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Tuberculoma Involving an Upper Molar Tooth: Report of Case*, *
1694
T h e Journal of the American Dental Association
ure is the distal aspect o f the deciduous cuspids. T o restore these cavities prop erly, it is necessary to provide adequate retention by a lingual step preparation. Silver am algam serves w e ll as a filling material. A ft e r the eruption o f the first perma nent m olar, it is im portant that the distal surface o f the second deciduous m olar be w atch ed fo r caries. I f caries occurs, this surface can be restored w ith the proce du re as has been described fo r a com pound filling. PEDODON TEXESIS
Pedodontexesis may be defined as the scaling, polishing and cleaning o f the teeth o f children. It is one o f the opera tive procedures that has been m uch neg lected by the profession. T h e slogan “ See your dentist every six m onths” has caused a m isunderstanding am ong par ents. M a n y m others feel that they can neglect their children ’s m outh six months and still n ot approach the danger line. T h e frequency o f pedodontexesis and exam ination is dependent on the indi v idu al’s susceptibility. M a n y children ’s m ouths may be a com plete w reck if six
months is a llow ed between visits. O n ce each m onth is not too often fo r certain children, w h ile others may go as lon g as three months. Cleanliness o f the m outh is o f para m ou n t im portance in the prevention o f decay, and every child should be im pressed w ith the necessity and instructed regarding hom e care. CONCLUSIONS
1. P roperly applied psychology in creases on e’s ability to manage children, and instead o f pedodontia being a dis agreeable ordeal fo r both child and oper ator, it becomes a pleasure. 2 . A large percentage o f cases o f m al occlusion and dentofacial deform ities cou ld be prevented by careful operative procedures. 3. F requent inspection and pedodon texesis provide a means for early detection o f dental disorders and perm it correction before the effects have becom e harm ful. 4 . D entistry fo r children is not a lu x u r y ; neither is it an expensive necessity, if care is provided early, regularly and systematically. 2039 North Prospect Avenue.
T U B E R C U L O M A IN V O L V IN G A N U PPE R M O L A R T O O T H : R E P O R T O F CASE* B y E D W A R D C . S T A F N E , D .D .S ., R och ester, M in n .
u b e r c u l o m a s are com m on even in the absence o f any evidence o f active tuberculosis, and careful postm ortem examinations reveal that
T
*From the Section on Dental Surgery, T he M ayo Clinic. *Read at the meeting o f the International Association for Dental Research, Louisville, Ky., March 14, 1936. Jour. A .D .A ., Vol. 23, September, 1936
they are present in an unusually large percentage o f cases. R obertson 1 and others have show n that tuberculous in fections m ay remain latent or dorm ant fo r indefinite periods. T h e com m on lo cations fo r such tuberculom as are the , 1. Robertson, H. E .: Persistence o f Tuber culous Infections, Am. J. Pathol., (Suppl.), 9:711-718, 1933.
Stafne— Tuberculorna In volvin g U pper M o la r
lungs, prostate gland and kidneys, and it is n ot u ncom m on to find them in bones, particularly the vertebrae. Recently, H ayes2 reported the finding o f one in an edentulous m andible. T o m y k n ow ledge, the occurrence o f a tuberculom a in the m axilla or m andible is rare, and it is this fact that prom pts me to report the f o l low in g case. R EPO RT O F CASE
H istory.— A man, aged 63, came to the Section on Dental Surgery of T h e M ayo Clinic complaining o f pain in an upper left first molar. This pain had been present for about three weeks, and, at first, there had been considerable swelling. O n examina tion, a fistulous opening, from which there was slight drainage, was seen on the buc cal mucosa slightly distad from the roots of the first molar. T h is tooth had been filled several times, and a large filling had be come loose and had fallen out a few months before. Prior to the onset o f the present trouble, this tooth had not given any trouble. Examination.— O n roentgenographic ex amination, the pulp chamber and root ca nals o f this first m olar were found to be almost completely obliterated by secondary dentin, but there was no evidence o f filling o f the root canals. (Fig. 1.) Such exten sive formation o f secondary dentin is not uncommon among elderly persons. T h e pulp chambers, in this case, w ere almost obliterated in several o f the other teeth. T h e roentgenogram revealed w hat appeared to be a radicular cyst involving the roots of this first m olar and the entire mesial sur face of the root of the second molar. A diag nosis o f infected radicular cyst was made from the clinical and roentgenographic evi dence, and extraction was advised. Physical examination, which is a routine procedure prior to dental operations, did not suggest any organic disturbance, and the patient had no other complaints. T h e
1695
systolic blood pressure in millimeters of mercury was 120, the diastolic 72. T h e specific gravity of the urine was 1.030; the reaction was acid, and there was no al bumin nor sugar, but an occasional pus cell. T h ere was a history o f pleuropneumonia with adhesions and of a condition thirty years previously that suggested pericarditis. T h ere was no known contact with tubercu losis. Operation.— T h e mucoperiosteum was first freed o f its attachment to the teeth and then retracted upward. A small open ing through the buccal plate was seen at the site of the fistula. T h is opening had probably been produced a short time before, for there w ere no adhesions such as are found when the fistulous tract is of long standing. T h e buccal w all was then re-
Fig. 1.— Periapical radiolucence typical of radicular cyst of root. T he lesion proved to be a tuberculoma.
moved to allow enucleation of what was thought to be a dental cyst. T h e second molar came away readily, without the use o f much force. W h en extraction o f the first molar was attempted, it was found that the contents o f the bony cavity ap peared to be firmly adherent to the roots of the tooth. T h e mass of tissue separated readily from the walls o f the bony cavity, and it was removed without disturbing its attachment to the roots of the tooth. E x amination o f the area that this mass of tis sue had occupied revealed a closed bony cavity within the body o f the maxilla. T h e 2. H ayes, L. V .: C lin ical D iagnosis of D is floor o f the maxillary sinus had been forced upward, but the sinus had not been pene eases of Mouth, Brooklyn: D ental Items of trated. Interest Publishing Co., Inc., 1935.
1696
T h e Journal of the Am erican D en ta l Association
Diagnosis.— T h e presence of tuberculous, infected granulation tissue was diag-
cilli. M icroscopic examination of decalcified sections disclosed that the lesion was
F ig. 2.—Tubercles in tissue attached to roots of first and second molars. nosed on microscopic examination o f tissue taken from the border o f the mass. (Fig. 2.) Sections stained for M ycobacterium tuberculosis revealed a few acid-fast ba-
continuous with the periodontal membrane. (F ig. 3.) In view o f the pathologic findings, the patient was returned to the examining phy
Stafne— Tuberculom a In volvin g U pper M o la r
sician for further investigation. Subsequent roentgenographic examination of the thorax revealed that the patient had once had pleurisy at the right base and tubercu losis o f the right apex o f the lung. T here was no evidence of active tuberculosis. It
1697
COM M ENT
F o ld i3 has said that oral tuberculous infections (u lcerou s o r n onu lcerou s) are exogenous o r hem atogenous, but never dental in origin. T h is case raises the
Fig. 3.—Decalcified section, show ing attachment of tuberculoma to buccal roots of first molar. was thought possible that the lesion o f the ja w might have been related to the form er tuberculous condition in the right apex of the lung.
question as to w hether, in rare instances,
3. Foldi, E lik : T u bercular Infection of Teeth (ab str.), J. D. Res., 15:204-205 (JuneA ug.) 1935.
1698
The Journal of the American D en tal Association
tuberculous lesions m ay not be dental in origin. T h e lesions had w ith ou t dou bt appeared at a time prior to the onset o f the acute periapical infection that brou gh t the patient to the clinic.
I f it w a s dental in origin, the most probable port o f entry w as through deep caries in the first m olar, and such entry m a y have taken place at an early age.
M O R P H O L O G Y OF R O O T CAN ALS* By A . H. MUELLER, D.D.S., M .S., Chicago, 111.
T U D E N T S o f anatomy have always kn ow n that the central portion o f the tooth is h ollow , but it was not u n til about 1870 that any e ffort w as m ade to set dow n definite inform ation about the exact form ation o f root canals and pulp chambers o f human teeth. E arly w ritings on this subject w ere n ot exten sive. M o s t o f the available literature is fou n d in textbooks. M u h lreiter,1 a G e r man anatomist, published his first edition in 1870, a very sm all but thorough w ork . In the late eighties and early nineties, D . M . C a ttell gave many lantern slide lectures on his research w ork . T h e den tal jou rnals o f those years2 state that D r . C a ttell’s lectures expounding his findings w ere in great dem and. I t is unfortunate that he never w ro te n or published the results o f his w ork . F rom w h a t older m en w h o heard him and w h o w ere as sociated w ith him during his research w ork at the C h icago C ollege o f Q en tal surgery say, D r . C a ttell must have had thousands o f sectioned teeth fro m w hich he m ade deductions to carry on his lec tures.
In 1890, G . V . B lack3 published the first ed ition o f his “ D escriptive A n atom y o f H u m a n T e e th .” T h e m ethod used in the study o f the anatomy o f human teeth by early w riters w as sectioning, consisting in attaching teeth to w ooden blocks and saw ing them or grin din g them into sections. A p p aren tly, the first man to digress from this m ethod w as Preisw erk, w h o em p loyed a unique m ethod. A ft e r ex posing the pulp chambers o f extracted teeth and then placing these teeth in w ater in an incubator fo r three weeks, P reisw erk w ou ld , by chem ical and physi cal m eans, rem ove the contents o f the pulp cham bers and canals. T h e n , after d ryin g and heating these teeth, he at tem pted to pou r m olten W o o d ’s metal into the pulp chambers and canals. T h e casts w ere defective because the m etal did n o t reproduce the finer canals and foram ina. A b o u t this time, others also felt the need o f a m ethod m ore exacting than sec tion in g teeth. G u id o Fischer,4 in 1907, reported the results o f his attempts, using
*Read before the Section on Therapeutics, Pathology and Research at the Seventy-Second Annual M idw inter Clinic o f the Chicago Den tal Society, Feb. IS, 1936. 1 . Muhlreiter, E .: Anayomie des Menschlichen Gebisses, Leipsic: Arthur Felix, 1870. 2. Dental Review, 1889-1890.
3. Black, G . V .: Descriptive Anatomy of Human Teeth, Ed. 4-, Philadelphia: T h e S. S. W h ite Dental Manufacturing Company, 1902. 4-, Fischer, G uido: Uber die feinere Anatomie der Wurzelkanale Menschlicher Zahne, Deutsche Monatschr. f. Zahnheilk., September, 1907.
S
Jour. A .D .A ., Vol. 23, September, 1936
T h e Journal of the American Dental Association
ure is the distal aspect o f the deciduous cuspids. T o restore these cavities prop erly, it is necessary to provide adequate retention by a lingual step preparation. Silver am algam serves w e ll as a filling material. A ft e r the eruption o f the first perma nent m olar, it is im portant that the distal surface o f the second deciduous m olar be w atch ed fo r caries. I f caries occurs, this surface can be restored w ith the proce du re as has been described fo r a com pound filling. PEDODON TEXESIS
Pedodontexesis may be defined as the scaling, polishing and cleaning o f the teeth o f children. It is one o f the opera tive procedures that has been m uch neg lected by the profession. T h e slogan “ See your dentist every six m onths” has caused a m isunderstanding am ong par ents. M a n y m others feel that they can neglect their children ’s m outh six months and still n ot approach the danger line. T h e frequency o f pedodontexesis and exam ination is dependent on the indi v idu al’s susceptibility. M a n y children ’s m ouths may be a com plete w reck if six
months is a llow ed between visits. O n ce each m onth is not too often fo r certain children, w h ile others may go as lon g as three months. Cleanliness o f the m outh is o f para m ou n t im portance in the prevention o f decay, and every child should be im pressed w ith the necessity and instructed regarding hom e care. CONCLUSIONS
1. P roperly applied psychology in creases on e’s ability to manage children, and instead o f pedodontia being a dis agreeable ordeal fo r both child and oper ator, it becomes a pleasure. 2 . A large percentage o f cases o f m al occlusion and dentofacial deform ities cou ld be prevented by careful operative procedures. 3. F requent inspection and pedodon texesis provide a means for early detection o f dental disorders and perm it correction before the effects have becom e harm ful. 4 . D entistry fo r children is not a lu x u r y ; neither is it an expensive necessity, if care is provided early, regularly and systematically. 2039 North Prospect Avenue.
T U B E R C U L O M A IN V O L V IN G A N U PPE R M O L A R T O O T H : R E P O R T O F CASE* B y E D W A R D C . S T A F N E , D .D .S ., R och ester, M in n .
u b e r c u l o m a s are com m on even in the absence o f any evidence o f active tuberculosis, and careful postm ortem examinations reveal that
T
*From the Section on Dental Surgery, T he M ayo Clinic. *Read at the meeting o f the International Association for Dental Research, Louisville, Ky., March 14, 1936. Jour. A .D .A ., Vol. 23, September, 1936
they are present in an unusually large percentage o f cases. R obertson 1 and others have show n that tuberculous in fections m ay remain latent or dorm ant fo r indefinite periods. T h e com m on lo cations fo r such tuberculom as are the , 1. Robertson, H. E .: Persistence o f Tuber culous Infections, Am. J. Pathol., (Suppl.), 9:711-718, 1933.
Stafne— Tuberculorna In volvin g U pper M o la r
lungs, prostate gland and kidneys, and it is n ot u ncom m on to find them in bones, particularly the vertebrae. Recently, H ayes2 reported the finding o f one in an edentulous m andible. T o m y k n ow ledge, the occurrence o f a tuberculom a in the m axilla or m andible is rare, and it is this fact that prom pts me to report the f o l low in g case. R EPO RT O F CASE
H istory.— A man, aged 63, came to the Section on Dental Surgery of T h e M ayo Clinic complaining o f pain in an upper left first molar. This pain had been present for about three weeks, and, at first, there had been considerable swelling. O n examina tion, a fistulous opening, from which there was slight drainage, was seen on the buc cal mucosa slightly distad from the roots of the first molar. T h is tooth had been filled several times, and a large filling had be come loose and had fallen out a few months before. Prior to the onset o f the present trouble, this tooth had not given any trouble. Examination.— O n roentgenographic ex amination, the pulp chamber and root ca nals o f this first m olar were found to be almost completely obliterated by secondary dentin, but there was no evidence o f filling o f the root canals. (Fig. 1.) Such exten sive formation o f secondary dentin is not uncommon among elderly persons. T h e pulp chambers, in this case, w ere almost obliterated in several o f the other teeth. T h e roentgenogram revealed w hat appeared to be a radicular cyst involving the roots of this first m olar and the entire mesial sur face of the root of the second molar. A diag nosis o f infected radicular cyst was made from the clinical and roentgenographic evi dence, and extraction was advised. Physical examination, which is a routine procedure prior to dental operations, did not suggest any organic disturbance, and the patient had no other complaints. T h e
1695
systolic blood pressure in millimeters of mercury was 120, the diastolic 72. T h e specific gravity of the urine was 1.030; the reaction was acid, and there was no al bumin nor sugar, but an occasional pus cell. T h ere was a history o f pleuropneumonia with adhesions and of a condition thirty years previously that suggested pericarditis. T h ere was no known contact with tubercu losis. Operation.— T h e mucoperiosteum was first freed o f its attachment to the teeth and then retracted upward. A small open ing through the buccal plate was seen at the site of the fistula. T h is opening had probably been produced a short time before, for there w ere no adhesions such as are found when the fistulous tract is of long standing. T h e buccal w all was then re-
Fig. 1.— Periapical radiolucence typical of radicular cyst of root. T he lesion proved to be a tuberculoma.
moved to allow enucleation of what was thought to be a dental cyst. T h e second molar came away readily, without the use o f much force. W h en extraction o f the first molar was attempted, it was found that the contents o f the bony cavity ap peared to be firmly adherent to the roots of the tooth. T h e mass of tissue separated readily from the walls o f the bony cavity, and it was removed without disturbing its attachment to the roots of the tooth. E x amination o f the area that this mass of tis sue had occupied revealed a closed bony cavity within the body o f the maxilla. T h e 2. H ayes, L. V .: C lin ical D iagnosis of D is floor o f the maxillary sinus had been forced upward, but the sinus had not been pene eases of Mouth, Brooklyn: D ental Items of trated. Interest Publishing Co., Inc., 1935.
1696
T h e Journal of the Am erican D en ta l Association
Diagnosis.— T h e presence of tuberculous, infected granulation tissue was diag-
cilli. M icroscopic examination of decalcified sections disclosed that the lesion was
F ig. 2.—Tubercles in tissue attached to roots of first and second molars. nosed on microscopic examination o f tissue taken from the border o f the mass. (Fig. 2.) Sections stained for M ycobacterium tuberculosis revealed a few acid-fast ba-
continuous with the periodontal membrane. (F ig. 3.) In view o f the pathologic findings, the patient was returned to the examining phy
Stafne— Tuberculom a In volvin g U pper M o la r
sician for further investigation. Subsequent roentgenographic examination of the thorax revealed that the patient had once had pleurisy at the right base and tubercu losis o f the right apex o f the lung. T here was no evidence of active tuberculosis. It
1697
COM M ENT
F o ld i3 has said that oral tuberculous infections (u lcerou s o r n onu lcerou s) are exogenous o r hem atogenous, but never dental in origin. T h is case raises the
Fig. 3.—Decalcified section, show ing attachment of tuberculoma to buccal roots of first molar. was thought possible that the lesion o f the ja w might have been related to the form er tuberculous condition in the right apex of the lung.
question as to w hether, in rare instances,
3. Foldi, E lik : T u bercular Infection of Teeth (ab str.), J. D. Res., 15:204-205 (JuneA ug.) 1935.
1698
The Journal of the American D en tal Association
tuberculous lesions m ay not be dental in origin. T h e lesions had w ith ou t dou bt appeared at a time prior to the onset o f the acute periapical infection that brou gh t the patient to the clinic.
I f it w a s dental in origin, the most probable port o f entry w as through deep caries in the first m olar, and such entry m a y have taken place at an early age.
M O R P H O L O G Y OF R O O T CAN ALS* By A . H. MUELLER, D.D.S., M .S., Chicago, 111.
T U D E N T S o f anatomy have always kn ow n that the central portion o f the tooth is h ollow , but it was not u n til about 1870 that any e ffort w as m ade to set dow n definite inform ation about the exact form ation o f root canals and pulp chambers o f human teeth. E arly w ritings on this subject w ere n ot exten sive. M o s t o f the available literature is fou n d in textbooks. M u h lreiter,1 a G e r man anatomist, published his first edition in 1870, a very sm all but thorough w ork . In the late eighties and early nineties, D . M . C a ttell gave many lantern slide lectures on his research w ork . T h e den tal jou rnals o f those years2 state that D r . C a ttell’s lectures expounding his findings w ere in great dem and. I t is unfortunate that he never w ro te n or published the results o f his w ork . F rom w h a t older m en w h o heard him and w h o w ere as sociated w ith him during his research w ork at the C h icago C ollege o f Q en tal surgery say, D r . C a ttell must have had thousands o f sectioned teeth fro m w hich he m ade deductions to carry on his lec tures.
In 1890, G . V . B lack3 published the first ed ition o f his “ D escriptive A n atom y o f H u m a n T e e th .” T h e m ethod used in the study o f the anatomy o f human teeth by early w riters w as sectioning, consisting in attaching teeth to w ooden blocks and saw ing them or grin din g them into sections. A p p aren tly, the first man to digress from this m ethod w as Preisw erk, w h o em p loyed a unique m ethod. A ft e r ex posing the pulp chambers o f extracted teeth and then placing these teeth in w ater in an incubator fo r three weeks, P reisw erk w ou ld , by chem ical and physi cal m eans, rem ove the contents o f the pulp cham bers and canals. T h e n , after d ryin g and heating these teeth, he at tem pted to pou r m olten W o o d ’s metal into the pulp chambers and canals. T h e casts w ere defective because the m etal did n o t reproduce the finer canals and foram ina. A b o u t this time, others also felt the need o f a m ethod m ore exacting than sec tion in g teeth. G u id o Fischer,4 in 1907, reported the results o f his attempts, using
*Read before the Section on Therapeutics, Pathology and Research at the Seventy-Second Annual M idw inter Clinic o f the Chicago Den tal Society, Feb. IS, 1936. 1 . Muhlreiter, E .: Anayomie des Menschlichen Gebisses, Leipsic: Arthur Felix, 1870. 2. Dental Review, 1889-1890.
3. Black, G . V .: Descriptive Anatomy of Human Teeth, Ed. 4-, Philadelphia: T h e S. S. W h ite Dental Manufacturing Company, 1902. 4-, Fischer, G uido: Uber die feinere Anatomie der Wurzelkanale Menschlicher Zahne, Deutsche Monatschr. f. Zahnheilk., September, 1907.
S
Jour. A .D .A ., Vol. 23, September, 1936