Vol. XXXVII.

Original Contributions

[EXCLUSIVEly for the MEDICAL HErald.]

PYORRHEA AND ITS TREATMENT
DR. HUBERT HUTTON, Kansas City, Mo.
Pyorrhea Defined

Pyorrhea, or purulent alveolitis, is a chronic, non-specific, infectious diseases of the alveolar process and of all the immediately adjacent structures, producing a dissolution of the osseous elements of the process, with cavity formation about the roots of the teeth involved. Its clincal manifestations, primarily local, but later generalized into systemic disturbances, consist for the most part of tender, sore, bleeding gums, and later on loosening of the teeth, presenting a marked tendency to mal-position and ultimate loss. The disease is absolutely preventable, and curable as well, but when once established is found stubbornly to defy most remedial meas

ures.

Clinically, the disease presents itself in three distinct pathological varieties, making itself in some instances difficult of early recognition, and thereby escaping the observation of both clinician and patient until a deep-seated and widespread involvement has obtained. One variety of the disease-process manifests its existence by alarming symptoms, early, so that even the patient affected will often be able to make a satisfactory diagnosis long before the condition has attained its height; but in the majority of cases no such troublesome symptoms present themselves to betray the destructive influences at work, and often before the case is regarded as vorrhea, great destruction has been wrought. Hence it is that we must recognize the distinctive characteristics of each variety separately, and thereby be put on guard to overcome each case in its incipiency.

Pathology of the Disease-Virulent Type In this variety more distinctly than in either i the other two, the infection is clearly of an exogenous nature. From the multitude of organisms existing on or about poorly kept teeth,

No. 5

infection first gains entrance into the mouths of tiny ducts located at the gingival margin, which leads from glands placed deeply within the gum tissue. Inflammation with extension of the infectious process now proceed hand in hand until, within a very brief space of time, the entire gum tissue becomes the seat of a widespread bacterial invasion. Serumal exudation with leuccocytic infiltration into the tissues determines the final issue. Either the condition becomes generalized over the whole dental arch, or remains localized and is walled off by fibrous tissue outside of which is gathered a defensive wall of leuccocytes, enclosing an inflamed area of infection. One or several such fields may be observed scattered over the gum surface, while in close proximity to them may be seen the normal and uninvolved gum area. Hence the gums may be said to have a mottled appearance.

This infection with its subsequent inflammation gives rise to a deformity, characterized by inversion of the gingival border which lends to the gum a folded-in appearance at the point where it meets the teeth. This seems to be an endeavor on the part of the gums to evade further irritation by bringing the mouths of the infected ducts beneath the gingival margin.

The Secretion

On making an examination of the secretion coming from the glands affected, we find alterations in one or all of its characteristics. In this type of disease, however, there is generally a notable increase in the quantity and a marked variation in the quality of the fluid, whose thick ropy consistency together with its strong acid. reaction, constitute the most characteristic features of the secretion.

Following upon the establishment of the disease in the gum, the peridental membrane is the structure next in order subjected to the disturbance. Having been successfully invaded by micro-organisms, liquefactive processes come into evidence and thus the alveolar process is denuded of its protective covering and predisposed to destructive changes.

In the state of infection which has now become quite extensive in the membrane, inflammation and serumal exudations that tend toward calcification form the most striking features of early pathology. Soon following this secondary

invasion of the deep structures, liquefaction of the bone and membrane is instituted, producing the pockets, filled with necrotic and purulent matter surrounding the necks of the teeth. These pockets, as a result of their rapid production, show an almost equal tendency to a lateral and vertical extension. Their boundaries have sharp limitations as though cut away by an instrument, and immediately outside of, and bounding the pocket, is found the defensive wall of leuccocytes. That portion of the pocket in close apposition with the tooth involved has a greater vertical range than any other part, so that the pocket formed resembles a funnel-shaped depression, the mouth of which is directed toward the roots of the tooth first attacked."

The pericementum that normally encases the roots of the tooth and furnishes the attachment to the firm process is covered with fine granular deposits of lime salts that in common parlance are termed "the serumal deposits." These deposits are very hard, and being firmly attached to the underlying membrane, are removed only with great difficulty. The membrane, by the time the disease has clearly asserted itself, has suffered greatly from liquefactive and necrotic changes to so great an extent that only the elements of Sharpey's fibres, embedded within the protective cementum, still retain their healthy condition. This they do, apparently, for quite a long time after the other elements have been destroyed. Studying the tooth itself, we find on those root areas from which the peridental membrane has been lost, deposits similar to those previously formed on the membrane. The attachment of the tooth to the process, has, through the effects of the disease, been largely destroyed, and as it is then very yielding, the tooth easily goes into mal-position.

Examining the neck of the tooth carefully. we find striking evidence of extensive erosion on the surface from which the gum has now retracted, and over which the pus, coming from the chief seat of the disease, is seen to flow in abundance.

The Non-Virulent Variety

In this type of the disease, no such surface manifestations are seen, as are met with in the virulent form, and hence the deep undermining destructive elements often pass unchallenged into the very last stages, when the afflicted subject, alarmed by his loose and falling teeth, first calls attention to his condition. Even then its real nature frequently escapes detection and the patient is dismissed with the explanation that nothing can be done for his relief. Of course not-little or nothing can ever be done for an individual whose condition is unknown, but the disturbance is really present, and if we but look deeply and examine carefully, we will find evi

dences of destruction very similar to those encountered in the virulent form. Taken as a whole, the two types do not differ markedly, except in the light of a few striking differential features. In the latter, or non-virulent variety, the glands of the gums may entirely escape being involved, and when so affected it is nearly always secondary to long-standing foci of infec tion located elsewhere in the tissues. Hence we have in this sub-division of the disease a more nearly normal appearance of the gum tissue than is found at any time in the virulent variety. In the latter stages, the gums appear flat and de pressed over the areas of subjacent alveolar necrosis, but aside from the presence of a flat and collapsed appearance, nothing distinctive or characteristic is noticeable on the gums.

The production of the pockets by bone disso lution is started, etiologically, by factors nearly identical with those engaged in the virulent form

the chief distinguishing features consisting in the nature of the resulting pathology. The de velopment of this form of the disease is mor insiduous and the pockets formed, though deep in the vertical direction, are more shallow hori zontally. The margins of the pocket are ill-de fined and irregular, so that the whole bony pro cess seems to be more or less completely and progressively involved.

The peridental membrane, while sharing ir the effects of the disease quite as extensively a in the virulent form, seldom becomes the sea of lime salt deposits, and hence we are not calle upon to deal with that obstinate feature in ou treatment of this form of pyorrhea. In substi tution for the calcareous deposits of the viru lent form, we often find soft, and apparently re cently formed, organic adhesions, which fre quently may be dealt with summarily in the firs sitting.

On studying the necks of the teeth carefully we find erosions similar to those met with i the virulent form, though never so extensive In addition to the erosions which serve to dis tinguish this type of disease, a more striking feature is observable. The large quantities o pus seen coming from beneath the gums in th virulent cases, are wholly absent in the non-virt lent, and are obtainable only by pressing on th gums, producing pressure on the underlying

structures.

The Catarrhal Type

As regards the third or catarrhal variety, w find evidences of generalized tropic disturb ances and long standing infection. The epighe lial constituents of the gum suffer from atrophi degeneration and this is followed by a fibrou tissue overgrowth, giving to the gums a tough leathery consistency and imparting the pal grayish appearance characteristic of scar tissu The glands are involved in the disease proces

with signs of a catarrhal-like disturbance. The secretion manifests itself as a profuse discharge of a thick, slimy, ropy consistency that adheres closely to all structures with which it comes in

contact.

The alveolar process suffers more generalized destruction in this type of the disease than in either of the other two varieties. When the case is well advanced the bone is extensively riddled by liquefactive and necrotic processes, so that the pockets formed are ill-defined and very irregularly marginated. Pus is present, though only in small quantities, and is only very rarely seen to exude from the pockets at the gingival margin.

In the catarrhal variety, the peridental membrane enjoys no greater freedom from attack than does the bony process. Liquefactive necrosis early obtains. Broadly speaking, so far as deposits on the teeth are concerned, we find that they are generally free from such, but the necks of the teeth, early present signs of distinct.

erosions.

Causes of Pyorrhea

In any localized disease, so diverse in nature, so disastrous in results, and so notoriously obstinate in its treatment as in pyorrhea, it is very natural to attribute its existence to a multiplicity of causative agents, and so has it been with the disease. We should not be at all amazed at this fact when we realize the frequent failures and difficulties experienced by some in making their diagnosis of the condition. A large majority of the cases completely escape detection until the advanced stage is reached, and then, because of the absence of purulent matter appearing at the gingival border, the diagnosis is often incorrectly made. Then, too, unchallenged by rational treatment, the disease advances spelling widespread disaster to the mouth, making it still more difficult of recognition, and unfortunately those few cases recognized early, have to extend higher on the root than that point to which the peridental membrane extends intact and healthful. For this reason all the structures appear greatly shrunken and the involved teeth much elongated and less firmly rooted in their osseous attachments. In this condition the gums will be seen to have fallen back and turned away from the neck of the tooth, causing eversion of the mouths of the ducts coming from the glands higher up. This, together with loss of the gum flap deprives the new attachment of its natural protection by the gum against food accumulations. In this way, sooner or later, loss of the teeth or recurrence of the disease is made a conspicuous end-result in the great majority of cases dealt with by this form of surgical treat

ment.

In outlining the principles involved in caring

for this disease, it is convenient to divide the treatment into prophylactic and surgical fields, respectively. Prevention

This disease is absolutely preventable, and when found existing, we may feel sure that an ill-kept mouth was the early or remote antecedent of the trouble. Poor or faulty prophylactic considerations in caring for the teeth may work their ill effect in two ways—either the teeth are not kept free from organic matter, or if so kept, by faulty methods, injury may be wrought to structures, hard or soft, that will predispose to the pyorrheal infection.

In the first instance, the bulky accumulations of organic matter, or the less noticeable placques and adhesions variously spread over the teeth, furnish an ideal culture-bed for bacterial growth. The fermentation products from those accumulations, being kept in continual contact with the gum tissue, lower their vitality, and thus make. possible the pyorrheal infection that is to follow later. The gums and the ducts leading therefrom become inflamed by the chemical and mechanical irritation produced by the presence of these foreign substances, so that the bacterial invasion is readily made possible. The removal of these substances is therefore clearly imperative, and it is equally necessary to care for one part of the tooth as much as for the other. The interproximal spaces, like the free surface, must be kept free from all accumulations of foreign matter.

Process of Treatment

In the treatment of the disease itself, after it is once established in any one of the previously mentioned varieties, we are ever to bear in mind its infectious nature, and like any other local infection, that it is to be treated surgically. The surgical principles and indications involved in the treatment of the disease are in no respect different from those governing a similar infection of the arm or leg. The indications to be met with here as well as elsewhere may be dealt with under three distinct heads, viz., first, relieve the infection; second, prevent the reinfection; third, stimulate a healthy, vigorous blood supply to the parts. The accomplishment of these ends is indeed all-sufficient, so far as the cure of the disease is concerned, but the difficulty with which they are realized has constituted our most baffling problem in the treatment of pyorrhea.

Preparations designed to assist in the realization of each of the surgical indications separately have frequently been presented and their efficiency tried, but to a remarkable degree the difficulties still prevail.

Antisepsis

In overcoming the infection in pyorrhea, we find difficulties of the most obstinate nature.

In the great majority of the cases of drainage the pus and other infectious matter is fairly well carried out by means of the openings leading from the pockets. However, some of the septic material always remains, and that element having the greatest responsibility in perpetuating the trouble takes its form in the deposits so often found on the roots of the teeth involved. So long as they are present, resolution of the disease process is an impossibility, their removal by harsh methods occasioned such damage that the results have never been desirable. Efforts have been made everywhere to secure some kind of chemical compound that would effect a dissolution of these deposits, but with what results you all know.

The paste which is used in conjunction with the pocket packer and wet spray from the gas machine, in a manner to be more fully explained in the description of the treatment from its clinical aspects, has for its field of useful application the treating of pyorrhea pockets with their contents, as well as any recesses formed beneath the gingiva and around the necks of the teeth.

Being highly antiseptic in nature, the paste inhabits all bacterial growth in places where it finds lodgment. By virtue of its dehydrating properties, it performs the double office of dehydrating the toxins, besides inducing the formation of a serous exudate into the pocket from the adjoining healthy structures. The toxins. contained within the pocket, because of the dehydrating influence of the paste, yield up one molecule of water from each molecule of toxin.

Their nature is thus altered, and though still harmful in action, they seem far less capable of exerting their former disastrous influences. As a result of the serous exudate which is caused to flow from all of the tissues surrounding the pocket, its passage through those structures supporting the fixed sanguinary deposits causes a loosening of the elements, because of the fluid formation which gathers beneath their bases. This aids greatly in their detachment and because of its combined activities its application leads to an early resolution of the disease pro

cess.

Reinfection

The second surgical indication which has for its object the prevention of reinfection of the parts under treatment, while less difficult of accomplishment than the foregoing, is no less vital to the cure we are seeking. Located within the mouth, and impossible of elimination, is the same group of organisms that caused the original infection, and to prevent their admission into the affected area is equally important with the elimination of those engaged in the destructive process. Their entrance into the field of infection is prevented by sealing the parts involved with

a preparation known as the pocket packer.

The pocket packer is a preparation of medicated paraffin that at body temperature is firm, maintaining the form and position into which moulded when heated for application. It is antiseptic, stimulating, and impermeable to moisture, so that when applied over any portion of the gums and in openings leading from pockets, it reduces the infection of the parts, together with exerting a stimulating effect on the tissue cells. In its chief capacity, owing to its antiseptic qualities and the close contact which it assumes with the disease-structures, it prevents the entrance into these areas of any infective agents in the form of food, moisture, or liquids from the mouth. We have thus reduced our difficulties to a parallel with those confronting a surgeon in caring for an infected wound on any part of the body.

Nature Helps

In the third surgical indication to be met, an effort is made to induce nature to render her assistance in overcoming and effecting a cure of the local disease. By securing a hyperemia of the affected part it is believed that nearly every morbid condition involving the tissues will be greatly benefited, if not entirely conquered. The principle of hyperemia is one of the most ancient and yet most modern of surgical procedures.

Its beneficial influences seem manifold, and possibly the greatest benefits we realize from our treatment are due to the hyperemia produced. All of the disease conditions seem rapidly to improve upon its establishment, and that you may realize its possibilities. Professor Bier says regarding its effects: "I have not the least doubt that arterial and venous hyperemia relieves pain, that both are solvents, that arterial hyperemia absorbs, and that passive hyperemia cures infectious diseases, for I have seen these with my own eyes innumerable times."

Granting the fullness and accuracy of Professor Bier's findings, I am sure you will agree with me in saying that so potent a therapeutic agent of so obstinate a disease as pyorrhea; and with is one of the greatest importance in the cure it, we are in the possession of an invaluable means for not only arresting the disease, but also for curing it. The rebuilding of structures lost by the disease has been our most difficult problem, because in most cases the vitality of the cells seemed greatly impaired, but, owing to the nutritive and invigorating effects of the hyperemia, reproduction of the lost elements is extensively and often quite fully realized. On this Professor Bier has said: "The assertion that hyperemia as such has a nutritive effect is very old, and it even seems that by means of hyperemia the deficient stimulus to formation of bony tissue in absent formation of callous can be fanned into life."