The Surgical Treatment of Pyorrhea Alveolaris*

Kaiser— Surgical Treatm ent o f Pyorrhea Alveolaris sid er it im portant that w e h a v e som e sort o f g u id e o r rule in m ind as an in d e x as to w h eth er o r n ot a film is acceptable f o r in ter­ pretation, an d I k n o w o f no better g u id e in this respect than the co n sid e ra tio n o f the dentino-en am el ca p . I f the ro e n tg e n o g ra m re­ v e a ls a v e r y definite contradistinction betw een the enam el and the dentin, w e m ay rest assured that w e h ave g o o d deta il and an acceptab le film f o r co m p a riso n . D r . M ille r has b ro u g h t out m ost ad equ ately the d iffe re n ­ tiation o f an atom ic lan dm arks as fo u n d in the oral ca v ity . T h e m a n y n orm al an atom ic points fr o m both a m a cro sco p ic and sh a d o w g ra p h ic p oin t o f v ie w m ust be k n ow n b e fo re w e can c o n c e iv e o f a n y d e v ia tio n fr o m the norm al. R e la tiv e to D r . M ille r ’ s statement that w h en a film is m ade w ith the rays d irectly through an im pacted lo w e r third m o la r, the tooth m a y ap p ear as though com p letely c o v ­ ered w ith bon e, w h erea s, on d irect e x a m in a ­ tion, the cro w n m a y be fo u n d e x p o s e d : I w ish to em ph asize this statem ent to som e extent. F undam entally, w e m ust not lose sight o f the fa c t that roen tg en og ra m s are m erely sh a d o w g ra p h ic represen tation o f tissue and a slight d e v ia tio n o f the ra y w ill cause the o b je ct to a p p e a r in g ro ss d isp ro p o rtio n . T o obtain a n orm al roen tg en og ra m o f a lo w e r third m olar, the third m o la r sh ould not be taken as an in d e x o f n orm al, but a n orm al

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represen tation o f the first an d second m olar. T h e film should present a norm al enam el cap o f the first and second m o la r and a norm al con tact p oint b etw een the first and second m ola r. T h e third m olar w ill then b e show n in its true position . T h is is the o n ly m eans by w h ich the p ro p e r relation ship o f the third m o la r and the su rrou n d in g osseous tissue can be definitely ascertained. D r . M ille r has also co n sid ered fees, and I w o u ld fe e l rem iss if I d id not em phasize the fa c t that the m ak in g o f roen tg en og ra m s is but a tech nical p roced u re and the resultant film s are valueless, w ithout the k n ow led g e o f the dentist in his in terpre­ tation an d the correla tion o f all fa ctors enter­ in g in to d iagn osis. T o be a self-respectin g p ro fession a l m an, w e m ust p lace a v a lu e on ou r serv ices o r d iag n osis, an d w e must ch arg e a fe e fo r o u r k n ow led g e, ju d g m en t, an d ex p e­ rien ce. C o m p a ra tiv ely speakin g, w h en I co n ­ sult m y attorney I expect to p ay him f o r an o p in ion . I d o not expect him to present me w ith B lackstone or the last revised issue o f the statutes, bu t to ren d er m e an op in ion o f his c o rr e la te d k n o w le d g e ; and he ch arg es m e a fe e f o r that op inion, reg ard less o f w h eth er it m a y p ro v e right o r w r o n g . I h ave p a id the p rice o f a w r o n g op in ion , but at that I h a v e not lost m y respect fo r m y la w y er. T h e la w y er w h o is g iv in g fr e e a d v ice is not su cc e ssfu l; no m ore so the dentist.

TH E SURGICAL TREATM ENT OF PYORRHEA ALVEOLARIS* By FRANK S. KAISER, D.D.S., Los Angeles, Calif.

H E slogan of the American Dental Association is that dentistry can add ten years to your life. That expresses an ideal which is not beyond our limita­ tions, if we, as dentists, w ill recognize our responsibility to our patients and to the profession to which we are all proud

T

*Read before the Section on Orthodontia and Periodontia at the Seventieth Annual Session of the American Dental Association, Minneapolis, Minn., Aug. 23, 1928. Jour. A . D . A ., July, 1929

to belong. But are w e doing our part when we ignore the possibility o f focal infection in the gingival areas? T h e time is here when we must concern our­ selves with the systemic welfare of our patients. A fter hearing D r. Gardner’s lecture in his recent tour of the country, we must now admit, if never before, that we, as dentists, have a responsibility which is recognized by an enlightened and conscientious minority among the

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profession; but not until we all realize it can we be rightly considered as prac­ ticing one o f the healing arts, and as being helpful to humanity in general. D r. Gardner said that we are responsible for three links in the chain o f ten, namely, gingival infections, apical infec­ tions and cysts. D o not let us forget any o f our links, nor fail to refer our patients to the physician in order to check up on the other links. Periodontal infection is generally con­ ceded to have tw o main predisposing causes: first, lo ca l; second, systemic. Either or both may be present. N o mat­ ter what the predisposing causes may be, there is a local condition which must be taken care of, such as calcareous de­ posits, fibrosis and, in bone involvement, sharp spiculae. In order to solve the systemic problem, the patient should be referred to a diagnostician to have a thorough physical examination, and through consultation and cooperation with the physician, whatever the eti­ ology, the dentist is in position to cope with the condition adequately. A nd we must not overlook the fact that the physician is dependent on the dentist to do his part well. W ith many of our patients, it is a matter o f their being dependent on us for their health. Aside from the local causes which you have heard enumerated fo r years, such as poor dentistry, calcareous de­ posits and trauma, there is yet another problem with which we have to cope, and that is a lowered tissue resistance with a resulting lack o f attachment of the soft tissues, accompanied by round­ cell infiltration. These tissues suffer infection and cannot combat it ; there­ fore, we must remove them. T h e point I wish to make here is that traumatic occlusion, instead o f being the cause, is, many times, only a result. W ithou t first

eliminating the original cause o f trauma through bringing about the regeneration o f new alveolar crest fibers and transeptal fibers, grinding such teeth w ill actually make the condition worse. Aside from the facts just developed, there is another m ajor consideration, namely, the pathologic condition of the bone. Y ou w ill recall that, when there is bone in­ volvement, the periosteum is absorbed, together with the cortical layer of the alveolar process, leaving a spiculated concavity or, in other words, an osteo­ myelitis. W h ere gingivitis is present, proper prophylactic measures will suffice, as the condition is not chronic and the gingivae may respond readily. In chronic condi­ tions, where scaling technic has been used and failed, and the conditions are advanced to a stage o f bone destruction, or focal infection is a serious considera­ tion, as determined by the physical examination, time is a paramount factor, and the infection should be eliminated not only thoroughly, but also as promptly as possible. W hether the case is treated surgically or not, it is necessary to give the patient a course of instruc­ tion on tooth brushing and taping technic, and only after he has learned to take care o f the teeth and gingivae, and has had the masticatory apparatus put into proper balance, will he be in position to guard against a recurrence. Procrastina­ tion in the treatment o f gingivitis will mean pyorrhea. Roentgenographic examination should be made in all cases o f ginivitis, as in pyorrhea. M any times, involvement w ill be found when not expected. I believe also that before one can read roentgen­ ograms intelligently, he must himself perform, or have seen, several debride­ ments. T hen only can he comprehend the actual conditions show n ; and even

Kaiser— Surgical Treatment of Pyorrhea Alveolaris then he may be misled at times. It is preferable, of course, not to wait until the case is advanced to the stage where it is just possible to save the teeth, and therefore get a result which is not es­ thetic. Early diagnosis by the general practitioner may prevent a debridement; so to those of you who prefer conserva­ tism, I say: Let us get together, radicals and conservatives, and preach early diag­ nosis to the dentists and preventive den­ tistry to our patients. A n d one thing m ore: Let us agree that there is room for all measures where indicated. In performing a debridement, strict surgical technic should be employed

F ig. 1.— C ase b e fo re op era tin g.

throughout. T h e patient should be pre­ pared as for any surgical operation; not that we wish to infer that it is possible to operate in a purely aseptic manner in a mouth which is infected, but the more careful one is, the less the danger from a cross infection. I f an operator is accustomed to handling all types o f oral infection, I believe that it is necessary to use rubber gloves during the opera­ tion, as they can be sterilized thoroughly, and after one becomes accustomed to them they are not a hindrance to the touch, as claimed by some, but, to the

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contrary, are a positive benefit, for they insulate the fingers so there is no contact with the hemorrhage, thereby increasing speed in operating. In order to minimize any reaction from a débridement, a bacterial exam­ ination is made in every case, and, by so determining the nature o f the infec­ tion, we may take steps to sterilize the areas temporarily before any operative work is begun. W here streptococci are present, one should be careful to proceed slowly in order to build up resistance by the formation o f auto-antitoxins. In Vincent’s infection, all cases are treated until the clinical symptoms have disap-

Fig. 2.— F irst step. In cision s are m ade w ith in terproxim a l curettes to the depth o f the pockets fr o m the bu ccal to the palatal aspects.

peared. It is not possible to eliminate all Vincent’s organisms from a mouth when there are pockets in the soft tissues where the bacteria hibernate and flourish, but the mouth should be cleansed superficially, at least, before any surgical w ork is begun. Clotting and bleeding time are taken, and in cases of prolonged clotting time, an injection o f coagulen, hypoderm­ ically, will hasten the clotting. W h en local anesthesia is decided on, the conduction method should be used

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so that there is no danger o f spreading the infection by making an injection into an infected area. W h en patients are extremely nervous and dread the opera­ tion, the case should be hospitalized and some form of premedication used, such as morphin, one-fourth grain, atropin, one-one hundred fiftieth grain, hypo­ dermically one-half hour before the oper­ ation; or hyoscin, morphin (one eighth grain) and scopolamin (one-tw o hun­ dredth grain) hypodermically one-half hour before the operation; or, in ex­ treme cases, hyoscin, morphin (one four grain) and scopolamin (one-one hundredth grain), one and one-half

scaling. T h e process is curetted by m eans o f a p p rox im a l cu rettes and bone hoes until it is continuously smooth around and between all o f the teeth. T h e approximal curettes, as advocated by A . W . W a rd , are made with teeth so coarse that they w ill not cut healthy bone, but merely curette the necrotic bone and smooth off the spiculae that are present. T h e bone, as w ell as the soft tissues, should be trimmed so that there are no pockets, the removal being carried to a point where only normal tissue exists. A pack o f zinc oxid, eugenol, rosin and asbestos fiber is applied to all o f the

F ig . 3.— In cision s connected at the bottom o f the pocket.

F ig. 4.— Soft tissue and bone rem ov ed to the depth o f the pocket.

hours before, follow ed by hyoscin, mor­ phin (one eighth grain) and scopolamin (one-tw o hundredth grain) one-half hour before the operation. Either of these pre­ medications w ill create a relaxed condi­ tion, which w ill enable the operator to w ork under the most favorable condi­ tions, and the patient w ill have only a vague recollection o f the w ork done. T h e debridement consists o f a thorough removal of all loose and infected tissue from around the teeth, down as far as healthy alveolar process ; as well as gross

operative areas and allowed to set. This is trimmed so that it does not interfere with the occlusion, and the patient is dismissed with the pack in place. T h e patient is put on a diet o f liquid and soft foods for an ordinary case, but when it is desired to cleanse the ali­ mentary tract and blood in a complicated case, a balanced diet is prescribed, con­ sisting o f milk, orange juice, beef bouillon and tomato juice. A fte r a week or two, the time depend­ ing on the case, the pack is removed and

Kaiser— Surgical Treatment of Pyorrhea Alveolaris the curetted bone w ill now be covered with a thin layer o f connective tissue. This new tissue gradually thickens, and is later covered by epithelial tissue which is normal. A fter these tissues become firm, the case is scaled thoroughly, and investigations are made for any irreg­ ularities in the occlusion, which are re­ lieved where necessary; after which the entire case is polished. T h e sensitiveness, which is not a paramount factor, is taken care o f first by the application of the pack, and, secondly, by teaching the patient to cleanse the teeth thoroughly by the use of dental tape and the tooth­ brush immediately after the pack is re-

F ig. 5.— M a n d ib le c u re tte d ; sh o w in g elim ­ ination o f pockets.

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o f the alveolar process as well, a spiculated concavity being left which is irritating to the soft tissue. A fter thorough curettement, it is found, up to the present writing, that no new bone has been formed, but the periosteum has grown over and covers the curetted process, which is the result obtained when a tooth has been extracted. The new tissue is firmly attached to the periosteum, and a normal condition again prevails, with the exception that the process is lower than originally. I f there is any one present w ho is not in accord with this work, let me say that I was not in accord with it when it

F ig. 6.— C ase p acked w ith “ w on d rp a k ,” a su rg ical cem ent, b u cca lly and palatally.

moved. In extreme cases, the teeth may be treated in the office with zinc chlorid, together with a mouth wash containing zinc chlorid for home use. T h e question is often asked, “ Does regeneration of bone result after de­ bridement?” As I have been interested in this phase o f the work, dozens of patients have been operated on in whom teeth were present which, it was taken for granted, would have to be extracted later. In a case with bone involvement, you w ill recall, the periosteum has been absorbed together with the cortical layer

was first called to my attention, in 1922. M y early conclusions regarding the w ork may be attributed, first, to lack o f information, and, secondly, to timid­ ity. I watched cases of debridement for about a year before attempting the work, but after trying it out on my worst cases, I gradually arrived at the point where I became a strong advocate of the method. It may interest you to know that I have had many complete recov­ eries from many systemic diseases where no other focal infection was present

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nor had been previously eliminated, and I am sure that when you become familiar

with the true possibilities of this technic, you w ill become as enthusiastic as I am.

EFFECTS O F T R U E IN F A N T IL IS M O N T H E JAW S A N D T E E T H : A C A SE R E P O R T * By IRWIN F. STEUER, D.D.S., Cleveland, Ohio

I

N seeking material for the study o f the condition of the teeth and jaws

o f people suffering from endocrine dysfunction, the follow in g interesting case was brought to our observation. This case is sharply defined from others in that we have a comparison o f the endocrine victim with a so-called normal sister. O ften the diet is thought to be a pre­ disposing cause of endocrine disturbances, but in this instance, diet can be ruled out, for the children had always lived together and had eaten the same food. T h e patient, an Italian girl, aged 14, with the facial expression of a girl o f 6 or 8 years, was undersized, with a dis­ proportion o f the body in that the upper and lower extremities were very thin. T here was marked lordosis of the spine and a concavity in the upper dorsal por­ tion. T h e head was about normal in size; the nose was not contracted; the neck was short, and the lower ja w was small and pointed. Both children were born in this coun­ try, but were removed to Italy when 2 years old and again brought back this year. As a result, neither could speak English, and it was very difficult to make a fair Binet-Simon test. T h is test showed the patient’s mental age to be that o f a *F ro m the D ep artm en t o f O rth odon tia, N orth w estern U n iversity D en tal School, C hi­ cag o, 111.

Jour. A . D . A ., July, 1929

child 7 years old. H er performance age, which was o f more importance to us, registered her as a child o f 8/4 years. T h e skin was dry and showed normal pigmentation; the hands and feet were warm. T h e hair on the head was dark brown and normal in texture, and very

F ig. 1.— L eft, norm al 12-year-old g ir l; right, the patient, her sister, aged 14, sh o w ­ in g their com p a ra tiv e heights.

scant on the eyebrows, and there was none on the pubes, face, axillae, chest or extremities. Subcutaneous fat was abun­ dant over the abdomen and trunks, with small deposits on the mammae but no fat on the extremities. T h e bone system was tender and the muscle tonus poor. A roentgenogram revealed that the sella was unusually small, and the hands showed no evidence o f fusion o f the epiphyses. T here were seven carpal bones present, and the eighth, the os piciform, in the process o f formation. T h e ossifica-