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 'DIACxNOSIS OF 
 JN'^rAL INFECTION 
 5YSTEMIC DISEASES 
 
 SINCLAIR TOUSEY 
 
 
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ROENTGENOGRAPHIC 
 
 DIAGNOSIS OF 
 
 DENTAL INFECTION 
 
 IN SYSTEMIC DISEASES 
 
ROENTGENOGRAPHIC 
 
 DIAGNOSIS OF 
 
 DENTAL INFECTION 
 
 IN SYSTEMIC DISEASES 
 
 BY 
 
 SINCLAIR TOUSEY. A-M-. M-D- 
 
 CONSULTING SURGEON, ST BARTHOLOMEWS CLINIC, NEW YORK 
 
 NEW YORK 
 
 PAUL B. HOEBER 
 
 1916 
 
Copyright, 1916, 
 By Paul B. Hoeber 
 
 Published July, 1916 
 
 Printed in the United States of Amea'ca 
 
PREFACE 
 
 The author has for many years been called upon 
 to act in the capacity of adviser to dentists and 
 physicians, not only as to diagnosis but also for 
 treatment and prognosis. The advice in this 
 book regarding treatment is not intended as a 
 guide to the practice of dentistry and oral sur- 
 gery, but it is hoped that it may aid the physician 
 and the dentist to decide when an infected tooth 
 should be extracted and when it can be cured and 
 remain a safe and useful member. 
 
 This volume is an elaboration of articles on the 
 same subject read before the Roentgen Ray Asso- 
 ciation of Greater New York, Jan. 27, 1916; the 
 Bronx County Dental Society, Feb. 28, 1916; the 
 New York State Dental Society, May 13, 1916; 
 and the Medical Association of Greater New 
 York, May 15, 1916. 
 
 Sinclair Tousey. 
 New York, 
 
 July 3, 1916. 
 
CONTENTS 
 
 PAGE 
 
 I. Introduction 9 
 
 II. Infections of the Teeth and Pneumatic 
 
 Sinuses and Their X-Ray Diagnosis . 10 
 
 III. Conditions from Which Alveolar Abscess 
 
 and Pyorrhea Alveolaris Must Be Dif- 
 ferentiated 29 
 
 IV. Recent Bacteriological and Clinical 
 
 Studies 36 
 
 V. Lesions and Symptoms Secondary to Infec- 
 tion Connected with the Teeth or the 
 Pneumatic Sinuses op the Face ... 40 
 
 VI. General Conclusions 70 
 
 Author's Other Publications upon the 
 
 X-Ray in Dentistry 71 
 
 Index 73 
 
ROENTGENOGRAPHIC DIAG- 
 NOSIS OF DENTAL INFEC- 
 TION IN SYSTEMIC 
 DISEASES 
 
 CHAPTER I 
 
 IJSTTKODUCTION 
 
 ^'Tlie widest publicity should be given to the 
 fact that greatly varying and sometimes serious 
 or fatal systemic diseases and those affecting re- 
 mote organs are often due to infection connected 
 with the teeth or with the pneumatic sinuses of 
 the face. The infected foci are discoverable 
 by the x-trjb. Some of these cases are cured 
 by treatment of the oral lesion and some require 
 also autogenous vaccination with a bacterial cul- 
 ture from the pus in the oral lesion." These are 
 the words of an eminent jurist whose wife has been 
 dragged back from the verge of the grave through 
 the discovery by the :r-rays of the foci of infec- 
 tion in connection with the teeth. Pernicious 
 anemia and general spinal sclerosis were threaten- 
 ing to destroy life. The judge's remark is the 
 occasion for these pages. 
 
 9 
 
10 ROBNTGENOGRAPHIC DIAGNOSIS 
 
 CHAPTER II 
 
 INFECTIOlSrS OF THE TEETH AND PNEUMATIC SINUSES 
 AND THEIE X-EAY DIAGNOSIS 
 
 Alveolar Abscess. — This lesion sometimes de- 
 velops insidiously and without local symptoms, 
 and these are the most dangerous cases because 
 unrecognized and untreated. Other cases pursue 
 a perfectly frank and recognizable course as fol- 
 lows : There is toothache followed by a painful 
 swelling of the jaw. These cases naturally seek 
 relief at the hands of the dentist, but if they are 
 neglected an abscess forms in the jaw bone sur- 
 rounding the apex of the root, denuding the latter 
 and sometimes considerably eroding it. In some 
 cases there is more or less necrosis of the jaw. All 
 these conditions are clearly shown with almost 
 microscopic detail in a radiograph. The usual 
 treatment of a fully developed alveolar abscess is 
 by opening the pulp chamber of the tooth, remov- 
 ing the dead or dying nerve, draining the abscess 
 cavity through the root-canal, enlarging the apical 
 foramen if necessary and applying repeated 
 dressings through the root-canal, and finally fill- 
 ing the latter with a nonabsorbent material. 
 Worse cases require also amputation of the apex 
 
OF DENTAL INFECTION 
 
 11 
 
 of the root. Figure 1 shows a case cured by such 
 an operation. Still others require extraction of 
 the tooth with or without curettage of a necrotic 
 area of bone. 
 
 The origin of an alveolar abscess is as follows : 
 The pulp or ' ' nerve " of a tooth is richly supplied 
 with blood-vessels and nerves. It completely fills 
 a cavity with unyielding walls which has a tiny 
 opening called the 
 apical foramen. 
 The latter is occu- 
 pied by what may 
 be called the stem 
 of the nerve which 
 practically stop- 
 pers the opening. 
 The pulp may be- 
 come inflamed 
 from any cause 
 such as exposure 
 to cold, a neglected 
 
 carious cavity in the tooth substance or some 
 other cause. The rigid walls of the pulp-cham- 
 ber prevent any expansion of the inflamed and 
 congested mass of ^' nerve" or pulp. The effect 
 is the same as if an inflamed and congested mass 
 of exquisitely sensitive living tissue were forcibly 
 compressed into a space only half large enough to 
 contain it. An analogy from general surgery is 
 
 Figure 1. 
 
12 KOENTGENOGEAPHIC DIAGNOSIS 
 
 found in the subperiosteal suppuration commonly 
 known as bone felon, in which it is imperatively 
 necessary to relieve tension by an incision through 
 the periosteum. 
 
 Attention to the carious cavity, counterirritant 
 
 Figure 2. Figure 3. 
 
 applications to the gums and an ice bag to the 
 cheek may relieve the congestion and the pulp may 
 return to a normal condition. 
 
 Other cases may not have been properly treated 
 or the congestion may have been so severe as not 
 to yield to treatment. The inflamed pulp becomes 
 strangulated and we have the condition known as 
 a ^' dying nerve." The dentist's treatment at this 
 stage consists in drilling into the pulp-chamber 
 and removing the nerve. A local anesthetic 
 makes the drilling perfectly endurable and the 
 same application is successful in anesthetizing the 
 
OF DENTAL INFECTION 
 
 13 
 
 ''nerve." This process has many advantages 
 over the old method of hastening the deatli of the 
 nerve by an application of arsenic. A radiograph 
 like Figure 2 made with a small wire in the root- 
 canal will show whether the apical foramen has 
 been reached. The removal of a dying nerve and 
 the treatment and tilling of pulp-chamber and 
 
 Figure 4a. 
 
 Figure 4b. 
 
 root-canals commonly prevent any further trouble. 
 If the dying nerve is not treated, it dies and 
 breaks down into a liquid mass of decayed tissue 
 which often has a foul odor from the presence of 
 microorganisms of putrefaction, commonly the 
 streptococcus viridans. This purulent liquid is 
 under pressure and the apical foramen is no 
 longer completely blocked by living tissue. Infec- 
 tion passes into the alveolus or the bony socket 
 and soon there is an alveolar abscess surround- 
 
14 ROENTGENOGEAPHIC DIAGNOSIS 
 
 ing the apex of the root. Figures 3, 4:a and b, 
 and 5 are examples of alveolar abscess as it oc- 
 curs in the mouths of prosperous persons whose 
 teeth have always been carefully treated by the 
 best dentists. Of course at a clinic one can 
 find cases of extensive necrosis in some of the 
 worst cases. Figure 6 is, however, of a prosper- 
 ous young lady 
 with a gold probe 
 passing through 
 the root-canal and 
 a fistulous tract in 
 the upper jaw and 
 emerging in the 
 nostrils. This was 
 one of my earliest 
 pictures and not 
 nearly as clear as 
 the later ones. It 
 is especially inter- 
 esting to note that 
 the fistula healed 
 without any operative treatment, either in conse- 
 quence of the x-YSij exposure or of the stimula- 
 tion through the passage of the gold probe. 
 
 Very many if not most of the cases of alveolar 
 abscess referred for ic-ray examination are con- 
 nected with teeth which have already gone through 
 the history of death and removal of the nerve. 
 
 FlGUKE 5. 
 
OF DENTAL INFECTION 
 
 15 
 
 The rr-ray often shows in such a case that the 
 root-canal has been only partly filled. A cavity 
 remains in the tooth, lodging germs which keep 
 up infection of the jaw and the general system 
 and on occasion start an abscess in the jaw bone. 
 Figure 7 illustrates this. 
 
 Pyoekhea Alveolaeis {Also Called Riggs' Dis- 
 
 FlGUEE 6. 
 
 Figure 7. 
 
 ease). — This is another disease the symptoms of 
 which point directly to the teeth and which the 
 dentist is naturally called upon to treat. The 
 name implies a discharge of pus from the alveolus 
 or tooth socket. The gums around certain in- 
 dividual teeth are swollen and usually red and 
 bleeding, but sometimes white and cartilaginous. 
 Pressure upon the gum causes an escape of a drop 
 of pus along the neck of the tooth. And this may 
 be repeated every five minutes. Day and night 
 this discharge of pus and infected blood is swal- 
 
16 ROENTGENOGRAPHIC DIAGNOSIS 
 
 lowed with tlie saliva. The pus comes from a 
 pocket extending from the neck of the tooth per- 
 haps even beyond the apex of the root. The 
 root of the tooth is often covered by dense black 
 adherent calcareous scales. (See Figure 31b, page 
 56, shown later in connection with a special 
 case.) The pocket is formed by greater or less 
 
 Figure 8a. 
 Figures 8a. 8b axd 8c. 
 
 Figure 8b. 
 -Different Stages of Pyorrhea. 
 
 absorption of the alveolar process surrounding 
 the affected tooth. The pocket may be demon- 
 strated by passing an instrument into it as is 
 done by the dentist for the purpose of removing 
 scales and applying suitable antiseptics. In the 
 presence of the scale-covered root of the tooth 
 and under the influence of the constant suppura- 
 tion there is progressive absorption of the alveo- 
 lar process until the tooth lies loosely in a large 
 painful cavity from which it is an act of mercy to 
 extract it. The pocket is much more clearly dem- 
 onstrated by the rr-ray as reported in the author's 
 
OF DENTAL INFECTTOX 
 
 17 
 
 various papers and clinics before dental conven- 
 tions during the past twelve years. ^ The radio- 
 graphs referred to and of which Figures 8a, 8b, 
 and 8c are examples, show the location and 
 extent of the pocket. And in many cases the ra- 
 diographs reveal the cause of the pyorrheal 
 pocket. A famous ^ 
 actress was re- 
 ferred to the au- 
 thor for treatment, i 
 by the x-raj and | 
 ultra-violet ray, of ' 
 pyorrhea affecting 
 the left upper cen- 
 tral incisor. Fol- 
 lowing my usual 
 custom, I made a 
 radiograjDh of the *- 
 affected portion of 
 the superior max- 
 illa and found an unerupted supernumerary tooth 
 pressing upon the root of the incisor and acting as 
 a constant source of irritation (Figure 9a). This, 
 far from being an isolated case, is but one of nu- 
 merous cases of pyorrhea originating from a sim- 
 ilar cause. Fig-ure 9b shows another such case. Of 
 course, the discovery of this cause affords the key 
 to successful treatment by removal of the un- 
 
 ^ See bibliography at end of volume. 
 
 FlGfKE 8c. 
 
18 ROENTGENOGEAPHIC DIAGNOSIS 
 
 erupted tooth, and saves the patient fruitless 
 attempts at a cure by other means. Figure 9c 
 
 Figure 9a. 
 
 FiGUKE 9c. 
 
 Figure 9b. 
 
 shows how clearly an un- 
 erupted tooth is demon- 
 strated by modern appa- 
 ratus and technique. In 
 other cases the x-ray 
 shows a root-filling ex- 
 truded through the apical 
 foramen or through a 
 false passage and forming an irritant foreign 
 body. Removal of the offending substance either 
 through the root-canal by enlarging the foramen, 
 or more effectively by an amputation of the apex 
 of the root, cures such a case, and other methods 
 of treatment must necessarily fail. Figures 10a 
 
OF DENTAL INFECTION 
 
 19 
 
 and 10b are examples, also 25b, i^age 46. A 
 retained root (Figure 11a) or an instrument 
 broken oft in tlie bone (Figure lib), will some- 
 times keep up a discharge of pus. It used to seem 
 desirable to allow a stump to remain after the 
 crown of the tooth had all vanished through decay. 
 This was on the theory that any kind of a root 
 tended to prevent absorption of the alveolar proc- 
 
 FiGURE 10a. Figure 10b. 
 
 FiGUEES 10a AND 10b. — Pyorrhea Due to Extrusion of Root- 
 
 FlLLIXG. 
 
 ess and so preserve the contour of the face. Re- 
 cent cases have shown that this is sometimes dan- 
 gerous. In one case (Figure 33c) an alveolar ab- 
 scess of such a root was the seat of infection pro- 
 ducing cardiac and arthritic lesions. In another 
 ease (Figure 21a, page 40) infection from such 
 a retained root started up pyorrhea in a neigh- 
 boring tooth and acted as a causative factor in 
 neurasthenia. 
 
20 ROENTGENOGEAPHIC DIAGNOSIS 
 
 Pyorrhea alveolaris makes the teeth very sore 
 and in the tirst case treated with the x-trj the pa- 
 
 FlGURE 11a. 
 
 tient, a medical student in London, had to warm 
 his beer and cool his tea. The dental treatment 
 
 also is exceedingly 
 painful. The suf- 
 fering and the in- 
 evitable loss of the 
 affected teeth and 
 the constant ab- 
 sorption of pus, 
 both through the 
 local circulation 
 and also from the 
 ..^j discharge that is 
 Figure lib. swallowed, make a 
 
OF DENTAL INFECTION 21 
 
 cure extremely important, and especially before 
 too great bony absorption lias occurred. 
 
 The treatment of pyorrhea alveolaris involves 
 the removal of any cause revealed by the x-ray 
 examination. The dentist removes the hard cal- 
 careous scales from the root of the tooth and 
 makes suitable chemical applications to the pocket. 
 This treatment by the dentist is indispensable, but 
 there are many cases in which these measures 
 alone will not effect a cure. The author's own 
 practise for the last twelve years, when such cases 
 have been referred to him by the dentist, has been 
 to make applications of the x-xaj and high fre- 
 quency currents from ultra-violet ray vacuum elec- 
 trodes. The author was not the first to do this and 
 has not been alone in his observations of success- 
 ful results, but it certainly requires a great deal 
 of experience and study in this particular field 
 to make applications which shall be effective 
 through the flesh and bone and still shall have 
 no undesirable effect upon the skin. The practi- 
 cability of this is paralleled in other fields of 
 Roentgen ray therapy, as when an application to 
 the knees in a case of leukemia produces an ef- 
 fect upon the bone marrow, the nursery of white 
 blood cells, reducing the number of leukocytes 
 from perhaps 200,000 to perhaps 60,000 per cu. 
 mm. Figure 12a is of a case of pyorrhea alveo- 
 laris referred to the author by Dr. Van Saun. 
 
22 ROENTGENOGEAPHIC DIAGNOSIS 
 
 Very extensive pockets were present about several 
 teeth and had persisted in spite of dental treat- 
 ment. A course of twelve applications of the 
 rr-ray and the ultra-violet ray resulted in a com- 
 plete cure and at the last report, three years later, 
 there had been no relapse. Some other cases re- 
 quire a longer course of treatment and some have 
 
 Figure 12a. Figure 12b. 
 
 Figures 12a and 12b. — Pyorrhea Alveolaris Before Success- 
 ful Treatment by X-Ray and High Fre- 
 quency Currents. 
 
 occasional relapses which are disposed of by den- 
 tal treatment and a very few x-yrj and ultra- 
 violet ray applications. Figure 12b is of another 
 case of pyorrhea cured by the x-yslj and high fre- 
 quency currents. 
 
 In case after case, the pain and swelling and 
 discharge have ceased and the loosened teeth have 
 become firm again. During the discussion of one 
 of the author's papers at the meeting of the Roent- 
 gen Ray Society of Greater New York, this ohser- 
 
OF DENTAL INFECTION 23 
 
 vation was corroborated hi/ Dr. Goldberg, luho 
 had treated pyorrhea at one of the large hospi- 
 tals. 
 
 It should be noted that the author does not rec- 
 ommend this treatment as a substitute for treat- 
 ment by the dentist, but only as an adjunct when 
 dental treatment fails. 
 
 The author regards this as the method of elec- 
 tion and has applied it to members of his own 
 family as well as to strangers. 
 
 There is a new method of treatment for pyor- 
 rhea alveolaris which is having world-wide pub- 
 licity at the present moment and which, if success- 
 ful, will have the advantage over the a;-ray of not 
 requiring special apparatus or special skill and 
 of being therefore very much less expensive. This 
 is by the use of the ipecac alkaloid emetine. This 
 substance acts very powerfully upon the endameba 
 which is assumed by the proposers of the treat- 
 ment to be the cause of pyorrhea alveolaris. So 
 far some favorable reports have been published, 
 but the author has heard it denounced in unmeas- 
 ured terms by patients upon whom it had been 
 tried without a particle of benefit. It is evidently 
 too early to form a final opinion as to the value of 
 the emetine treatment of pyorrhea alveolaris, but 
 if it fails in a given case or should prove generally 
 unreliable, one has the tried and proven x-trj and 
 ultra-violet ray as a reliance. 
 
24 ROENTGENOGRAPHIC DIAGNOSIS 
 
 One of the worst cases of local infection the au- 
 thor has ever seen was referred for x-iaj exam- 
 ination by Dr. M. H. Brown. There was a cavity 
 in the lower jaw opening in the mouth behind the 
 last molar tooth. A yard of the foulest gauze 
 packing was drawn out and it seemed as if noth- 
 ing short of cancer could possibly produce such 
 a mass of corruption. The radiograph, Figure 
 
 FiGUBE 13a. 
 
 Figure 13b. 
 
 13a, showed a large thin-walled cavity in the 
 lower jaw at the bottom of which was an un- 
 erupted supernumerary tooth. The latter lay far 
 from the ordinary tooth-bearing area. 
 
 Another case, referred by Dr. Fellowes Davis, 
 presented swelling and a fistulous opening. Into 
 this was injected a bismuth paste by means of 
 which the radiograph Figure 13b showed the path 
 of the fistulous tract and its origin in a root at a 
 distance from the swelling. 
 
 Several years before the discovery of the x-tslj, 
 a case was referred to the author. A fistula had 
 
^ r-, 
 
 25 
 
ROENTGENOGRAPHIC DIAGNOSIS 27 
 
 been discharging externally under the angle of 
 the jaw for seven years in spite of treatment by 
 the best physicians, and I was asked to recom- 
 mend a good skin specialist. It seemed desirable 
 to introduce a probe which led up through the jaw 
 bone to the root of a tooth. And it was a simple 
 enough matter under a general anesthetic to ex- 
 tract the tooth and curette the bony socket and the 
 entire length of the fistulous tract. The latter was 
 permanently healed in ten days. 
 
 The above is a brief exposition of some of the 
 local lesions directly affecting the teeth which may 
 form the focus of constitutional infections pro- 
 ducing an amazing variety of secondary lesions 
 and symptoms. 
 
 The Focus of Infection Not Always Con- 
 nected WITH the Teeth. — A case in point was 
 one in which an eye and ear specialist had for 
 two years and a half suffered tortures from pain, 
 and had constitutional symptoms for which the 
 ethmoid cells had been scraped out and every 
 upper tooth extracted. The pain continuing, spic- 
 ules of bone had been cut out of the upper jaw 
 by rongeur forceps. A number of radiographs 
 showed no retained broken root of a tooth as had 
 been suspected and no alveolar abscess. A radio- 
 graph of the whole face (Figure 14), however, 
 showed that one antrum was absolutely opaque. 
 It was operated on by Dr. Cryer, of Philadelphia, 
 
28 ROENTGENOGRAPHIC DIAGNOSIS 
 
 who removed a mass of pus and granulation tissue 
 and the pain was cured. If the x-mj had been 
 resorted to in the beginning, two and a half years 
 of suffering and the useless extraction of all the 
 upper teeth would have been avoided. 
 
 The x-raj will reveal any source of infection 
 connected with the teeth or the pneumatic sinuses 
 of the face, if these are present. If these were un- 
 discovered and untreated, the most serious conse- 
 quences might follow which could easily have been 
 averted and which may be exceedingly difficult 
 to cure after they have developed. A case in 
 point is described later in which the author dis- 
 covered the cause, but the teeth seemed perfectly 
 sound to the dentist with his usual means of ex- 
 amination. The patient, himself a physician, had 
 terrible neuritis, high blood pressure and eventu- 
 ally died of apoplexy, apparently from neglect 
 to remove the cause in time. 
 
ROENTGENOGRAPHIC DIAGNOSIS 29 
 
 CHAPTER III 
 
 CONDITIONS FEOM WHICH ALVEOLAE ABSCESS AND 
 PYORRHEA ALVEOLARIS MUST BE DIFFERENTIATED 
 
 Pulp-stones. — These are calcareous concretions 
 in the pulp or "nerve" of the tooth. They cause 
 pain, and the patient comes for a radiograph 
 which is expected to ^ 
 
 show the location of an 
 alveolar abscess. The 
 picture, however, shows 
 an area of density in 
 what should be the per- 
 fectly transparent con- 
 tents of the pulp-cham- 
 ber. The ''nerve" is 
 more or less irritated and there is as in Figure 
 15 a slight departure from the normal appear- 
 ance of the bone surrounding the apex of the root. 
 Such cases are treated by removal of the "nerve." 
 Malocclusion. — Pain, similar to that of chronic 
 alveolar abscess, and very slight radiographic in- 
 dications of apical irritation, may occasionally be 
 simply the result of constant pressure, this tooth 
 alone making contact with the opposing teeth 
 when biting or chewing. The dentist can remedy 
 the cause by regulating the teeth slightly or by 
 
 Figure 15. 
 
30 ROENTGENOGRAPHIC DIAGNOSIS 
 
 gTinding the surface of this tooth or the one it 
 collides with. This explanation of the case should 
 be accepted with more than the traditional grain 
 
 Figure 16a. 
 
 r 
 
 Figure 16b. 
 
 Figure 16c. 
 
 Figures 16a, 16b and 16c. — Apical Abscess in Case of Arthri- 
 tis, Endocarditis, Meningitis, Pleurisy, Pneumonia • 
 AND Hemiplegia. 
 
 Discomfort at first considered due to malocclusion. 
 
 of salt. Of course if the pain ceases and the 
 radiographic appearance becomes normal, that is 
 all that can be desired. But if more or less dis- 
 
OF DENTAL INFECTION 31 
 
 comfort remains and the radiographic appearance 
 continues distinctly abnormal, the case should not 
 be temporized with even though the usual tests 
 by the dentist indicate a vital and healthy tooth. 
 Figures 16a and 16b show the progress of such 
 a case under expectant treatment. The symptoms 
 and radiographic appearance at the start were as 
 described above. Grinding the surfaces of the 
 opposing teeth did away with their collision, but 
 the discomfort and abnormal radiographic ap- 
 pearance persisted for years. Then there was an 
 attack of intense pain necessitating the use of 
 morphin and accompanied by swelling and sup- 
 puration. This required months of treatment 
 through the root-canal. Figure 16c shows the 
 same tooth a year later with the root filled to 
 the apex and surrounded by healthy bone. It 
 proved to be sterile when extracted (page 49). 
 
 The treatment of just such a case should, ac- 
 cording to the author's view, consist in drilling 
 into the tooth and removing the dead or dying 
 or simply chronically irritated nerve. This should 
 be done before its putrid decomposition has poi- 
 soned the alveolus or bony socket almost beyond 
 recovery. 
 
 The very serious subsequent developments in 
 the case of this patient are described at page 
 46. 
 
 Cysts. — A cyst in either the upper or the lower 
 
32 ROENTGENOaRAPHIC DIAGNOSIS 
 
 jaw may cause symptoms resembling those of 
 alveolar abscess and the radiographer should be 
 careful to differentiate between the two. In a re- 
 cent case (Figure 17a), treated by Dr. Clawson, 
 there was a large area of transparency between 
 the roots of the lateral incisor and the canine. 
 
 Figure 17a. 
 
 Figure 17b. 
 
 Both these teeth had healthy ''nerves." The cyst 
 contained a clear straw-colored liquid and was 
 successfully treated by incision, curettage and 
 packing without disturbing the two neighboring 
 teeth. Figure 17b shows a cyst accidentally re- 
 vealed in a radiograph made to determine the 
 presence of an unerupted upper canine tooth in 
 a man 45 years old. A large, thin- walled, clearly 
 defined cavity is frequently a cyst ; while an alve- 
 olar abscess often is evidenced by decalcification 
 
OF DENTAL INFECTION 
 
 33 
 
 gradually shading oft* into healthy bone without 
 a distinct line of demarcation. 
 
 A dentigerous cyst commonly shows as a hard 
 swelling upon the jaw and is essentially a cavity 
 in the bone wherein lies an unerupted and usu- 
 
 
 HH 
 
 
 / '""'^-^i^^BS/M 
 
 
 % i 
 
 
 -w4 
 A 
 
 FiGUEE ISa. 
 
 ally supernumeraiy 
 tooth. Exceptionalh^ 
 the a?-ray shows that 
 
 such a swelling is an Figure ISb. 
 
 odontoma, a tumor of 
 
 almost stony hardness and consisting of a con- 
 glomeration of nodules of dentine covered by 
 enamel. 
 
 Alveolae Abscess and Unerupted Tooth Com- 
 bined, — In a patient seventy years old with pain- 
 ful swelling of the lower jaw, the dentist could 
 not determine whether the cause was an unerupted 
 tooth or an alveolar abscess. The radiograph 
 (Figure 18a) showed that both conditions were 
 present. Another patient aged fifty years was 
 
34 ROENTGENOGRAPHIC DIAGNOSIS 
 
 referred for an exam- 
 ination to determine the 
 presence of an nnerupt- 
 ed upper canine. The 
 radiograph (Figure 
 18b) showed the un- 
 erupted tooth and an 
 unsuspected alveolar 
 abscess of an upper molar. 
 An IMPACTED WISDOM TOOTH lying perhaps in a 
 
 FiGUEE IDa. 
 
 Figure 19b. 
 Flariiig apical foramina of the 12-year molar are normal. Ab- 
 scess of the anterior root of the 6-year molar. 
 
OF DENTAL INFECTION 35 
 
 horizontal position concealed in the jaw and grow- 
 ing directly against the root of the second molar, 
 causes pain suggestive of neuralgia or neuritis. It 
 is mentioned in this place because of the misin- 
 terpretation that has sometimes been made of the 
 radiographic appearance. The unerupted tooth 
 (Figure 19a) lies in a natural cavity in the jaw 
 and if the root is not fully developed a trans- 
 parent area is seen at that end. This represents 
 soft tissue in which tooth substance is developing 
 and is not an abscess. 
 
 The FLARING FOEAMEN of a still gTowiug tooth in 
 a young person should not be mistaken for an 
 abscess. Figure 19b shows a case with both ab- 
 scess and this normal appearance. 
 
36 ROENTGENOGRAPHIC DIAGNOSIS 
 CHAPTER IV 
 
 KECENT BACTERIOLOGICAL AND CLINICAL STUDIES 
 
 Hartzell, Henrici and Leonard ^ have been able 
 to verify the statement that ''para-apical abscesses 
 and pyorrheal pockets both harbor streptococci 
 which will induce in animals inflammation of the 
 heart muscle, vegetations in heart valves, infected 
 joints, inflammation in blood-vessels, inducing vas- 
 cular lesions and both focal and diffused infec- 
 tions of the kidneys." During the past year they 
 found similar post mortem human lesions particu- 
 larly of the heart valve, heart muscle and kidney, 
 which they believe are produced by the same or- 
 ganisms. The medical department of the Minne- 
 sota University Medical School report that 12 per 
 cent of the individuals admitted to the hospital are 
 suffering from conditions due to mouth infec- 
 tion. Their bacteriological work shows the con- 
 stant presence of the streptococcus viridans in 
 chronic dental abscesses and pyorrheal pockets 
 and a sterile condition of healthy teeth. Hemo- 
 lytic streptococci are absent from these abscesses 
 and from pyorrhea. The pneumococcus is absent. 
 
 ^ The report of The Minnesota Division of the Scientific Foun- 
 dation and Kesearch Commission, Journal of National Dental As- 
 sociation, November, 1915. 
 
OF DENTAL INFECTION 87 
 
 Their studies convince them that peridental in- 
 flammations are primary lesions, the organisms 
 gaining access to the tissues either through the 
 pulp canal or at the gingival margin, and not sec- 
 ondary to some other focus. Their studies of the 
 endameba buccalis confirm the statement of Bass 
 and others that these organisms are practically 
 always present in diseased mouths, but they do not 
 find them most numerous in the deep parts of the 
 pockets nor in the tissues. They find these amebae 
 in the pus which contains their natural food, 
 this being bacteria and pus cells. They are un- 
 able to confirm a causative relation between 
 the endameba and pyorrhea and alveolar ab- 
 scess. 
 
 In the medical wards they have studied espe- 
 cially arthritis, acute and chronic ulcer of the 
 stomach, heart lesions, pernicious anemia, ne- 
 phritis and nervous diseases of the neuralgic type. 
 They find no important distinction between dental 
 abscess and pyorrhea as causative factors in these 
 diseases. Either is frequently the sole cause and 
 even in cases originating from tonsillar or other 
 large focus of infection, the presence of pyorrhea 
 or dental abscess will keep up the disease after 
 the large focus has been cured. All these cases 
 are markedly improved by complete extirpation 
 of these foci of infection. To quote from Dr. 
 Leonard's report: 
 
38 ROENTGENOGRAPHIC DIAGNOSIS 
 
 ' ' A minute examination with every means avail- 
 able is necessary. With the aid of the x-YSij and 
 careful exploration, it is still difficult to find all 
 foci about the teeth. Without these aids it is im- 
 possible. When a physician refers a patient suf- 
 fering from rheumatism or other disease liable 
 to come from dental infection, it is impossible for 
 the dentist to make a complete determination with- 
 out the use of the x-yslj. It is our experience and 
 the experience of others who use the x-yslj a good 
 deal that the majority of dental abscesses give no 
 clinical sign of their existence. The teeth are not 
 sore, no swelling or palpable soft spot at the root 
 end reveals what the radiograph shows and what 
 the subsequent operation confirms. It is not un- 
 common to find abscesses shown in the radio- 
 graphs in cases in which there are no breaks in 
 continuity of the pulpal wall, as under crowns, 
 fillings or even sound teeth. 
 
 '' Experience with radiography also shows that 
 a very large proportion of artificially filled roots 
 subsequently become abscessed. A study made 
 by Dr. Henry Ulrich of Minneapolis of a thousand 
 radiographs taken at random indicated that over 
 70 per cent of the artificially filled roots were ab- 
 scessed. We partially checked this up by look- 
 ing over a hundred, in which, according to our 
 diagnosis, over 60 per cent of such were ab- 
 scessed. A consideration of the necessary means 
 to do away with this condition is out of place in 
 this report. The point is, that this must be taken 
 into account in a determination of dental foci in 
 cases suffering from systemic disease. It has 
 been very rare that we have extracted a tooth 
 which showed an abscess in the radiograph and 
 failed to get streptococci when we cultured from 
 
OF DENTAL INFECTION 39 
 
 tlie root end. Our technique is sucli that con- 
 tamination in making these cultures seems impos- 
 sible. 
 
 ' ' It is amazing to find in well cared for mouths 
 how much pyorrhea may exist without being evi- 
 dent except to painstaking exploration. To those 
 familiar with systemic results coming from pyor- 
 rhea in such a large proportion of cases and even 
 from a slight pyorrhea, the careless ignoring and 
 overlooking of such trouble on the part of most 
 dentists, seems nothing less than malpractise. 
 
 ^ ^ ^ ^ ^ ^ ^ 
 
 ''The last year's work has tllro^\^l some doubt 
 on the advisability of the use of vaccines in all 
 of the cases. There is no question but that bril- 
 liant results frequently follow the use of autogen- 
 ous vaccines or even those prepared for similar 
 lesions in other patients. A vaccine prepared 
 in the case of Miss A. F., whose case is given 
 above, was used by one of the physicians for an- 
 other rheumatic case, in his opinion with satis- 
 factory results. The use of vaccines, hoivever, is 
 liable to create a confidence in them which is 
 likely to make the dentist less careful in eliminat- 
 ing all local foci, and until such local foci are re- 
 moved it can hardly he expected that a vaccine luill 
 give any permanent relief. In most of the cases 
 where we were sure that all local foci were re- 
 moved the recovery was sufficiently rapid and 
 complete to indicate that vaccine was not needed. ' ' 
 
 Four cases had a diagnosis of myocarditis and 
 three of pericarditis. Removal of the causative 
 foci of infection prevented further damage to 
 the heart in valvular cases and general medical 
 measures were adopted to favor compensation. 
 
40 ROENTGENOGRAPHIC DIAGNOSIS 
 
 CHAPTER V 
 
 LESIONS AND SYMPTOMS SECONDAEY TO INFECTION 
 CONNECTED WITH THE TEETH OR THE PNEU- 
 MATIC SINUSES OP THE FACE 
 
 Tuberculosis. — It has long been known ^ that 
 one of the common sites of infection in pulmonary, 
 bony and glandular tuberculosis is an alveolar 
 
 abscess. And the con- 
 tinued existence of such a 
 pus pocket is, therefore, 
 a distinct menace to life 
 itself. Figure 20 shows 
 such an abscess in a 
 patient shortly before 
 death from tuberculosis. 
 Neurasthenia. — A man 
 
 Figure 20. 
 
 Figure 21a. Figure 21b. 
 
 ^ Tousey, ' ' Medical Electricity, Eoentgen Eays and. Eadium. ' ' 
 W. B. Saunders Co., Philadelphia. 
 
Figure 22. — Fro^'tal Sinus Opaque in a Case of Neuras- 
 thenia. Anteroposterior View. 
 
 41 
 

 &4 H 
 
 fin 
 
 43 
 
ROENTGENOGRAPHIC DIAGNOSIS 45 
 
 of powerful physique and weighing 220 pounds, 
 was lately referred to me suffering from neuras- 
 thenia. He complained chiefly of not being able 
 to stand as much business activity and respon- 
 sibility as one of his apparent strength would be 
 
 r 
 
 M ^ 
 
 ••* 
 
 J ^ 
 
 Figure 24. — Alveolab Pigure 25a.— Pyorrhea in 
 Abscess ix Digestive Spinal Arthritis. 
 
 Neurasthenia and 
 fueunculosis. 
 
 expected to. There had been no dental but some 
 nasal symptoms. 
 
 The radiographs showed several pyorrheal 
 pockets including (Figure 21a) one of the right 
 lower second bicuspid due probably to irritation 
 from the retained and infected roots of the first 
 molar. An antero-posterior and also a lateral 
 radiograph of the head showed the frontal sinus 
 to be opaque either from pus or some other opaque 
 substance or because of congenital absence of the 
 
46 ROENTGENOGEAPHIC DIAGNOSIS 
 
 frontal sinus. Dr. Culbert, the rhinologist, tliinks 
 the latter is the case. 
 
 In another case of neurasthenia applying to the 
 author for x-rsij examination, the radiograph 
 (Figure 21b) showed an alveolar abscess with ero- 
 sion of a considerable part of the root. The canal 
 was only partly filled and the foramen wide open. 
 
 Figure 25b. 
 
 Figure 25c. 
 
 Akthkitis has become known within the last 
 few years to be frequently due to toxemia origi- 
 nating from and maintained by an alveolar ab- 
 scess or pyorrheal pockets. Figures 25a, 25b and 
 25c illustrate dental infections in these cases. And 
 since this discovery many a case of acute or 
 chronic '' rheumatism" has been cured in a short 
 time by treating the focus of infection. 
 
 Aetheitis, Pleueisy, Endocaeditis, Meningitis 
 AND Hemiplegia. — A patient was referred to on 
 page 30 with a lower first bicuspid which the 
 dentist at first thought was simply irritated by 
 
OF DENTAL INFECTION 47 
 
 striking against an ujjper tooth. This went on to 
 the formation of an alvejolar abscess. Following 
 prolonged treatment through the root-canal the 
 tooth was filled. 
 
 Figure 26 shows this tooth in an apparently 
 cured condition. The root filling reaches about 
 to the apical foramen and the ^ ~ 
 surrounding bone has regen- 
 erated. During the latter part 
 of the summer, the patient be- 
 gan to complain of renewed 
 discomfort and wanted to have 
 the tooth extracted, but a ra- 
 diograph showed it to be all 
 right. There was a peculiar 
 
 ^ ^ . Figure 2G. 
 
 appearance to the adjacent 
 second bicuspid. Then followed a series of fugi- 
 tive attacks of arthritis, myositis and neuritis. 
 Each attack lasted a week or ten days and pro- 
 duced very severe pain. During these two months 
 the patient lost twenty pounds in weight and at 
 times had a slight rise in temperature. A diet 
 from which sugar and meat were excluded and 
 medication by aspirin, salophen and sodium sa- 
 licylate produced little or no elf ect. Finally a few 
 applications of high frequency currents from ul- 
 tra-violet vacuum electrodes seemed to have 
 brought these attacks to an end. On December 
 5th, however, she was seized by sudden severe 
 
48 ROENTGENOGRAPHIC DIAGNOSIS 
 
 pain in the left npper quadrant of tlie abdomen 
 with great rigidity of the left rectus muscle. This 
 pain was not relieved by laxatives and enemata 
 and gradually extended to the left side of the chest, 
 where in two or three days the physical signs of 
 pleurisy with effusion developed. The heart was 
 greatly dilated and there were rasping mitral 
 murmurs. Absolute rest in bed, a purin-free diet 
 and an ice bag over the heart temporarily reduced 
 the severity of the symptoms without much change 
 in the physical signs. 
 
 After five weeks of this acute illness, Dr. Harlow 
 Brooks in consultation found that she presented 
 the clinical picture of tubercular peritonitis and 
 tuberculous pleurisy on the left side. There was 
 also flatness at the base of the right lung behind, 
 which with the onset of meningitic symptoms and 
 constant leukocytosis led to a suspicion of ab- 
 scess which was disproven by an exploratory 
 puncture. 
 
 The meningeal symptoms became rapidly worse ; 
 the patient was unable to speak a connected sen- 
 tence. There were several severe convulsions 
 lasting from an hour to an hour and a half each. 
 A spinal puncture showed a clear fluid under nor- 
 mal pressure and containing no microorganisnls, 
 and negative to the Wassermann test. The spinal 
 fluid contained one lymphocyte to about 15 red 
 cells. The blood contained no microorganisms and 
 
Figure 27.^Dilated Heaet, Enlarged Thymus and Mottling 
 
 OF Lung. 
 
 Case of arthritis, endocarditis, pleurisy, pneumonia, meningitis 
 
 and hemiplegia from dental infection. 
 
 49 
 
ROENTGENOGRAPHIC DIAGNOSIS 51 
 
 was negative to the Widal and Wassermann tests 
 and contained 25,000 leukocytes per cubic milli- 
 meter. The urine contained albumin and casts, A 
 radiograph of the chest (Figure 27) made with a 
 portable outfit showed no collection of fluid in 
 either side of the chest, but mottling on the right 
 side. It showed a greatly dilated heart and an 
 enlarged thymus gland. The pulse was 120, respi- 
 ration 34, temperature 102 1/> degrees F. 
 
 Dr. N. B. Potter and his assistant. Dr. Ord- 
 way, had always been suspicious of streptococcus 
 infection, possibly from the teeth shown in my 
 radiographs. And it had been the plan that the 
 first time the patient went out of doors it should 
 be to the dentist's office to have the suspected sec- 
 ond bicuspid drilled into and the question of the 
 life or death of its nerve decided. It had now 
 become evident, however, that it was a question 
 of the life or death of the patient to discover 
 and remove the source of infection at once un- 
 less it should prove to be tubercular and not 
 removable. Dr. Henry Sage Dunning accordingly 
 operated upon the patient in bed under local an- 
 esthesia. He extracted the originally infected first 
 bicuspid without difficulty. The hooked root of 
 the second bicuspid broke off as had been antici- 
 pated and had to be chiseled out. The operation 
 took about two hours, but was entirely painless. 
 
 Improvement in every particular began from 
 
52 ROENTGENOGRAPHIC DIAGNOSIS 
 
 that moment. The original tooth was found to 
 be sterile, but a culture of the streptococcus viri- 
 clans was obtained from the second bicuspid and 
 on the fifth day after the operation inoculations 
 with autogenous vaccine were begun. After this 
 the improvement was more rapid and on the 
 thirteenth day after the removal of the teeth the 
 respiration was 24, pulse 74, temperature 98 de- 
 
 FlGUKE 28. 
 
 Figure 29. 
 
 grees F., and the patient's strength increasing 
 daily. The physical signs were clearing up. The 
 subsequent course of this case has been remark- 
 able. The patient has recovered from an attack 
 of pneumonia and has partly recovered from 
 hemiplegia supposed to be due to an embolus. 
 She is still in bed running an irregular septic tem- 
 perature and the only treatment that seems to 
 have any beneficial effect is the inoculation with 
 a dead culture of the streptococcus viridans. It 
 is believed that if her strength holds out her re- 
 sistance to the infection will be increased to such 
 
Figure -"^n. — Unfkhpied 'iooin in the T owek Jaw. 
 
 Facial neuralgia for which extirpation of the Gasserian ganglion 
 
 was planned. 
 
 53 
 
ROENTGENOGRAPHIC DIAGNOSIS 55 
 
 an extent as to bring about recovery. The case 
 at present seems to be one of endocarditis with 
 vegetations upon the heart valves which occa- 
 sionally produce infarctions in such organs as the 
 spleen and kidneys, where the consequences are 
 very serious. 
 
 Neubitis, neukalgta, tic douloureux, sciatica, 
 constitute a group of cases in which one's first 
 thought is to determine the presence or absence 
 of a cause connected with the teeth or sinuses, 
 for no ordinary medical agents will avail if the 
 trouble is due to such a cause. Figure 28 is 
 an example of positive findings in these cases. 
 Figure 29 shows one of the dental foci of in- 
 fection in a case of headache persisting for 3 or 
 4 years in spite of medical and hygienic measures. 
 Another patient had very severe tic douloureux 
 spasms of pain at a few seconds' interval, feeling 
 exactly as if a tack were driven into the jaw bone. 
 The x-iaj and high frequency currents from ul- 
 tra-violet ray vacuum electrodes gave a great deal 
 of relief, but the final cure was accomplished 
 through overcoming intestinal auto-intoxication, 
 which appears to have been the underlying cause. 
 The negative x-raj findings saved the patient 
 from needless and ineffective sacrifice of his teeth. 
 Figure 30 is of a case referred by the late Wm. 
 T. Bull. The patient had been treated by neurolo- 
 gists and electrologists in this country and Paris 
 
56 ROENTGENOGEAPHIC DIAGNOSIS 
 
 for trigeminal neuralgia which had persisted for 
 three years. Dr. Bull had arranged to perform an 
 operation for the removal of the Gasserian gan- 
 glion, but as a final preparatory step sent her for 
 an x-iaj examination. The pictures showed an 
 unerupted tooth near the angle of the jaw, which 
 Dr. Bull operated upon with a cure of the dis- 
 
 FiGUEE 31a. 
 
 FiGtTRE 31b. 
 
 ease and the patient was saved the fruitless suf- 
 fering and danger of an intra-cranial operation. 
 
 Pakoxysmal Cough. — Such a case in a man who 
 has recently become blind, was referred to the au- 
 thor by Dr. Osborne. The radiographs, among 
 them being Figures 31a and 31b, showed alveolar 
 abscess and numerous pyorrheal pockets. Dental 
 treatment not having been beg-un, the calcareous 
 scales are clearly visible upon the root of one of 
 the lower centrals. 
 
 Cases of aeteeial hypeetension, leading to ae- 
 
OF DENTAL INFECTKJN 
 
 57 
 
 TERioscLERosis witli maiiy distressing symptoms 
 and a prospect of apoplexy and death, call for an 
 a:;-ray examination of the teeth and pneumatic 
 sinuses. Figure 32a showed extensive pyorrheal 
 and abscess areas about the teeth. The patient 
 was professor of laryngology and rhinology in one 
 
 Figure 32a. 
 
 of our universities and had been referred to me 
 for treatment of neuritis of the arm. He was un- 
 der treatment elsewhere for high blood-pressure, 
 which I thought was of the same toxic origin as 
 the neuritis. Suspecting dental infection, I made 
 the radiographs which showed the area of infec- 
 tion. I most strongly urged treatment either by 
 extracting the alTected teeth or by applications 
 made through the root-canals. The dentist, how- 
 ever, found the teeth healthy according to his 
 
58 ROENTGENOGRAPHIC DIAGNOSIS 
 
 tests and refused credence to the ic-ray findings. 
 It was before the general recognition of tliis 
 source of systemic infection and so the doctor 
 was allowed to go from bad to worse until he was 
 in a desperate condition in the Battle Creek Sani- 
 tarium. There he met a dentist who believed the 
 
 Figure 32b. 
 
 Figure 32c. 
 
 story told by the radiographs. A number of 
 terribly abscessed teeth were extracted with im- 
 mediate and marked constitutional benefit, but on 
 his return to New York the radiograph (Figure 
 32b) showed other infected areas remaining in 
 the upper jaw from which all the teeth had been 
 extracted and in a few weeks he died of apoplexy. 
 Timely extraction of all the infected teeth, I be- 
 lieve, would have saved this useful life. He was 
 only 56 years old. 
 
OF DENTAL INFECTION 
 
 59 
 
 Figure 32c is of a lady with high blood-pres- 
 suEE, seldom lower than 220, and with auricular 
 fibrillation and occasional syncope — altogether 
 
 Figure 33a. 
 
 Figure 33b. 
 
 FlGURK 33c. 
 
 Figures 33a, 33b and 33c. — Alveolar Abscesses ix a Case of 
 Mitral IivSLTirFiciEXCY. 
 
 calling for the immediate sacrifice of the infected 
 teeth if her life is to be saved. 
 
 Caediac lesions secondary to dental infection 
 with its accompanying rheumatism, nephritis or 
 
60 ROENTGENOGRAPHIC DIAGNOSIS 
 
 neuritis, were endocarditis in twenty-three out 
 of thirty-one of Hartzell, Henrici and Leonard's 
 cases and were evidenced by valvular disease, usu- 
 ally mitral insufficiency. Four cases had a diag- 
 nosis of myocarditis and three of pericarditis. Re- 
 moval of the causative foci of infection prevented 
 further damage to the heart in valvular cases and 
 general medical measures were adopted to favor 
 compensation. 
 
 Cardiac lesions have already been referred to; 
 and Figures 33a, 33b and 33c are of a case in 
 which they are the most important result of dental 
 infection. The patient has a mitral murmur, mit- 
 ral regurgitation with some compensatory en- 
 largement of the heart, but no edema of the ex- 
 tremities or dyspnea. Getting up quickly from a 
 reclining posture would cause him to drop back 
 practically in a faint and he has to avoid turning 
 suddenly for the same reason. The urine contains 
 numerous granular casts, calcium oxalate, uric 
 acid and formerly contained albumin. The recent 
 occurrence of a swelling of one or two finger joints 
 and one knee caused him to have radiographs 
 made of all the teeth. Pyorrheal pockets were 
 found about several teeth; and there were three 
 alveolar abscesses with considerable destruction 
 of bone. The three abscessed teeth were extracted. 
 The first two contained no pathogenic microor- 
 ganisms. The third yielded a culture of strepto- 
 
OF DENTAL INFECTION 
 
 61 
 
 coccus viridans from which an autogenous vac- 
 cine has been prepared. 
 
 Exophthalmic Goitre. — This is a disease in 
 which an ic-ray examination of the teeth is very 
 necessary. Arising in youth as it often does, 
 it might seem unlikely that a dental infec- 
 
 Fi3UEE 34a. 
 
 Figure 34)j. 
 
 tion should have been present as an exciting 
 cause. Figure 5 (page 14), however, is a pic- 
 ture of a young girl with an alveolar abscess, and 
 Figure 19b (page 34) is another. In nearly every 
 family some case of dental abscess can be found to 
 have occurred during youth or childhood. Those 
 with manifest symptoms have usually been treated 
 more or less successfully, but the x-yrj alone 
 would have disclosed those with an insidious 
 course. Figures 34a and 34b show typical dental 
 x-YSLj findings in exophthalmic goitre. In one 
 case there had been alveolar abscesses of two 
 
62 ROENTGENOGEAPHIC DIAGNOSIS 
 
 lower molars for a long time. In the other case all 
 the upper and lower teeth except two or three iso- 
 lated ones had been lost through pyorrhea. 
 
 Eye Diseases. — Some of the cases which were 
 
 Figure 35a. — Alveolar Abscesses in Case of Tinnitus 
 
 AuRIUM. 
 
 Figure 35b. Figure 35c. 
 
 Figures 3ob and 35c. — Alveolar Abscesses and Pyorrhea in 
 
 Case of Pernicious Anemia and Spinal Sclerosis. 
 
 formerly diagnosed as due to rheumatism or to 
 syphilis have been found to be due to dental infec- 
 tion. The uveal tract including the choroid, the cil- 
 iary body and the iris, is most apt to be affected by 
 
OF DENTAL INFECTION 63 
 
 this cause. Cases have been known in which even 
 one eye has been lost and this cause of infection 
 discovered in time to save the other. The pa- 
 tient represented by radiograph No. Ki liad 
 neuroretinitis as an effect of meningitis and at 
 another stage episcleritis as a direct effect of the 
 infection or as a reaction from the autogenous 
 vaccine. The patient in radiographs Figures 31a 
 and 31b became blind and without any perception 
 of light shortly before the infection was discov- 
 ered, but perhaps not in consequence of it. 
 
 Tinnitus aueium was the symptom complained 
 of by a patient referred to me by Dr. Clawson. 
 The radiographs showed no dental lesion. Figure 
 35a, on the other hand, show^s three alveolar ab- 
 scesses in a physician with a noise as of ten thou- 
 sand crickets in each ear. The ringing in the ears 
 may in other cases be an indirect result due to 
 high blood-pressure caused by the dental infection. 
 
 Spinal coed lesions have recently been recog- 
 nized to be sometimes due to infection arising 
 from the teeth. Figaires 35b and 35c, are of a pa- 
 tient of Dr. SoUey's, with pernicious anemia and 
 numbness and loss of power in the upper and 
 lower extremities. She was in a desperate con- 
 dition with hemoglobin of 33 and becoming weaker 
 every day. Dr. Pearce Bailey found positive evi- 
 dence of general, not merely lateral, spinal 
 sclerosis with symptoms indicating a stage of ir- 
 
64 EOENTGENOGEAPHIC DIAGNOSIS 
 
 . ritation rather than destruction of the nerve fibers 
 and cells and with a possibility of partial or com- 
 plete cure if the source of infection could be 
 discovered and removed. The radiographs showed 
 alveolar abscesses of several teeth. These teeth 
 were extracted and an autogenous vaccine of the 
 streptococcus viridans administered which was 
 prepared from the pus. The same germ had been 
 found in this patient's blood. There has been im- 
 mediate improvement in her general condition and 
 restoration of power in the arms but there is still 
 a paretic condition of the lower extremities. 
 
 Gasteic IJLCEE.^The most surprising success 
 has been reported by Hartzell, Henrici and Leon- 
 ard ^ in the treatment of gastric and duodenal 
 ulcer. Unmistakable cases were cured so 
 promptly as to indicate a causative relation be- 
 tween the dental infection and the destructive 
 process in the gastric wall. We cannot tell which 
 of the two factors is most important. There is 
 the irritation from the infected matter which is 
 constantly swallowed with the saliva and there is 
 the hematogenous infection. The demonstration 
 of this easily discoverable and removable cause 
 of many cases of gastric and duodenal ulcer, is a 
 fact of great importance. Consider the number of 
 
 ^Eeport of the Minnesota Division of the Scientific Founda- 
 tion and Eesearch Committee, Journal of National Dental Asso 
 ciation, November, 1915. 
 
OF DENTAL INFECTION 
 
 65 
 
 these cases coming to the roentgenologist for diag- 
 nosis after months or years of pain and loss of 
 weight and strength. Also the tendency to re- 
 currence after medical treatment and the tendency 
 to produce adliesions interfering with gastric and 
 intestinal digestion and transit. Also the danger 
 
 Figure 36a. Figure 36b. 
 
 Figures 36a and 36b. — Alveolar Abscesses and Pyorrhea in 
 
 Two Cases of Gastric Ulcer. 
 
 of adhesions following operative treatment and 
 the ever-present danger that a chronic ulcer will 
 develop into cancer. 
 
 Figure 36a shows alveolar abscesses of both 
 roots of a lower molar tooth as one of the lesions 
 in the case of a lady who for two years had been 
 treated unsuccessfully for symptoms of gastric 
 or duodenal ulcer. After seeing the radiograph 
 she recalled that three years previously there had 
 been pain about this tooth, the only treatment 
 having been by counter-irritant applications. 
 
66 EOENTGENOGRAPHIC DIAGNOSIS 
 
 Figure 36b shows an alveolar abscess as one 
 of the three dental foci of infection in a lady who 
 had a large hemorrhage from the stomach with 
 temporary recovery under absolute rest and suit- 
 
 FiGURE 37 — Radiograph to Determine Presence of Gastric 
 Lesion Requiring Operation, 
 
 able diet. Later there were further gastric symp- 
 toms and a large six-hour residue as demonstrated 
 by a radiograph. 
 
 The dentist thought it wise to extract this tooth 
 and two others. 
 
 It seems as if x-yslj examination of the stomach 
 and of the teeth should go hand in hand in cases 
 
Figure 38. — Radiograph to Determine Presexce oe Gastric 
 OR Intestinal Lesion Requiring Operation. 
 
 67 
 
ROENTGENOGRAPHIC DIAGNOSIS 69 
 
 of suspected gastric or duodenal ulcer. Of course 
 radiographs of the stomach and intestine like Fig- 
 ures 37 and 38 should be made to exclude the 
 presence of a lesion requiring an abdominal op- 
 eration. 
 
70 ROENTGENOGRAPHIC DIAGNOSIS 
 CHAPTER VI 
 
 GENEEAL CONCLUSIONS 
 
 The following general conclus'ons are to be 
 drawn : A putrescent mass in the pulp chamber of 
 a tooth may exist for months or years because the 
 walls of the cavity cannot collapse and are incap- 
 able of throwing out granulations and eventually 
 filling the cavity with healthy tissue, like the 
 natural process of curing an abscess in the soft 
 tissues of the body. This putrescent mass may 
 constantly poison the bony tissues surrounding 
 the apical foramen sufficiently to produce an effect 
 clearly recognizable in a radiograph. This condi- 
 tion may be unknown ta the patient and sometimes 
 not reveal itself to the usual tests applied by the 
 dentist. From this long-persisting source of in- 
 fection secondary lesions and symptoms of the 
 gravest and most diversified character may arise. 
 
 The rr-ray is to be depended upon to show 
 whether or not the source of trouble is connected 
 with the teeth or the pneumatic sinuses, and if so, 
 whether the trouble is due to malposition and un- 
 natural pressure or to infection. It would be a 
 mistake to regard every case as due to the teeth 
 and proceed to sacrifice the latter without first 
 making a radiograph which may acquit them of 
 any complicity in the matter. 
 
AUTHOR'S PUBLICATIONS 
 
 THE AUTI-IOR'S OTHER PUBLICATIONS UPON 
 THE X-RAY IN DENTISTRY 
 
 "Radiotherapy in Pyorrhea Alveolaris, and Dental 
 Radiography." Read before the New York Institute of 
 Stomatology, March 1, 1904. Interstate Dental Journ., 
 July, 1904, pp. 495-502. 
 
 "Recent Work with the A'-ray and High Frequency 
 Currents in the Diagnosis of Dental Cases and in the 
 Treatment of Pyorrhea and Cancer." Read before the 
 New York Odontological Society, Oct. 17, 1905. Dental 
 Cosmos, June, 1906. 
 
 "A"- ray Examination of the Teeth." Read before the 
 New York Institute of Dental Technique, Feb. 28, 1905. 
 Dental Brief, Philadelphia, May, 1905; Vol. X, No. 5, 
 pp. 257-266. 
 
 "A'-ray and High Frequency Currents in the Diag- 
 nosis and Treatment of Dental Cases. ' ' National Dental 
 Association, Buffalo, 1905. Dental Cosmos, 1905, New 
 Jersey State Dental Association, July, 1905. 
 
 ' ' Application of the A'-ray and High Frequency Cur- 
 rents in Dentistry." Dental Brief, Sept., 1906. 
 
 "Radiographs Illustrating the Topography of the 
 Pneumatic Sinuses of the Face." Read before the Sec- 
 tion on Laryngology and Rhinology, New York Academy 
 of Medicine, Dec. 18, 1907. 
 
 "The X-ray and the Ultra- Violet Ray in Dentistry." 
 
 Read before Philadelphia Academy of Stomatology, 
 
 March 24, 1908. 
 
 71 
 
72 AUTHOR'S PUBLICATIONS 
 
 "The X-ray and the Ultra-Violet Ray in Dental Diag- 
 nosis and Treatment." Paper and practical demonstra- 
 tion presented before the Northern Dental Society, May 
 13, 1909. New York Medical Journal, March 19, 1910. 
 
 "A"-ray Measurement of the Unerupted Teeth at the 
 Age of Five or Six Years to Provide for Preliminary 
 RegTilation of the Dental Arch if Required." Annual 
 Meeting of the Dental Society of State of New York, 
 May 8, 1913. 
 
 ' ' X-ray Measurement of the Unerupted Teeth at the 
 Age of Five or Six Years to Provide for Preliminary 
 Regulation of the Dental Arch if Required." Read 
 before the Eastern Association Graduates of the Angle 
 School of Orthodontia, 5th Annual Meeting, April 23, 
 1914. Harvard Odontological Society, Oct. 15, 1915. 
 
 ''X-ray Prevention of Nasal Diseases ; X-ray Examina- 
 tion at the Age of Five or Six Years as a Prophylactic 
 against Spurs and Deviations of the Septum and Dis- 
 orders of the Tonsils, Adenoids, and Accessory Pneu- 
 matic Sinuses." New York Medical Journal, March 13, 
 1915. 
 
 "Medical Electricity, Roentgen Rays and Radium." 
 W. B. Saunders Co., Philadelphia, 1910 and 1915. 
 
 " Roentgenographic Diagnosis of Dental Infection in 
 Systemic Diseases." Papers read before the Roentgen 
 Ray Association of Greater New York, Jan. 27, 1916, 
 The Bronx County Dental Society, Feb. 28, 1916, the 
 New York State Dental Society, May 13, 1916, and the 
 Medical Association of Greater New York, May 15, 1916. 
 
INDEX 
 
 Alveolar abscess, 10 
 
 cysts differentiated from, 31 
 
 fistulous type of, 14 
 
 flaring foramen differentiated 
 
 from, 35 
 impacted wisdom tooth dif- 
 ferentiated from, 34 
 in teeth already treated, 14 
 malocclusion differentiated 
 
 from, 29 
 origin of, 11 
 
 pulp-stones differentiat- 
 ed from, 29 
 symptoms of, 10 
 treatment of, 10 
 dentists', 12 
 in mild cases, 12 
 unerupted tooth and, 33 
 Anemia, pernicious, dental in- 
 fection and, 37 
 Arterial hypertension, 56 
 Arthritis, 46 
 
 dental infections and, 37 
 Autogenous vaccines in systemic 
 diseases due to dental 
 infection, 39 
 
 Bacteriological studies of the 
 mouth, 36 
 
 Cough, paroxysmal, 56 
 Cysts, 31 
 
 dentigerous, 33 
 
 Dental foci of infection in sys- 
 temic diseases, a;-ray ex- 
 amination for, 38 
 Dental infections, 10 
 
 bacteriological studies of, 36 
 lesions and symptoms second- 
 ary to, 40 
 Dentigerous cysts, 33 
 Duodenal ulcer, 64 
 Dying nerve, removal of, 12 
 untreated, infection from, 13 
 
 Endocarditis, 46 
 Exophthalmic goitre, 61 
 Eye, diseases of, 62 
 
 Fistulous type of alveolar ab- 
 scess, 14 
 of pyorrhea alveolaris, 24 
 Flaring foramen, 35 
 
 Gastric ulcer, 64 
 
 dental infections and, 37 
 Goitre, exophthalmic, 61 
 
 Cardiac lesions. See Heart, le- Heart, lesions of, 59 
 
 sions of. dental infections and, 37 
 
 Clinical studies of infections, 37 Hemiplegia, 46 
 
 73 
 
74 
 
 INDEX 
 
 High-frequency currents in 
 treatment of pyorrhea 
 alveolaris, 22 
 
 Impacted wisdom tooth, 34 
 Infection, bacteriological stud- 
 ies of the mouth and, 36 
 clinical studies of, 37 
 dental, 10 
 
 foci of, in systemic dis- 
 eases, a;-ray examina- 
 tion for, 38 
 lesions and symptoms sec- 
 ondary to, 40 
 focus of, value of a;-ray in 
 
 revealing, 26 
 from untreated dying nerve, 
 
 13 
 in sinuses, 25 
 
 in teeth {see also Infection, 
 dental), 10 
 Ipecac alkaloid emetine in 
 treatment of pyorrhea 
 alveolaris, 23 
 
 Malocclusion, 29 
 Meningitis, 46 
 
 Myocarditis, dental infection 
 and, 39 
 
 Nephritis, dental infections 
 
 and, 37 
 Nerve, dying, removal of, 12 
 untreated, infection from, 
 13 
 Neuralgia, 55 
 
 dental infections and, 37 
 Neurasthenia, 40 
 Neuritis, 55 
 
 Paroxysmal cough, 56 
 
 Pericarditis, dental infection 
 
 and, 39 
 Pernicious anemia, dental in- 
 fections and, 37 
 Pleurisy, 46 
 
 Pneumatic sinuses, infection 
 in, 25 
 lesions and symptoms sec- 
 ondary to, 40 
 value of a;-ray diagnosis 
 in, 26 
 Pulp-stones, 29 
 Pyorrhea alveolaris, 15 
 cases, 24 
 causes of, 17 
 
 from broken instrument, 19 
 from extruded root-filling, 18 
 from retained root, 19 
 from unerupted tooth, 17, 24 
 in otherwise healthy mouths, 
 
 39 
 painfulness of, 20 
 symptoms of, 15 
 treatment of, 21 
 by dentist, 21 
 by ultra-violet ray, 22 
 by a;-ray, 21 
 high-frequency currents in, 
 
 22 
 ipecac alkaloid emetine in, 
 23 
 with fistulous opening, 24 
 Pyorrheal pocket, demonstra- 
 tion of, 16 
 
 Eadiographic diagnosis of den- 
 tal infection, 26 
 in systemic diseases, 38 
 
 Eetained root a cause of pyor- 
 rhea alveolaris, 19 
 
INDEX 
 
 75 
 
 Elieuinatism, use of vaccines in, 
 39 
 
 Eiggs' disease {see also Pyor- 
 rhea alveolaris), 15 
 
 Roentgenographic diagnosis of 
 dental infection, conclu- 
 sions, 70 
 
 Sciatica, 55 
 
 Sinuses, pneumatic, infection 
 in, 25 
 lesions and symptoms sec- 
 ondary to, 40 
 value of aj-ray in diagno- 
 sis of, 26 
 Spinal cord, lesions of, 63 
 Stomach, ulcer of. See Gastric 
 
 ulcer. 
 Systemic diseases, alveolar ab- 
 scess and pyorrhea as 
 causes of, 37 
 due to dental infection, use 
 of vaccines in {see also 
 diseases by name), 39 
 fl;-ray examination for dental 
 foci of infection in, 38 
 
 Teeth, infections of, 10 
 
 bacteriological studies of, 
 36 
 
 Teeth, infections of, lesions and 
 symptoms secondary to, 
 40 
 a;-ray examination of, for 
 foci of infection in sys- 
 temic diseases, 38 
 
 Tic douloureaux, 55 
 
 Tinnitus aurium, 63 
 
 Tuberculosis, 40 
 
 Ulcer, gastric and duodenal, 64 
 Ultra-violet ray in treatment 
 of pyorrhea alveolaris, 22 
 Unerupted tooth, a cause of 
 pyorrhea alveolaris, 17, 
 24 
 combined with alveolar ab- 
 scess, 33 
 
 Vaccines, use of, in systemic 
 diseases due to dental 
 infection, 39 
 
 X-ray examination for dental 
 foci of infection, 26 
 in systemic diseases, 38 
 
 X-raj treatment of pyorrhea 
 alveolaris, 21 
 
 Paul B. Hoeber, 67-69 East 59th St., New York. 
 
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RK270 
 
 T64 
 
 Tousey 
 
 Roentgenograph! diagnosis of den- 
 tal infeotion in systemio diseases. 
 
 f^$^^V ^^/i-3i3