inoculation. Necropsy was negative except fo r the eye findings. T h e patient’s vision at the present time is 15/100. C ase 5.— Acute Pyelonephritis. His tory.— W . W ., a medical student, aged 34, stated that two weeks previously he had
Fig. 9.— Kidney o f rabbit fo llo w in g the intravenous injection o f culture from- tooth shown in Figure 8. T he abscesses in thé medulla may be noted.
928
T he Journal of the Am erican D ental Association
suffered from frequent burning urination, hematuria, chills and fever as high as 102F. T h e symptoms improved at first under medication, but the chills and fever recurred. He had had a similar attack, nine years previously. There had been no other illness. T he tonsils were cleanly removed. Examination.— T h e physical examination was negative. T h e urine showed gross blood, many pus cells and a short chain streptococcus, which was recovered by cul ture. One bicuspid tooth (F ig . 8 a) held a large inlay under which the pulp had
Fig. 10.— Photomicrograph o f lesion medulla o f kidney shown in Figure 9.
in
died. There was no area o f rarefaction at the tip. T he tooth was extracted. From the tip a pure culture o f a green-produc ing streptococcus ( Streptococcus1 fecalis) was obtained. Animal Inoculations.— -Tw o rabbits were injected with the culture o f the streptococ cus. One showed at necropsy multiple ab scesses in the pyramids and a purulent arthritis (F ig . 8 b ) . T he other showed an acute hemorrhagic nephritis and a fe w en docardial vegetations. T he urine became normal, and there have been no further symptoms. C ase 6.— Duodenal Ulcer. H istory.— H. A . A ., a business man, aged 44, had sev eral gastric hemorrhages in December, 1922. For six months previous to this, he had had indigestion, consisting principally
o f a feeling o f fulness after eating. A diagnosis o f duodenal ulcer was made. Several teeth were extracted at this time. There were no further hemorrhages, and the symptoms were largely relieved, al though the patient stated that he still had indigestion at times, f o r which he took soda. Roentgenograms taken in June, 1924, showed one tooth o f questionable vitality and one pulpless tooth with little roentgenographic evidence o f infection. A t the site o f extraction o f the upper left first bicus pid and first molar, some fillin g material remained, and the surrounding bone showed evidence o f infection (F ig . 9 c ) . T h e tw o teeth were extracted and the in fected bone curetted. Cultures in deep tubes o f glucose-brain-agar showed a short chain streptococcus in all. Animal Inoculations.— T w o rabbits were inoculated with the mixed broth cultures. One rabbit was dead the fo llo w in g morn ing and showed many hemorrhages in the duodenum. T h e second rabbit was killed. This one showed also many hemorrhages in the first third o f the duodenum without lesions elsewhere (F ig . 9 a ) . In order to determine whether the area o f infected bone might play a part in the causation o f the ulcer, one rabbit was injected with 5 c. c. o f the broth culture from this area only. A t necropsy, twenty-four hours later, the duodenum showed massive hemorrhages (F ig . 9 b ) . There were no other lesions. C a s e 7. — M ultiple Onychia. H istory.— M . K ., a housewife, aged 51, was first seen in regard to her present infection, Jan. 10, 1922. She gave no history o f the acute in fectious diseases o f childhood. Until three years before, she had led an exceedingly ac tive life on a farm . She had had palpita tion o f the heart and soreness in the chest fo r many years. A t intervals during the last twenty-three years, she had had painful swellings o f the larger joints. She had had nycturia two or three times, without pain on voiding. T w elv e years before, she began to have trouble with her finger nails. This con sisted o f swellings, redness and tenderness around the nail roots. A t times, pus could be expressed. T h e nails o f all the fingers were successively involved, as w ell as the nails o f the great toe on the left fo o t. The infection usually ended with exfoliation o f the nail. There was no history o f injury
H aden— T h e Pulpless Tooth or o f the use o f irritating substances. T he trouble had continued until five years be fore, when the patient was referred f o r den tal treatment. Four teeth were fou n d to have periapical abscesses and were extracted. One tooth, although pulpless, was negative roentgenographically, and was filled and allow ed to remain. A fter the dental treat ment, all the active nail lesions cleared up, as did the arthritis.
929
was rapid; and the sounds were distinct with a tendency to gallop rhythm. T he b lood pressure was: systolic, 110; diastolic, 65. A blood count showed 5,592,000 red blood cells, 4,950 white cells and 90 per cent hemoglobin (norm al standard). A differential count o f 500 cells showed: polymorphonuclear neutrophils, 58 per cent; eosinophils, 1 per cent; basophils, 0 ; large
Fig. 11.— A , duodenum o f rabbit injected with the mixed cultures from patient m Case 6, who had had a duodenal ulcer. T h e numerous hemorrhages in the duodenal bulb may be noted. B, duodenum o f another rabbit fo llo w in g the injection o f the culture from an area o f infected bone only from the same patient. C, area o f infected bone the culture from which produced the lesion shown in B. D , photomicrograph o f the lesion shown in A. Jan. 10, 1922, the patient returned be cause she had begun to have pain and red ness around one finger nail. She was also having palpitation o f the heart. She now had no joint symptoms. Examination.— T h e middle finger o f the le ft hand showed marked swelling and red ness around the nail root. The nail was tender on pressure. No pus could be ex pressed. There was no glandular enlarge ment. T he right tonsil was red and showed a fe w plugged crypts. T he heart action
mononuclears, 7 per cent; and lymphocytes, 34 per cent. T h e Wassermann test was negative. A roentgenogram o f the teeth revealed areas o f rarefaction around the roots o f the low er right molar. A ll other teeth were vital. There was no pyorrhea. O utcom e.— T he low er right second m olar was extracted. T he nail infection quickly subsided. A urine examination, six weeks later, showed no albumin or pus cells. T he palpitation o f the heart disappeared. T he
930
The Journal of the American Dental Association
patient was seen several months later. There had been no return o f the nail infection. Animal Inoculations.— A culture on blood-agar o f the roots o f the extracted tooth showed a profuse growth o f Strepto coccus nonhemolyticus 1 (H olm a n ). Jan uary 13, one rabbit was injected intraven ously with a broth culture o f the organ-
There was hemorrhage around the nail roots o f the other toes o f the same foot. T he other toes were normal. A drawing o f the section o f the toe that revealed grossly the most marked change is shown in F ig ure 9 b. T he nail was removed before the section was cut. T h e area o f polym or phonuclear leukocyte infiltration is evi dent (F ig . 10 c ) . The of
organism
the first
others.
recovered
rabbit
T hese
was
show ed
m uscle
a purulent
arthritis and
kidney,
no
The
but
organism
fr o m
in jected
jo in t
into
tw o
hem orrh age,
abscesses o f
in v olv em en t was
the
carried
of
the
th rou gh
the nails. tw o
m ore sets o f rabbits, w ith sim ilar results. SU M M ARY
Fig. 12.— T o e o f rabbit injected with the culture from the tooth o f patient in Case 7. T he swelling o f the toe is indicated by the arrow. ism. Four days later, a second injection was given. Eight days after the first in jection, the animal was killed. T he post mortem examination revealed hemorrhages in the lumbar muscles, a fe w small abscesses in the cortex o f the kidneys and purulent fluid in the shoulder joints. T he organism was recovered in pure culture from the joint fluid. Around the nail root o f the second toe o f the left fo re foot, there was marked swelling and injection (F ig . 10 a ) .
AND
C O N C L U S IO N S
A very high percentage of teeth that are negative roentgenographically harbor infection. The roentgenogram should thus never be depended on to eliminate a tooth as a possible focus of systemic disease. A fairly large percentage of teeth that are positive roentgenographically did not harbor any infection or suffi cient infection to be a factor in sys temic disease at the time the culture was taken. In such cases, the infec tion has probably run its course and become bacteria free, as happens in in fections elsewhere in the body. The periapical tissues of a certain percentage of pulpless teeth, either pbsitive or negative roentgenographi cally, are sterile when cultured in glucose-brain broth. This does not prove that such are really sterile since some other method of culture might reveal organisms. The findings sug gest, however, that a pulpless tooth is not necessarily infected. The bacteria concerned in chronic foci are quite pathogenic as judged by their ability to produce lesions in ani mals on intravenous injection. In selected cases, one can prove an
931
Haden— The Pulpless Tooth
Fig. 14.'— Photom icrograph o f lesion around the base o f nail. o f polymorphonuclear infiltration is indicated by the arrow.
T h e area
932
The Tournai of the American Dental Association
unmistakable tendency of bacteria from chronic foci to localize in cer tain parts of the body. These cases afford valuable experimental proof of a causal relation of a chronic focus to systemic disease. D ISCU SSIO N
W eston A . Price, Cleveland, O hio: T o start the questionnaire I w ill ask D r. Haden tw o questions. In the culturing o f teeth that have been extracted, do you feel you are pretty safe in concluding that by bathing them in iodin or alcohol or both the percentage that carried infection was re duced? D r. H aden: I think the answer to that is fou n d in the results o f the cultures o f the vital teeth, and that is the crucial part o f the entire study. In vital teeth, we get a small percentage o f positive cultures, and it is only fa ir to conclude our percentage o f contami nations w ould not be greater in pulpless than in vital teeth. D r. P rice: In your chart, you show in fec tions with ten colonies or more. W ou ld you explain again w hy you have not counted those fro m one to ten? D r. H aden: A pathologic study o f this kind should not be confused. One has to select a way o f doing things, do them that way, and then record the findings. What we all are interested in is knowing something about the numbers o f bacteria and trying to differentiate the teeth we think harbor enough bacteria to cause disease. T o me, it seems a wise thing to differentiate the way indicated from our standpoint; that is, those that had ten or more colonies and those that had more than 100, because it gives a concrete idea o f the extent o f the infection.
D r. H ert: There was 23 per cent to the eye and then something went up to 18, and I think the stomach and duodenum went up to 12 or 13. D r. H aden: I think you referred to the first chart, which included all animals in jected. In that group, including all pa tients, the incidence o f peptic ulcer was 13 per cent. T he elective ■localization chart was made by dividing the b ig group into tw o groups, namely, the animals injected with cultures from patients who did not have peptic ulcer, and those injected with cultures from patients w ho were suf ferin g from peptic ulcer. In the first group, only 7 per cent o f the animals developed peptic ulcer; in the latter, 53 per cent were similarly affected. Clifford Rudine, Salt Lake City, Utah: W hen a patient has a kidney lesion and, as fa r as physical examination is concerned, shows nothing else, and you discover an infected tooth and make an inoculation in the rabbit, does it show anything except the kidney infection? D r. H aden: Frequently such an injec tion w ill produce more than one lesion. M any o f the animals, however, have only single lesions. In the case I showed you, the animals had no lesions except the kidney lesion. One thing that I think should be emphasized is the clinical study o f the pa tients. One finds pus cells in the urine and other evidence o f kidney trouble, when the patient does not complain o f , or know that he has, a kidney infection. It is the rule to find more than one lesion in patients suffer ing from fo ca l infection.
D r. P rice: It is sometimes as important to have the question asked as to have it an swered f o r the reason that some workers, in making determinations as to whether or not localization has taken place, are reporting B. S. H ert, Rochester, N. Y .: In the that only those cases show localization that chart shown on the screen, the localization show only one lesion— the one they are look was reduced in percentage from the left ing fo r . Let me illustrate: W e inoculated hand side to the right hand side.T he last thirty rabbits from the culture o f the pulp two were on the eye, and stomach and duo o f the tooth o f a boy who was brought to denum. I understood they were incorrect. us f o r rheumatism. He had definite joint W hy were they incorrect and the others cor lesions. His physician, or at least the nurse rect? who brought him in, did not report and D r. H aden: I did not mean to say they probably didn’t know that he had heart were incorrect. These charts presented what trouble. Had we been lookin g f o r heart conditions only, we w ould have been able we found.
Haden— The Pulpless Tooth to use, on this last basis, only tw o rabbits. Tw enty-eight o f the thirty developed heart lesions and tw o o f the thirty developed joint lesions. Incidentally the boy was dead in a fe w months from endocarditis. Supposing we were making our determination on that case and threw out the twenty-eight cases o f arthritis because they also had heart in volvements, do you see h ow clearly we w ould be misinterpreting the facts in the case? D r. Rttdine: diagnosis?
W ill
that
develop
in
the
D r. H aden: T h e diagnostician should be very cautious in assuming that the patient has o r w ill have lesions similar to those foun d in the inoculated animal. S. W . W herry, Ogden, Utah: D o you find, in inoculating through the tooth and injecting a rat or rabbit, that you get more heart lesions o r kidney lesions than you do from the intravenous injection? D r. H aden: This cannot be done on rab bits and guinea-pigs, but has been done on dogs. I do not think enough w ork has been done to ju stify us in draw ing any conclu sions, except, to say that it has been shown that lesions such as these can be produced. D r. P rice: D r. Meisser gave a paper on that subject and he has the reports n ow on 100 dogs that were inoculated. He has produced lesions by inoculating the pulp chamber o f the tooth, letting the dog carry the tooth fo r months and months, and he has a high percentage o f localization. This other is also important and interesting. When he produced pulpless teeth in the dogs and they were healthy, the pulpless teeth did not become infected in afe w months unless he infected some other tooth in the same dog. Then theyalways became in fected. M em b er: Isn’ t a 5 c.c. dose o f pure cul ture an overdose f o r a rabbit w eighing, say, 1,500 gm.? D r. H aden: Th at is a very fair dose. D r. Rosenow has used up to 75 c.c., but we use on ly 5. This is a b ig dose— much more than a patient ever gets at one time, but I think it is a perfectly fair amount to use to get comparative data in the cases
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studied. Patients are receiving small doses over a lon g period o f time instead o f a single large dose such as is given the rabbit. R. W . Bunting: T h e w ork in our school along this line has been done largely by Drs. Rickert and Lyons. However, I am much interested, and I know D r. Rickert w ill be, in this statement o f specific localiza tion from typical cases that have occurred under D r. Haden’ s observation. In an in terjectory remark made concerning one o f the early slides, he stated that he thought it possible, that such conditions might heal o f themselves. I have wondered upon what he based his opinion and i f he had any actual evidence that some o f these cases o f root-end infection, could be permanently cured especially those in which there is an incomplete fillin g and considerable space at the end o f the root o f the teeth fo r residual infection. Possibly, I misunderstood him. D r. H aden: I did make such a statement. I know little about dental tissue pathology, but I base the statement upon several facts. T h e area with granulated tissue, in itself, is evidence o f a reparatory process on the part o f the body. T he obtaining o f sterile cul tures, and other w ell recognized facts con cerning bone infection elsewhere in the body are added evidence. In chronic osteomyelitis, healing certainly takes place, even in the presence o f a great deal o f infection. This statement is true only o f the low grade in fections. D r. Bunting: I should like to have your opinion as to this particular point o f view : In all other form s o f osteomyelitis, the body defenses are able to reach the process; D r. Price says that unless the body processes ab sorb all the portions o f the tooth that are infected, they cannot reach the source, al though residual infection in unfilled por tions o f the root end may become dormant, and may be hemmed in by the scar and granulation tissue. Whenever, as D r. Price says, these protective forces decrease or whenever the organisms increase, there is a possibility that, at any time, these infections, livin g like cave-dwellers, may come out to attack the surrounding tissues. T o me, it seems that root-end affections are different from other form s o f osteomyelitis, and the only hope I can see is to treat pulpless teeth so that infection does not occur. I have no
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The Journal of the American Dental Association
hope or confidence in any tooth that has a residual infection that cannot be reached by medicaments or cannot be removed by sur gical operation. D r. P rice: T o fo llo w up your last point: D o you deem it possible to sterilize infected cementum while the tooth is in the mouth? D r. Bunting: I was not speaking o f ce mentum because there are many infections in which the cementum is not seriously in volved. I f the cementum is extensively in volved, I w ould either amputate or extract. But when the cementum is not involved, I have reason to believe, fro m the w ork o f D r. Rickert and from bacteriologic evi dence, that such a tooth can be sterilized and can be made permanently stable as fa r as control o f an infective process within the tooth is concerned. When this is done, the body has an opportunity to take care o f whatever infective processes may be in the periapical tissues, unless there is a large amount o f periodontal tissue involved, in which case it must be treated surgically, either by amputation or b y curettage simi lar to the surgical treatment o f pyorrhea. Such an area w ill never heal spontaneously any m ore than a pyorrhea pocket w ill heal unless there is surgical interference. D r. Price: H ow large an area would you consider too large? D r. Bunting: I cannot say. I f it went over the convex surface at the end o f the root o f the tooth, I would want such a case in m y ow n mouth treated surgically. D r. H aden: As regards the point Dr. Bunting brings up, I do not believe there is
any data published that covers this point. What we need is more w ork and more con scientiously prepared data. I have no fa rreaching conclusions to draw. I have sim ply attempted to present the results o f the w ork that has been done up to the present time. •S'. H . B rock, Dallas, T exas: W ith a re construction o f the bone tissue after the granuloma, say, fou r, five or six months after the cast, is the reconstruction bone tis sue still infected? D r. Price: I w ill answer that by asking you the explanation o f this case: I w ill show you by the slide here a tooth that in April, 1923, was painfully abscessed. A woman developed the influenza. T h e tooth ceased to be sore. T h e record I made a year later showed the bone filled in, and the tooth be came seriously infected. T he woman had a nervous breakdown. M y answer is that the fillin g in o f bone around the root o f a tooth is one o f the most misleading and un certain pathologic conditions with which we have to deal. In the second place, I have drilled fo r one-fourth inch into such con ditions that had the area fo r several years, in a tooth which I had filled a number o f years before. A fter this filled in and the bones became dense right down on the tooth, the woman was in bed with arthritis. I sent f o r her and took out the tooth and took cultures from the bone, one-eighth and one-quarter inch in three directions, and got the same stress. So my judgment is, from that and many other cases, that such bone may be infected.