Pyorrhea (Riggs disease, tooth infection) is one medical term that seems to have been thoroughly mastered by the general public. This is another way of saying that this disease has a wide distribution.
First as, to causes. Brackett’ says one fact is absolutely sure of this disease, when it once becomes deeply established it can never cure itself or come to an end spontaneously with any result short of loss of the teeth. Another is that any treatment the dentist institutes will bring no real success unless the treatment includes the thorough removal of all concretions (hard deposits) from the surfaces of the teeth and especially and emphatically from those surfaces beneath the gums. Attention should also be directed to the fluids of the mouth that they may be slightly alkaline or at least neutral. If slightly alkaline the food is better prepared for stomach digestion. Another advantage of great practical consequence is that this alkalinity (tested by litmus paper which is turned blue by alkalis, the stronger the alkali the deeper the blue while acids turn the color of blue litmus paper to red) gives protection to the teeth from the acids to which they are frequently exposed such as the acids of condiments (spices, sauces, pickles, relishes and of many fruits). Whenever the teeth are “set on edge” the explanation lies in superficial corrosion and irritation by the acid.
The dentist often sees, particularly in the case of young girls who are overworking or indulging too much in late hours and unwise diet, mouths that show unmistakably the presence of acidity. Associated therewith are almost always found the ravages of extensive decay, extreme sensitiveness and an entire absence of calcareous deposits (limestone like), or tartar (consisting of mineral and organic matter). The general health needs attention first in such cases and adoption of the proper regimen to neutralize the acid condition. More rarely there may be such extreme alkalinity and such a superabundance of lime salts held in suspension that there becomes
attached to the teeth great quantities of calcic (lime) concretions which are hard to detach. These do not cause decay but their influence is in the direction of Riggs disease.’
In antagonizing mouth acid we have four principal agents. The first is prepared chalk, which chemically neutralizes acid; a second is the bicarbonate of soda (cooking soda). As much as can be held on a dime in a small glass of warm water (half a drinking glass) and used in rinsing the mouth is a good temporary method. A third is lime water. As lime is soluble in water only to a very slight degree its affinity for water may first be satisfied by slaking it. Put the slaked lime mixture in a bottle and fill with water. This may be diluted some-what with plain water.* It may be also used as an addition to milk to avoid curds in the stomach and neutralize excessive gastric acidity. A fourth and most effective agency for neutralizing mouth acids is milk of magnesia, It should be smeared over the teeth and left there. As teeth ordinarily decay more at night than during the day this use of magnesia at night is peculiarly helpful’
There is a way of practicing dentistry which has been proved capable of preventing a large part of the ills of teeth. As sometimes pursued this method gives the dentist an annual fee so that the teeth are given a thorough cleansing and scrubbing once a month regularly. This process commenced with children and persistently followed up results in the prevention of a very large percentage of decay cavities of the second class. If the dentist has the opportunity of using the stick and fine pumice stone on all the tooth surfaces of a child there is developed greatly increased hardness and capacity of resistance, just as callosity of the palms results from hard use. Pyorrheal conditions would thus be altogether prevented and sets of beautiful, sound teeth developed.
In this connection one or two additional suggestions are pertinent. Sugar when properly eaten by a child after a meal is not harmful. The mischief from sweets comes from their power to create fermentation. They may be taken in such quantities as to impair digestion and lead to a decided acidity which, if not directly developed in the mouth, is conveyed from the stomach to the marked disadvantage of the teeth. The second is that nursing mothers are fraught with a peculiar danger to the teeth. A popular idea is that “every child costs the mother a tooth.” This is partly explained by the extra demand on the mother’s vitality in the nourishment of the new being during pregnancy; but probably the greater source of danger lies in the derangement of the mother’s digestive system as manifest in the morning sickness.
We are indebted to Osborne for a thoughtful paper on this subject. It is based on the four suggestions: (1) Open infections in the mouth should be treated and eradicated. (2) The same for root infections. (3) Ill-fitting crowns and non-removable bridges are generally odoriferous abominations. (4) The dangerous mouth germs are those found in inflammation of the heart, focal pneumonia, lobar pneumonia and conditions induced by syphilis.
Early pyorrhea can be treated so as to save the teeth and preserve the health. Such temporizing treatment as is often resorted to does no more than keep the deeper infection concealed. More efficient methods are necessary.
If putridity is concealed in a closed pocket, as under crowns and bridges, will anyone assert that the absorption of the putrefactive poisons-present is not dangerous? All dentists know the odor present when some of these gold attachments are removed.’
Unfortunately some forms of infection cannot be disclosed by X-ray films. Also many X-ray pictures are imperfect or misread and many teeth are extracted unnecessarily. These films should be examined by experts and also by the patients’ physician. If the patient is seriously ill, then extraction is often the safer course. Everyone knows of one or more deaths from tooth infection. One of the most frequent and the most serious systemic disturbances caused by mouth infection is disease of the heart. The next most frequent is disturbance of the endocrine glands and the symptoms from such disturbance are manifold.
Rosenau says children need about five times as much calcium (food-lime) in their diet as adults. The first permanent molars (6 year molars) are perhaps the most important teeth in the mouth and are the most frequently neglected, partly because they are often mistaken for temporary teeth. Decay is favored by the fermentation of starchy foods and sugars, so that all food particles should be removed after each meal by the use of silk floss. Children should be discouraged from eating crackers and candy between meals.
The noses and throats of all children require examination for adenoids, polypi, deviation of the septum (partition), etc., and all inflammations of tonsils, throat and nose treated promptly. Nose-bleeds and mouth-breathing during sleep should be reported. In all cases of acute illness the throat and mouth should be examined for indications of scarlet fever, measles and signs of tonsillitis or diphtheria and a culture taken promptly of any suspected case of diphtheria. Those with large tonsils, recurring tonsillitis and enlargement of the neck glands should be examined by a competent physician.
Simple inflammation of the gums in the majority of instances, says Goadby, results from a too-vigorous use of a stiff tooth brush. The gum injuries are generally most marked on the left upper jaw in right-handed people and the right lower jaw in left-handed people. The gum edge is generally thin and transparent next the teeth but thickened and irregular nearby. These injuries are seldom found on the internal surface of the gums. Their prevention lies in the use of a small tooth brush with a circular motion, which allows the interstices or crevices of the tooth surface to be cleaned, in addition to polishing the labial (lip) portions. Anything in the nature of gritty dentifrices should be avoided. By far the best method of cleaning the gums in any form of inflammation is a swab of cotton wound around the finger, by which the surfaces are gently mopped and pressed, care being taken to avoid any rubbing motion. The movement should be upward in the lower jaw and downward in the upper. This use of the finger is common to many races including a majority of Hindus of all classes (in India) .2
The mildest inflammation of the gums affects the gum margins. It is usually but not invariably associated with general cold in the head and catarrhal condition of the mucous membrane of the upper air passages. The gums are generally sore to touch, even with food, although there is little to be seen; the teeth feel elongated and loose.
The gums may be so congested (accumulation of blood to the part) that pulsation is complained of. Cold sore of the lips is more common to persons with catarrhal gum trouble. The tooth feels long because of engorgement of the vessels of the tooth socket, which forces the tooth slightly upward. In simple cases there is no pus. The affection as a rule passes off as the symptoms of the throat and nasal mucous membrane subside, but shedding of the gum and mucous membrane occurs. Mild acid lotions are usually the best treatment. If inflammation of the tough fibrous membrane surrounding bone tissue ensues local ionization is recommended (decomposition of a chemical compound used medicinally by electricity).
This catarrhal affection, although slight, has consider-able bearing on other affections of the gums, more especially predisposing to infection which may develop into pyorrhea, the catarrhal condition causing slight swelling of the gum margins, leading to occasional small ulcerative patches. There is little doubt that chronic congestion and inflammation of the gums, leading to final loss of many or all the teeth, is increasing in civilized communities?
Chronic inflammation of the gums and stomatitis (inflammation of the mouth) characterized by bright red gums, commences insiduously with bleeding. There is no pus but general swelling and irregular attacks of ulceration of the gums alone or of the whole mouth may. occur sporadically (separately or apart). The disease does not heal of itself. In early stages diarrhea and gastrointestinal symptoms are common. The best local application is borax and glycerine painted on the ulcerated surfaces. Fresh fruit juices and other anti-scorbutics (relating to scurvy) should be used. As to vitamin efficiency information is not yet forthcoming.
Chronic infection and irritation around crowns, badly fitting dentures (false teeth) and their clasps, ill-designed bridges, projecting edges of fillings and other forms of dental irritation are often associated with localized enlargement of the gum tissue? The discovery of infected bony tissue in relation to the margins of caps and crowns is such a common routine observation that it may be al-most regarded as a foregone conclusion, especially when a cap crown has been fixed upon a tooth for any length of time, and when the pernicious habit of driving the edges of the crown under the margin of the gums is adopted, a method which can only be described as criminal, signs of alveolar infection (of the bony socket), or thickening of the border of the socket, being practically constant. Many fillings, particularly between teeth, are apt to show tooth decay. Very often a third tooth root is thus exposed. It is not always possible to determine the depth of a “pocket” from an x-ray film?
Wasting of the gum tissue, leaving the necks of the teeth exposed, is brought about by wasting of the gum as a whole. The diagnosis is not always easy. The absence of pus, congestion and bleeding distinguishes the affection from pyorrhea?
In true aveolar abscess the teeth become destroyed by the action of bacteria on fermentable foodstuffs left between the teeth, which fermentation results in acids, mainly lactic, which attack the lime salt which composes 90 per cent of the enamel?
As to treatment, not a few acute dental abscesses discharge and clear up. Therefore an attempt should be made of clearing and sterilizing the Tooth root in bad cases by incision and drainage. It may be taken as a general principle that no tooth should be sacrificed be-cause of abscess from infection of the gums, but abscesses arising from tooth pulps (the soft, vascular tissue occupying the central cavity), and which have produced inflammatory changes around the tooth apex (top of the root arch) are not frequently dealt with except by removal of the tooth. But the mere presence of a point of suppuration in the jaw without associated, definite symptoms, either in the blood stream or in the patient’s general health, significant of chronic suppuration, should not call for removal of a single tooth. The modern policy of removing a large number of teeth in cases of, say, arthritis (inflammation of a joint) is not a wise one. Definite association between the disease and focus should first be demonstrated. A considerable percentage of arthritis cases fail to improve after general tooth extraction in fact, often become aggravated. In cases open to this risk preliminary vaccine treatment is of the greatest ad-vantage,* and where no urgent symptoms call for the immediate removal of the teeth, vaccine immunization (making the patient resistant) by appropriate vaccine to raise the patient’s general resistance, greatly diminishes the risk of delayed secondary infection. On the other hand, acute or subacute infections often demand immediate surgical intervention, but whenever suppurative mouth infections must be dealt with by wholesale extraction, careful consideration should first be given to this point (of secondary focal infection) the question of progressive extraction raised and the rule followed that a bacterial examination should first be made. Before making a definite conclusion that the mouth is the source of infection all other possible sources should be eliminated such as chronic appendix, uterine infection, post-nasal suppuration and intestinal putrefaction.
A large proportion of cases of stomach disturbance is due to infection from organisms of mouth origin and are easily recognizable. Gradual degeneration of the digestive function follows the persistence of lactic acid fermentation, followed by actual infection of the gastric wall. Infection of the blood stream direct, as suggested by Rosenau, is probably the chief road by which bacteria set up diseases in other parts of the body. In such cases the air passages have presented symptoms of chronic lung affection leading to a diagnosis of tuberculosis and in a considerable percentage of cases the patient has been so treated.
Rosenau produced 84 per cent of disease in rabbits by the injection of the streptococci of endocarditis (inflammation of the lining membrane of the heart) and but 14 per cent in rabbits inoculated with strains from other sources.
Inflammation of the joints for ordinary purposes can be divided into two classes, rheumatic arthritis and rheumatic gout (joint inflammation; chalky deposits and increase of uric acid in the blood). Many such cases are not chronic but acute, of which the following is an instance: The patient, a girl aged 24, suffering from chronic tooth suppuration, had two teeth removed. The next morning she had a chill with an evening temperature of 101°. Next day it was 100°, but both wrist joints were swollen and acutely painful for 48 hours. Some weeks later two more teeth were extracted. The fever and wrist pains and swelling returned. Large numbers of streptococci were obtained from the jaw where the extraction wounds had not healed, and also from the urine. Subsequent vaccination from urine culture specimens resulted in the gradual disappearance of the joint. symptoms, but after each of the four injections a rise of temperature with swelling and tenderness of the affected joints occurred. Poynton and Payne have demonstrated that many cases of acute rheumatism or rheumatic fever are due to streptococci infection.
In another case, a male aged 47, who suffered from pus in tooth socket, had 7 teeth removed. Four months later he noticed stiffness of the left knee joint followed a few weeks later by stiffness in the right knee. Six months later, when advice was sought, considerable pain on movement was present. X-ray films showed bony excrescence in both knee joints and the beginning of disease of the ankle and wrist. An examination of the mouth showed no source of infection. The post-nasal spaces and tonsils gave streptococci of the sub-acid group. There is little doubt that the infection had remained latent in the tonsils and later became chronic.
Tooth Pastes and Powders as a Cause of Bad Teeth
Head’s investigation into the cause of decay of tooth enamel has attracted much attention. For instance, he ‘ found that 1 part lactic acid (produced in the fermentation of milk) to 1,000 parts of water at mouth temperature will cut enamel into a rough white surface in 30 minutes. A tooth placed in 1 part to 500 lactic acid and saliva will be unharmed. A 1 to 500 saliva and lactic acid solution has an extremely acid taste and instantly turns blue litmus brilliantly red. A 1 to 20,000 lactic acid and water solution will at the end of three or four days leave the appearance of a tooth intact, yet the outer surface of the enamel will, with the edge of a lancet, be found to have distinctly softened.’
The action of water solutions of acid calcium phosphate and acid sodium phosphate on the teeth has been mentioned by Kirk as causing smooth, white decalcification (injury to the enamel), As a matter of fact many acids in water solutions cause smooth primary softening if the solution is sufficiently weak. Two sound teeth with enamel impervious to the lancet Were placed in the lobe of a navel orange. These lobes were each placed in a bottle, with a few drops of ether to prevent fermentation, at the body temperature for two days. It was found that the lobe around one of the teeth had fermented, the other had not. All the enamel of the fermented lobe was soft enough to be pared with a lancet. The enamel of the other tooth was also distinctly softened. These teeth were then washed and kept in saliva at body temperature for two weeks. At the end of five days there was a decided rehardening. In ten days the enamel could no longer be scratched. In two weeks the white area had almost disappeared and both teeth appeared normal. These experiments were verified.
This softening and hardening of enamel has a very practical bearing on the use of dentifrices. Enamel that while hard will show but insignificant wear to dentifrice grit will show an appreciable loss under the same friction when softened. This softening and hardening may readily account for the reason why some patients, especially those fond of fruit, wear their teeth down to the gum at a comparatively early age. The mere friction of mastication is sufficient to take off a layer of enamel softened by fruit or vinegar which, if given the opportunity, will reharden.
In the other article by the same author (previously set out) the results of numerous experiments with popular tooth powders and pastes are fully described. He says that tooth powders even of chalk are largely instrumental in cutting the well-known smooth grooves in the necks of teeth that so frequently appear from the second molar forward. These tests were the beginning of a long series of experiments to determine just what would happen to the enamel and cementum (layer of bone over the root of the tooth) of teeth when brushed with certain mouth washes on the market and precipitated chalk.
It should be carefully noted that McCollum and Simmons, of Johns Hopkins, recommend soap as a good dentifrice and particularly point out that the film on the teeth against which certain manufacturers of dentifrices make a drive as being injurious is, in fact, Nature’s protective covering of the teeth and should not be removed. Even if this were not so persons with a nice hygienic sense might well hesitate before smearing over the teeth an animal product, such as pepsin, derived from the stomach of a lower animal, generally the pig, in order to “digest off” this protective film.