THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY ORAL SEPSIS IN ITS RELATIONSHIP TO SYSTEMIC DISEASE OKAL SEPSIS SYSTEMIC DISEASE BY WILLIAM W-lDUKE, M.D., Pn.B. KANSAS CITY, Mo. PROFESSOR OF EXPERIMENTAL MEDICINE IN THE UNIVERSITY OF KANSAS SCHOOL OF MEDICINE; PROFESSOR IN THE DEPARTMENT OF MEDICINE IN WESTERN DENTAL COLLEGE; VISITING PHYSICIAN TO CHRISTIAN CHURCH HOSPITAL; CONSULTING PHYSICIAN TO KANSAS CITY GENERAL HOSPITAL, KANSAS CITY, MO., AND TO ST. MARGARET'S HOSPITAL, KANSAS CITY, KANSAS. WITH 170 ILLUSTRATIONS ST. LOUIS C. V. MOSBY COMPANY 1918 COPYRIGHT, 1918, BY C. V. MOSBY COMPANY Press of C. V. Mosby Company St. Louis Bicmedicsl Library wu TO MY FATHER HENRY BUFORI) DUKE THIS BOOK IS AFFECTIONATELY DEDICATED 577956 PREFACE In the preparation of this little book, the aim has been to present as briefly and clearly as possible the rather complex relationship which frequently exists between infections of the gum and alveolar process and certain systemic disorders. This has necessarily involved a dis- cussion of some of the more complex problems of bacteri- ology, immunology, and pathology as well as of dentistry. In so small a space it has not been possible to take up any of these subjects in great detail, and for this reason those especially interested in certain particular phases are referred to the writings of Eosenow, Billings, Schott- muller, Poynton and Payne, Libman, Vaughan, von Pir- quet, Wolff-Eisner, Richet, Rosenau and Anderson, and other investigators to whom we are indebted for many of our more recent ideas which have a bearing upon this very important subject. In the opinion of the writer, the discovery of the rela- tionship which frequently exists between the various chronic infections and systemic disease marks a great practical advance in the science and therapy of medicine. For centuries it has been evident to physicians that cer- tain acute inflammatory lesions give rise to systemic dis- turbances. One of the main advances of recent years, therefore, has been the disclosure of the fact that small and apparently innocent infections which give rise to lit- tle or no local disturbance may likewise be the source of serious generalized disease. For the proper care of medical cases, the hearty and intelligent cooperation of the dentists is absolutely es- sential. In the writer's experience, it has been found 7 8 PREFACE that the teeth should be taken into account in nearly every medical case. For this reason, the welfare of the affected individual demands that the dental surgeon un- derstand and appreciate the problems and aims of the physician, and that he be willing at times to sacrifice apparently useful teeth for the sake of the patient 's gen- eral welfare. Consequently, the main purpose of this volume has been to assemble facts which show, first of all, that dental sepsis is an extremely common condition, and, second, that it may cause serious systemic disorder in many different ways. For the sake of completeness, it has been necessary to discuss some of the purely dental problems. These have been discussed purely from a pathologic viewpoint based upon an experience with more than one thousand care- fully studied medical cases observed in a consulting of- fice practice on whom dental roentgenograms were made as part of a routine examination. In all over eight thou- sand dental films were taken. It is believed and sincerely hoped that the views here expressed are in harmony with those of the dental surgeons who have given the problem of oral sepsis the attention and study it deserves. For a more detailed account of this subject from a dental standpoint, the reader is referred to the publications of the investigators in this field: G. V. Black, and A. D. Black, Hartzell, Price, Rhein, Thoma, Grieves, etc. Finally, I wish to acknowledge with thanks the hearty cooperation of my friend and coworker in this study, Rex Dively, under whose direction the roentgenologic work was done, to L. S. Milne and W. A. Myers, my office associates, to Joseph Kelly and Miss Rose Mary Trott, for their careful work in clinical pathology, and to Miss Elizabeth Leas, assistant in the roentgenologic laboratory. WILLIAM W. DUKE. Kansas City, Mo. CONTENTS CHAPTER I INTRODUCTION PAGE History 17 Publication of Benjamin Rush on the Relationship Between Defective Teeth and 111 Health 17 General Observations Concerning a Relationship Between Defective Teeth and 111 Health "....... 20 Relative Importance of Caries, Malocclusion, Infection of Food, Pyorrhea, and Alveolar Abscesses in the Causation of Systemic Disease . 21 Frequent Occurrence of Oral Sepsis 22 Variation of Oral Sepsis with Age and Dental Work, etc 22 Aims of the Dentist in the Past and at Present 23 CHAPTER II PYOKRHEA ALVEOLARIS Ktiologir, Factors 24 Brief Discussion of : Microorganisms 24 Mechanical factors 24 Relative importance of the various factors 25 Frequency with which several factors coexist and its cause .... 26 The Role Played By: Infection . 27 Various microorganisms , .... 28 Mechanical factors 32 Lowered resistance to infection 32 CHAPTER III ALVEOLAR ABSCESSES Sources of Origin - ... 37 Statistics Concerning the Occurrence of Alveolar Abscesses 37 Sources of Infection of Root Pulp 42 9 10 CONTENTS PAGE Statistics Concerning the Relative Frequency with which Treated Teeth Become Infected 42 Teeth purposely devitalized 4.> Crowned teeth not purposely devitalized 45 Root remnants 45 Pathology of Alveolar Abscesses 46 Mode of development 46 Time of onset 47 Symptoms of Alveolar Abscesses 47 Symptoms of acute abscesses 47 Osteomyelitis of jaw 49 Symptoms of chronic abscesses 49 Diagnosis of Alveolar Abscesses 50 Interpretation of roentgcnograms 50 Significance of radioluccnt areas 52 Significance of radiolucent areas in bone other than that of the alveolar process 52 Comparison Ixjtween infection in the alveolar process and that in the bone elsewhere in the body 53 Viability of Organisms in Alveolar Abscesses 56 Importance of the Root Canal and Necrotic Roots as a Source of Reinfec- tion of healing abscesses 56 Treatment of Periapical Infections 57 Illustrations of Palliative Measures in the Treatment of Alveolar Abscesses 59 Importance of Careful Root Canal Work Immediately after Devitaliza- tion of a Tooth 67 CHAPTER IV METASTATIC INFECTION Spread of Infection from a Primary Focus 71 Influence of Lowered Resistance to Infection 71 Streptoeoccic Infections 72 Selective affinity of streptococci 72 Transmutation of species of streptococci 72 Relation of selective affinity to virulence of organisms 74 Diseases which may be caused by streptococci 74 General Virulence of Organisms 75 The Role of Local Injury in Determining Site of Localization of Infection 75 Relation of Local Injury in Determining the Nature of the Pathologic Process Caused by Infection 76 Comparison Between the Result of Infection in Normal Individuals and Those Subjected to Various Poisons, Injury, Strain, etc. ... 77 Comparison Between the Effect of Poisons, Injury, Strain, etc., upon Nor- mal Individuals and Those Having Chronic Infections .... 77 CONTENTS 11 CHAPTER V NONRELATED INFECTION AS INFLUENCED BY ORAL SEPSIS PAGE Influence of One Infection upon Another 79 Acute infections 79 Chronic infections 79 111 Effects of Sepsis upon Individuals with Syphilis of the Nervous System 80 Illustration of the influence of an acute infection upon the symptoms of tabes dorsalis 81 Illustration of the effect of chronic sepsis in a case of general paresis 82 Illustration of the relief obtained by the removal of sepsis in a severe rapidly progressive case of tabes dorsalis 82 Conclusions Concerning the 111 Effect of Sepsis upon Patients with Syphilis of the Central Nervous System 83 Importance of Eradicating Sepsis as a Preliminary Step in the Treat- ment of Syphilis of the Central Nervous System 83-84 CHAPTER VI TOXIC EFFECT OF ORAL SEPSIS Niiluro of the Toxic Products Formed by Organisms Which Ordinarily Take Part in the Pathology of Oral Sepsis 85 Allergy as Illustrated by the Action of Tuberculin 85 Comparison Between a Tuberculin Reaction and that Produced by In- oculation with Living Bacilli 86 Comparison Between Tuberculous Infections and Other Infections . . 86 Comparison Between the Local, General, and Focal Reactions Observed Clinically After the Use of a Vaccine, etc., and After the Acute Onset of a New Infection 87 Influence of Acute and Chronic Infections upon Chronic Infections in Gum and Alveolar Process 88 Influence of Oral Sepsis upon Other Coexisting Infections Localized in Remote Organs 88 Untoward Effects Occasionally Caused by the Extraction of Infected Teeth 88 Beneficial Results Frequently Obtained by the Extraction of Infected Teeth 89 Functional Disturbance in Infected Organs as a Result of a Toxic Effect of Oral Sepsis 90 Sensitization and Tolerance for Bacterial Proteins 90 Relation Between the Systemic Effect of an Infection and Sensitiza- tion and Tolerance 91 Sensitization against Proteins not of Bacterial Origin 91 Symptoms of Anaphylaxis in Animals 92 Symptoms of Anaphylaxis in Humans 92 12 CONTENTS PAGE Scnsitization 93 Methods of Producing Artificial Scnsitization 93 Protein Scnsitization as Observed Clinically 93 Examples Showing High Degree of Protein Sensitization in Humans . . 93 Comparison Between Protein Sensitization as Seen Clinically and Experimentally 95 Oral Sepsis as a Cause of Protein Sensitization and Intoxication ... 95 Chronic Mild Anaphylaxis 95 Vaughan's Theory 9(5 Tolerance of Alien Proteins 97 Clinical Symptoms Attributable to Protein Sensitization or Anaphylaxis 9^ The Relative Importance of Anaphylaxis as a Cause of Systemic Disorder 9s Anaphylaxis as a Cause of Functional Disorder 99 Symptoms Frequently Believed by the Removal of Sources of Chronic Intoxication !'.> General symptoms 99 Diseases of the skin 100 Functional disorders and neuroses 100 Disorders of the vegetative nervous system 100 Functional disturbance due in part to organic disease 100 Symptoms due in part to other infections 100 CHAPTER VII HEADACHE AS BELATED TO ORAL SEPSIS Oral Sepsis as a Primary and as a Contributing Cause of Headache . 102 Oral Sepsis as a Source of Arthritis in Cervical Spine, etc 102 Oral Sepsis as a Source of Neuralgia or Neuritis in Facial Nerve . . 104 Headache as a Referred Pain from a Diseased Tooth 104 Headache Caused by Antrum Infection Due Primarily to Oral Sepsis . 105 CHAPTER VIII SUMMARY AND CONCLUSIONS Frequent Occurrence of Oral Sepsis 106 Statistics Showing the Comparison Between the Occurrence of Oral Sepsis and That of Other Chronic Infections 106 Limitation of Conclusions Drawn from Clinical Observations .... 107 Statistics Showing the Frequency with which Oral Sepsis and Other Chronic Infections Coexist 107 Conclusions Concerning the Importance of Oral Sepsis as a Cause of Systemic Disorder 109 Conclusions Concerning the Various Ways in Which Oral Sepsis May Cause III Health 109 Results Which Follow the Eradication of Oral Sepsis 109 Treatment of Oral Sepsis 110 ILLUSTRATIONS FI G. PAGE 1-4. Illustrations showing a normal condition of roots and alveolar process 25 5-6 Illustrations showing erosion of alveolar process 26 7-10. Case of pyorrhea alveolaris of long standing 27 11-14. Illustrations of cases in which the alveolar process has been so destroyed by infection that some of the teeth are held in place by soft tissues alone 28 15-10. Pyorrheal abscesses 29 17. Abscess at the root apex of a vital tooth 29 18-21. Showing ill effect upon the alveolar process of careless dental work 30 22-24. Showing the ill effect upon the alveolar process of careless dental work 31 2;"5-."0. Illustrations showing deposits on necks of roots 33 31-36. Case of chronic recurrent pyorrhea alveolaris 35 37-41. Illustrations of large alveolar abscesses 38 42-43. Osteomyelitis of the jaw derived from an infection at the roots of a molar tooth 39 44-49. Illustration of the less active type of pcriapical infection . . 40 50-55. Typical example of oral sepsis in a patient with a great deal of dental work 41 56-50. Example of the occurrence of numerous large abscesses ... 42 60-65. Example of an individual having a great deal of dental work, who shows relatively little periapical sepsis 43 66-71. Illustration of the commonest source of periapical infection; namely, devitalized teeth with incompletely filled root canals 44 72-74. Illustration of abscesses due to perforation of root by pins . . 45 75-77. Apical sepsis due to infection of the pulp by decay 46 78-83. Examples of root remnants which arc the site of infection . . 47 84-89. Examples of infection at the apices of filled teeth whose pulp was not intentionally destroyed 48 90-91. Examples of infection at the root apices of unerupted teeth . 49 92. Example of periapical infection of teeth whose pulp was de- stroyed by severe trauma 50 93-97. Example of periapical infections of crowned teeth whose pulp was not purposely devitalized 51 98-99. Examples of periapical infection of untreated teeth .... 52 13 14 ILLUSTRATION'S / llV[ G. PACK 100-102. Absorption of the tips of the root apices and necrosis of the apex 5.", IO.'5-l 00. Several teeth showing one or more completely necrosed roots 54 107-11.). Illustrations of shadows indicating areas of increased density in the alveolar process as a result of healing of infected areas 55 114-11(5. Illustrations of radiopaque areas which simulate the healed abscesses shown in Figs. 107-113 50 117. Eoentgenogram showing bone of increased density 57 118-120. Examples of root remnants which have apparently become encysted 57 121. Roentgenogram taken immediately after drainage and filling of the root canal 00 122. Roentgenogram of the same tooth as in Fig. 121 approximately one year later (50 12)!. Roentgenogram taken just before drainage and filling of the root canal 00 124. Roentgenogram of the same tooth as in Fig. 123 two months later (() 125. Roentgenogram showing small area of apical sepsis (51 120. Roentgenogram of same tooth taken approximately six months after its treatment 01 127. Roentgenogram showing small area of sepsis 01 128. Roentgenogram showing same tooth approximately three months after its treatment (51 129. Roentgenogram showing apical infection 02 130. Roentgenogram taken shortly after the filling of the root canal . 02 131. Roentgenogram taken approximately eight months after that shown in Fig. 130 02 1 .'12. Roentgenogram showing an abscess at the root of a crowned left upper incisor 03 !.'!.">. Roentgenogram taken three months after irrigation through the root canal of the left incisor followed by filling of the root canal 03 1 )!4. Roentgenogram taken six months after treatment (>"> 1.">5. Roentgenogram showing apical infection at the root of a lower molar tooth 04 1 .'!(>. Roentgenogram taken approximately six months after drainage and filling of the root canal 04 1. '57-135). Roentgenograms showing sepsis at the apices of two lower molar teeth before, during, and after treatment ... 04 140-142. Roentgenograms showing large alveolar abscess before and after treatment 05 143-14(5. Roentgenograms showing abscesses at the roots of two lower incisor teeth before, during, and after treatment ... 65 ILLUSTRATIONS 15 FIG. PAGE 147-148. Roentgenograms showing large discharging alveolar abscess at the apex of a lower incisor tooth before and after treat- ment 66 149-150. Roentgenograms showing an abscess at the root of an upper bicuspid tooth before and after treatment 66 151-152. Roentgenograms showing an abscessed lower molar tooth lie- fore and after treatment 66 153-161. Examples of careful root canal work 67-70 162. Case of chronic migratory polyarthritis of several months' dura- tion which was completely relieved by extraction of tooth shown in illustration 76 163. Case of multiple neuritis relieved by extraction of tooth ... 76 164. Case of recurrent pain in gall bladder region associated with jaundice relieved by extraction of tooth 76 1(55. Case of staphylococcus septicemia 80 166-167. Roentgenograms showing broaches which had been introduced with ease through the root canal and alveolar process practically as far down as the dental nerve 103 168. Case of severe headache due to cervical arthritis and myostitis relieved by extraction of tooth 104 169. Case of severe facial neuralgia relieved by extraction of a tooth . 104 170. Case of headache due to antrum infection, the source of which was an abscess at the root of a bicuspid tooth 104 ORAL SEPSIS IN ITS RELATIONSHIP TO SYSTEMIC DISEASE CHAPTER I INTRODUCTION The discovery of a relationship between ill health and defective teeth is by no means recent. It has received casual mention in the older literature and has been in- dependently recognized, perhaps for centuries, by prac- titioners of medicine and dentistry. The subject has not received the prominence it deserves, however, previous to the past decade. We wish to quote in toto an article published by Benjamin Rush, one of the signers of the Declaration of Independence, and one of America's most noted physicians, on observations commenced by him in 1801. This remarkable article, written before the dis- covery of bacteria and when our knowledge of pathology was meager indeed, harmonises in its essentials with the more popular views of the present day. I have taken the liberty of italicizing several striking sentences. MEDICAL INQUIRIES AND OBSERVATIONS* By Benjamin Rush, M.D. Professor of the Institute and Practice of Medicine and Clinical Practice in the University of Pennsylvania * * Some time in the month of October, 1801, I attended Miss A. C. with rheumatism in her hip joint, which yielded for a while, to the several remedies for that dis- *Vol. I, p. 199, published in 1818 bv M. Carey & Son, Philadelphia. This article was found by Mrs. Rose M. Hibbard of the Kansas City Medical Library in the pri- vate collection of Dr. A. E. Hertzler. It has also been referred to by George N. Kreider, A. D. Black, and David Riesman. 17 18 ORAL SEPSIS ease. In the month of November it returned with great violence, accompanied with a severe toothache. Suspect- ing the rheumatic affection was excited by the pain in her tooth, which was decayed, I directed it to be ex- tracted. The rheumatism immediately left her hip, and she recovered in a few days. She has continued ever since to be free from it. "Soon after this I was consulted by Mrs. J. R. who had been affected for several weeks with dyspepsia and toothache. Her tooth, though no mark of decay appeared in it, was drawn by my advice. The next day she was relieved from her distressing stomach complaint, and has continued ever since to enjoy good health. From the soundness of the external part of the tooth, and, the adjoining gum, there was no reason to suspect a discharge of matter from it had produced the disease in her stomach. "Some time in the year 1801 I was consulted by the father of a young gentleman in Baltimore, wiio had been affected with epilepsy. I inquired into the state of his teeth, and was informed that several of them in his up- per jaw were decayed. I directed them to be extracted, and advised him after to lose a few ounces of blood, at any time when he felt the premonitory symptoms of a recurrence of his fits. He followed my advice, in con- sequence of which I had lately the pleasure of hearing from his brother that he was perfectly cured. "I have been made happy by discovering that I have only added to the observations of other physicians, in pointing out a connection bettveen the extraction of de- cayed and diseased teeth and the cure of general diseases. Several cases of efficacy of that remedy in relieving head- ache and vertigo are mentioned by Dr. Darwin. Dr. Grater relates that Mr. Petit, a celebrated French surgeon, had often cured intermitting fevers, which had resisted the bark for months, and even years, by this prescrip- tion ; and he quotes from his works two cases, the one of INTRODUCTION 19 consumption, the other of vertigo, both of long continu- ance, which were suddenly cured by the extraction of two decayed teeth in the former, and of two supernumerary teeth in the latter case. "In the second number of a late work, entitled Bib- liotheque Germanique Medico Chirurgicale, published in Paris, by Dr. Bluver and Dr. Delaroche, there is an account, by Dr. Siebold, of a young woman who had been affected for several months with great inflammation, pain, and ulcers, in her right upper and lower jaws, at the usual time of the appearance of the catamenia, which at that period were always deficient in quantity. Upon inspecting the seat of those morbid affections, the doctor discovered several of the molars in both jaws to be de- cayed. He directed them to be drawn, in consequence of which the woman was relieved of the monthly disease in her mouth, and afterwards had a regular discharge of her catamenia. "These facts, though but little attended to, should not surprise us, when we recollect how often the most dis- tressing general diseases are brought on by very incon- siderable inlets of morbid excitement into the system. A small tumor, concealed in the fleshy part of the leg, has been known to bring on epilepsy. A trifling w^ound with a splinter or a nail, even after it has healed, has often produced a fatal tetanus. Worms in the bowels have produced internal dropsy of the brain, and a stone in the kidney has excited the most violent commotions in every part of the system. Many hundred facts of a simi- lar nature are to be met with in the records of medicine. "When w.e consider how often the teeth, ivhen decayed, are exposed to irritation from hot and cold drinks and aliments, from pressure by mastication, and from the cold air, and hoiv intimate the connection of the mouth is ivith the whole system, I am disposed to believe they are often the unsuspected causes of general, and, par- 20 OKAL SEPSIS ticularly of nervous diseases. When we add to the list of those diseases the morbid effects of the acrid and putrid matters, which are sometimes discharged from the carious teeth, or from the ulcers in the gums created by them, also the influence which both have in prevent- ing perfect mastication, and the connection of that ani- mal function with good health, / can not lielp think hit/ that our success in the treatment of all chronic diseases irould be very much promoted, by directing our inquiries into the state of the teeth in sick people, and by a