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ORAL ABSCESSES
BY
Kurt H. Thoma, d.m.d.
LECTURER ON ORAL HISTOLOGY AND PATHOLOGY AND MEMBER OF THE RESEARCH
DEPARTMENT OF HARVARD UNIVERSITY DENTAL SCHOOL
INSTRUCTOR IN DENTAL ANATOMY, HARVARD MEDICAL SCHOOL
ORAL SURGEON TO THE ROBERT B. BRIGHAM HOSPITAL
VISITING DENTAL SURGEON TO THE LONG ISLAND HOSPITAL
CONSULTING ORAL SURGEON TO THE BOSTON DISPENSARY
BOSTON
RITTER & COMPANY
1916
.,' '
J*r
The right of reproduction of the original illustrations is
strictly reserved.
Copyrighted at the Registry of Copyrights, Washington,
D. C, 1916.
All Rights Reserved
AUTHOR OF
ORAL ANAESTHESIA
LOCAL ANAESTHESIA
IN THE ORAL CAVITY, FOR THE
DIFFERENT BRANCHES
OF DENTISTRY
Digitized by the Internet Archive
in 2010 with funding from
Open Knowledge Commons
http://www.archive.org/details/oralabscessesOOthom
INTRODUCTION
The important discovery that septic lesions in the month
may be foci or primary causes of many acute or chronic
diseases of systemic nature has brought about great
changes in the relationship between dentistry and medi-
cine. The teeth, which formerly were regarded as organs
totally apart from the rest of the body, are now considered
as one of the most important gateways through which dis-
ease may enter. The dentist who originally held it his
duty mechanically to repair diseased or lost dental tissue
is now confronted with a problem the vitality of which,
if he has a sincere interest in the health of his patients
and in the development of his prof ession, demands a new
study of the septic conditions of the mouth.
This book is intended for the practicing dentist as well
as for the student. It aims to give a clear understanding
of the pathology, treatment, and prevention of oral le-
sions, and to familiarize the student with the recognition
and nature of certain infectious diseases which may be
caused by them.
The practicing physician will also find this book of in-
terest. In the search for the primary or secondary foci
of systemic diseases he often has occasion to look into
the condition of the oral cavity, as it stands out as an im-
portant entrance for disease, although it has been until
recently neglected as such.
This volume has been written with a view to establish-
ing a correct relationship between the condition of the
VI INTRODUCTION
oral cavity and the health of the patient, and also in the
hope that a clear presentation may lead to a more general
understanding of this new field.
The author wishes to express his sincere thanks to those
of his friends who have aided him in bringing his book
before the profession. He wishes especially to express
his indebtedness to Dr. T. B. Hartzel for his kind assis-
tance in furnishing colored microphotographs of lesions
produced experimentally in the rabbit ; to Dr. L. B. Mor-
rison, of the Robert B. Brigham Hospital, for his compe-
tent assistance in radiography of hospital cases; to Dr.
William P. Cooke, for furnishing radiographs; to Dr.
W. H. Potter, for his examination chart; and to Dean
Eugene H. Smith, of the Harvard Dental School, for
photographs of models of two cases showing the results
of judicious extraction of decayed teeth in children. In
connection with the more detailed compilation of the
various parts of this volume, the author wishes to thank
Miss Herf ord, for her efficient work in delineation, and
Mr. John W. Cooke, for his aid in the preparation of the
manuscript.
Kurt H. Thoma, d.m.d.
43 Bay State Road,
Boston, Massachusetts.
July 3, 1916.
CONTENTS
PAGE
I. THE PHENOMENA OF INFECTION 1
The Infective Virus 1
Bacterial Ferments 2
Extracellular Ferments ; Intracellular Ferments .... 2
Toxins (extracellular toxin) 3
The Body Cell 3
Ferments of the Body Cell 3
Phagocytes 4
Two Biological Laws • 4
Protective Defences of the Body 4
Resistance 4
Decrease of Resistance ; Increase of Resistance 4, 5
Bacterial Immunity 5
Natural Immunity ; Acquired Immunity 5
Toxin Immunity 6
The Process of Infection 6
Incubation 6
Sensitization 7
Protein Poison (Intracellular Toxin) Caused by
Bacterial Destruction 7
Protein Poison Caused by Bacterial Metabolism from
the Body Cell 8
The Action of the Bacterial Ferments 8
The Influence of the Medium 8
By-products of Bacterial Metabolism 8
Toxin 9
Clinical Picture of the Infection 9
Influence of Quantity in Infection 9
Influence of Bacterial Growth in Infection 9
Influence of Virulence in Infection 9
Acute and Chronic Infection 10
Viii OEAL ABSCESSES
PAGE
Local Infection 10
Local Effects 10
General Effects 10
Fever ; Changes in the Blood 10
Geneeal Infection 11
Toxemia 11
Bacteremia 11
Metastasis 11
Secondary or Transported Infections 11
The Focus 12
Channels of Absorption 12
Oral Foci 13
Secondary Manifestation 13
II. HISTORY AND CLASSIFICATION OF ORAL AB-
SCESSES 15
History 15
Classification 15
III. PATHOLOGICAL DEVELOPMENT AND DIAGNOSIS
OF ALVEOLAR ABSCESSES CAUSED BY DIS-
EASES OF THE DENTAL PULP 18
Varieties.
Acute Periodontitis and its Sequels 18
Proliferating Periodontitis and its Sequels 19
1. Acute Periodontitis and its Sequels.
Definition.
Varieties.
Acute Apical Periodontitis 19
Acute Lateral Periodontitis 19
Acute Interradial Periodontitis 19
CONTENTS IX
PAGE
Etiology.
Traumatic Injury of the Tooth 20
Infection from Adjacent Teeth .' 20
Infection from Pus Pockets 20
Thermal Shocks 21
Chemical Action of Fillings 21
Crowned Teeth 21
Decay of Deciduous Teeth 21
Decay of Permanent Teeth 22
Filling Teeth with Infected Pulps 23
Instrumentation 23
Change in Oxygen Tension 23
Course of the Disease.
Acute Periodontitis 24
Acute Alveolar Parulis 24
Subperiosteal Parulis 24
Subgingival Parulis 25
Sinus into Mouth 25
Sinus to the Face 25
Sinus to the Antrum of Highmore 26
Sinus to the Nasal Cavity 26
Complications.
Osteomyelitis 26
Ostitis 26
Necrosis 26
Termination.
Resolution 27
Scar Bone 27
Chronic Alveolar Abscess 27
With Active Sinus 27
With Closed Sinus 27
Subacute Alveolar Abscess 28
Exostosis of the Root 28
Necrosis of the Root 29
ORAL ABSCESSES
PAGE
Diagnosis. (Local Symptoms, General Symptoms,
Clinical Signs, Radiographic Examination.)
Acute Periodontitis 29
Acute Alveolar Abscess 30
Dento Alveolar Parulis 31
Chronic Alveolar Abscess 33
2. Proliferating Periodontitis and its Sequels.
Definition.
Varieties.
Apical Granuloma 35
Lateral Granuloma 35
Interradial Granuloma 35
Etiology.
Decay of the Tooth 36
Incomplete Pulp Extirpation 36
Inefficient Root-canal Treatment 37
Inefficient Root-canal Filling 38
Invasion of Bacteria 38
Death of Pulp Without Access of Air 38
Haematogenous Infection 39
Course of the Disease.
Proliferating Periodontitis 39
Granuloma 39
Subacute Attacks 40
Exostosis of the Root 40
Necrosis of the Root 40
Termination.
Resolution 41
Osteomyelitis 41
Cysts 41
Diagnosis. (Local Symptoms, General Symptoms,
Clinical Signs, Radiographic Examination.)
Proliferating Periodontitis 42
Granuloma 42
Subacute Attacks 43
CONTENTS XI
PAGE
IV. PATHOLOGICAL DEVELOPMENT AND DIAGNOSIS
OF ALVEOLAE, ABSCESSES DUE TO OTHER
CAUSES THAN THE DISEASE OF THE DENTAL
PULP 45
I. Alveolar Abscesses Due to Diseases of the Gum 45
Etiology 45
Course of the Disease 46
Diagnosis (Local and General Symptoms, Clinical
Signs, Radiographic Examination) 47
II. Alveolar Abscess due to Difficult Eruption,
Impaction, and Unerupted Teeth 47
Etiology 47
Course of the Disease 49
Diagnosis (Local Symptoms, General Symptoms,
Clinical Signs, Radiographic Examination). . .49, 50
V. PATHOLOGICAL DEVELOPMENT AND DIAGNOSIS
OF ABSCESSES OF THE TONGUE AND SALI-
VARY GLANDS AND DUCTS 51
I. Abscesses of the Tongue 51
1. The Simple Abscess of the Tongue 51
Etiology 51
Clinical Course of the Disease 52
Diagnosis (Local Symptoms, Clinical Signs) 52
2. The Phlegmonous Abscess of the Tongue 52
Etiology 52
Clinical Course of the Disease 52
Diagnosis (Local Symptoms, General Symptoms,
Clinical Signs) 53
3. The Tubercular Abscess of the Tongue 53
Etiology 53
Clinical Course of the Disease 54
Diagnosis (Local Symptoms, General Symptoms,
Clinical Signs) 54
Xll
OEAL ABSCESSES
PAGE
II. Abscesses of the Salivary Glands and Ducts . . 54
Etiology 55
Primary Infections 55
Secondary Infection 55
Salivary Calculi 55
Clinical Course of the Disease 56
Diagnosis (Local Symptoms, Clinical Signs, Rad-
iographic Examination) 56, 57
VI. BACTERIOLOGY OF ORAL ABSCESSES 58
Importance of Bacteriological Study 58
Methods of Collecting Bacterial Specimens 59
From Acute Abscesses 59
From Chronic Abscesses and Granulomata of Teeth
which are extracted 59
From Chronic Abscesses and Granulomata in Apiec-
tomy 60
Methods of Bacterial Study 60
Immediate Microscopic Study 60
Inoculation of Artificial Culture Media 60
Inoculation of Animals 61
Review of the Bacteriological Study of Oral
Abscesses 61
Schreier, 1893, on Parulis 61
Miller, 1894, on Acute Alveolar Abscess. . . 62
Arkovy, 1898, on Chronic Alveolar Abscess . . 62
Goadby, 1903, on Acute Abscess 62
Partsch, 1904, on Zahne als Eingangspforte
fur Tuberculose 63
Monier, 1904, on Osteo Periostite (Alveolar
Parulis) 63
Vincent, 1905, on Suppuration Dentaire sous
Periostique 65
Mayerhofer, 1909, on Periostitis Dentalis 65
Idman, 1913, on Acute A lveolar Abscess. . .66-70
Gilmer, 1914, on Acute and Chronic Ab-
scesses 70
Thoma, 1915, on Actinomycosis of Dental
Hartzel and Granulomata 70
Henrici, 1913-14-15, on Streptococci of Chron-
ic Oral Infections 71-75
CONTENTS Xlll
PAGE
Author's Remark, 1916 75
Steinharter, 1916, on Staphylococci causing Sec-
ondary Infection 75
m. HISTOLOGICAL PATHOLOGY 77
Acute Periodontitis 77
Acute Alveolar Abscess 77
Dento- Alveolar Parulis 78
Chronic Alveolar Abscess 78
Proliferating Periodontitis 79
Dental Granulomata 79
Simple Granuloma 79
Epitheliated Granuloma 81
Granuloma with Lumen 82
Cysts 82
VIII. SECONDARY COMPLICATIONS 84
1. Involvement op Neighboring Parts 86
1. Maxillary sinusitis 86
Acute maxillary sinusitis 86-88
Chronic maxillary sinusitis 88-92
2. Pharyngitis 92
3. Trismus 93
2. Ophthalmic Disturbances 94
1. Infectious conjunctivitis 95
2. Suppurating Keratitis 95
3. Scleritis 95
4. Iritis 96
5. Cyclitis 97
6. Choroiditis 97
7. Retinitis 97
8. Intraocular optic neuritis 98
9. Retrobulbar optic neuritis 98
10. Glaucoma 99
3. Aural Disturbances 100
1. Otitis media 100
2. Otalgia 101
3. Reflex otalgia 101
XIV ORAL ABSCESSES
PAGE
4. Infections op the Lymph System 102
1. Lymphangitis 103
2. Lymphadenitis 104-106
3. Tubercular lymphadenitis 106
5. Diseases of the Alimentary Canal 109
1. Septic gastritis 110
2. Septic enteritis 112
3. Colitis 113
4. Appendicitis 113
5. Proctitis 113
6. Gastric and duodenal ulcers 113
6. Infectious Diseases op the Blood 115
1. Septicemia 116
2. Pyemia 117
3. Toxemia 118
Malaise 119
4. Anaemia 121
Pernicious anaemia 121
Septic anaemia 122
7. Infectious Diseases of the Heart 123
1. Pericarditis 124
2. Myocarditis 125
3. Endocarditis (valvular and mural) 125
8. Affections of the Nervous System . . . . 128
1. Neuritis 128
2. Neuralgia, trifacial 130
3. Chorea 132
4. Mental depression and melancholia 133
9. Diseases of the Joints 135
1. Acute arthritis 135
2. Hypertrophic arthritis 137
3. Gouty arthritis 137
4. Infectious and atrophic arthritis 137-143
IX. EXAMINATION OF THE ORAL CAVITY 144
Method op Oral Examination for the Physiclvn .... 145
1. Examination of the Soft Tissues of the Mouth 145
2. Examination of the Teeth. 145
3. Enlarged Lymph Glands 146
CONTENTS XV
PAGE
Method op Oral Examination for the Dentist 146
Physical Examination 146
1. General Health, of the Patient 146
2. Diseases of the Soft Tissues of the Mouth 147
3. Diseases of the Teeth 147
Radiograph Examination 148
1. Obscure Pain 148
2. Diagnosis of Condition of Devitalized Teeth .... 148
3. Prognosis before Root-canal Treatment 149
Potter Case Charts 149
Report Charts for Radiologists 149
X. TREATMENT OF ORAL ABSCESSES 150
1. Treatment op Acute and Subacute Conditions . . . 150
Removal of the Cause 151
Rest of the Diseased Tooth 152
Application of Counter-irritants 152
Alveolatomy 152
Incision 152
Extraction 154
Systemic Treatment (Palliative, Relief of Pain,
Diet) 155
Treatment of Sinus to the Face 157
2. Treatment op Chronic Conditions 157
Removal of Cause 160
Treatment with Antiseptics placed into Root Canal 160
Ionic Medication 161
Apiectomy 162
Extraction and Curettage 167
Extirpation of Teeth 168
3. Treatment op Abscesses Due to Diseases of the
Gum 169
Abscesses Due to Injury of the Gum 169
Abscesses Due to Pus Pockets 169
4. Treatment of Abscesses Due to Difficult Erup-
tion, Impaction, and Unerupted Teeth 169
Extirpation of Impacted and Unerupted Teeth. . . . 170
Xvi ORAL ABSCESSES
PAGE
5. Treatment op Abscesses of the Tongue 171
Incision in Non-Tubercular Lesions 171
Excision of Small Tubercular Lesions 172
"Wedge Excision of the Tongue 172
Treatment of Large Tubercular Abscesses on the
Side of the Tongue 173
6. Treatment of Abscesses of the Salivary Glands
and Ducts 173
Operation from the Floor of the Mouth 174
Excision of the Glands 175
7. Treatment of Systemic Complications 175
Surgical Autoinoculation 176
Restoration of Masticating Efficienev 177
XI. PREVENTION 178
Prevention of Secondary Disease from Oral Ab-
scesses 179
Prevention of Periapical Infection 180
Radiographic Diagnosis Before Root-canal Treatment 180
Anaesthesia for Pulp Extirpation 181
Complete Pulp Extirpation 181
Cleaning and Enlarging the Canal 181
Antiseptic Medication 182
Ionic Medication 184
Root-canal Filling 184
Sterilization and Asepsis 185
Summary of Important Factors to Prevent Periapical
Infection 186
Prevention of Devitalized Teeth 186
Devitalization for Sensitive Dentine and Prostheses
Not Justifiable 186
Treatment of Hyperemia and Exposures to Prevent
Devitalization 187
Early Treatment of Caries and Prophylaxis 188
XH. THE TRUE VALUE OF A TOOTH 189
CHAPTER I
THE PHENOMENA OF INFECTION
To understand intelligently and fully appreciate the
pathology, bacteriology, and treatment of oral abscesses
and their secondary manifestations it is well to study
first the phenomena of infection generally. The investi-
gations made by Vaughan and Ehrlich and others throw
new light on many of these questions. They solved prob-
lems of greatest interest which formerly were only
vaguely understood. For investigations on focal infec-
tion we are indebted especially to Rosenow and Billings.
It is my privilege to use freely in this chapter the state-
ments of these authorities.
In all infectious processes there are two principal fac-
tors : the infective virus and the body cell. Besides these
there is to be considered the environment in which the
infection takes place, the unorganized fluids of the body.
THE INFECTIVE VIRUS
The infective virus may be a particular protein and
physically different from the medium in which it exists,
so that its substance and form can be recognized with the
aid of the microscope. This we call a microorganism.
It may, on the other hand, be a semi or wholly fluid pro-
tein, not sufficiently differentiated from the medium to
render it recognizable even with the most delicate micro-
scope. Many such proteins pass through the finest
porcelain filters and cannot be deposited even by the cen-
trifuge from the fluids in which they exist.
According to Vaughan, a living protein can be solid,
semi-solid, gelatinous, or liquid, but need not be of a form
ORAL ABSCESSES
which our limited senses are capable of recognizing, even
when aided by the most perfect lens. It is capable of
growth and reproduction, and in order to do this it must
assimilate and eliminate. It can only procure this nour-
ishment from material which is within its reach.
A bacteria or another infective virus is, therefore, only
able to live if it can split its surrounding media into
groups which fit into the molecular structure of its cell.
Therefore organisms which can make use of the proteins
of the body in which they live are pathogenic for their
host. If they cannot make use of the substances they
live in they cannot cause an infection.
The agents in an organism which prepare
MENTS the f °° d fOT aSslmilati0n are Called fer_
ferments me nts. They are of analytic and synthetic
natures. We also speak of intracellular and extracellular
ferments.
Extracellular Ferments. Extracellular ferments pass
out of the cell and diffuse more or less widely through the
medium which surrounds it. They are of analytic nature,
rendering soluble the proteins of the medium, and the
complex molecules are broken down into simpler struc-
tures, some of which can be assimilated, while others
remain as protein poison. The activity of the extra-
cellular ferments is easily affected by modifications in the
mediiun through which they diffuse. Species of a nim als,
peculiarities of individuals, slight changes of tempera-
ture, or changes in the tissue cause variations in the
growth and multiplication of the bacteria. Hence it is
that one kind of organism grows slowly under unfavorable
conditions, causing chronic disease, while the same bac-
teria under favorable conditions may cause violent acute
attacks.
Intracellular Ferments. The intracellular ferments
remain in the cell in which they are elaborated and are
in general nondiffusible. They bear a wider variation
in temperature and are not so easily influenced by varia-
tions of the composition of the medium in which they
exist. While the extracellular ferments prepare the pro-
THE PHENOMENA OF INFECTION
teins so that they can be absorbed by the cell, it is left to
the intracellular ferments to construct the molecules
into the specific proteins which can be assimilated or
built into the structure of the cells.
toy ins Extracellular Toxin. Besides these fer-
ments which are necessary to maintain
life certain bacteria elaborate another excretion.
This is a soluble extracellular substance known as
toxin. It is also probably a ferment or a closely allied
body. A remarkable characteristic of the toxins is that
they are highly specific in their properties and have the
power to stimulate the production of antibodies in the
infected body. These antibodies are called antitoxins
and are also specific. Antitoxin of diphtheria protects
only against diphtheria toxin and not against that of any
other organism. The number of bacteria-producing
toxins, in large quantities at any rate, is small ; the diph-
theria and tetanus bacilli are good examples of toxin-
producing bacteria.
THE BODY CELL
The cells of the body also have ferments, as just de-
scribed. There is no living organism which does not
produce its ferment, and all ferments are produced by
living organisms. The preparation of food for assimi-
lation is due to ferment action.
The ferments of the body cell also work
op the analytically and synthetically. They are
BODY CELL of extracellular and intracellular natures.
Their primary function is to supply
the cells which elaborate them with food. In
doing this they also protect the cells to which
they belong by destroying the harmful bodies both
particulate and formless. They are, however, of
a specific nature. While the ferments of the body cells
of one animal may digest one or more bacterial proteins,
they may be unable to break down the proteins of certain
other infectious organisms. Another animal, under the
same general conditions, may resist the latter organism,
ORAL ABSCESSES
but prove incapable of combating the former. If they
are able to break down the bacterial proteins these are
destroyed and the animal will resist disease.
Some cells not only destroy invading or-
^J ganisms by their extracellular ferments,
as just described, but even engulf entire
bodies of bacteria and dispose of protein poisons, digest-
ing them by the action of their intracellular ferments.
Cells with such functions are the wandering leucocytes,
lymphocytes, plasma cells, as well as fixed endothelial
and connective tissue cells.
Vaughan* formulated the following bio-
TWO biologi- logical laws which well describe the
CAL LAWS phenomena of infection.
1. If the body cells are permeated or
come in contact with a foreign protein (bacteria), the
former elaborates a specific ferment by which the latter
are destroyed.
2. If the body cells are attacked by destructive fer-
ments (toxins), the former form anti-ferments (anti-
toxins) which have the office of neutralizing the ferments
to protect the body cells.
PROTECTIVE DEFENCES OF THE BODY
The body cells of the host attempt in the manner de-
scribed to resist the growth and multiplication of the
foreign proteins : this growth constitutes infection. The
resistance in an animal or a person has
resistance ^ een f ounc [ to be greater at one time and
diminished at another. In youth the resistance is smaller
than in old age.
Decrease of Resistance. The proteolytic action of the
body cells, which checks the progress of infection, can be
greatly decreased or removed by any cause which lowers
the general or local vitality of the tissue. Among these
belong hunger and starvation, bad ventilation, overexer-
tion, exposure to cold, acute or chronic diseases, and focal
infection. Local affections such as injury, tissue changes
* See Bibliography.
THE PHENOMENA OF INFECTION
from disease, the presence of foreign bodies, and the in-
terference with the circulation of the blood also tend to
lessen the vitality.
Increase of Resistance. All conditions which are
favorable to the health of the body increase its resistance
and render the tissue cells more able to overcome the in-
fection. Healthy food, beneficial exercise, and good
circulation, fresh air and all prophylactic means further
an increase in the resisting power of the body. The treat-
ment of disease and the careful search for and surgical
removal of chronic foci, from which protein poison or
toxins are absorbed, will also remove causes which sap
the vitality of the individual and lower the resistance
against new infections.
RArTF-Riai Natural Immunity. Natural immunity
immunity * s ^ ue e ^ ner ^° ^ ne ^ ac ^ ^ na ^ bacteria are
unable to feed upon the proteins of the
body and therefore cannot live, or because they are de-
stroyed by the specific ferment, formed as a protective
measure by the body cells. There are germicidal agents
found dissolved in the plasma as well as in the serum.
These are probably extracellular ferments, while similar
agents are found in these cells themselves, which are
probably intracellular ferments. The first act directly
on protein organisms if they are contained in the plasma
or blood serum ; the latter act only after these organisms
have permeated into the body cells which produce them.
Cells which have such functions in a marked degree are
called phagocytes.
Acquired Immunity. Immunity is acquired either by
disease or by therapeutic measures.
Immunity which is due to recovery from an infection
is the result of the development in the body, during the
course of infection, of a specific ferment which on renewed
exposures immediately destroys the infection.
Immunity established by vaccination is similar to that
induced by an attack of the disease. A vaccine is the
same protein that causes the disease. It is, however,
6 ORAL ABSCESSES
modified by passage through animals, by growth at high
temperature, or by killing the bacteria by heat, so that
it does not induce the disease but yet it must be so little
altered that it will stimulate the body cells to form a
specific ferment which will promptly on exposure destroy
the infecting agent. This process also is called ''protein
sensitization. ' '
toxin '^' understand toxin immunity it is neces-
m m n ity sar 7 ^° nrs ^ understand toxin activity. The
toxin, which is produced only by a small
number of bacteria, is a soluble and diffusible ferment.
It splits up the proteins of the body, setting free the
protein poison. The body cells of animals are stimulated
by this to produce an antitoxin which neutralizes the
toxin and prevents its cleavage action. The antitoxin
does not destroy the foreign proteins, as do the proteolytic
ferments of the body cells, but only prevents the action
of the elaborated toxin.
Antitoxin for therapeutic purposes can be produced by
injecting the toxin, gained by injecting a very virulent
culture in broth, into an animal, usually a young horse.
The serum of the horse then contains the antitoxin. Anti-
toxin is rather a preventive than a cure. It is much
more active if given before or in the very beginning of
the infection. The inununity procured with serum con-
taining antitoxin is but temporary.
THE PROCESS OF INFECTION
Pathogenic proteins entering the body feed upon man's
proteins, and they convert the body proteins into bac-
n cub ati on Serial proteins by their digestive ferments.
They grow and multiply rapidly. This
is essentially a process of building up, as no poisonous
protein is liberated and the process goes on without any
recognizable disturbance in the health of the body. We
call this stage of infection the period of incubation. Dur-
ing this period the body cells do not resist the growth
and multiplication of the foreign protein.
THE PHENOMENA OF INFECTION"
During the period of incubation the body cells are being
prepared for their combat with the foreign proteins.
From the action of the foreign protein
TiON on the body cell we note the development
in the latter of a specific proteolytic fer-
ment, a new function. This process we call protein sen-
sitization. It is a process of distinction of the invading
organisms. The new ferment digests the invading pro-
teins, setting free the protein poison.
PROTEIN {Intracellular Toxin) caused by bacterial
poison destruction. After the body cells have
been sensitized the specific ferment which
is formed starts at once to break down the bacterial cells.
This, however, does not mean that the analytic process
of the bacteria is stopped at this moment ; on the contrary
the constructive action of the bacterial ferments con-
tinues, the invading organisms still grow and multiply
but the process of destruction is going on at the same time.
A fight for supremacy ensues between the invading organ-
isms by their f ermentive action of bacterial construction
and the defending body cells by their destructive action
of their newly-formed proteolytic ferments. All bacteria
contain an intracellular poison which is a group in the
protein molecule and is neutralized in most organisms by
combination with nonpoisonous groups. Therefore such
proteins have no action until they undergo molecular dis-
ruption. It is the action of the proteolytic ferments
which splits the molecules of the invading proteins, set-
ting free the protein poison (intracellular toxin) which
makes the symptoms of the disease appear. Protein
poison is not a true toxin, although the term toxin is
loosely applied to all poisons of infectious origin. It is
formed during all processes of infection, while true toxin,
as we have already seen, is a special ferment character-
istic of certain bacteria. Protein poison is produced by
destruction of the bacterial proteins, is not affected by
heat and does not excite the formation of an antibody and
differs probably in quality with the variety of the
bacteria.
8 ORAL ABSCESSES
Protein Poison Caused by Bacterial Metabolism from
the Body Cells. It has already been described bow bac-
teria split by their extracellular ferments the surround-
ing media of their host. From the newly-formed struc-
tures some are absorbed and others remain as protein
poison. The intracellular ferments split again into mole-
cules which are ass imil ated and built into the structure
of the cell, and substances which are excreted. These
by-products of extracellular and intracellular bacterial
metabolism may be harmless or may be important protein
poisons. Their nature depends upon the special action
of the ferment as well as the quality of the media of the
host in which the bacteria grow.
The action of the bacterial ferments. The action of
the bacterial ferments is of greatly varied nature. There
are proteolytic ferments, hemolysin, nuclease, lab-
ferment, lipase, diastatic ferments, invertase, pectase,
gelase, oxydase and katalase.
The Influence of the Medium. There is usually a sub-
stance which the bacteria are able to digest particularly
easily, but if this is not present they will attack harder
and less accessible material. The chemical make-up of
the medium naturally has a great deal to do with the
result and with the by-products of bacterial metabolism.
By-products of Bacterial Metabolism. The by-prod-
ucts of the extra- and intracellular ferment action of the
bacteria are almost always relatively strong poisons to
the host. Various colored pigments are formed which
have not been studied very much. From nitrogenized
bodies, or proteid substances which constitute the greater
proportion of animal tissue, there are formed complicated
protein poisons, ammonia, ptomaines, alkalies, hydrogen
sulphid, aromatics (Indol, Skatol, Phenol, Tyrosin) and
gases such as Nitrogen. From carbohydrates and animal
fats there are formed acids (lactic acid, Formic acid,
acetic acid, butyric acid) and gases (carbon dioxide, Ni-
trogen, methane, Hydrogen).
This process of bacterial action is a decomposition, re-
sulting in various combinations of the by-products of the
THE PHENOMENA OF INFECTION 9
metabolism. These by-products can almost always be
recognized by the sense of smell and it is small wonder
that such substances if absorbed into the system cause
diseases of all kinds.
Toxin. Toxin is a term which is clinically applied in a
loose manner to any poisonous substances formed during
the process of infection. It includes in this sense fer-
ments, extra- and intracellular toxin, and any protein
poison produced by the process of bacterial metabolism.
In its strict sense the term toxin is, as we have already
seen, applied only to the specific extracellular bacterial
poisons, as these alone cause the body cells to produce
antitoxins.
CLINICAL PICTURE OF THE INFECTION
The clinical picture and course of the infection depend
upon several factors.
Influence of Quantity in Infection. The number of
pathogenic organisms introduced into the body plays a
great role. A small number of bacteria may die, while
from a large number a certain amount is sure to survive
and cause disease.
Influence of Bacterial Growth on Infection. Bacteria
differ as to the rapidity with which they grow. This de-
pends mostly upon the conditions they find; if the body
proteins are easily digested they grow rapidly but if
they can make use of the proteins of their host only with
difficulty and if the circumstances under which they have
to grow are unfavorable, as exclusion of oxygen for
aerobic bacteria, the growth and multiplication is slow.
This also has its reaction upon the body cells. If the
infective virus multiplies rapidly, sensitization of the
body cells is general and starts early. If the infecting
organism finds less favorable conditions for its growth it
multiplies slowly and the body cells are sensitized locally.
Influence of Virulence in Infection. With bacteria
whose virulence is great, disease will be produced quickly
by a small number of bacteria, while a very large number
is necessary if the bacteria is of the low virulent type.
10 ORAL ABSCESSES
Acute and Chronic Infection. If the pathogenic or-
ganisms enter the body in large number, increase rapidly,
or are highly virulent, and sensitization of the body cells
therefore is marked, starts early and is general, the
developing disease is acute. If only few organisms in-
vade the body, or if the infecting organisms multiply
slowly and find unfavorable conditions, if sensitization
of the body cells is mild and only local, the disease takes a
chronic course.
LOCAL INFECTION
If the infecting virus and the sensitization of the body
cells is limited to a certain part of the body, we call the
infection local.
The effect of the toxins (protein poisons)
effects upon the body cells gives rise to various
kinds of inflammation such as serous, fibri-
nous, purulent, necrotic, gangrenous or proliferative.
Serous exudations into the subcutaneous tissue follow
certain bacterial infections in certain tissues, while the
same or other bacteria cause purulent inflammation in
other tissues or under other conditions.
general Fever. Heat is produced during the
EFFECTS processes of infection from the following
sources: (1) from the unaccustomed
stimulation and consequent increased activity of the
cells which supply the ferments; (2) from the cleavage
of the foreign protein; and (3) from the reaction between
the proteolytic ferment of the body cells and the foreign
proteins, especially if active and virulent poison is lib-
erated. Fever must therefore be regarded as a benefi-
cent process although it often leads to disaster, especially
if the reaction takes place with great rapidity. The tem-
perature is the most delicate test of the severity of the
inflammation.
Changes in the Blood. The microbian proteins almost
always produce an increase in the number of leucocytes
and a decrease in the amount of protein. The red blood
cells are sometimes directly injured by some of the bac-
terial substances.
THE PHENOMENA OF INFECTION 11
GENERAL INFECTION
If the infective virus is distributed widely through the
whole body and if sensitization of the tissue cells is gen-
eral, we speak of general infection. Today we know
that infections are never entirely localized and that there
is always absorption of bacteria or of the toxins formed
by the infectious process.
toxemia ^ e resm ^ f rom absorption of bacterial
toxins (either true toxins or toxins of
bacterial metabolism) varies according to the quality and
amount absorbed. If the system is flooded by large
amounts, so that there are marked symptoms of intoxi-
cation, we have the picture of acute toxemia. The
process, however, may go on for years without causing
gross symptoms, and we have a chronic toxemia which
often causes physical discomfort and mental depression.
bacteremia ^ e Dac "teria are absorbed in quantity
into the blood and multiply, we have an
acute general infection called septicemia, which is of
most severe character, resulting often in death.
Frequently, however, we find conditions when bacteria
are not potent enough to cause gross symptoms of infec-
tion, although they actually wear out the cells, whose duty
it is to combat and kill them, thus lowering the resistance
of the body.
metastasis ^e P resence °^ bacteria or toxins in the
blood and tissue fluid may cause new in-
fections or diseased conditions in other parts of the body,
which are either predisposed by lowered resistance or
which have a special affinity for the injurious agent.
SECONDARY OR TRANSPORTED INFECTIONS
Billings says: "The knowledge of the principle of sec-
ondary infection is of importance for preventive as well
as therapeutic treatment. The recognition and the re-
moval of the focus is imperative to prevent secondary
disease and is demanded as a fundamental principle to
stop the progression of ill-health/'
12 ORAL ABSCESSES
It has just been shown that bacteria and toxins are
absorbed from local infections into the blood and that
new infections occur at remote parts of the body. This
is called secondary or transported infection, a process
which has been discovered only recently but which is of
frequent occurrence.
the focus The focus may be found in any part of the
body and may be an acute or chronic local
infection. Foci are sometimes apparent, but often only
recognized after careful examination by the specialist.
They may be in the nose and adjacent sinuses, the oral
cavity, the throat, the alimentary canal, or the genito-
urinary system.
channels of ^ ac ^ er ^ a an( ^ their products are absorbed
absorption tn r011 g]i two channels, the blood and the
lymph system. They are carried into the
blood by passive entrance through the stomata of the
capillary walls, by growth of the bacteria through walls
of the vessels, and by carriage into the blood by leu-
cocytes. They also may reach the blood by the way of
the lymph vessels after their transmission through the
lymph glands. The deeper the infection is seated in the
tissue, and the greater the pressure of the accumulated
bacterial products, the larger is the amount of absorption.
Also the tissue in which the infection occurs is of im-
portance. Mucous membrane absorbs easily. An ab-
scess enclosed by bone gives no chance for infiltration or
extension; therefore the pressure is great and the bac-
terial products are absorbed readily. If there is a sinus
the pressure is decreased and the amount of absorption is
diminished. When abscesses or other lesions discharge
their exudates into the mouth, they reach different parts
of the alimentary canal where a new focus may be formed,
especially if the pus supply is long continued. But sec-
ondary lesions may in turn also become foci for further
and more general infection. Such conditions must not be
mistaken for the primary cause of the focal disease, but
they should be removed so that they will not serve to
further prolong and intensify the disease. (Billings.)
THE PHENOMENA OF INFECTION" 13
oral foci Oral foci may cause secondary infections
via the capillary or lymph system. Ab-
sorption is most likely to be caused by blind, acute, or
chronic abscesses, but occurs also from pyorrhoea pockets,
diseased gums, and other lesions of the mucous membrane.
But infection may also occur by pus discharging into the
oral cavity, as in pyorrhoea, and suppurative gingivitis
caused by poorly fitted crowns and bridges, and in alve-
olar abscesses with sinus ; the result then is mostly a local
infection such as stomatitis, pharyngitis, or an infection
of the alimentary canal, as septic gastritis, enteritis, or
appendicitis. But if the surface immimity of the diges-
tive tract is overcome, the alimentary canal will become
a new focus, bacteria being absorbed, causing further sec-
ondary infection.
Oral abscesses, especially of the unsuspected chronic
type, are in these days of overdentistried teeth a common
infection and are of greatest importance in the diagnosis
and treatment of secondary disease. The unsuspecting
and deceived individual is usually not aware of the men-
ace which has undermined his health or is ready to cause
the most terrible chronic diseases if the conditions for
secondary infections are right.
The part of the body affected and the dis-
SECON D ARY ease produced by absorbed toxins and bac-
T!ONS ESTA " teria depends upon several factors. The
different toxins have special affinities for
a certain tissue. The varieties of bacteria have prefer-
ences to grow in certain tissues and even strains of a cer-
tain class of bacteria have a predilection of the place in
which they may accumulate. Some forms of streptococci
grow only in conditions with abundant oxygen supply (en-
docarditis), while others prefer places of decreased oxy-
gen tension (arthritis). The part of the body in which
they start a secondary infection is often predisposed
by traumatic injury or lowered resistance from other
reasons.
A place which is liable to become affected by secondary
disease may at other times be the seat of the focus, while
14 ORAL ABSCESSES
lesions which usually are primary infections can be
caused by transported or secondary infection. Alveolar
abscesses are almost always primary lesions whether they
are the cause of secondary disease or not, but occasionally
abscess formation starts on devitalized teeth, with perfect
root-canal fillings from haematogenous infection, due to
diseased tonsils or some other focus.
PLATE I
Fig. 1. — Predynastic Egyptian Skull from Upper Egypt, shows loss
of bone due to abscess condition on the buccal roots of the upper
first molar. The pulp in this tooth was exposed from abrasion.
Fig. 2. — Oeclusial view of upper jaw of same skull showing abra-
sion of the teeth and the exposed pulp chamber of the first molar.
PLATE II
Fig. 3. — Prehistoric Peruvian skull from the cave Huaricauc. There
is a great deal of bone lost in the upper incisor region from acute
abscess condition.
CHAPTER II
HISTORY AND VARIETIES OF ORAL
ABSCESSES
...~~^»» Abscesses of the teeth are known to have
occurred centuries ago. We find their bone
destructive processes both about the jaws of ancient civi-
lized people such as the Egyptians, as well as in ancient
native tribes.
The older literature knows only the alveolar abscess
with acute symptoms of calor, dolor, rudor, and tumor,
while the discharge of pus from sinuses on the gum which
gave the patient no discomfort was an obscure quantity
neglected by the dentist who then considered it his duty
only to relieve pain and plug cavities. Later this con-
dition was considered the termination of the acute alve-
olar abscess which did not yield to treatment. It was
called chronic alveolar abscess.
Abscess sacks found adhering to extracted roots or
teeth furthered the knowledge of the pathology of the
dental abscesses, and in cases where neither the gum nor
the tooth showed any sign of suppurating condition, the
term " blind abscess" was applied. The blind abscess
usually gave no apparent discomfort and therefore was
classified with the chonic abscess. At that time, teeth
with diseased pulps were either neglected by the patient,
or if treatment and relief of pain was sought, extracted.
But when the value of the teeth for mastication became
better understood, men set out to preach the saving of
teeth, and methods were invented to treat the pulpless
teeth. I do not believe that the fathers of conservative
dentistry meant to convey the meaning of the doctrine
which became popular. It is not reasonable to try to
16 OKAL ABSCESSES
save every tooth, no matter how diseased it is and how
inaccessible the root-canals may be. But it was expected
of every dentist that his greatest aim should be to save
all teeth and that it showed lack of ability to be obliged
to sacrifice a tooth. On account of the difficulty of root-
canal operations and the obscurity of the achievement,
the results frequently were poor, even if careful technique
were employed, and miserable if carelessly incompetent.
Because recommendation of extraction was looked upon
with disfavor, the many overdentistried teeth with incom-
plete root-canal work were left in the mouth. The result-
ing condition was apparently normal. There was no
discomfort or perhaps only slight grumbling sensations,
overlooked by dentist and patient.
Not until the X-rays were applied for diagnosis in
dentistry have we discovered the true condition of such
teeth, and since the progressive dentist secures the ser-
vices of the dental radiologist, or has an X-ray machine of
his own, we stand before the grave fact that most pulpless
teeth are the cause of chronic inflammatory processes in
the alveolar process of the maxillary and mandibular
bone, which give no trouble or only the slightest local
symptoms, but are the cause of much ill-health and dis-
ease.
^, a «-.«-»■*-. ^« Oral abscesses are best divided into three
CLASSIFICA- -, -,. i ,-1 ,. t ,
_.«.. classes according to their etiological
factors :
1. Alveolar abscesses caused by diseases of the dental
pulp.
2. Alveolar abscesses due to other causes than diseases
of the dental pulp.
3. Abscesses of the tongue, salivary glands, and ducts.
The first class is by far the most important one ; it in-
cludes acute alveolar abscesses caused usually by acute
diseases of the pulp and the chronic alveolar abscesses
which are so commonly found on pulpless teeth. It has
been estimated that these are found in the mouth of a
large percentage of the population of the United States.
In the Eobert B. Brigham Hospital, where the only
HISTOEY AND CLASSIFICATION 17
patients are those who suffer from chronic diseases, I
found such abscesses in eighty-eight per cent, of the pa-
tients examined. The second class includes abscesses
caused by pyorrhoea, infection of the gums, and impacted
and unerupted teeth. These are by far less frequent
than the previous group.
In the third class we have conditions which are of
rather rare occurrence and are frequently secondary to
diseases of the teeth. However, abscesses may occur on
the tongue and in the salivary glands and in ducts, which
are due to various other causes.
CHAPTER III
PATHOLOGICAL DEVELOPMENT OF ALVE-
OLAR ABSCESSES CAUSED BY DIS-
EASES OF THE DENTAL PULP
varieties Generally alveolar abscesses due to dis-
eases of the pulp have been divided into
two classes: the acute and the chronic condition. This
division is selected, according to the large or small amount
of discomfort the patient experiences, that is, according
to the symptoms, without considering either the etiology,
the histopathological picture, or the termination of the
disease. We know that the acute alveolar abscess if not
cured will terminate in the chronic form, but some of the
so-called " chronic" forms occur without passing through
the acute stage. As a matter of fact, since only a very
small percentage of chronic abscesses have ever started
with symptoms of discomfort, the classification of
" acute" and " chronic" is therefore not scientifically
correct. A closer study of the pathological stages shows
that the acute abscess involves a process of destruction
while the so-called chronic abscess is a process of inflam-
matory new growth. This proliferating new growth is of
a more or less circumscribed character, while the acute
condition of destruction is of a diffuse nature, spreading
into the adjacent parts.
I shall therefore distinguish two varieties of alveolar
abscesses due to diseases of the dental pulp. Both repre-
sent a progressive chain of pathological changes, the first
of a destructive, the second of a constructive, nature.
1. Acute Periodontitis and its sequels — or changes of
destructive nature beginning with acute periodontitis,
PLATE
Fig. 4. — Bicuspid with apical abscess. Incisor with lateral abscess.
Molar with inter-radial abscess.
ALVEOLAE ABSCESSES 19
culminating in acute alveolar abscess or alveolar parulis,
and ending in chronic alveolar abscess and its sequels.
2. Proliferating Periodontitis and its sequels — or
changes stimulating inflammatory new growth beginning
with proliferating periodontitis and resulting in a
granuloma.
1. ACUTE PERIODONTITIS AND ITS SEQUELS
definition Acute periodontitis and its sequels are
changes which involve suppurative de-
struction of the surrounding tissues of the tooth, culmi-
nating in a collection of pus in or about the alveolar
processes, called alveolar abscess or alveolar parulis.
Acute Apical Periodontitis. The natural outlet from
the pulp chamber is the apical foramen, or the apical
foramina, and therefore we find these openings the most
common mouths of the infection, since they are the natu-
ral passages through which infected matter may pass
from the dental pulp chamber into the surrounding
tissues of the apex of the tooth. . The sequel of the acute
apical periodontitis is the " apical alveolar abscess."
Acute Inter radial Periodontitis. This is inflammation
which occurs between the roots of multirooted teeth from
decay extending from the diseased dental pulp through
the floor of the pulp chamber. Infection by perforation
of the floor of the pulp chamber or inner sides of the roots
with burr or root canal instruments also gives rise to this
condition. Its sequel is the acute interradial alveolar
abscess.
Acute Lateral Periodontitis. Perforation of and in-
fection through the lateral wall of a tooth by the burr or
root-canal instrument gives rise to inflammation of the
periodontal membrane, resulting in a lateral alveolar
abscess.
etiology ^ e diseases °f the dental pulp or pulp
chamber are responsible for the formation
of acute periodontitis, which later develops into the
acute alveolar abscess. This condition is always due to a
20 ORAL ABSCESSES
large invasion of virulent pyogenic bacteria. The causes
of the infection are the following :
Traumatic Injury of a Tooth. Injuries received by
falling or from a blow result in inflammation of the pulp.
The tooth may be fractured in the crown, exposing the
pulp to outside influences, or fractured in the root, ex-
posing it to the irritation caused by the fractured seg-
ments. The hard substances of the tooth are almost
always fractured if traumatic injury occurs, but occa-
sionally this does not take place and pulpitis is then
caused by injury to the tissue in the periapical regions.
The same condition occurs occasionally from the action
of orthodontia appliances, if force has been applied too
abruptly or if the teeth are moved too rapidly. The in-
terference with the circulation of the pulp and the lowered
resistance of the tissue invite hematogenous infection,
which results in suppuration of the tissues involved. In
this way acute periodontitis may result from primary in-
fection of the periapical region or by means of the pulp
if the injury occurred in the crown or side of the root. If
no therapeutic measures interfere, this will develop into
an acute alveolar abscess.
Infection from Adjacent Teeth. Suppuration often
spreads in the cancellous part of the alveolar process
causing acute infection of the periodontal membrane of
adjacent teeth. If the infection occurs in this manner
there is, however, less danger of involvement of the pulp
if it is in good condition. Neighboring teeth are fre-
quently involved to an extent which makes them so loose
that their condition seems hopeless, but the pulp resists
disease in these cases for a long period, and if the cause
is removed in time, the periodontal membrane, the fibres
of which have a wonderful resisting power to destruction,
returns to normal and the tooth regains its firmness in
the jaw. Occasionally, however, especially if drainage
of the abscess is delayed, the pulp becomes infected, re-
sulting in violent suppurating pulpitis.
Infections from Pus Pockets. Pus pockets between
the gum and the tooth are the result of the destruction
PLATE IV
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Figs. 5 and 6. — Abscess caused by trauma. The tip of the teeth having been
fractured.
Figs. 7 and 8. — Show the treatment of the case Fig. 5. The tooth was extracted
and replaced by a porcelain tooth, the root having been carved according to the
X-ray picture and attached to the next tooth.
Figs. 9, 10 and 11. — Show teeth with abscesses which have involved neighboring
teeth.
PLATE V
Fig. 12
Fig. 13
Fig. 14
Fig. 15
'/
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Figs. 12 and 13.— Apical abscesses due to pyorrhea pockets.
Figs. 14 and 15. — Abscesses from temporary teeth.
Figs. 16, 17, 18, and 19. — Abscesses due to decay of permanent teeth. In Figures
17 and 18 the decay has started under the filling.
ALVEOLAE ABSCESSES 21
of the alveolar process surrounding the tooth by pyor-
rhoea alveolaris or of septic descending periodontitis
caused by unclean, unsanitary, ill-fitting, eyiLcrowns and
bridges as well as irritating fillings. The infection pro-
gresses towards the apex, and when it reaches this part,
it destroys the blood supply of the pulp, producing septic
pulpitis and apical alveolar abscess, which usually dis-
charges through the pocket.
Thermal Shocks Conducted to the Pulp by Large
Metal Fillings cause hyperemia of the pulp, and if the
irritation is strong enough and continued, it will result
in pulpitis, death of the pulp, and alveolar abscess.
Crowned Teeth. Teeth, fitted with entire porcelain or
gold crowns, either for purposes of restoration of lost tis-
sue or for bridge work, are often believed to become
devitalized because contact with air and with the fluids
of the mouth is prevented. It is the author's opinion
that this is not the real cause. The latest discovery in
dental histology teaches us that the dentin metabolism
comes from the dental pulp, while only the metabolism
of the adult enamel is dependent on the fluids of the
mouth. The metabolism of the dentin of a tooth, which
is covered entirely by a crown, is therefore not interfered
with. From practical experience we know that a great
number of teeth with well-fitted, entire crowns, stay in
perfectly healthy condition, while the pulps of others
die. Two reasons can be attributed to the death of the
pulp in these cases. It may be due to thermal shock,
and from the grinding which is necessary to reduce the
contour of the tooth. The second reason is decay, which
has not been entirely removed, or, which is caused by ill-
fitting crowns.
Decay of Deciduous Teeth. Deciduous teeth are very
frequently neglected and their office is very vaguely
understood by most of the patients. The need of teeth
for the purpose of mastication is most important in chil-
dren because they require more nourishment than the
adult to build up their bodies and to resist childhood
illnesses. These should perform the function of masti-
22 OBAE ABSCESSES
cation until the permanent teeth erupt. Their other duty is
to hold the space open and prevent other teeth from mov-
ing forward until the permanent teeth take their place,
in order to prevent malocclusion. This function which
concerns normal occlusion of the permanent teeth is of
greatest importance and should stimulate us to keep these
temporary teeth in good condition so as to prevent their
pulps from becoming diseased. Acute abscesses form
easily on deciduous teeth if the pulp has been infected on
account of the physiological process of bone absorption
caused by the eruption of their successors — and this in-
fection is easily carried into deeper areas ; indeed, fistulas
to the face, cervical and submaxillary adenitis caused by
temporary teeth are very frequently found in children.
If the disease has progressed to the stage of an acute
abscess, the question arises whether these teeth should
be extracted with malocclusion as a consequence, or
whether they should be retained with the risk of infection
and its serious possibilities involving the development,
health, and even the life of the patient.
Decay of the Permanent Teeth. Caries of the dentin
if not stopped will progress in the dentinal tubules and
cause suppurative pulpitis before the cavity has reached
the pulp ; frequently, however, the cavity extends directly
into the pulp chamber. The same process of infection
develops from decay which has not been entirely re-
moved, before restoring the shape of the tooth by crown
or filling. The pulp may also be infected during the
therapeutic act of excavating a cavity. Even a pulp
exposure of minute size, almost always has suppurative
pulpitis as a consequence, unless it receives the careful
treatment which is called pulp-capping. This treatment
is advisable only in children's teeth, when the root canal
is wide open, which prevents strangulation during the
usually resulting period of hyperemia and mild inflam-
mation. In the cases where the decay forms an opening
into the pulp chamber, the disease very seldom affects
the periapical tissue. The exudates escape through this
outlet, and after the stage of inflammation, the pulp tis-
ALVEOLAE ABSCESSES 23
sue degenerates and frequently becomes hypertrophied,
which is a measure of protection. But if suppuration
occurs in a tooth with a filling, or where the natural open-
ing becomes stopped up by food or other substances, the
infectious matter is forced through the apical foramen
and forms an acute alveolar abscess.
Filling of Teeth with Infected Pulps. A tooth with an
open root canal and a pulp or part of a pulp in acute in-
flammatory condition should not be sealed up after the
first treatment has been applied, because in doing so we
would close the natural outlet through which the products
of fermentation and suppuration make their escape ; these
products would be forced through the apical foramen
and infect the periapical tissue. Such treatment is often
the result of acute periodontitis and acute alveolar
abscess.
Instrumentation. Instruments inserted into septic
root canals and root-canal instruments used for cleaning
of septic root canals act often as plungers forcing septic
material through the apical foramen into the periapical
tissue, inoculating directly the periodontal membrane and
the bone. Such instruments should therefore not be used
until the bacteria have been destroyed by antiseptic drugs.
Perforation of the floor of the pulp chamber in multi-
rooted teeth or piercing of the sides of a root with a root-
canal instrument may also be the cause of acute periodon-
titis and acute abscess.
Change in Oxygen Tension. Very often a tooth with a
diseased pulp is in a quiescent condition until the pulp
chamber is opened in order to gain access for treatment.
The patient will return the next day with all symptoms
of an acute periodontitis, having suffered a great deal of
pain during the night. This is due to a change in oxy-
gen tension, and the bacteria which developed only slowly
because of lack of oxygen now become extremely active
on account of the access of air, causing suppuration
which will progress through the apical foramen if the
tooth is sealed hermetically after the operation.
24 ORAL ABSCESSES
Acute Periodontitis. If bacteria or
THE DISEASE
products of suppuration escape through
the apical foramen, the periodontal
membrane is first attacked, causing acute apical
periodontitis. The swelling of the blood vessels
and the serous infiltration enlarges the perio-
dontal membrane and pushes the tooth for a short
distance out of the socket. This stage of hyperemia
is of short duration. Small particles of pus collect
near the apical foramen and soon spread between the
fibres of the periodontal membrane, which finally becomes
dissolved. A tooth extracted at this stage shows, if the
periodontal membrane adheres to the cementum, a red
appearance in the apical region. The apical periodon-
titis may spread over the whole surface of the root and is
then called acute total periodontitis.
Acute Alveolar Abscess. The inflammation now in-
volves the linea dura, the compact layer of bone lining the
alveolar socket. The bone is destroyed as suppuration
progresses and the cavity formed fills with pus. This
condition is called acute alveolar abscess.
Alveolar Parulis. The pus which stands more or less
under pressure proceeds in the cancellous part of the bone
and finds its way through some Haversian canals, pene-
trating the plate or dense cortical layer surrounding the
bone. This stage is sometimes reached in a short time, as
quickly as overnight, but at other times, especially in the
mandible, it takes four to five days for the pus to burrow
to the surface.
Subperiosteal Parulis. The Haversian canals are en-
larged and show in dissected skulls as small perforations
through which the pus escapes between the bone and
periosteum. The periosteum, like the periodontal mem-
brane, is tough and has a considerable resisting quality
to destruction. The pus therefore spreads under the
periosteum and often accumulates in large quantity,
sometimes causing a widely distributed oedematic swel-
ling of the face.
PLATE VI
Fig. 20
Fig. 21
Fig. 22
Fig. 23
Fig. 20. — Acute periodontitis.
Fig. 21. — Acute abscess.
Fig. 22. — Subperiostial parulis.
Fig. 23. — Sub-gingival parulis.
PL ATE VII
fcV Mi!
Spit
Pig. 24
Pig. 25
Fig. 26
Fig. 27
Fig. 28
Fig. 29
Fig. 30
Fig. 31
Fig. 24. — Sinus to the gum.
Fig. 25. — Sinus to the palate.
Fig. 26. — Sinus into the antrum.
Fig. 27. — Sinus into the nasal cavity.
Fig. 28. — Sinus to the cheek.
Fig. 29. — Sinus to the gum of the lower jaw.
Fig. 30. — Sinus to the skin of the lower jaw progressing along the outside of
the bone..
Fig. 31. — Sinus to the chin.
ALVEOLAE ABSCESSES 25
Subgingival Parulis. If the pus penetrates the perios-
teum and collects under the gum we speak of a subgingival
parulis. This stage is usually reached quickly, but, in
other cases, only after the subperiosteal parulis has lasted
for a long time. The rate depends on the resistance of
the periosteum. The swelling caused by the subgingival
parulis is more rounded, while the tumor of the subperios-
teal parulis is flat.
Sinus from Acute Alveolar Abscess into the Mouth.
If the pressure of the pus at this stage is not relieved by
surgical interference, the parulis will come to a point and
break through the gum, usually opposite the apex of the
root. This passage is called a sinus. The course of the
pus, however, is not always so direct. If the periosteum
is very resistant and if the pus accumulates in large quan-
tity, it may follow the laws of gravity and least resistance
and pierce the periosteum at a place quite remote from its
source. Sinuses occur almost always at the buccal or
labial part of the gum ; palatal sinuses are more rare and
usually are derived from the superior incisor teeth and
often lead some distance back into the mouth. Sinuses
are still more rare at the lingual gum of the lower teeth,
from which point the pus usually sinks downwards, in-
volving the tissues of the floor of the mouth.
Sinus from Acute Alveolar Abscess to the Face. If the
pus does not readily find an outlet through the gum, it
passes along fascias and muscles through submucous and
subcutaneous tissue until it reaches the skin of the face.
Here it collects in a similar way, as under the gum. It
causes a swelling and extends the skin to its limit before
it penetrates to the surface. (Fig. 30.) The course of the
sinus is often a long and tortuous one. Sinuses to the skin
occur especially from severe subperiosteal parulis and
are often caused by ignorant application of heat or poul-
tices to the outside of the face to relieve the pain. Sinus
to the face from the upper jaw is not very common. If
it occurs, the outlet usually is near the malar process, as
seen in Pig. 28. In the lower jaw the pus settles more fre-
quently into the tissue, breaking below the lower border
26 ORAL ABSCESSES
of the mandible. The pus has been found to follow the
course of muscles, finally finding an outlet on the neck or
chest. From the inside of the mouth and from the front
teeth the sinus, if it does not find any outlet to the gum,
leads almost always to the chin.
Sinus for Acute Alveolar Abscess to the Antrum of
Highmore. The roots of the superior bicuspids and mo-
lars sometimes extend into the antrum and are covered
only by the linea dura of the alveolar socket. Acute
abscesses of such teeth easily form a sinus into the antrum
following the course of least resistance. This condition,
of course, has acute inflammation of the antrum as its
sequel.
Sinus for Acute Alveolar Abscess to the Nasal Cavity.
If an abscess on a superior incisor does not find relief by
piercing the periosteum and gum, a sinus may be formed
to the inferior meatus of the nose.
Acute Osteomyelitis, or destruction of
tions ^ e cance H° us P ar t of the bone, occurs
always during the formation of an acute
apical alveolar abscess. The disease spreads easily in the
spongiosa of the bone and the neighboring teeth are usu-
ally affected and are considerably loosened. If radical
treatment is not undertaken at an early time, it may ter-
minate in pyemia or septicemia, with fatal result.
Ostitis, or death of the bone, cell by cell, may be caused
by prolonged subperiosteal parulis where the pus finds
no escape and destroys the outer plate of the bone. After
reaching the cancellous part of the bone it continues as
osteomyelitis, which is not different from the osteomye-
litis which starts from within.
Necrosis, or the death of bone en masse, is also fre-
quently the result of the acute alveolar abscess. Necrosis
may start from without by subperiosteal parulis where
the blood supply from the periosteum is cut off by the
pus which separates it from the bone. It may also start
from within the bone by osteomyelitis, as a result of alveo-
lar abscesses. It most always attacks the facial wall of
the bone and is not often very extensive. The necrosed
PLATE VIII
Fig. 32. — Skull showing large bone destruction due to abscesses.
PLATE IX
Fig. 33
Fig. 34
Fig. 33. — Ostitis of the hard palate caused by a tooth.
Fig. 34. — Osteomyelitis of the mandible caused by an
abscess on the lower first molar. The molar was ex-
tracted before the patient came under the author 's
observation.
ALVEOLAR ABSCESSES 27
part detaches from the healthy bone by absorption, the
dead part being called a sequestrum. Pus discharges
from a sequestrum in great amount until it is removed.
Resolution. Return to the normal will
TERMINATION not occur without early therapeutic
measures.
Scar Bone. Frequently we find conditions which have
become chronic and in which a certain amount of repair
has taken place, usually leaving but a comparatively small
area of lessened density immediately around the apices of
the roots. This new bone which fills in the area de-
stroyed during the stage of active suppuration, is very
much more dense than normal bone and appears in radio-
graphs as a lighter area of denser structure. This is
called scar bone. (Figure 37.)
Chronic Alveolar Abscess. After the pus has forced a
sinus through the soft tissue, the swelling slowly subsides,
and the flow of pus diminishes, the condition then passing
into the chronic stage. Inflammatory granulation tissue
is formed as an attempt of healing, which becomes en-
closed by fibrous tissue to prevent the involving of larger
areas.
Active Sinus. The suppuration, however, continues
and the discharge flows through the original sinus or finds
a new and shorter way, through the tissue which has been
rendered more or less immune during the stage of acute
inflammation. The walls of the sinus become fibrous
forming an adhesion between the abscess cavity and the
gum, or if the sinus leads to the face, between the abscess
cavity and the skin. The skin on these places appears,
therefore, fixed to the bone ; it is drawn towards the dis-
eased root apex in funnel fashion. This depression har-
bors the mouth of the sinus at its deepest point. Chronic
abscesses discharge products of suppuration in large or
small amount for months and years.
Closed Sinus. The mouth of the sinus of a chronic al-
veolar abscess sometimes becomes closed during a period
of inhibition of pus formation. This is especially apt to
occur if the discharge starts to drain through another
28 ORAL ABSCESSES
passage, such as is the case if an opening occurs into the
root canal when the process of decay breaks down the
tooth. This not only gives relief to the discharge from
the chronic abscess, but also relieves the primary source
of infection due to the death of the dental pulp. The
clinical picture of this condition is similar to the one of
the blind abscess, with the exception of a scar on the gum
or upon the face, formed by the closing of the mouth of
the sinus. This sort of chronic abscess without sinus is,
however, always a sequel to the acute abscess, while the
true blind abscess is formed in an entirely different way,
as we will see later.
Subacute Alveolar Abscesses. The closing of the sinus
by the process of granulation, during a period when sup-
puration is subdued or drained through a cavity via the
root canal, is usually not a stationary condition. The
cavity may become closed up by food debris, or the in-
fection may become active again. This happens par-
ticularly during a period of lowered resistance, as during
pregnancy, when all the effort of the system is directed
to other parts. In recurring cases, this secondary proc-
ess of suppuration is similar to the primary one. The
pus accumulates in the cancellous part of the bone, the
granulation tissue is destroyed, the sinus is reopened, or
a new outlet is formed to drain the discharge. The symp-
toms of the inflammation are, however, much less acute ;
oedematic infiltration seldom occurs because the tissue
has been rendered more or less immune by previous at-
tacks. A subacute attack usually quiets down after
a while and the condition continues as a chronic abscess
with sinus, or the sinus may even become closed again.
Such changes are liable to be repeated innumerable times
with irregular intervals of quietude.
Exostosis of the Root. The fibres of the periodontal
membrane have a great power of resistance and usually
they escape destruction if there is early and sufficient
drainage of the acute alveolar abscess. But if a chronic
periodontitis persists the cementoblasts are stimulated
by irritation from the chronic inflammation to deposit
PLATE X
Fig. 35
Fig. 36
Fig. 37
Figs. 35 and 36. — Photographs of teeth showing
exostosis of the z'oot.
Fig. 37. — Molar with scar bone.
PLATE XI
Fig. 38
Fig. 39
Fig. 38. — Central incisor with acute abscess showing large bone destruction.
Fig. 39. — Photograph of sub-gingival parulis caused by first bicuspid.
ALVEOLAE ABSCESSES 29
new cementum causing hypercementosis, which is usually
restricted to the place of disease, namely, the apex of the
root. This thickening or bulging of the root is called
exostosis and histologically shows an accumulation of
lamellae of cementum containing an abundance of cement
corpuscles and Haversian canals.
Necrosis of the Root. In cases where the parulis has
been severe, and the formation of a sinus retarded, as is
almost always the case in prolonged subperiosteal parulis,
we usually get destruction of the apical part of the perio-
dontal membrane. The cement of the tooth is then ex-
posed and the denuded area shows a rough surface from
contact with pus, and if the chronic alveolar abscess lasts
a long time the root becomes discolored, having first a
greenish, and later an almost black appearance. Absorp-
tion of tooth substance takes place at the apex which
shows a ragged appearance if the tooth is extracted. The
hard substances of the tooth have not the power to divide
and expel diseased fragments, as in bone, but we will have
to consider this absorption as a process of necrosis. The
whole tooth represents the sequestrum, dead bone, cut off
entirely from the blood supply which nourished it, from
the inside through the pulp and from the outside through
the periodontal membrane. In long standing chronic
conditions, where the whole periodontal membrane has
been destroyed, the tooth has the true appearance of dead
tissue, the cementum of the whole root having a greenish
black appearance.
diagnosis Acute Periodontitis. Local Symptoms:
If the periodontal membrane becomes in-
fected from a septic pulp, the tooth becomes very tender,
the beating of the pulse can be felt by the patient, and
the tooth protrudes out of the socket. The pain is felt
principally at night. Cold and hot food have no influ-
ence, but mastication causes great pain because the tooth
is, as the patient expresses it, too long.
Clinical signs: The tooth which causes the trouble is
sensitive or even extremely painful on percussion ; often
it is also more or less loose.
30 ORAL ABSCESSES
Radiographic examination: The radiograph at this
stage of the disease shows a dark shadow of the thickened
periodontal membrane.
Acute Alveolar Abscess. Local symptoms: The stage
of acute periodontitis is usually of very short duration.
If relief does not come at once the pus will collect and
form an acute abscess. The symptoms seem similar to
the ones of acute periodontitis. Pain is very persistent
and increases in severity ; it is constant, deep and throb-
bing, sometimes excruciating. Hyperemia of the adja-
cent tissue sometimes is so marked as to loosen the neigh-
boring teeth. Oedematic swelling of the neighboring
parts occurs.
General symptoms: There is usually a marked rise in
temperature ; fever up to 104° F. is not uncommon. Chills
may precede the fever and general malaise accompanies
the disease.
Clinical signs: If an alveolar abscess has formed, the
neighboring teeth usually become tender and it is difficult
sometimes to find out which tooth has started the trouble.
As the abscess starts from a diseased pulp, we can diag-
nose the case by testing the vitality of the pulp. A
discolored tooth or a tooth with a large filling should be
suspected. But to find out definitely we can apply the ice
test ; vital teeth give a reaction. The galvanic or the high
frequency current can also be used. The teeth are dried
and rendered isolated by putting a piece of cellu-
loid or rubber-dam between their contact points ; the gal-
vanic current is then applied. If the galvanic current is
used, one electrode is held in the hand and the other, sur-
rounded by cotton saturated with normal salt solution, is
applied first to a healthy tooth. The patient notes the
sensation the current produces in the healthy tooth. The
teeth that are suspected are then examined in the same
manner and if a tooth gives no reaction it can be con-
cluded that its pulp is diseased. If a high frequency
apparatus is at hand, we let a small spark jump at the
suspected tooth, dried and isolated in the manner just
ALVEOLAE ABSCESSES 31
described. Pain caused signifies that the pulp is
healthy, as a diseased pulp gives no such reaction.
Radiographic examination : Radiographs usually show
distinct areas of lessened density where the bone has been
destroyed by the process of suppuration. However, in-
filtration of the cancellous part of the bone is sometimes
visible on account of the fluoroscopic properties of the
pus. The apex of the diseased tooth usually occupies the
centre of the area. In the upper jaw where the apices are
close to the surface, so that the pus may easily find an out-
let and accumulate under the periosteum and gum without
destroying a large amount of bone, sometimes, even de-
stroying no bone at all, we may find no area of lessened
density at all, the bone appearing perfectly normal.
Alveolar Parulis. Local symptoms : After the pus has
penetrated the bone, it accumulates under the periosteum,
causing a flat swelling. In appearance the gum is highly
inflamed and red, and the pain becomes very intense.
Great relief usually occurs as soon as the pus penetrates
the periosteum, when the high pressure is relieved and
the pus collects under the gum, producing a ball-like
swelling. If the abscess is on the palatal side, this part
usually presents an enormous swelling, while parulis oc-
curring on the buccal and labial sides, which usually is the
case, is accompanied by an extensive infiltration of the
surrounding tissue. The oedema sometimes partly or
even entirely closes the eye if the trouble is in the upper
jaw, while in the lower jaw, the floor of the mouth, lower
part of the cheek and neck are principally infiltrated.
The localization of this oedema is characteristic of the
location of the diseased tooth. From a molar or bicuspid
in the upper jaw where the upper part of the cheek is
involved the corner of the mouth is drawn upwards, while
the swelling from the lower parts draws the mouth down-
ward. If an abscess occurs at the front teeth the re-
spective lip is swollen and protruding. The submaxillary
and submental glands for the front teeth are almost al-
ways enlarged. When the pus is about to come to the
surface we note that a yellowish spot appears. This is
32 ORAL ABSCESSES
called pointing of the abscess. The abscess, however,
does not always point near the tooth that is the principal
cause. The pus sometimes travels under the periosteum
for quite a distance and may penetrate at a convenient
point quite remote from the place where it leaves the bone.
A sinus discharging from the mucous membrane of the
mouth or skin is not always connected with and caused by
an abscessed tooth. Impacted teeth, sequestra, diseased
salivary or lacrimal glands sometimes cause sinuses, but
it is not difficult to ascertain the cause.
Differential diagnosis : The lesions which may be mis-
taken for parulis are those of epulis, g umm a and cyst.
A true parulis resulting from a diseased pulp may also be
mistaken for a parulis caused by an impacted, partially
or entirely unerupted tooth, or by an abscess caused by
pyorrhoea without involvement of the pulp. There is
usually little difficulty in making the right diagnosis.
Benign epulis is of slow development without any pain-
ful symptoms; sarcoma in the mouth is very modified,
and the only malignant epulis we have to consider is car-
cinoma. Patients with carcinoma usually have a
neglected mouth, and the bad condition of the teeth and
the swelling of the glands, frequently gives the clinical
picture of parulis. The generalizing character of the
carcinoma and the anamnesis of the disease helps in diag-
nosis, and in a questionable case the histopathological
picture of a piece excised for examination will decisively
answer the question. Gummata are slow in growth ; the
history and manifestations at other parts as well as the
Wasserman test will give the desired information. Cysts
are of slow growth and show no symptoms of inflamma-
tion; an exploratory puncture gives escape to a clear,
yellowish, odorless fluid. The diagnosis of parulis by
impacted, unerupted teeth and pyorrhoea will be de-
scribed in another place. That sinuses may also derive
from glands, necrosed bone and impacted or unerupted
teeth has already been mentioned, while oedema of the
face also occurs from the salivary glands, if their ducts
are obstructed or if infection involves them.
ALVEOLAE ABSCESSES 33
General symptoms : Parulis formation is almost always
accompanied by general malaise ; fever reaches its highest
mark during the stage of subperiosteal parulis, and leu-
cocytosis is very marked. The patient gets worn out
from pain and loss of sleep, but as soon as the pus finds
an outlet, the health improves rapidly.
Clinical signs: The same that has been said for acute
alveolar abscess and acute periodontitis is true for
parulis. In addition we feel by digital examination a fluc-
tuation which is especially marked in subgingival parulis.
Pressing upon the swelling increases the pain consider-
ably. If the abscess points or if a sinus has already been
formed, there is little difficulty in making a diagnosis.
Radiographic Examination: The radiograph, usually
shows the amount of bony destruction and is employed to
find which tooth is the causative factor, but in certain
cases no areas of decreased density are visible. This is
especially the case when the apices of the teeth are close
to the outer surface, as in the upper central incisors. In
extreme cases where films canot be put into the mouth and
in cases with sinuses leading to the face, large extraoral
pictures should be taken, as the cause is often far removed
from the mouth of the sinus.
Chronic Alveolar Abscess. Local symptoms: The pa-
tient who always remembers and presents a history of the
acute process almost always complains of subacute
attacks, where the gum swells up slightly and pus empties
into the mouth, and there is usually a sense of pressure
and soreness of touch and lameness of the tooth.
General symptoms: The submaxillary and submental
lymph glands are usually slightly enlarged. Complica-
tions such as tonsilitis, pharyngitis, and gastric and intes-
tinal infections may occur due to pus which is discharged
into the mouth, but infectious arthritis, endocarditis,
toxemia, and other diseases may also set in, and these can
be considered as general symptoms calling our attention
to the causative factor. These complications will be con-
sidered in a special chapter.
34 ORAL ABSCESSES
Clinical signs: A sinus is almost always found on the
gum, or face; if it has closed, there is a visible scar.
Whether or not we have a healed condition, the extent
of the lesion can only be ascertained, if the sinus is closed,
by radiographic examination.
Kadiographic diagnosis: The radiograph reveals the
chronic abscess by an area of lessened density, it also
discloses if there is exostosis or necrosis of the root apex,
which is an important factor in the determination of the
method of treatment.
2. PROLIFERATING PERIODONTITIS AND
ITS SEQUELS
In the last decades, teeth have been devitalized for
several reasons without realizing the danger of such pro-
ceedings. Dentists knew only of the mechanical diffi-
culties encountered in extirpating pulps and filling of
root canals. The result of imperfect root-canal work
was, however, not known until radiography was developed
for dental use. When the so-called areas of lessened
density were shown in radiographs at the apices of devi-
talized teeth, little attention was paid to them ; they were
considered a neglible quantity because the patient had
no alarming symptoms of disturbance and often not even
the slightest discomfort, and it was considered good den-
tistry to retain such teeth rather than lose an important
organ of mastication. But since the pathology and bac-
teriology of these symptomless lesions has been studied
more carefully and since the important discovery of focal
infection, we have come to realize the grave fact that such
septic conditions about the teeth may be more dangerous
than the violent acute conditions, principally on account
of the fact that their deceiving nature undermines the
patient's general health and causes, if conditions are
right, secondary infections in other parts of the body, the
nature of which we shall study in a special chapter.
definition Proliferating periodontitis and its sequel,
the granuloma, are changes in which new
formation of tissue from the periodontal membrane is the
important feature; suppuration plays a secondary role
PLATE XI!
Fig. 40
Fig. 41
Fig. 42
Fig. 40. — Lateral granuloma.
Fig. 41. — Apical granuloma.
Fig. 42. — Interradial granuloma.
PLATE XIII
Fig. 43
Fig. 44
Fig. 45
Fig. 46
Fig. 41
Fig. 48
Fig. 49
Fig. 50
Figs. 43, 44 and 45. — Granulomata caused by decay of the tooth. There is free eonimuxii-
eation from the root canal into the mouth.
Figs. 46, 47 and 48. — Granulomata caused by incomplete pulp extirpation.
Figs. 49 and 50. — Granulomata due to broken instruments left in root canal.
ALVEOLAE ABSCESSES 35
and does not involve the surrounding tissues. It is
characteristic that the condition starts without the pa-
tient's knowledge and without symptoms of inflammation.
varieties Apical Granuloma. The most common
seat of chronic periodontitis and its sequel
and is the periapical region, at the outlet of the root
canal from which the disease starts.
Lateral Granuloma. Sometimes teeth have accessory
foramina as high as the middle of the root. These may
become a source of trouble if the root canal has to be
treated. Perforations by root canal instruments at the
side of a root are, however, more frequently the cause of
lateral abscesses.
Interradial Granuloma. The floor of the pulp cham-
ber is sometimes penetrated in multirooted teeth by burrs
or root-canal instruments, seldom by decay, causing
granulomata or chronic abscesses between the roots. It
it almost impossible to treat these interradial abscesses on
account of anatomical difficulties.
etiology Proliferating periodontitis is primarily
caused as a protective reaction of the tis-
sue against irritating excretions from the root canal, such
as pus bacteria and toxins, or against injudicious appli-
cation of irritating drugs, such as formaldehyde, sul-
phuric acid and other medicaments used during root canal
treatment. Ulrich believes that haematogenous infection
is the explanation for all apical abscesses with the prob-
able exception of teeth which have been capped following
caries. I fully believe that haematogenous infection is
the cause in certain cases, especially those of infection or
reinfection after medicinal treatment, leaving an area of
lowered resistance in the periapical region, such as a peri-
odontal membrane or a denuded or necrosed apex ; but it
seems to me very improbable that all or even a large
amount of the cases should be due to this cause. The histo-
pathological picture speaks so plainly for an irritating
and infective source from the root canal, the fact that I
discovered blind abscesses in persons in whom no other
foci could be found after careful search, and the fact that
the streptococcus, which is almost always found in the
36 ORAL ABSCESSES
dentinal tubules, is also the bacteria which most fre-
quently inhabits the granuloma, seem to me simpler and
more probable reasons, especially where we have such an
obvious source as the root canal from which infection may
be continued.
The microorganisms which sooner or later invade the
granuloma are never very large in number. Their viru-
lence has usually been decreased by unfavorable
conditions, such as lack of oxygen and lack of nutrition
where most of the organic matter has been removed, and
the blood supply is cut off. The result is a symptomless
or chronic inflammation walled off by the fibrous sack
enclosing the granuloma, containing lymphocytes and
leucocytes.
Proliferating periodontitis can be caused whether the
pulp chamber is open or closed and results from the fol-
lowing conditions :
Decay of the Tooth. If caries has destroyed the enamel
and dentin, so that there is an opening into the pulp
chamber, the products of decomposition have a chance to
escape into the mouth. This prevents them from pene-
trating through the apical foramen thereby infecting the
deeper tissues surrounding the root of the tooth. While
the disease of the pulp progresses slowly towards the
apex, protective measures are taken by the surrounding
tissue against the poisonous substances of fermentation
and decomposition. The periodontal membrane prolif-
erates and forms a granuloma, and harbors in its center
fluids of decomposition and absorption.
Incomplete Pulp Extirpation. The extirpation of the
dental pulp is an operation which should not be under-
taken except after serious consideration of its necessity
and most careful prognostic study of the case. Our
present knowledge of the alveolar abscess should warn
us of the possible consequences of such an operation and
teach us to make the greatest effort to save the pulp by
prophylactic as well as by therapeutic means. A tooth
should be radiographed to diagnose if a root is straight
ALVEOLAE ABSCESSES 37
or bent and to ascertain the size, length, direction, and
branching of the root canals. Some teeth are bent to
such an extent, or their root canals are so obstructed by
secondary deposits of dentin or pulp stones, that we are
not able to remove the pulp entirely, no matter how
skilled the operator and how much time is spent. We
stand therefore before an impossible task. Among these
cases belong many teeth which have moved forward dur-
ing childhood on account of loss of an anterior tooth and
these teeth have been moved for large distances for ortho-
dontic purposes. This may result in bent roots. Most
of the permanent teeth erupt long before the calcification
of their roots is finished, and if force is applied at the
stage of root formation, it will move the calcified part and
bend the uncalcified apical region.
If parts of diseased pulp are left to remain in the roots,
in branches of the root canal, apical part or accessory
foramina, this organic matter will, after the tooth has
been filled, stimulate proliferation of the periodontal
membrane and cause a granuloma. If a healthy tooth has
to be devitalized to give attachment to bridge work or to
remove pulp stones which cause neuralgia, the remaining
pulp particles are often infected by careless treatment,
or by bacteria supplied by the blood stream. The con-
dition then is the same as if the pulp had been infected
in the first place.
Inefficient Root-canal Treatment. Root canals which
have not been sufficiently treated previous to the insertion
of the root filling, are liable to cause the same result as
just described. After all the organic matter has been
removed by mechanical and chemical means, we must still
consider the bacteria which are growing in the micro-
scopic dentinal tubules and the accessory apical foramina.
These should be destroyed by antiseptics [ionic treatment
with iodine was found specially helpful by the writer] or
they will become the source of infection, which is espe-
cially favored by incomplete or poorly condensed root
canal fillings. The same condition occurs if root canal
38 ORAL ABSCESSES
instruments are broken and left in the canals. They ob-
struct the way to the apical part which is left in a septic
and unfilled condition.
Inefficient Root-canal Fillings. A root-canal filling
which is perfect should seal the apical foramen hermet-
ically so that no infection can pass from the tooth into the
surrounding tissues. Scrupulous asepsis is also of great-
est importance, not only during root-canal treatment, but
also during root-canal filling. If the filling leaves a space
at the apex containing organic matter, moisture, or air,
or if the filling material is of such a nature that it shrinks,
irritates or relies on antiseptic properties, which wear
out with time, it gives chance for bacterial growth.
Invasion of Bacteria. It may also be caused by inva-
sion of bacteria, reaching the pulp by way of the dentinal
tubules, which can be easily entered if the enamel has
been removed. If this is the case several factors must
be reckoned with. Danger of infection is certain if the
tooth is young and if it must be greatly reduced to fit a
crown, because the dentinal tubules in this case are larger,
less calcified, and nearer the pulp. If these little wounds
(sections through the dentinal tubules) are not carefully
protected during the preparation of the tooth and during
the time which elapses until the crown is set, bacteria
which abound in the mouth will invade these dentinal
tubules, multiply, and progress even after the crown has
been set, until they reach the pulp and cause suppurative
pulpitis.
Death of Pulp without Access of Air. It is a well-
known fact that the pulp of a tooth may become diseased
because the irritating action of certain fillings forms
progressive decay under a filling or a gold or porcelain
jacket crown. It is usually due to lack of oxygen that
such cases proceed in a chronic manner and often large
apical granulomata are formed without symptoms of
disease. If the pulp of such teeth is opened, it often
results in a violent subacute attack due to the change in
the oxygen tension.
PLATE XIV
Fig. 51
Fig. 52
Fig. 53
Fig. 54
Fig. 55
Fig. 56
Fig. 57
Fig. 58
Fig. 59
Fig. 60
Fig. 61
Fig. 62
Figs. 51, 52, 53, 54, 55 and 56. — Granulomata caused by inefficient root canal fillings.
Figs. 57, 58 and 59. — Granulomata from decay under fillings without access of air.
Figs. 60, 61 and 62. — Granulomata occurring on crowned teeth.
Fig. 63. — Skull of Italian showing bony destruction caused by an apical granu-
loma on the left upper second bicuspid.
ALVEOLAR ABSCESSES 39
Haematogenous Infection. Granulomata usually are
due to direct entrance of the disease through the root
canal but may also be caused as a secondary manifestation
due to bacteremia, that is, the presence of the microorgan-
isms in the blood. Any devitalized tooth has around its
apex a place of lowered resistance with lowered oxygen
tension due to the destruction of nerve and blood supply
of the apex and contiguous bone areas, a destruction
which may have been caused by the use of caustic and
irritating drugs for root canal medication or the destruc-
tive process of suppuration.
Proliferating Periodontitis. The poison-
TH^Dis^ASE ous P r0( lucts °f bacterial decomposition
and fermentation reach the peripheral
tissues of the tooth and stimulate protective new growth.
If the tooth is extracted at this stage we find a marked
thickening of slightly reddish character at the apical
region.
Granuloma. The proliferation usually goes on until
the new growth has reached the size of a pea. Larger
granulomata are, however, not uncommon; they may
reach the size of a robin's egg. A fibrous layer surrounds
the lesion, which is very thick in the beginning and firmly
attached to the healthy part of the periodontal membrane.
The extracted tooth usually carries with it such a granu-
loma, or so-called abscess sack. Later, when the
granuloma reaches larger sizes, it becomes thinner and is
often destroyed by fatty degeneration, which decreases
its resisting power to suppuration. In the center we find
the seat of chronic inflammation, harboring often a small
amount of pus or other products of degeneration and
absorption, which are usually taken up by the lymph or
capillary system. Destruction of bone depends upon the
progress of the chronic inflammation. In the upper jaw,
where the apices of the roots are close to the facial sur-
face of the bone, the alveolar plate is almost always de-
stroyed; in the lower jaw it is a most infrequent occur-
rence to find the thick cortical layers of the mandible
40 ORAL ABSCESSES
involved. If the tooth is extracted at this stage the
abscess will usually remain in the jaw and has to be re-
moved by careful curettage.
The microorganisms which inhabit the granuloma have
to struggle for their existence in this tissue which is
formed by lymphocytes, leucocytes, and fibroblasts ; pus,
therefore, is formed only in very minute quantity.
Subacute Attacks. At one time or another the suppu-
ration may become more active and destroy the fibrous
tissue of the granuloma. The causes of such acute bac-
terial activity may be lowered resistance of the body and
wearing out of the cells, whose function is to destroy for-
eign bodies. It may come from a change in oxygen ten-
sion, a thing with which almost every dentist is familiar,
namely, an acute attack after opening into the pulp
chamber of the tooth which gives the air a chance to enter.
It also may be caused by haematogenous infection, the
invasion of another kind of bacteria, causing a mixed
infection. In these subacute attacks the pus usually bur-
rows a sinus to the gum, the tissues react, not, however,
very actively, as in the acute abscess, because partial im-
munization has taken place in the tissues surrounding
the chronic condition. After the pus has evacuated, the
signs of inflammation usually disappear without treat-
ment and the sinus closes up. This, however, does not in-
dicate that the abscess has now completely healed, but
only signifies that pus formation has decreased and granu-
lation predominates, which may be reversed at any favor-
able time.
Exostosis of the Root. If the fibers of the granuloma
persist for a long time, so that the metabolism of the
cementum is not interfered with, the constant irritation
from the chronic inflammation stimulates the activity of
the cementoblasts which results in new formation of
cementum, which we call exostosis of the root. This usu-
ally results in a bulbous form at the apex which makes
extraction extremely difficult.
Necrosis of the Root. If the apical part of the peri-
odontal membrane has been destroyed, the nutrient
PLATE XVI
Fig. 64. — Skull showing bony destruction due to a granuloma caused by a
left upper bicuspid, bearing a gold crown.
PLATE XVI I
1 • .1 N
Fig. 65
Fig. 66
Fig. 67
i v X
Fig. 68
Fig. 69
Fig. 70
Fig. 71
Fig. 72
Fig. 73
Fig. 74
Fig. 75
Figs. 65, 66, 67, 68, 69 and 70. — Radiographs of teeth with granulomata showing marked
exostosis of the roots.
Figs. 71, 72 and 73. — Radiographs of teeth with necrosed apices due to granulomata.
Figs. 74 and 75. — Radiographs of teeth showing large osteomyelitic area.
ALVEOLAE ABSCESSES 41
supply of the tooth is doubly cut off. The cementum,
which at this stage contains numerous accessory apical
foramina and Haversian canals, soon becomes infected
and necrosed. The condition then is that of bone with
the periosteum raised and no blood supply from within.
Here such areas become separated and are expelled as
sequestra. In the tooth this cannot take place, and we
must consider the whole organ as the sequestrum which
is retained by the remaining periodontal membrane at
the cervical part of the root. In some cases, chronic in-
flammation of the remaining periodontal membrane sets
in, causing necrosis of the entire root, which then has a
greenish appearance, a condition which is often spoken
of as " gangrene of the root."
Resolution. The condition of chronic
yfoivi " abscess may be considered the termination
for the larger percentage of the cases ; it
may continue for years. Resolution never occurs with-
out treatment.
Chronic Osteomyelitis. The bone destruction, occur-
ring as a result of the inflammatory granulation, involves
an osteomyelitis even at its early stages. Fortunately,
nature in most cases prevents an extensive involvement
by circumscribing the lesion with a protective layer of
fibrous tissue enclosing the seat of inflammation, as will
be shown later in microscopic pictures. Osteomyelitis
produced by such conditions is much less severe than in
other parts of the body and frequently symptomless.
Cysts. There has been much writing by German scien-
tists tracing root cysts of larger or smaller dimensions
back to epitheliated granulomata. Dependorf * has devo-
ted a large amount of time to the study of the development
of such cysts. He says that not all epitheliated granulo-
mata will become cysts, and that cyst formation depends
on a partial and concentric degeneration of the inner part
of the granuloma first of all ; secondly, dependent on epi-
thelium which is able to develop and proliferate, and
thirdly, due to the interference with the blood supply, due
* See Bibliography.
42 ORAL ABSCESSES
to the chronic inflammatory conditions. The growth of
the cyst is dependent upon chronic inflammatory condi-
tions, which are enclosed in the lumen and which cause
degeneration of the larger or smaller parts of the central
core. The inner surface becomes lined with epithelium
and the cyst may develop to almost any dimension. It is
the author's opinion that cysts may form from epitheliated
granulomata, although judging from the number of
granulomata which do not form cysts, we may draw the
conclusion that such a formation is decidedly rare-
Proliferating Periodontitis. Local symp-
D I AG N OS IS toms: It is characteristic of the prolifer-
ating periodontitis that it occurs and grows without caus-
ing any local symptoms. The tooth is not elongated
because the growth occurs at the expense of the bone.
Sometimes, however, the patient has a sense of pressure
over the tooth and often the pulsation of the blood is felt
in the vascular granulation tissue around the apex, espe-
cially after violent exercise.
General symptoms: In the beginning stage there is
rarely any systemic involvement, although the writer
has procured streptococci cultures from many apices of
teeth which in radiographs showed only the slightest in-
dication of proliferating periodontitis. In a hospital
case of endocarditis such a small area prevented entire
recovery and the removal was followed by rapid improve-
ment.
Clinical signs : There are no signs which would indicate
proliferating periodontitis.
Radiographic examination: With the intraoral radio-
graph we can diagnose the early stages of periodontitis.
The dark line around the contour of the root which repre-
sents the periodontal membrane is thickened at the apex,
and in later stages we find distinct areas of lessened den-
sity which indicate loss of bone taken up by the prolifera-
tion of the periodontal membrane.
Granuloma. Local symptoms: The granuloma very
frequently gives no symptoms; a sense of pressure and
lameness of the tooth may be noticed occasionally.
ALVEOLAR ABSCESSES 43
General symptoms: At this stage we frequently find
complications due to the absorption of toxins and bac-
teria. Malaise, a tired feeling, and inability to do a day's
work is a frequent indication of an intoxication which
may come from oral lesions besides all the other complica-
tions mentioned in the previous chapter. These con-
ditions should be recognized and inquired into and looked
at as a reason for careful diagnosis of the mouth by means
of radiographs.
Clinical signs : As clinical signs are absent at this stage,
it is of greatest importance to rely on radiographic
diagnosis.
Radiographic examination: The granuloma shows in
the radiograph as a circumscribed area of decreased den-
sity and is easily recognized when present at the apex of a
devitalized tooth. While there is usually little doubt
about the location of an abscess on a single-rooted tooth,
it is often more difficult to make a correct diagnosis on
multirooted teeth, especially the upper ones. The upper
first bicuspids should be radiographed from a bucco-
mesial direction, while two radiographs are necessary to
show distinctly the condition of the two buccal roots and
the palatal root. The first is taken about perpendicular
to the buccal roots, the other perpendicular to the palatal
root.
Subacute Attacks. Local symptoms: If suppuration
becomes more active in the granuloma, the patient often
feels a grumbling and lameness of the tooth which may
disappear after several days. In other instances, the
wall of the granuloma is broken down, resulting in a regu-
lar subacute attack. The patient then experiences the
symptoms of the acute abscess, pain, redness, fever, and
swelling. The tissue, however, has been rendered more
or less immune, and the symptoms of inflammation are
more modified, sometimes hardly noticeable, at other
times extreme. The condition, however, will usually pass
through the stages of parulis until a sinus occurs on the
gum to give exit to the accumulating pus.
44 OKAL ABSCESSES
General symptoms: The general symptoms depend
upon how severe and acute the attack is. There may be
none at all, or they may be equal to an acute process pass-
ing through the stages of parulis.
Clinical signs : When the gum over the abscess is found
to be swollen and in subacute condition, the guilty tooth
is usually easily located. When the pulp has been dead
for a long time, electric tests will give negative results,
while in acute conditions there is usually some doubt,
especially if the nerve fibres of the pulp have not been
entirely destroyed. The patient usually tells upon ques-
tioning a history of previous attacks or treatment of the
tooth.
Radiographic examination : Radiographs will reveal an
area of lessened density on a devitalized and partly filled
root. This is the important feature of differentiation
between an acute attack, where the pulp has been diseased
only recently and where there is no evidence of previous
root-canal work.
PLATE XVIII
Fig. 76
Fig. 77
Fig. 78
Fig. 79
Fig.
Fig. 81
Fig. 82
Fig. 83
Figs. 76 and 77. — Radiographs of teeth showing small areas of lessened density indicating
periodontitis.
Figs. 79, 80 and 81. — Radiographs of teeth showing large areas of lessened density
indicating grannlomata.
Figs. 82 and 83. — Radiographs of teeth with subacute abscesses. The root canals of the
teeth have been partly filled, indicating chronic disease of long standing.
PLATE XIX
Fig. 84
Fig. 85
Fig. 86
Fig. 87
Fig. 88
Fig. 89
Fig. 90
Fig. 91
Figs. 84, 85 and 86. — Badiographs of teeth showing dark areas about their necks representing pus
pockets caused by mechanical injury.
Figs. 87, 88, 89 and 90. — Badiographs of teeth showing dark areas indicating pus pockets at the
alveolar border.
Fig. 91. — Badiograph showing a lower incisor with an apical abscess caused by pus pockets, mesial
as well as distal. The tooth is vital.
CHAPTER IV
PATHOLOGICAL DEVELOPMENT AND DIAG-
NOSIS OF ALVEOLAR ABSCESSES DUE
TO OTHER CAUSES THAN THE DIS-
EASE OF THE DENTAL PULP
We have noted in the preceding chapter that the largest
percentage of the oral abscesses are due to diseases of the
dental pulp. However, other forms of abscesses in and
around the alveolar process occur which are due to dif-
ferent causes. These sometimes give almost the same
symptoms as some of the already described types and it is
important to distinguish them because their treatment
is so widely different.
According to the etiological factor we can distinguish
alveolar abscesses due to diseases of the gum and alveolar
abscesses due to difficult eruption, impaction and un-
erupted teeth.
1. Alveolar Abscesses due to Diseases of the Gum.
etiology Injury of the Gum. The gum is occasion-
ally injured by the use of a toothpick or a
bristle of a toothbrush which may become lodged between
the gingival margin and the tooth. An inflammation may
occur if the wound had been infected, involving not only
the gum but frequently the cervical part of the periodon-
tal membrane and the periosteum, resulting in a marginal
periodonditis with subgingival parulis formation. Other
causes are poor fillings, either projecting into the gum or
lacking in contour, faulty bands and gold crowns, which
project into the gum instead of being closely fitted around
the neck of the tooth. After the cement by which they
are fastened has washed away, these places will harbor
46 ORAL ABSCESSES
contaminated food and be the seat of fermentation and
later suppuration. A similar condition occurs under
fixed bridges, which can be properly cleaned neither by
patient nor dentist, the gum becomes inflamed, and after
the removal of the bridge we often discover an extensive
ulcerated area. The vile odor which is released after
removing such appliances speaks for itself and makes
superfluous further comment as to its unsanitary and
disease breeding properties.
Pus Pockets. Pus pockets such as are characteristic
of pyorrhoea alveolaris sometimes become closed up.
This, or any other reason which prevents the pus from
escaping at the cervical margin, causes accumulation of
pus or abscess formation.
In abscesses caused by injury of the gum,
the disease ^ e ^ n ^ ec ^ on i- s usually superficial. The
pus is seldom formed under the perios-
teum, but accumulates between the periosteum and gum
in the submucosa of the mucous membrane. A red swel-
ling is formed at the gingival margin, a small parulis,
which heals spontaneously after it breaks or after an in-
cision is made. In more deep-seated cases the ligamen-
tum circulare and periodontal membrane may become
infiltrated. The Haversian canals then become
infected, causing destruction of the cervical part of the
alveolar process. If pus pockets such as occur in py-
orrhoea alveolaris or other forms of marginal periodon-
titis are the cause of the abscess, the accumulation of pus
is usually more deeply seated than in the case of injury
of the gum. On account of the closure of the natural
outlet at the cervical margin the pus will invade the alve-
olar process and find its way to the surface of the gum.
The process usually passes through the stages of subperi-
osteal and subgingival parulis, which, however, gives no
very severe symptoms as the tissues have been pretty
well immunized by the long existing chronic inflamma-
tion. This destructive process may, however, be halted
any time if the outlet at the gum margin is reopened, when
the disease continues in its former chronic form.
ALVEOLAR ABSCESSES 47
diagnosis Local an d general symptoms: The pa-
tient experiences about the same discom-
fort as in the parulis formation already described, only
perhaps in a modified way, because the tissue has almost
always been more or less immunized by a preexisting and
causative chronic condition, as in pyorrhoea, or because
the abscess is very superficial and little destruction is
necessary to form an outlet for the discharge.
Clinical signs: Upon examination, a tumor-like swel-
ling is seen nearer the gum margin than in true alveolar
abscess and parulis. The surrounding tissues are less
involved. There is usually no history of pulp disease;
the tooth may be vital or devitalized. The patient often
remembers that the gum had been injured or there may be
indication of pyorrhoea from the general condition of the
mouth. The differential diagnosis may be established by
the radiograph.
Radiographic examination: Very often we are left in
doubt, whether we have to deal with a true alveolar ab-
scess, caused by a diseased pulp, or whether the condition
is wholly periodontal. Especially doubtful cases are those
where the tooth has a gold crown or large fillings, as both
are conditions which indicate the involvement of the pulp.
The importance of knowing whether the pulp is involved
or not is evident if we consider the first and most impor-
tant therapeutic measure, the removal of the cause. A
radiograph will help a great deal in diagnosis; if there
is no area of lessened density at the apex of the tooth, we
know that the abscess is not formed from a dead pulp,
and often we see a large dark area at the neck of the tooth
indicating marginal destruction of the alveolar process
due to a gingival abscess or parulis.
2. Alveolar Abscess Due to Difficult Eruption, Im-
paction or Unerupted Teeth.
etiology Difficult eruption and partial impaction:
The lower third molar is the tooth which
most frequently is impacted, but also the upper third
molar is often in irregular position. The reason is that the
48 OKAL ABSCESSES
third molars are the last teeth to take their places in the
dental area, and as the jaw is often too short (a result of
civilization) to accommodate all the teeth, the third molar
becomes locked under the bulging of the crown of the
second molar. In the lower jaw there is an additional
obstacle, the ascending ramus, the terminal boundary of
the part of the mandible that accommodates the teeth.
The cuspid teeth are the next in the series which are most
likely to be impacted, the reason being that the tooth in
abnormal conditions does not appear until long after the
lateral incisors and the first bicuspids are in place. While
the lower third molars and cuspids are most likely to be
impacted, any tooth in the lower as well as the upper jaw
may become impacted if the space which they are to oc-
cupy is taken up by other teeth, or if the malposition has
been assumed at an early period during the development
of the tooth germ.
Inflammation may start before the tooth has pierced
the gum, from the irritation caused by biting on the tissue
overlying the occlusal surface of the tooth. In most
cases, however, the infection occurs after the gum has
been pierced by the erupting cusps and may be due to
food and fluids of the mouth entering through this wound.
The soft tissue does not adhere to the enamel of the crown,
as it does to the cementum on the root by means of the
periodontal membrane and ligamentum circulare, and
therefore foreign material is free to pass deep into the
tissue around, slowly erupting teeth both impacted and
normal. In other cases the infection is due more to irri-
tation of the gum, which is crowded over the occlusal sur-
face during mastication and becomes bruised by the teeth
of the opposite jaw. In such conditions inflammation
again sets in and is maintained.
Unerupted Impacted Teeth. In some cases teeth grow
in an entirely horizontal or even downward direction
and are so interlocked, that it is impossible for them to
come to the surface. Such teeth may lie dormant for
several years but at any time may suddenly become asso-
ciated with active pathological conditions, when exert-
ing pressure on the tissue towards which they grow. It
PLATE XX
Fig. 92
Fig. 93
Fig. 94
Fig. 95
Fig. 96
Fig. 97
Fig. 98
Figs. 92, 93, 94 and 95. — Radiograph showing dark areas indicating abscesses caused by impacted
but partly erupted wisdom teeth. In Fig. 93 the pulp has been involved and periodontitis caused at
the apex.
Fig. 96, 97 and 98. — Radiographs of unerupted molars showing dark areas indicating abscesses.
PLATE XXI
Fig. 99
Fig. 100
Fig. 101
Fig. 102
Fig. 103
Fig. 104
Fig. 105
^
Fig. 106
Fig. 107
Fig. 99. — Radiograph showing impacted second and third molar.
Fig. 100. — Kadiograph shows impacted second molar which had been broken off. The third molar
is partly erupted and prevents the second molar from coming up.
Figs. 101 and 102.— Radiographs show impacted temporary molars.
Figs. 103, 104, 105, 106, 107 and 108. — Radiographs show other impactions causing more or less troubh
ALVEOLAE ABSCESSES 49
seems to be a physio-pathological law that any abnormal
pressure in the body causes resorption of the part most
easily dissolved. This in turn forms a place of lowered
resistance and is liable to infection. Infection may occur
from a blind abscess on a neighboring tooth or through
the blood.
After the infection has taken place the
the: di<5e-a«sf P rocess °f inflammation may take on a
chronic course. This is especially the
case if there is an outlet for the pus through the gingival
opening made by the erupting tooth. This outlet, how-
ever, is rarely adequate, pus is accumulated and when
under pressure is forced deeper into the bone as well as
into the soft tissue. The inflammation then extends to
the adjoining parts, involving the fauces, mucous mem-
brane and muscles about the ramus. A pharyngitis often
sets in, trismus of the muscles of mastication is of common
occurrence, and deglutition becomes difficult. The abscess
usually passes through the stages of alveolar parulis, and
the trismus becomes so marked that the patient is unable
to open his mouth. At this time usually there is a sinus
formed, the pus evacuates and the movements of the jaw
become less constrained. If no surgical procedure res-
tores the condition to normal, the patient may have recur-
rent attacks of the same character at frequent intervals.
If the impacted tooth causes absorption of another tooth,
this is sometimes carried so far as to involve its pulp.
Such conditions cause severe neuralgic pains, and if the
pulp becomes infected severe alveolar abscesses.
diagnosis Local symptoms: The local symptoms
are usually well marked but not character-
istic or distinctive of the cause. There is intense pain,
sometimes almost unbearable, referred to the ear, eye,
forehead, or opposite jaw. If the condition is due to a
third molar, the patient complains of a sore throat and
inability to swallow ; often the mouth can be opened but
very little. There may be extreme swelling of the face on
the affected side ; at other times the external swelling is
less marked, all the infiltration being on the inside of the
mouth.
50 ORAL ABSCESSES
General symptoms: There is usually fever up to 104°
F., general malaise, and the patient often presents serious
symptoms, especially if severe pain has caused continual
loss of sleep.
Clinical signs: If a third molar is the cause of the
trouble, examination of the mouth is often very difficult.
.Ankylosis should be excluded, which is a disease of the
mandibular joints and is usually not accompanied by
severe pain or temperature. Pus can frequently be
pressed from the swelling and often a white cusp is seen
sticking out from the inflamed gum. If we have to do
with an unerupted tooth the radiograph will be the only
means by which a positive diagnosis can be made.
Radiographic diagnosis: The radiograph is a most
valuable means of detecting the real cause of the trouble
and is furthermore a valuable aid in determining the
mode of operation. Partly erupted impacted teeth can
be taken on small, intraoral films, but unerupted teeth
should be taken on large extraoral films or plates, because
there is a possibility of malposition. Third molars have
been found in the ramus as far up as the mandibular notch
and as low down as the angle of the ramus, places which
cannot be reached with intraoral pictures. For impacted
upper teeth in the anterior region of the mouth, a large
film placed between the teeth with an exposure from well
above the head will give in most cases good results. For
impacted cuspids in the lower jaw the rays should be
directed somewhat from underneath, as these teeth are
often situated as low as the lower border of the mandible.
Stereoscopic radiographs would be more desirable in
many cases, as an ordinary radiograph is flat and does not
give the exact location of the tooth. For example, you
cannot tell whether the impacted cuspid in Figure 107 is
external or internal to the other teeth ; however, the tak-
ing of stereo-radiographs requires a great deal of skill and
necessitates the use of special apparatus. The stereo-
radiographic technique is still in the process of develop-
ment ; good results, however, can be obtained, and in diffi-
cult cases these pictures, which give a perspective view,
are of great value.
PLATE XXII
Fig. 109. — EadiograpMe plate showing an impacted upper third molar in the pos-
terior wall of the antrum. Symptoms covering a period of one year prior to its
discovery: Periodical unilateral headaches, with ent're absence of nu, but bad
taste in the mouth every morning. There is a sinus opening just back of the
second molar. The tooth discharges half a dram of pus in twenty-four hours.
Reproduced by courtesy of Dr. Gibbons. Radiograph by Dr. A. TV. George.
PLATE XXIII
Fig. 110. — Radiographic plate by which an unerupted lower third molar was
discovered at the angle of the jaw. Note the large cyst.
CHAPTER V
PATHOLOGICAL DEVELOPMENT AND DIAG-
NOSIS OF ABSCESSES OF THE TONGUE
AND SALIVARY GLANDS AND DUCTS
Thus far abscesses occurring in and about the mandi-
bular and maxillary bones have been described; these
are by far the most common ones. The tongue and sali-
vary glands are, however, occasionally the seat of abscess
conditions.
1. ABSCESSES OF THE TONGUE
The tongue is comparatively rare as the seat of inflam-
mation and infection, but if abscesses of the tongue occur,
we have a condition which may bear grave results.
Diffuse infiltration frequently occurs and often spreads
to the posterior part of the tongue, and, on account of its
increased size, causing difficulty in breathing which often
can be relieved only by tracheotomy.
. „-.„.-, Three varieties of tongue abscesses shall
VAR5ET8ES u j .i j °
be described.
1. The simple abscess of the tongue.
2. The phlegmonous abscess of the tongue.
3. The tubercular abscess of the tongue.
1. Tide Simple Abscess of the Tongue.
^^.«. ~~w Circumscribed abscess formation of the
ETIOLOGY , », -, ,
tongue is very oiten due to injury or en-
trance into the tongue of a foreign body, such as a fish
bone, during mastication. More often, however, there
are sharp, broken-down teeth which cause the primary
52 ORAL ABSCESSES
injury, and if such teeth are abscessed, discharging pus
from sinus or pocket, the wound at once becomes infected.
~. .*.._.. The infection usually assumes a more or
CLINICAL ii- x
course chronic appearance, causing a tumor-
like thickening at the infected part. If no
therapeutic interference occurs, the abscess may break,
but more frequently it will end in the phlegmonous type.
„..„ MAeie Local symptoms: The simple abscess of the
tongue causes more or less local discomfort.
The place where the lesion occurs is extremely tender to
touch, causing difficulty in eating and speaking.
Clinical signs: If the tongue is palpitated, one can
feel distinctly a hard swelling in the substance of the lin-
gual muscle ; the tongue is usually slightly enlarged, which
causes indentations on its sides because it is crowded
into the interdental spaces. In the first stages it may be
hard to differentiate this lesion from gummata and tu-
mors, but later when the signs of inflammation are more
marked and when there is discharge of pus, there is
usually no doubt about the diagnosis. An exploratory
incision or puncture may be made ; this should be deep
enough to reach the seat of trouble and will, if pus is
drawn, verify the diagnosis.
2. The Phlegmonous Abscess of the Tongue.
etiology Injuries due to infected foreign bodies, as
already described, and injury from carious
teeth surrounded by septic conditions very often take on a
more acute form than the one just described. Progressive
alveolar abscesses may also cause phlegmonous abscesses
of the tongue, if their course involves the deeper, posterior
lingual muscles.
In the phlegmonous abscess of the tongue, a purulent
or fibrino-purulent infiltration, causes a diffuse swelling.
The size of the tongue increases rapidly, the anterior
part is pushed forward and no longer has room between
the teeth. The soft palate and the mould are pushed
PLATE XXIV
Fig. 11 L
Fig. 112
Fig. 111. — Simple abscess of the tongue.
Fig. 112. — Tubercular abscess of the tongue.
TONGUE, SALIVARY GLANDS AND DUCTS
upward and the epiglottis downward into the larynx. In
severe cases, swallowing is impossible, causing the saliva
to flow out of the month, and even breathing is rendered
difficult. If the epiglottis becomes enlarged by oedematic
swelling, tracheotomy may be necessary, but more often
the disease is less grave, pus discharge occurring sooner
or being facilitated by early surgical interference, which
is possible if the center of the infection can be located.
diagnosis -k° ca l symptoms: The patient complains
of the tongue being swollen and too large, of
difficulties in swallowing and breathing. If the tongue
comes in contact with hard food, it causes a great deal of
pain and the saliva often flows from the mouth.
General symptoms: The pulse is generally increased
in rate, the temperature rises, and may reach the high
marks of septic conditions.
Clinical signs: Examination of the mouth is usually
impossible on account of the muscular trismus and the
sensitiveness of the tongue to touch. The cervical and
submaxillary lymph glands are involved at an early stage
of the disease and are extremely tender to touch. Later
there is marked angina, causing the patient to bend the
head forwards on the chest, which somewhat facilitates
the breathing through the nose.
3. Tubercular Abscesses of the Tongue.
Tubercular abscesses of the tongue may be
primary or secondary infections. Tubercu-
lar bacilli are found in mouths of healthy persons and
primary tubercular infections may therefore occasionally
occur at an injured part of the tongue. This, however,
is said to be a rare condition. Secondary infection is
more common, slight wounds on the tongue caused by
carious teeth or sharp artificial dental prostheses are
easily infected by the bacilli of the saliva and expecto-
rated material.
54 ORAL ABSCESSES
Tubercular abscesses of the tongue occur
course mostly on the tip, the sides, and the mucous
membrane reflection between tongue and
floor of the mouth. When first seen they are very small
nodules of yellow. A clear infiltration develops, becom-
ing gradually thick and increasingly visible. The lesion
usually extends deep into the substance of the tongue,
developing a fissure or an ulcer. Tuberculosis fissures are
very short, often stellate or branching, and are generally
single. The margin is indicated, causing an elevation of
the edges which are liable to caseate, forming a foul and
ragged surface. The tuberculosis ulcer is the more ag-
gressive form of the fissures and presents edges which are
a little thrown up, but not undermined, and are usually
sharp in outline. The secretion is small in quantity and is
of grayish yellow color. Pale red flesh warts, and here
and there small gray knots may be visible.
diagnosis -k° ca l symptoms: Tuberculosis of the
tongue is seldom noticed early by the pa-
tient, as the lesions first are very small and produce no
symptoms; later they become tender and pain becomes
pronounced.
General symptoms: The patient may suffer from
pulmonary tuberculosis or lupus of the face. However,
he may be perfectly well, the lesion of the tongue being a
primary infection.
Clinical signs: The appearance of the tubercular le-
sions of the tongue has already been described. Bacteri-
ological examination of the sputum and excretions is
important for making a sure diagnosis. A negative
Wasserman test excludes gummata, but carcinoma of the
tongue is often difficult to differentiate from tuberculosis
with certainty.
II. ABSCESSES OF THE SALIVARY GLANDS AND DUCTS
Abscesses of the salivary glands and ducts may be
divided into primary and secondary infections. The sub-
lingual and submaxillary glands are most frequently
TONGUE, SALIVAKY GLANDS AND DUCTS 55
involved by primary infection, the disease entering
through the salivary ducts. The parotid gland is more
often the seat of secondary infection, the bacteria entering
the gland through the circulation. Salivary calculi are
also to be considered. They may either cause or be
caused by infection.
etiology Primary Infection. The primary infection
of the salivary glands may be due to a con-
tinuous septic process, such as necrosis or ostitis of the
mandible, or alveolar abscesses from lower teeth. The
pus burrows through the tissue, following the path of
least resistance, and often reaches the submaxillary gland,
causing Ludwig's angina, a disease which, however, is not
restricted to the submaxillary gland, but attacks the
muscles of the floor of the mouth and neck. More com-
monly, however, the infection enters by way of the ducts,
originating from pus discharged by sinuses of abscessed
teeth, pyorrhoea pockets, or other forms of oral sepsis.
Secondary Infections. Haematogenous infection of
the parotid gland is known to occur occasionally after
infectious diseases, such as scarlet fever, typhoid fever,
measles, meningitis, appendicitis, chalecystitis, and acute
abscesses. Any focus causing secondary infection seems
therefore to cause disease of the parotid gland and in very
rare cases of the other salivary glands.
Salivary calculi. Calculi are more commonly found
in the sublingual and submaxillary ducts and glands and
are of rather rare occurrence in the parotid gland. The
question whether the calculus is primary or secondary to
the infection has not yet been entirely settled. The be-
lievers in the primary origin of the calculi think that the
infection is due to its irritating presence. The men who
believe in the infectious origin of the calculi founded
their idea upon microscopic investigations. They think
that calcium phosphate or carbonate is deposited in con-
centric fashion around organic exudates as epithelial cells,
leucocytes, bacterial emboli, or mucin, or that precipita-
tion of the salts may be due to direct bacterial activity.
56 ORAL ABSCESSES
Whether primary or secondary, the calculus plays an
important role in the infections of the salivary glands,
and cases which will not yield to treatment and which
recur often harbor in their ducts or glandular substance
calculi which are a source of irritation and reinfection.
Stones may be found in Stenson's or Wharton's duct
or in the body of the glands. They most frequently occur
in Wharton's duct and the sublingual gland.
clinical ^ ^ e disease starts from the mouth, the
course infection often does not progress farther
than a short distance through the duct. The
duct walls become swollen, accumulation of products of
infection occurs, and calculi may be formed. Either con-
dition obstructs the flow of saliva. During the time of
glandular activity, at meal times, and if tasty food is seen,
a tumor like a swelling will occur at the site of the obstruc-
tion, causing more or less pain until the duct is suffi-
ciently dilated to allow excretion. Abscess formation
usually occurs, discharging either through the duct or
forming a new sinus to the mouth.
In ascending duct infections, the process spreads
through the accessory ducts, finally involving the glands
and interlobular tissue. In the parotid gland the abscess
may point towards the face, the mouth, the external
auditory canal, or may extend upwards into zygomatic
fossa. In the submaxillary and sublingual gland, the
abscess will break either to the mouth or through the floor
of the mouth to the skin of the submandibular region or
the neck. The salivary fistula occuring in this fashion
is extremely difficult to heal and often can be closed only
by radical surgical procedures.
In the secondary infections the bacteria are carried
to the glands in the blood stream and the abscess starts
in a blood vessel and progresses to the adjacent parts.
diagnosis ^ oca ^ symptoms: The patient usually com-
plains of marked swelling in the region of
the gland which may frequently change its size. If the
duct is affected, the swelling becomes especially marked
during glandular activity. If the abscess and stone lie
PLATE XXV
Fro. 113
Fig. 114
Fig. 113. — Swelling under the tongue on the left side.
Fig. 114. — Eadiograph showing salivary calculus causing
the condition indicated in the picture above.
TONGUE, SALIVARY GLANDS AND DUCTS 57
in the substance of the gland, the swelling is usually of a
more inflammatory nature. At times, due to some un-
known factor, probably renewed bacterial activity, there
are sudden reactions and the patient complains of intense
pain. Such attacks occur at irregular intervals and
cause a large amount of suffering.
Clinical signs: During the attacks, we usually find
the characteristic symptoms of acute abscess formation
with more or less swelling of the neighboring tissue, which
is not alone due to the accumulation of saliva in the gland,
but to oedematic infiltration, especially so in streptococcic
infection. The corresponding lymph glands are en-
larged, soft, and tender in acute conditions, hard and
solid in cases of longer standing, which have passed more
or less into a chronic stage. There may be discharge of
sero-purulent material through the inflamed orifice of
the duct or a fistular bidigital palpitation and careful
exploration of the duct with a fine silver probe may reveal
a stone, but if the trouble is harbored in the gland itself,
this method of diagnosis will be found unsuccessful.
Radiographic examination: Radiographic diagnosis
is of greatest importance in glandular affections. Extra-
oral, as well as intraoral films, are of greatest value ; they
not only tell us whether there are calculous obstructions,
but also give us their location, a helpful aid for the opera-
ting procedure. For sublingual calculi and stones in
Wharton's duct, a large film may be placed between the
patient's teeth, the head being bent in an extreme back-
ward position so that the rays can be directed from the
submandibular region vertically on the film. Submaxil-
lary calculi may be taken by the same method or by plac-
ing a film or plate under the mandible, more towards the
diseased side, reaching farther back than the angle of
the jaw. The picture is taken from above with the mouth
wide open.
The treatment of the abscesses of the tongue and sali-
vary glands will be found in the general chapter of treat-
ment of abscesses.
CHAPTER VI
BACTERIOLOGY OF ORAL ABSCESSES
importance The careful scientific study of the bacteria
OF the found in oral abscesses requires a great
ogkJaiTstudy ^ ea * °^ ^ me an( ^" P a ti ence on account of
the many varieties which normally in-
habit the mouth. These may become the direct cause of
abscesses or inhabit the lesions accidentally, living upon
the products of decomposition. It is especially the culti-
vation and isolation of the anaerobic bacteria which ren-
ders the investigations difficult. No one has been able to
demonstrate that one type of bacteria causes one typical
form of dental abscess and it has generally been accepted
that any one of the pyogenic bacteria may cause abscesses
in the mouth. It has been observed and demonstrated
that it is not so much the variety of the bacteria which
determines the course of the disease but that it depends
upon the number, vitality, and virulence of the invading
organisms and, moreover, upon the abundance or scarcity,
as quality of the media ; such as organic matter in the root
canal, whether an abscess will develop as an acute or
chronic condition. But also secondary invasions of bac-
teria and the different combinations of mixed infections
determine slight changes in the pathological picture, such
as the production of gases, odor of the exudates, and color
of the pus. The variations, however, are so manifold and
the bacterial causation so accidental that a study of the
bacteriology of the dental abscesses was found a fruitless
task, and furthermore, an undertaking of small practical
importance, until lately, when the process of focal infec-
tion was discovered. The bacteriological question, then,
becomes at once one of first importance, if we look at the
PLATE XXVI
Fig. 115
Fig. 116
Fig. 115. — Kadiograph, showing granuloma from which the smear
below was made.
Fig. 116. — Microphotograph of a smear taken from abscess seen in
Fig. 115. Note the two chains of streptococci and groups of
staphylococci.
Specimen prepared by author; stained with methylen blue.
BACTERIOLOGY 59
unfilled root canal containing remnants of diseased pulp,
or the acute and chronic dental abscess and the granuloma
as a focus from which not only bacteria may become ab-
sorbed and distributed to other parts of the body, but
where protein poisons (see Chapter I) may be generated
and taken up by the circulation, thus causing general
toxemia or local disease of certain delicate tissues. We
have already seen that the protein poisons which are
formed during infection differ, among other things,
according to the species of the invading bacteria and it
is therefore desirable to know which of the bacteria en-
countered in these lesions produce secondary disease,
either by direct infection or by the formation of patho-
genic poisons which become absorbed and may cause auto-
intoxication similar to that of intestinal origin.
The study of the bacteria of dental abscesses, which was
first undertaken to find the etiological factor of the local
lesion, has now become of new importance, but from a
different reason, namely : that of investigating the effect
of pathogenic or saprophytic bacterial life in a certain
part of the body called a focus such as a root canal, ab-
scesses, or granuloma upon other parts of the body.
From Acute Abscesses. Wash the mucous
methods OF membrane thoroughly with a mild anti-
bacterial. se Ptic mouth wash (the spray may be
specimen used). Apply iodine on the gum, and as
soon as the incision is made, introduce a
sterile pipette deeply into the abscess to collect the pus.
The pipette is then sealed and sent to the laboratory.
Instead of the pipette a sterile syringe may be used.
From Chronic Abscesses and Granulomata of Teeth
which are Extracted. First of all remove the tartar or
other deposits from the tooth and spray the mouth and
teeth with an antiseptic solution, then scrub the mucous
membrane in the region of the offending tooth as care-
fully as possible. Pack sterile gauze on either side of
the tooth to exclude saliva, dry the mucous membrane
with gauze and compressed air, and saturate tooth and
gum with tincture of iodine. The ligamentum circulare
60 ORAL ABSCESSES
is then cut free from the tooth, after which iodine is em-
ployed a second time to destroy bacteria which always
lodge immediately under the mucous membrane. Extract
the tooth and place the forceps holding the tooth on a
piece of sterile gauze, apex of the tooth uppermost. Cu-
rette with a sterile instrument the alveolar socket from
which the tooth was extracted to remove the granulations,
and smear some of the removed tissue over the slant sur-
face of a culture tube. Two plantings may be made, one
for aerobic, the other for anaerobic cultures. Imme-
diately after the operation clip off the apex of the removed
tooth with sterile Rongeur forceps and drop it into an-
other culture tube. It is advisable to let it drop into the
water of condensation and smear it afterwards over the
surface of the media.
From Chronic Abscesses and Granulomata in Apiec-
tomy. As this operation is performed under the princi-
ples of asepsis no further precautions need to be taken.
The amputated root is at once dropped into a culture
tube held and opened by an assistant. Other cultures are
made from the removed granulation tissue.
Immediate Microscopic Examination.
bacte > rial )F ^ us gained from acute abscesses may be
STUDY examined directly under the microscope
by making the usual cover glass prepara-
tions. Also, from chronic condition may we secure cover
glass preparations by smearing the end of the root or a
piece of infectious granulation tissue over the cover glass.
Inoculation of Artificial Culture Media. Specimens
gained from acute or chronic abscesses by the methods
already described may be inoculated on artificial media
for special identification, and pure cultures may be made
of the bacteria which perhaps have already been recog-
nized in a general way in a cover glass preparation.
The cultures should be grown on various media and
both under aerobic and anaerobic conditions. Anaerobic
bacteria are especially hard to cultivate and it is of great-
est importance to inoculate the media without loss of time
so as not to endanger the vitality of the anaerobes.
BACTEKIOLOGY 61
Inoculation of Animals. The animals which are or-
dinarily used for inoculation are rabbits, guinea pigs, and
mice. Rabbits and guinea pigs are usually inoculated by
the subcutaneous or intraperitoneal method. A very
simple method in rabbits is the intravenous inoculation.
The tip of the ear is held by thumb and fingers of the left
hand, while the right manipulates the syringe. The
needle is pushed through the skin on the external surface
into the posterior vein which runs along the margin of
the ear. By the exercise of care and gentleness the ani-
mal may thus be inoculated without being anaesthetized
or even held by an assistant, especially if the fur between
its ears is stroked for a short time.
Animal inoculation is used to find out whether the bac-
teria in question are pyogenic or not. The animal usually
dies of the same disease that was produced in man. If
bacteria taken from a questionable focus produce in the
animal the same disease the patient suffers from, we can
conclude that we have found the organism which causes
the systemic disease.
Schreier* (1893) gives in his article the
the bacter- reSTinL s °f n i ne examined cases. In five
iological cases he took his material from the in-
study OF flamed periosteum, involved by an
^!^ A _ B " alveolar abscess, and in four cases from
a subgingival parulis. In three cases he
found only the diplococcus pneumoniae, in three cases
only the staphylococcus pyogenes albus, in the remaining
three cases he found both the diplococcus and the staphy-
lococcus present. He concludes from this that periostitis
(acute abscess) is due to infection by pus producing bac-
teria and especially to the diplococcus pneumoniae, which,
he adds, was also found in two abscesses due to caries
examined by Nannotti* ; Miller and Sieberth contest that
Schreier 's diplococcus is identical with the diplococcus
pneumoniae.
* See Bibliography.
62
ORAL ABSCESSES
SCHREIER 1893
DlPLOC.
PNEUMONIAE
Staphylococ. p. albus
Case 1.
+
Case 2.
+
Case 3.
+
Case 4.
+
Case 5.
+
Case 6.
+
Case 7.
+
+
Case 8.
+
+
Case 9.
+
+
Nannotti 1891
Case 1.
+
Case 2.
+
Miller* (1894) examined two cases of alveolar abscesses
and found in one two different varieties, in the other one
variety of a coccus.
Arkovy* (1898) examined four cases of periostitis
alveolaris chronica diffusa (chronic alveolar abscess, as a
sequel to the acute alveolar abscess) and found in one case
the bacillus gangraenae pulpae alone, in two cases to-
gether with the staphylococcus pyogenes aureus and
albus, and in another case there was no growth on the
culture plates.
Aekovy 1898
Bac. gangeenae pulpae
Staphylococ. p.
AUREUS
Staphylococ. p.
ALBUS
Case 1.
+
Case 2.
+
+
+
Case 3.
+
+
+
Case 4.
Goadby* (1903) pronounces the cocci as the bacteria
found in almost all the alveolar abscesses. He examined
twenty cases and very often finds a staphylococcus de-
* See Bibliography.
BACTEEIOLOGY 63
scribed under the name of staphylococcus viscosus. The
staphylococcus he finds in half of the cases, the staphy-
lococcus aureus in three cases, and sometimes also the mi-
crococcus tetragenus. In two cases with fetid pus he
discovered the bacterium coli and in four cases of diffuse
alveolar abscesses he grew besides the staphylococcus al-
bus a constant anaerobic bacterium which formed long
threads and produced much gas. When stained with
methylen blue it took the color irregularly. He was not
able to get a pure culture. This is the first mention of
the discovery of an obligate anaerobic microorganism in a
pathological process of dental origin.
Partsch* (1904) reports a well observed case of 'tuber-
culosis of the jaws near the apex of a root and for the
first time described the microscopic picture of a tuber-
cular periodontitis.
Monier* (1904), a Frenchman, was the first to make
a study of the anaerobic bacteria in connection with his
bacteriological study of six alveolar abscesses. In Case
VI, a boy of the age of nine, who was suffering with
" osteo-periostite" (alveolar parulis) caused by a carious
left lower first molar he found a micrococcus and a bacil-
lus by microscopic examination and gram stain of the
lightly fetid pus. On the surface of agar cultures fine
gray colonies grew, which he identified as streptococci.
In the depth of the agar cultures where there is exclusion
of air he found longitudinal and round granular colonies
which he identified as the bacillus Ramosus. In Case
VII, a woman at the hopital * Saint- Antoine, the follow-
ing diagnosis was made: Osteo-periostite, absces bien
collects, overture (large alveolar parulis with sinus) on
the left superior or lateral incisor. Microscopic exami-
nation of the very liquid, fetid, grayish pus shows leuco-
cytes in the stage of destruction scarcely stained. He
found gram positive micrococci of small number and a
gram positive bacillus; besides these a gram negative
bacillus. Aerobic cultures yielded a scarce growth of
streptococci and in anaerobic cultures he found the bacil-
* See Bibliography.
64 OEAL ABSCESSES
lus f ragilis in large quantity and the bacillus Ramosus in
small numbers. Case VIII lie saw in consultation at the
"hopital de VInstitut Pasteur" with " Osteo-periostite du
maxillaire inferieur avec oedeme considerable (alve-
olar parulis, with large oedematic swelling) caused by a
right lower bicuspid. The abscess broke during the ex-
amination ; he found streptococci, staphylococci albi, and
numerous anaerobic bacteria, among them the bacillus
Ramosus. As the material could not be collected with
the necessary precautions, the study of this case was not
further followed up. Case IX was a patient who suf-
fered from an enormous swelling in the submaxillary
region, extending over the whole cheek, suborbital region
and subhyoid region caused by a tooth in the left lower
jaw. There was intense trismus, the skin was covered
with an erysipelitic reddish color. During the night
there was delirium, the swelling became fluctuating in
the submaxillary region and an opening was made with
thermocautery. Examination of the horribly fetid
pus showed partly destroyed leucocytes and a veritable
mixture of microorganisms. He found bacilli of fine and
short form often encapsulated, V-shaped bacilli, cocci in
chains, and a rare bacillus occurring in filaments. Cul-
tures yielded a streptococcus, bacillus Fragilis and Ramo-
sus which were most abundant; the other unnamed bac-
teria could also be obtained in pure culture. Case X,
23atient with ll absces volumineux de la voute palatine"
(palatal alveolar parulis) from a right upper incisor
tooth. The pus which was mixed with black blood showed
on microscopic examination only fragments of leucocytes
which hardly stained. The enormous quantity of bac-
teria consisted of diplococci, curved bacilli, often of the
shape of a V, which were gram positive, a short and fine
bacillus and a rare bacillus of very large form, both gram
negative. Inoculation on the surface of agar yielded no
growth whatever, but the anaerobic bacteria were very
abundant. He isolated the bacillus Fragilis, the curved
bacillus which was identified as bacillus Ramosus and the
See Bibliography.
BACTERIOLOGY
65
diplococcus which was found to be the coccus foetidus.
The large bacillus which was seen in small quantity grew
in large white, coarse cultures and was found to be a
bacteria that had not yet been described. This case is
interesting because a large amount of pus was produced
in this abscess without the presence of any aerobic bac-
teria but was due to four anaerobes. Case XI, a young
girl at the "hopital des Enfants-Malades," had suffered
with a great deal of pain from a left inferior first molar
for three months. The abscess broke first into the mouth
and later formed a sinus to the outside of the face. Micro-
scopic examination of the abundant pus showed well
stained leucocytes, and gram positive curved bacilli some-
times occurring in chains of two. Surface cultures
stayed sterile but in the middle, deprived of air, he ob-
tained cultures of the bacillus Ramosus, which was the
only microorganism found.
Aerobes
Anaerobes
1904
Strepto-
cocci
Strepto-
cocci
Diplococci
foetidus
B. Bamosus
B. Fragilis
Undescribed
bacilli
Case VI
+
+
Case VII
+
+
+
Case VIII
+
Case IX
+
+
+
+
Case X
+
+
+
+
+
Case XI
+
Vincent* (1905) writes in his article "La symoiose
fusospirillaire ses di verses determinations pathologique"
that he found seven times in seventeen cases of "suppu-
ration dentaire sous periostique" (subperiosteal parulis)
the association of fuso spirillae, once as a pure infection.
Mayerhofer* (1909) thinks the streptococci are the pri-
mary cause of " periostitis dentalis" (alveolar parulis).
In examining twenty-two cases of pus gained from un-
opened abscesses and twenty-eight cases of pus taken
* See Bibliography.
66
OBAL ABSCESSES
from sinuses on the gum, he found thirty times strepto-
cocci in pure culture, fourteen times streptococci and
bacilli, twice streptococci and staphylococci, once staphy-
lococci and bacilli, twice stapylococci alone, and once ba-
cilli alone. He thinks that staphylococci are perhaps
present only on account of secondary infection of media
prepared by streptococci and that the bacilli are etiolog-
ically without importance. Apparently he made no
attempts to grow anaerobes.
Mayeehofee 1909
Steeptococci
Staphylococci
Bacilli
30 cases
+
14 cases
+
+
2 cases
+
+
1 ease
+
+
2 cases
+
1 case
+
+
Idman* (1913), of the Pathological Institute of the
Helsingfors University (Finland), has written the most
complete and thorough bacteriological study of the acute
alveolar abscess published in the "Arbeiten aus dem
Pathologischen Institut der Universitat Helsingfors/'
His publication is based upon most careful and painstak-
ing research work, each analysis representing four weeks
of steady, tedious work.
He described his method of obtaining and inoculating
the culture, the preparation of the fourteen different
media used and the staining methods for coverslip exam-
ination.
He examined eight cases of undoubted dental origin
which had not undergone therapeutic treatment at any
time, contamination from the fluids of the mouth was
carefully excluded, and by careful technique, the pus was
aspirated by a Pravaz syringe and emptied into a sterile
test tube. The different media were inoculated as soon
as possible, never later than an hour was allowed to elapse,
* See Bibliography.
BACTEEIOLOGY 67
so as not to endanger the vitality of the anaerobes. The
oxygen tolerating bacteria were grown on agar (Titer 15-
18), blood agar and glucose agar (Titer 15-18). The ob-
ligate anaerobes were gained by shake cultures in series
of 10-12 tubes of Agar (Titer 2-3), 10-12 tubes of glucose
agar (Titer 15-18), 10-12 tubes of ascites glucose agar
(Titer ca. 8) and 10-12 tubes of Indigo-glucose agar.
Some of the isolated bacteria he tested as to their viru-
lence by subcutaneous inoculation into rabbits or guinea
pigs, using 5-10 c.c. of a young bouillon culture. To study
the microorganisms gained in these cultures he used
gram stain, the polychrom-methylen-blue-tannin method,
and Ziehl's carbofuchsin stain.
Case A. A woman thirty years of age, with subgingival
parulis, caused by a suppurating pulpitis. The thick yel-
low pus was of neutral reaction and odorless. Microscopic
examination and cultivation showed an oxygen tolerant
streptococcus and bacillus mesentericus and obligate
anaerobes identified as a streptococcus, Bacillus Ramosus
and Idman's bacillus No. 13.
Case B. A nineteen year old peasant boy presented a
subgingival parulis from a putrescent pulp. The pus
which showed a slightly alkaline reaction, was odorless.
The bacteria he isolated were the oxygen tolerant strep-
tococcus, staphylococcus albus, micrococcus tetragenus
and the elongated cocci Idman No. 6, the obligate ana-
erobes, bacillus ramosus. Case C was a patient presenting
a subperiostal parulis from a first molar. The yellowish
white pus was of extremely fetid odor and slightly alka-
line. Cultivation and isolation yielded the oxygen tole-
rant corynebacterium pseudodiphtheriticum and the
obligate anaerobic streptococcus anaerobicus, bacillus
ramosus, bacillus thetoides, bacillus perfringens. Case
D, a young man, age seventeen, with subperiosteal pa-
rulis. Microscopic examination of the exudates showed
an abundant bacterial flora which were cultivated and
identified as follows: Oxygen tolerant; streptococcus,
bacillus Idman* No. 3, obligate anaerobic ; streptococcus,
See Bibliography.
68
ORAL ABSCESSES
staphylococcus parvulus, bacillus ramosus, bacillus the-
toides, bacillus perfringens, bacillus bifidus communis
and bacillus Idman No. 14. Case E, also a case of subper-
iosteal parulis with thick yellowish pus without odor nor
reaction yielded the oxygen tolerant bacillus Idman No. 3
and the obligate anaerobe bacillus ramosus. Case F, a
case of subperiosteal abscess, contained thin pus of
strongly alkaline reaction. The following bacteria were
found : oxygen tolerant ; streptococcus, obligate anaerobe ;
staphylococcus iungano, staphylococcus parvulus, bacil-
lus thetoides, bacillus ramosus and bacillus fusiformis.
Case G, a subgingival abscess with grayish white pus of
neutral reaction, contained large oxygen tolerant cocci
single, double and in packs, (staphylococci) also small
oxygen tolerant streptococci. The obligate anaerobes
were found to be streptococci and the bacillus ramosus.
Case H, a subgingival abscess, was not fully completed.
It contained oxygen tolerant staphylococci and the ba-
cillus ramosus.
Oxygen Tolerant
Obligate Anaerobic.
Idman
1913
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PLATE XXVII
Fig. 117
Fig. 118
Fig. 117. — Eadiograph of a tooth with large granuloma which proved
to contain colonies of actinomyces.
Fig. 118. — Microphotograph of a section of the above granuloma.
Specimen prepared by author; stained with methylen blue and Eosin.
BACTERIOLOGY 69
The animal experiments undertaken with these bacteria
he reported under a special head, describing the isolated
microorganisms.
Bacillus pseudodiphtheriticum (aerobic) was injected
into guinea pigs in the form of a 5 c.c. of a 22-hour old
bouillon culture. There was an increased temperature
on the second day, no other pathological conditions.
Aerobic streptococci, two of which form no haemolysis,
two others cause a very weak haemolytic phenomenon,
were not all used for animal experiments. One strain of
the latter was injected subcutaneously into a rabbit and
caused only temporary decrease of weight, but no other
pathologic conditions.
Bacillus ramosus (anaerobic) was tested on rabbits.
Five of the isolated strains were used, two immediately
after the isolation. Ten c.c. of a three to seven days' cul-
ture was injected subcutaneously. None produced an ab-
scess at the place of inoculation. In each case he ob-
served a slow decrease in weight lasting from two to three
weeks. Only one case resulted in death of the animal
after thirty-three days ; in all the other cases the animal
slowly recovered.
Bacillus perfringens (anaerobic) proved pathogenic
for guinea pigs. After injection of 3 c.c. of a fresh
bouillon culture an extensive local infiltration occurred
which showed, when cut, a foamy oedematic secretion re-
sembling saliva which contained the bacteria in pure
culture. With one strain experiments were made to in-
crease the virulence, which was successful after passage
through two guinea pigs. The third animal died inside
of thirty-six hours after injection of 3 c.c. of a fresh
bouillon culture. Culture from the heart blood gave a
positive result.
Bacillus bifidus communis (anaerobic) caused no path-
ogenic effects in rabbits from injection of 10 c.c. of a
bouillon culture.
Bacillus thetoides (anaerobic) was used only in one
strain for animal experiments. The weight of the rab-
70 ORAL ABSCESSES
bits decreased slowly for one week, after which they
recovered. Only on the second day there was an increase
in temperature.
Streptococci anaerobic, no animal experiments.
Staphylococcus parvulus caused no pathologic con-
ditions in rabbits.
Staphylococcus iungano caused no pathologic con-
ditions after injections of 10 c.c of a bouillon culture.
In regard to these animal experiments, it must be
remembered, when compared with the results of Hartzel-
Henrici, that the organs of these inoculated animals had
apparently not been examined pathologically, and that the
pathogenicity of the bacteria was only judged from local
effects and as to the life or death of the animal. Hartzel-
Henrici observed the low virulence of streptococci infec-
tions when injected into animals, producing death only
after a long period if at all, although there were serious
lesions developing in some of their important organs
which can only be demonstrated in microscopic sections
of the diseased parts.
Gilmer* (1914) . Gilmer, who reports bacterial exami-
nations of acute and chronic abscesses, in a general way,
found streptococci in aerobic cultures, and occasionally
the staphylococcus albus and aureus, and the micrococcus
catarrhalis. In anaerobic cultures he found streptococci
and the bacillus fusif ormis either alone or in mixtures, as
well as a black pigment-forming organism which usually
did not appear for about five days.
Thoma* (1915). The author reported in a paper read
before the American Academy of Dental Science his re-
sults of cultures taken since November, 1914, of all
abscessed teeth in the hospitals as well as in his private
practice. He concludes that any microbes belonging to
the flora of the oral cavity may be found in oral abscesses.
Streptococci which grew aerobically and anaerobically
were found in the majority of cases, sometimes as pure
* See Bibliography.
PLATE XXVIII
Fig. 119.
Microphotograph of a section of a granuloma containing colonies of
actinomyces.
Specimen prepared by the author and stained by the Gram-Weigert Method.
BACTERIOLOGY 71
cultures, but frequently mixed with staphylococcus albus
and aureus. Besides these he often found an admixture
of many other pathogenic and saprophytic bacteria such
as the bacillus fusiformis, bacillus coli, the influenza
bacillus, and the bacillus proteus.
In two cases he found the fungus of actinomycosis.
This organism has been demonstrated several times in
root canals by Partsch* and was found by the author in
a large granuloma of an upper lateral incisor, and in the
root canal as well as in a granuloma of a lower bicuspid
of another patient. Both men were city people, there
were no clinical symptoms of general actinomycosis of the
jaws of soft tissue, which is due to the fibrous encapsula-
tion of the lesion. The first granuloma was removed, by
the regular method of thorough curettage used by the
author, the character of the abscess was not discovered
until later when the specimen, a part of the granuloma,
was examined. There was no recurrence of the disease.
The other granuloma was adhering to the tooth and the
fungus of actinomycosis was found when the specimen
was prepared. In order to verify the findings different
stains were used, the colonies in the form of rosettes with
club-shaped radiating filaments were clearly visible, as
seen in Figure 118 and Figure 119.
Hartzel and Henrici* (1913, 1914 and 1915) . The mouth
infection research corps of the National Dental Associa-
ciation, consisting of Thomas B. Hartzel, Henrici and
Leonard, started in September, 1913, a closer study of
1 'the relationship growing out of the transplantation of
the chronic mouth infections to other parts of the body
and a study of the areas of inflammation in the human
and animal body which have been induced by these trans-
planted organisms." They were the first who undertook
to study systemically the bacteria found in the
dental abscesses in regard to their systemic effects
rather than as to their etiological local importance. Their
* See Bibliography.
72 ORAL ABSCESSES
bacteriological research work has sought to determine by
animal inoculation the character of the damage wrought
in the various organs of the body by the introduction of
intravenous injections of living organisms cultivated
from lesions in the mouths of the patients studied. The
bacteriological study reported October, 1914, and
November, 1915, in the Journal of the National Dental
Association alone represents an enormous amount of
work and the conclusions drawn from the pathological
study of the animal experiments mark a classic epoch in
the study of dentistry.
The first report is based upon a study of eighty-two
cases, the second report was published after about two
hundred additional cases of chronic periodontal infections
had been bacteriologically examined. Attention was
from two reasons directed almost solely to the strepto-
cocci, first because they were constantly present and fre-
quently were the sole cultivable organisms obtained, and
secondly, because the research workers made the relation-
ship of dental infections to rheumatism their immediate
problem. They however also obtained the staphylococ-
cus albus, the bacillus coli, the bacillus proteus, the
bacillus florescens non-liquefaciens and the pneumo-
coccus. Aerobic as well as anaerobic cultures yielded
the same results. Cultures made from healthy teeth have
constantly been found sterile. The cultural features of
the streptococci of these dental lesions then received the
writer's attention. On blood agar two kinds of colonies
were obtained: " green" colonies, which produced a green
halo, and gray colonies without halo. With regard to
sugar fermentation reactions for an indicator, for which
a beef serum with one per cent, of the various sugars
added had been used with acid fuchsin decolorized by
potassium hydroxide, they found that the majority of
cases ferment either ramnose (streptococcus salivarius)
or salicin (streptococcus mitis). Only in one case had a
manite fermenter been observed (streptococcus fecalis).
PLATE XXIX
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Figure 120.
Chronic myocarditis. The section shows the heart muscle of a rabbit which died 16
days after an injection of streptococci from case No. 55. The section shows an area of
fibrosis with several giant cells.
Figure 121
Acute myocarditis. Section of heart muscle from a rabbit which died 48 hours after
an injection of streptococci from case No. 60. The section shows an area of lympholdal
infiltration.
Both illustrations reproduced by courtesy of Dr. Hartzel.
BACTERIOLOGY
73
TABLE OF FERMENTATION OF STREPTOCOCCI FROM CHRONIC
DENTAL LESIONS
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Fig. 132
FIG 131 —Lithograph of high-power drawing of epitheliated granuloma as shown in Fig.
124, showing the inner part.
A-Fibroblast. B— Plasma cells. C— Hyalin bodies D— Eosinophils E— Lymphocytes.
F— Leucocytes between epithelial cells. G— Island surrounded by epithelium.
H — Epithelial cells.
Specimen prepared by author and stained with Hematoxylin and Eosin.
FIG 132 —Lithograph of high-power drawing of the inner part of the granuloma shown in
Fig. 128, showing the upper branch of the sinus.
A— Mouth of sinus. B— Plasma cells. C— Blood vessels. D— Leucocytes.
E— Polymorphonuclear leucocytes. F— Pus cells. H— Epithelial cells.
Specimen prepared by author and stained with Hematoxylin and Eosm.
PLATE XXXV
Fig 133
Fig. 134
Fig. 135
Fig. 133. — Kadiograph showing lateral incisor just after the root canal had been
treated and filled. A light circle marks the circumference of the granuloma.
Fig. 134. — Photograph of the same granuloma shown in Fig. 133 after its excision.
Fig. 135. — Microphotograph of granuloma shown in Fig. 133 showing a distinct
capsule and numerous spaces which were occupied by cholesterin crystals. Note
pink and blue appearance, the first represents fibrin, the second collagen formation.
Specimen prepared by the author, stained by Mallory's connective tissue stain.
HISTOLOGICAL PATHOLOGY 81
lation. Bacteria and toxins may be absorbed by the capil-
laries in the granuloma and transported to other parts of
the body. The inner part of the granuloma is made up
of granulation tissue (fibroblasts and vascular endoth-
elium) infiltrated by one large mass of plasma cells.
These are seen as cells with irregular cytoplasm which
has marked basophilic properties containing from one to
four nuclei in eccentric arrangement. If there are proc-
esses of retrogression going on we find also numerous
polymorphonuclear leucocytes, endothelial leucocytes,
lymphocytes, eosinophiles and mast cells abundant more
or less. Erythrocytes are found distributed sometimes
throughout the granuloma, at other times only in the
fibrous encapsulation; their presence is due to haemor-
rhage of extended capillaries during extraction.
Epitheliated granuloma. Remnants of the embryonic
enamel organ are commonly found in the normal perio-
dontal membrane of animals as well as man. They can
easily be seen with the microscope and occur either in
small groups, islands or in chains. But the presence of
epithelium is not constant in the periodontal membrane,
as has been demonstrated by Malassez, and therefore we
do not find epithelium in all dental granulomata. This
epithelium may be found only near the root of the tooth
in small areas or it may be found throughout the granu-
loma, having proliferated from the normal remnants,
stimulated by the irritating influence of chronic inflam-
mation. The cells of the proliferating epithelium differ
in appearance from the cells of the epithelial islands;
they become larger, the cytoplasm and nucleus become
more distinct, and leucocytes invade the intercellular
substance which loosely connects the various cells. The
epithelial strands are of uneven thickened bands radiat-
ing from the original island in various directions, and
form when examined in a microscopic section a wide
meshwork throughout the granulation tissue. The epith-
elium has further the tendency to grow between live and
necrosed tissue, and it has sometimes the appearance of
encapsulating the seat of suppuration.
82 OKAL ABSCESSES
Granuloma with Lumen. Suppuration of the simple
or epitheliated granuloma frequently sets in either near
the apical foramen from where the bacteria emigrate or
farther in the center. If the destructive process becomes
severe a subacute alveolar abscess results with subperios-
teal or subgingival parulis and sinus formation. After
the accumulated pus is discharged the symptoms will soon
quiet down, but the pus formation may persist in a mild
way and discharge through a chronic sinus, as seen in
Figure 128. The granulation tissue first shows a large
infiltration of polymorphonuclear leucocytes and later
areas of necrosis in the center. After a while the pus
may be resorbed and if the leucocytic infiltration stops, a
lumen remains, containing necrosed tissue. (Figures 124
to 127.)
Besides suppuration we may also find fatty degenera-
tion, especially at the periphery between the fibrous cap-
sule and the granulation tissue. In old conditions there
are also other retrograde processes such as the formation
of cholesterin crystals, which are recognized by the rhom-
boid shaped spaces left by the crystals, which dissolve
during dehydration in alcohol. They can be demon-
strated, however, in frozen section and appear as brown-
ish crystals. Foreign body giant cells frequently
surround one or more crystals, as seen in Figure 137.
Compare also cholesterin spaces in Figure 124 and Figure
135. Collagen is formed by the fibroblasts from the fibrin
which stains blue with Mallory's aniline blue connective
tissue stain in contrast to the fibrin and fibroglia fibres
which are stained red, as seen in oil immersion drawing
Figure 136.
Another retrograde process is the hyalin formation
which occurs in droplets of various sizes in the cytoplasm
of the plasma cells (Russell's fuschsin bodies). This
causes the cells to enlarge and often nothing remains of
the cell but the acidophilic hyaline bodies. These are usu-
ally diffusely scattered through the whole granuloma.
Cysts. In the epitheliated granuloma with lumen we
frequently find an attempt of the epithelium to line the
PLATE X XXV
Fig. 136
Fig. 137
Fig. 136. — Lithograph of high-power drawing showing the
construction of the granuloma shown in Fig. 135.
A, Fibroblasts, with fibroglia fibres. B, Fibrin.
C, Collagen.
Fig. 137. — Lithograph of high-power drawing showing
the construction of another part of the granuloma shown
in Fig. 135.
A, Fibroblast, with fibroglia fibres. B, Fibrin.
C, Erythrocyte. D, Connective tissue bundles.
E, Space from cholesterin crystal.
F, Giant cell enclosing cholesterin spaces.
HISTOLOGICAL PATHOLOGY 83
central space. This influenced the German writers to call
Epitheliated gramilomata with lumen formation, "root
cysts.'' Dependorf, in a lengthy article, describes with
careful illustrations the formation of cysts from dental
granulomata. The author agrees that cysts may be
formed in both jaws from such conditions, but this must
happen extremely seldom or we would meet with cysts
more co mm only in these days where granulomata are
found in almost everybody's mouth.
CHAPTER VIII
SECONDARY COMPLICATIONS
The acute forms of oral abscesses have always been
more or less feared, more because of their violent symp-
toms than on account of the serious complications which
may result if treatment is neglected or if the cause is
not removed. The chronic forms, on the contrary, have
mostly gone unnoticed, although they occur much more
frequently. They were not properly recognized until
the radiograph became essential as a means of diag-
nosis and only recently we became aware of the fact that
almost every devitalized tooth develops this condition.
In my opinion, it is a fair estimate to say that seventy-
five per cent, of the population of this country harbors
this lesion in the mouth. In the Robert B. Brigham
Hospital for chronic invalids I found that of eighty-two
patients, seventy-three suffered from chronic abscesses;
some of them also had pyorrhoea, and in the mouths
of these seventy-three patients I found three hundred and
thirty-four abscesses.
The fact that these chronic abscesses give little or no
local symptoms is the reason why the dental profession
at large has not been aware of what is going on. But
the last few years the deceiving character of these lesions
has come to light. Radiographic diagnosis, keen obser-
vation and research have revealed the knowledge of the
grave consequences of such conditions. These septic foci
not only are liable to spread disease to the adjoining
parts, but also cause disturbances in organs and tissues
quite remote from the teeth.
Continuous Infection. The infection is liable to spread
to adjoining parts and involve large areas of the mandib-
ular or maxillary bones, the antrum of Highmore or the
throat.
SECONDAEY COMPLICATIONS 85
Referred Nervous Irritation. Reflex manifestations
from one branch of the fifth nerve to another or to com-
municating nerves is of quite frequent occurrence, but
often such pains are due to the most obscure causes, found
only after a most painstaking examination.
Infections through the Alimentary Canal. Abscesses
with sinuses or pyorrhoea pockets as well as septic sur-
face lesions of the mouth discharge their pus into the oral
cavity where it mingles with the fluids of the mouth and
when swallowed reaches the stomach and intestine. The
persisting infection through this channel gives rise to
most serious diseases of the mucosa of the alimentary
canal. From these secondary lesions bacteria may be
absorbed into the circulation, in turn causing other dis-
eases by haematogenous infection.
Lymphatic Infection. The lymphatic system and espe-
cially the lymph glands have the office of absorbing and
disposing of harmful substances, such as liberated in all
inflammatory conditions. A certain amount of pus may,
however, reach the circulation via the lymph system,
while not infrequently we find the lymphatics or the
glands seriously affected.
Haematogenous Infection. Abscesses especially of the
proliferating type which have no outlet into the mouth,
contain, as we have seen, numerous capillaries and blood
vessels. Absorption of products of inflammation into the
blood stream is usually small in quantity, but constantly
wears out the protective cells and causes diseases of the
blood and secondary infections in other parts due to
transported bacteria, or toxin, or both. The bacteria and
products of infection are not only absorbed from the
original focus, but also from secondary diseases of the
lymph system or the alimentary canal as already men-
tioned.
The complications which arise from septic foci in the
mouth will not be classified in this book according to the
mode of infection, but the various disturbances and dis-
eases which have been found due to oral abscesses will be
86 ORAL ABSCESSES
considered in turn. Case reports are here given so as to
illustrate the connection of the oral abscesses with the
various systemic diseases.
1. Involvement of Neighboring Parts.
The infla mm ation, whether from acute or chronic ab-
scess, is liable to spread to adjacent parts. The spreading
to and involvement of other teeth has been mentioned at
another place. It has also been explained that necrosis,
osteitis, or osteomyelitis is involved in every case of alve-
olar abscess in a mild and localized way. These diseases
may become continuous and involve large parts of the
maxillary and mandibular bones if the conditions are
right.
Maxillary sinusitis or empyema of the
MAXILLARY
antrum of Highmore is very frequently
met with by the rhinologist as well as by
the oral surgeon. About 75% of the cases are due to
dental origin and most are a sequel to oral abscesses.
Etiology: Acute maxillary sinuses occur
maxTllary on ^ as ^^u^ °f nasa l or dental diseases.
sinusitis ^he nasa l sources are coryza, influenza,
tuberculosis and syphilis of the nasal mu-
cous membrane, and any suppurative process in the nose
or other accessory sinuses. Dental sources are acute al-
veolar abscess on an upper bicuspid or molar discharging
into the antrum, infection from a chronic abscess or osteo-
myelitis in the maxillary bone. Infected dental pulps
and root canal instrumentations have been mentioned as
etiological factors in cases where the roots project into
the antrum. Infection is liable to occur from the extrac-
tion of a tooth or root, if a root is pushed into the antrum,
or if infected tissue or pus is forced into it and by the
introduction of unclean instruments.
Symptoms: The cheek on the infected side becomes
reddened and tender, and often there is a marked oede-
matic swelling which may close the eye. The patient com-
plains of a fullness in the affected side, with a dull throb-
bing pain, and generally malaise, dizziness, and photo-
SECONDARY COMPLICATION'S 87
phobia. There may be discharge of pus through the nos-
tril, or if the patient lies in bed, into the pharynx. Often
the osteum is closed up, when the pain and fullness be-
comes more marked, and is relieved if part of the pus
escapes into the nose. Headaches and neuralgic face-
aches are principally found in less severe cases.
Clinical signs: Fever is always present in acute cases
and may reach 104 °F. An examination of the nares
shows usually crusts of pus and congested mucous mem-
brane. In doubtful cases the patient should be asked to
sleep on the suspected side and notice in the morning
whether there is any discharge upon turning the head to
the other side. The patient may be asked to apply suc-
tion to the nose while closing the nostrils. Transillumi-
nation shows bright illumination under the orbit of the
healthy face and darkness on the other. Radiographic
examination is the surest means of diagnosis. The dis-
eased antrum presents an opaque appearance on a frontal
plate, and a lateral view shows the cause if it is of dental
origin. Intraoral films are a great help to diagnose the
etiological factor, but are of no value in the diagnosis of
the condition of the antrum.
Treatment of Acute Maxillary Sinusitis from the Nasal
Cavity. In cases of nasal origin the treatment is under-
taken through the nose, but also in certain dental cases
this treatment is indicated, especially if the inflammation
of the antrum occurs after an extraction, the socket hav-
ing healed up before the complication sets in.
1. Irrigation Through the Natural Orifice. In mild
cases, which respond easily to treatment, daily irrigation
and medication through the osteum is sufficient.
2. Perforation of the Nasal Wall. If drainage and
treatment through the natural orifice is not sufficient, per-
foration of the naso-antral wall with a trocar and cannula
is recommended. The opening should be made as near
the floor of the antrum as possible. This closes up in a
comparatively short time, and resection of a larger part
of the wall is recommended if a more permanent opening
is desired.
ORAL ABSCESSES
Treatment of Acute Maxillary Sinusitis from the Oral
Cavity. It has already been stated that in a large number
of cases maxillary sinusitis is due to abscessed teeth. The
radical removal of the cause is naturally the first step,
but this also furnishes an opening into the antrum
through which treatment can be undertaken. The open-
ing is enlarged with the surgical burr and all granulations
and diseased bone should also be carefully removed. The
antrum is then washed out through the wound by inserting
a sterile soft rubber catheter, to which the antrum syringe
or fountain syringe is attached. Use lukewarm normal
salt solution. If the osteum is closed, spray the antral
side of the middle meatus with Sol. Adrenalin hydro-
chlorid 1 :6000. This will contract the mucous membrane
and reopen the natural passage way. After the washing
has been completed, close the wound with sterile gauze.
The washing can be repeated in the same maner until the
antrum is healed, when the socket should be closed by a
plastic operation. If the antrum is opened accidentally
after extraction, and curetting for alveolar abscess, espe-
cially if we desire to remove diseased bone, it is advisable
to clean first the socket thoroughly and then insert a
sterile soft rubber catheter, washing the antrum out as
above. Carefully close the wound, and if no reinfection
occurs the condition will heal without trouble.
Etiology : The chronic form of maxillary
max?llary sinusitis or chronic empyema of the an-
sinusitis tram frequently follows the acute form.
Often we find old chronic cases which
never were preceded by any acute or painful condition.
In these cases granulation is very pronounced and the
cavity is filled with polypi. Abscessed teeth play a most
important part in the etiology of chronic maxillary
sinusitis.
Symptoms : Pain in the cheek, which is often of neu-
ralgic character, is almost always the symptom from
which the patient seeks relief. The discharge of pus
through the nostril of the affected side is at times very
marked and, moreover, it is often of very offensive odor.
SECONDARY COMPLICATIONS 89
The osteum becomes occasionally obstructed, which in-
creases the severity of the symptoms. The patient almost
always loses weight. General malaise, arthritis, gastric
disturbances from swallowing pus, and mental depression
frequently accompany the disease.
Clinical signs: What has been said for the acute con-
dition is also true for the chronic. The differentiation of
acute and chronic empyema of the antrum cannot be
easily made either by transillumination or by radio-
graphic examination. The history of the case and con-
sideration of the etiological factor will help in ascertain-
ing the condition, but a sure diagnosis can only be made
by actual examination. Holmes's naso-pharyngoscope is
a great help for this purpose. A short incision in the
canine fossa allows us to make an opening through
the anterior wall with a surgical burr, through which
the naso-pharyngoscope is inserted. The condition of the
mucous membrane, the amount and quality of new growth
can plainly be seen. This is the safest way of making a
differentiating diagnosis.
Treatment: The cause of the disease has to be ascer-
tained and thoroughly removed. Frequently we find
cases of maxillary sinusitis which have not improved, al-
though a great amount of time has been spent for treat-
ment. After careful examination we find that a tooth is
continuing to reinfect the mucous membrane. To try to
save one tooth if two are involved is poor judgment if we
consider how difficult a task it is to cure chronic maxillary
sinusitis.
There are a large number of methods for treatment of
chronic empyema.
Treatment Through the Alveolar Border. The method
of draining the antrum through the alveolar process has
been in great favor with the dentists. Some have even
gone so far as to treat the antrum through the root canal
of a tooth. If we compare the small size of a root canal
even when enlarged with the capacity of the antrum hold-
ing 12 to 52 c.c. of fluid we must see the impossibility of
such an undertaking, not to speak of the consideration of
90 ORAL ABSCESSES
that tooth and the infected periapical tissue as a causa-
tive factor which ought to be removed. The tooth socket
sufficiently enlarged with a surgical burr is the most ideal
place for drainage, as it is at the lowest level. The an-
trum should be washed with the greatest aseptic precau-
tions. A soft rubber catheter can be introduced and is
connected either with the fountain or the antrum syringe.
I use warm normal salt solution or mild antiseptics as
washings, occasionally with application of fifteen per
cent. Argyrol. After washing the antrum, care should be
taken to remove all the moisture, as the antrum is an air
sinus with dry mucous membrane. Frequently I use
filtered compressed air for this purpose, administered
through the catheter. The washings should be under-
taken first daily and later at intervals until there is no
discharge for two weeks. It is important to construct a
rubber or gutta percha obturator to fit into the alveolar
socket principally to prevent food and saliva from enter-
ing the antrum, but also to keep the opening from closing
up. After the antrum has healed the socket should be
closed permanently by a plastic operation.
Operation Through the Canine Fossa. In cases where
examination of the antrum reveals granulations and new
growth, the foredescribed method is not sufficient to re-
sult in a cure. Surgical removal of all growth is indi-
cated. In cases of malignant growth, the lining mem-
brane should be removed radically, but in all cases of
polypous and granulating character the tendency is to be
contented to remove the growth and not the membrane.
A great deal depends in this operation on being able to see
all parts of the antrum, and the operation should there-
fore be performed from the place which gives the best
access to vision as well as instrumentation, and this is the
canine fossa.
The antrum is opened from the canine fossa by excising
the anterior wall with chisel and surgical burrs. The
opening should be made large, but care should be
taken not to injure the nerves and vessels of the teeth.
After the cavity has been freed from polypi, or other
PLATE XXXVII
w'
Fig. 138. — Antrum exposed so as to show the abscess formed at the
floor by the upper first molar.
PLATE XXXVIII
Fig. 139
Fig. 140
Fig. 139. — Radiograph of Case No. 1, showing the condition of the upper first
molar, causing the disease of the antrum.
Fig. 140. — Radiographic plate of Case No. 1, showing healthy antrum (dark) on
the left side of the picture, diseased antrum (cloudy) on the right side.
SECONDARY COMPLICATION'S 91
growth, and from bone septa, the extraction of the in-
volved teeth is undertaken. Chronic abscesses are to
be extensively removed and osteomyelitic bone is curetted.
After washing out all debris and diseased tissue the cavity
is dried out, the alveolar wound closed by sutures, and the
antrum packed with antiseptic gauze which should re-
main in place for about forty-eight hours. Then the
gauze is removed, the cavity again irrigated, dried and
repacked. This treatment should be continued for about
ten days, after which time an obturator, which has been
constructed from gutta percha or rubber, is inserted to
keep the antrum open for irrigation and observation
until it is entirely healed. The plug then can be left out
and the antrum is closed by a plastic operation.
Operation Through .Canine Fossa and Treatment
Through Nasal Wall. (Caldwell-Luc.) The operation is
undertaken through the canine fossa which is closed up
immediately afterwards. The after-treatment is then
continued through the opening in the antro-nasal wall
which is usually of permanent character.
Operation Through Canine Fossa and Treatment
Through Alveolar Socket. The canine fossa operation is
performed as described, but the alveolar wound is kept
open. The opening in the canine fossa is closed after the
healing has progressed to a satisfactory stage. An ob-
turator is constructed for the alveolar opening to close
the communication of the antrum and mouth after each
irrigation. When the condition is cured, the alveolar
opening is also closed by plastic methods.
<5TRATivE ^ ase !• (Chronic maxillary sinusitis
CASES with, polypoid granulations.) The pa-
tient, a man of 41 years of age, presented
symptoms of chronic maxillary sinusitis. A frontal radio-
graph is shown in Figure 140, and the cause was ascer-
tained by an intraoral film, Figure 139. The upper first
molar shows chronic abscesses on all roots, which appa-
rently infected the antrum. Examination of the nose re-
vealed no infectious condition. Surgical treatment was
undertaken by opening through the canine fossa. A large
92 ORAL ABSCESSES
amount of polypoid granulation was found, the antrum
was almost entirely filled with it. I removed the granu-
lations, extracted the tooth and removed all diseased bone
with surgical burrs. The canine fossa was permitted to
close after one week, and the treatment continued through
the alveolar socket. After the treatment was completed
so that no discharge collected during a period of three
weeks, I closed the alveolar opening by a plastic opera-
tion.
Case II. (Chronic maxillary sinusitis.) The patient, a
man 36 years of age, suffered from obscure pain in the
maxillary region. The two upper bicuspids on the af-
fected side he said had been treated several times, when
it was observed that a broach could be pushed up a sur-
prisingly long distance. An intraoral film showed no
extensive periapical condition; a frontal radiograph re-
vealed a slight cloudiness of the antrum. I opened the
antrum from the canine fossa. Inspection with the naso-
pharyngoscope showed a condition similar to Figure 138,
an antral abscess on the floor over each of the devitalized
teeth. The roots extended into the antrum, and as there
was no bone destruction, there was nothing to show in the
film. Extraction of the teeth and curettage of the dis-
eased part was the first step in the treatment, after which
the slightly inflamed membrane yielded rapidly to treat-
ment.
PHARYNGITIS P^^g^is ve3 T frequently occurs as a
complication of abscesses on lower im-
pacted wisdom teeth. The inflammation may spread over
one side of the pharynx and cause the patient to consult
the physician while the real cause is unnoticed on account
of lack of symptoms. (Figure 95.)
Symptoms : Examination of the mouth usually reveals
the true character of. the condition. Sometimes the cusp
of an unerupted wisdom tooth is visible, and upon pres-
sure on the lingual part of the gum there is usually more
or less discharge of pus through the gingival opening. A
radiograph aids sure diagnosis.
Treatment : The cause is to be removed at once. The
pharyngitis should receive general and local attention.
SECONDAKY COMPLICATION'S 93
illustrative Case III. (Marked pharyngitis and
CASE slight trismus.) The patient, a young
man, went to his physician for treatment of the throat.
He was referred to me and when he came to my office the
next day he had a temperature of 101 °F., enlarged maxil-
lary glands on the left side, and slight trismus of the
muscles of mastication. On examination of the mouth
and pharynx, I found the right side badly inflamed and
a large amount of pus discharging from behind the lower
second molar. The radiograph showed the cause of the
trouble as an impacted unerupted wisdom tooth with ex-
tensive abscess formation.
__.,,,,..„ Trismus is a tonic spasm of the muscles
TRISMUS p ,. ,. x
oi mastication.
Etiology: It is usually caused by an impacted wisdom
tooth with abscess formation and periostitis.
Symptoms: The patient complains of not being able
to open the mouth except a small distance. Sometimes
the teeth are locked in complete occlusion. Pain, inflam-
mation of the pharynx, and swelling of the submaxillary
glands are almost always found.
Diagnosis: By means of an extraoral radiograph we
are able to determine the cause in a very short time.
Treatment : In mild cases we may use local anaesthesia.
After the inferior alveolar nerve and tissues supplied
have been anaesthetized in the pterygo-mandibular space
by the intra- or extra-oral method, the patient is relieved
of pain and usually is able to open the mouth sufficiently
for the operation. It is advisable to insert a mouthprop
for the patient to bite on. In very severe cases and diffi-
cult impactions ether anaesthesia is advisable. The
mouth then can be forced open by means of the mouth
gag. A few days after the cause is removed the jaw
regains its normal function.
Case IV. (Mandibular trismus.) The
CAS STRAT ' VE patient, aged 24, suffered from pain in
the trigeminal region for several days ; he
also complained of severe earache. He was scarcely able
to open his mouth. An X-ray plate showed a right lower
94 OEAL ABSCESSES
third molar which had been decayed and abscessed. The
month was opened under ether anaesthesia and the tooth
extracted. An iodoform wick was inserted for drainage,
the patient improved rapidly and was entirely well after
one week.
2. Ophthalmic Disturbances.
Ophthalmic disturbances due to oral conditions may be
brought about in two ways: first, through nervous irri-
tation, and, second, through haematogenous infection.
The ophthalmic division of the fifth nerve, which is
purely sensory, supplies the eyeball, the mucous mem-
brane of the eye, the lacrimal gland, and the skin of the
brow and forehead. A branch of the second division, the
orbital nerve, communicates with the lacrimal nerve;
therefore we have direct communication between the first
and second divisions. However, the teeth are also con-
nected with the eye through the second and third divi-
sions via the Gasserian ganglion. The first division
further communicates with the motor nerves of the eye,
the third, fourth, and sixth cranial nerves. Reflex irri-
tation from the oral cavity therefore may not only result
in irritation of the parts of the eye supplied by the sensory
nerves, but may also cause motor nerve disturbances in-
terfering with the function of accommodation and con-
vergence.
Haematogenous infection, however, here plays an
important role. To me it seems more probable that secon-
dary ophthalmic disturbances should be of an infectious
nature. They may also have been predisposed by reflex
nerve irritation. In many cases there may be found a
cause in the mouth for referred nervous irritation, but al-
most always we can also discover a septic focus such as a
chronic abscess, an abscess around and caused by an im-
pacted tooth from which the secondary disease may have
originated. There is no doubt that oral abscesses as well
as oral nerve irritation cause ophthalmic disturbances in
many instances, such as iritis, keratitis, scleritis, and
PLATE XXXIX
CONJUNCTIVA
BULBI
CONJUNCTIVA
PALPEBRAE
N. OPTICUS
Fig. 141. — Cross section through eye.
SECONDARY COMPLICATIONS 95
other infectious diseases of the eye, as well as neurotic
affections such as intraocular and retrobulbar optic
neuritis.
infectious Conjunctivitis is an inflammation of the
coimjuncti- conjunctiva, the thin mucous membrane
vms lining the eyelids. We distinguish palpe-
bral and bulbar types. It is also known as ophthalmia.
Etiology : Infectious conjunctivitis is very often haem-
atogenous in character, but may also be the result of
direct contact, as by means of the fingers. It is fre-
quently found in children and may easily be contracted
from abscessed temporary molars if the child carries the
finger from the aching tooth to the eye.
Symptoms : The conjunctiva is of a brilliant red color
and is swollen. The discharge is mucopurulent, some-
times causing blurring of the sight. There are itching and
smarting sensations referred to the lids, which feel hot
and heavy.
suppurative The inflammation of the cornea is called
keratitis keratitis.
Etiology : It is a process of infection caused by various
organisms. It may come from conjunctival inflamma-
tions or other direct and indirect infections.
Symptoms: It begins with a dull, grayish or grayish-
yellow infiltration of a circumscribed portion of the cor-
nea. It may extend in area and in depth. There is pain,
photobia (intolerance to light), lacrimation (excessive
secretion of tears), and often blepharospasm (excessive
winking).
scleritis ^ke inflammation of the sclera, which
with the cornea forms the external tunic
of the eyeball, is called scleritis.
Etiology: Scleritis is often seen in connection with
rheumatism, syphilis, and tuberculosis. Exposure to cold
is sometimes an exciting cause. Reflex irritation and
secondary infection from oral foci are not uncommon
causes.
Symptoms: There is usually slight discomfort, lacri-
mation and pain.
96 ORAL ABSCESSES
illustrative Case ^ ' (Bulbar conjunctivitis.) The
case " P a ^ en ^ a J owa S man, about twenty-
two years old, had suffered for a long
period from bulbar conjunctivitis of both eyes, for
which he was treated by a competent ophthalmol-
ogist, who, however, was not able to cure the
condition permanently. The two upper central in-
cisors had been devitalized and in the radiograph
showed areas of lessened density around their apices.
After each subacute attack of these abscesses he suffered
from an attack of conjunctivitis. The root canals of both
teeth had previously been treated, but the left tooth did
not yield to treatment. I treated and filled the left in-
cisor and immediately performed apiectomy. The pa-
tient was normal for about four months, when he had a
recurrence. The right eye, which formerly was the worst,
showed only a slight conjunctivitis ; the left eye was mod-
erately inflamed. The right central incisor again felt
lame. I undertook at once to take radiographs of his
whole mouth and found a devitalized right lower bicuspid,
with slight periodontitis and poor root-canal filling. A
right upper bicuspid showed an area of decreased density.
Upon opening into this tooth the eye on the same side
cleared up almost immediately. The tooth was treated
twice with ionic medication and then filled with the chloro-
form-resin-gutta-percha method. The left eye stayed in-
flamed, the inflammation also extended into the conjunc-
tiva and did not improve until the root of the right
central incisor was amputated. A small granuloma was
removed with the root end, which yielded a streptococcus
and staphylococcus albus. Three days after the opera-
tion, when the patient came to my office for the removal
of the sutures, his eyes showed a clear and healthy ap-
pearance. Before this case is dismissed apiectomy will be
performed on the devitalized upper and lower bicuspids.
iritis Iritis is the inflammation of the iris, and
may be acute or chronic ; primary if devel-
oping in the iris itself, secondary if the inflammation
spreads from neighboring parts, such as the cornea.
SECONDARY COMPLICATION'S 97
Etiology : Iritis is frequently dependent upon some con-
stitutional disease and therefore may be caused by
haematogenous infection. Frequently the focus is found
in the nose or mouth.
Symptoms: There is pain, photobia, lacrimation, and
interference with vision. The iris appears swollen, dull,
with indistinct markings. The color changes and becomes
greenish to muddy according to the color of the eyes.
cyclitis Iritis is frequently associated with cycli-
tis which rarely occurs alone. (Iridocy-
clitis.) It is an inflammation of the ciliary body and
almost always involves the choroid.
Etiology: The various causes of iritis are responsible
for iridocyclitis. "The disease," writes May, "is often
due to the influence of toxins of bacterial origin derived
from the teeth (abscesses and pyorrhoea alveolaris) ton-
sils, pharynx, nose, and sinuses."
Symptoms : In iridiocyclitis we have the symptoms of
iritis and in addition tenderness in the ciliary region and
often swelling of the upper lid.
choroiditis Choroiditis may be non-suppurative or
suppurative. In the latter case there is
usually an involvement of the ciliary body and the iris.
It is then called iridochoroiditis.
Etiology : The condition may be of ectogenous or endo-
genous origin. The latter is due to septic infections from
the oral (abscesses pyorrhoea) and nasal cavities, from
intestinal autointoxication, syphilis and tuberculosis.
Symptoms: In pure choroiditis there are no external
signs; the symptoms are disturbances of sight. In iri-
dochoroiditis there are symptoms of iridocyclitis which
are acute and severe.
retinitis ^ e i n A ainma tion of the retina is called
retinitis.
Etiology : Retinitis occurs occasionally as a local lesion,
but almost always is a manifestation of a constitutional
disease, autointoxication or secondary infection.
Symptoms: Diminution of acuteness of vision is usu-
ally present. Pain is rare and there are no external
signs.
98 ORAL ABSCESSES
intraocu- in this type of optic neuritis the head of
NEumTis' ^ e °P^ C nerve is affected, causing marked
visible changes in the disc. Intraocular
neuritis is also called Papillitis.
Etiology : Among the causes of this disease we have
secondary infections from diseases of the nasal cavity,
the sinuses and the mouth and teeth.
Symptoms : Disturbance of vision varies and there may
be complete blindness. There is no pain and no external
signs.
retrobulbar Retrobulbar optic neuritis involves the
optic orbital portion of the optic nerve, the
neuritis process being an interstitial neuritis.
It may be acute or chronic.
Etiology: It may be due to direct extension from the
orbit, general diseases or haematogenous infection. Oral
sepsis plays an important part in the latter factor.
Symptoms : In the acute form there is severe headache
on the affected side, pain in the orbit aggravated by move-
ment of the eye and rapid impairment of sight, beginning
in the center of the field. In the chronic type there is
diminution in acuteness of sight, foggy vision, especially
in bright light, and blindness in the center.
Case VI. (Retrobulbar optic neuritis.)
case TRAT,VE: ^ e P a ti en ^' a voun g woman, was sent to
me by an ophthalmologist of this city, with
the following letter: "I treated Miss some three or
four years ago for an acute retrobulbar optic neuritis of
each eye. At that time we could trace no cause for the
process. About ten days ago, Miss developed the
same trouble again in her left eye. It is a coincidence
that both at the time of this attack and at her previous
attack she was having trouble with her teeth. I am send-
ing her to you to get an opinion as to what sort of con-
dition her teeth are in and as to whether there might pos-
sibly be an infection there responsible for the ocular
trouble. ' '
The patient complained of blurred vision ; she was al-
most blind for near sight, but vision for distance was
PLATE XLI
Fig. 145
Fig. 146
Fig. 147
Fig. 148
hn?w™;- 146 ' 14 v an ai\8.— Radiographs of Case No. 6, a patient suffering of a retro-
bulbar optic neuritis. Both maxillary third molars are impacted. Areas indicating graim-
lomata are found on devitalized teeth.
PLATE X LI I
Fig. 149
Fig. 150
Fig. 149. — Radiograph showing impacted un-
erupted third molar causing otitis media in
Case No. 7.
Fig. 150. — Radiograph showing lower second bi-
cuspid with decay under filling and granuloma
causing otalgia in Case No. 8.
SECONDARY COMPLICATION'S 99
not bad. Upon examination of the mouth several poorly-
fitting gold crowns were visible. Kadiographic examina-
tion revealed the following (Figures 145 to 148) :
Lower jaw : All the molars of the left side showed areas
which indicated chronic abscesses. A very large area on
the right second bicuspid.
Upper jaw: Third molar unerupted and impacted on
both sides. Left upper first and second bicuspid and
right upper first bicuspid, first and second molars also had
apical infections to a greater or less extent.
I extracted all these teeth, curetted thoroughly and
treated the sockets with iodine. The patient reported
improved ten days later, and since then has been steadily
growing better.
glaucoma Glaucoma is an important and co mm on
disease of the eye which has for its charac-
teristic an increase in intraocular tension. It may be
primary or secondary.
Primary glaucoma occurs without antecedent ocular
disease, and is divided into inflammatory or congested
acute and chronic stages and into non-inflammatory or
simple varieties.
Secondary glaucoma is the name given to cases of in-
creased tension and other symptoms of glaucoma due to
some other ocular diseases or injuries.
Etiology : The exact cause of primary glaucoma is un-
known. May thinks that arteriosclerosis, cardiac dis-
eases, chronic constipation, the gouty and rheumatic
diathesis are predisposing factors, all diseases which are
more or less caused by toxic or bacterial absorption.
Symptoms : There are different stages distinguished in
acute inflammatory glaucoma. The prodromal stage:
Sight appears to be obscured by a fog, with slight pain in
eye and head. The active stage of glaucoma (glaucoma-
tous attack) is characterized by rapid failure of sight,
severe pain in the eye and violent headache, accompanied
with nausea, vomiting, and general depression. After a
few days or weeks, a decided improvement takes place,
but the normal condition does not return. This condition
100 OKAL ABSCESSES
is the glaucomatous stage. At any time there may be new
attacks and with each succeeding attack the diminution
in vision becomes greater until blindness ensues. This
stage is called absolute glaucoma. Later the eyeball is
apt to degenerate.
Chronic inflammatory glaucoma is much more common,
the symptoms resemble those just described, but are less
intense and more gradual in onset. The termination is
absolute glaucoma and finally degeneration.
3. Aural Disturbances.
Pain in the ear is a very frequent symptom of oral
diseases, both the second division of the fifth nerve which
supplies the upper teeth and the third division which
supplies the lower teeth being in communication with the
nerves of the ear. The maxillary division is connected
with the tympanic plexus via spheno-palatine (Meckel's)
ganglion, the vidian and greater superficial petrosal
nerve. The mandibular division communicates with the
tympanic plexus by way of the optic ganglion and the
small superficial petrosal nerve.
Such irritation of the middle ear referred
media through nervous channels frequently pre-
disposes the tissue for infection and
through haematogenous transportation of bacteria may
result in acute median otitis as well as chronic purulent
infla mm ation of the middle ear and tympanum. Ab-
scessed teeth may become foci for purulent otitis in two
ways : first, by discharging a large amount of pus into the
mouth, which may reach the tympanic cavity via the Eus-
tachian tubes. It is well known that middle ear inflam-
mations occur most frequently in children at the time
when they are about to lose the temporary teeth, which
very often are badly neglected and abscessed. The patho-
genic connection between teeth and middle ear has, how-
ever, not alone been demonstrable in children. Grayson
reports that in adults he has failed a number of times to
PLATE X LI I I
d e f g h
/
Fig. 151. — Position of the lymph glands beneath the lower jaw
(Preiswerk) .
a, Submental lymph glands. ~b, Digastric muscle, c, Submax-
illary gland, d, f, h, Submaxillary lymph glands, A, B, C.
e, External maxillary artery, g, Masseter muscle, i, Parotid
gland.
PLATE XLI V
Pig. 152. — Schematic drawing showing which teeth are drained by the various
lymph glands.
A, B, C, the three submaxillary lymph glands,
i S. M., S. M., the submental lymph glands.
SECONDAKY COMPLICATIONS 101
make much impression upon chronic purulent inflamma-
tions of the tympanum until the dental cause had been
removed.
otalgia Otalgia or pain referable to the ear may
be from the Pinna, the external auditory
meatus, the tympanic membrane, the tympanic cavity,
and Eustachian tubes, from the mastoid process, or a re-
flex manifestation.
The jaws and teeth play a most important
OTALGIA r ^ e * n re ^ ex otalgia. The pain may be
continuous or periodical, with remissions
and exacerbations. The cause may be found in the molar
region, usually more in the lower than in the upper jaw.
Impacted teeth, teeth with acute or chronic abscesses,
periostitis, and wounds in that region play a great part as
etiological factors.
illustrative ^ ase VH- (Otitis media.) The patient
CASE suffered from repeated attacks of otitis
media of the right ear. There was a large
amount of discharge from the ear. Treatment did not
result in permanent relief, and pain persisted after the
inflammation had subsided. The specialist she consulted
during her last attack in San Francisco, before she left
for the East, advised her to have her teeth examined. The
patient was then referred to me, and I immediately took
radiographs of her mouth. There was a large area over
the right upper second bicuspid, shadows on each of the
roots of the first molar and a badly impacted upper wis-
dom tooth with pus discharge from an opening in the gum.
I extracted the upper second bicuspid and first molar and
extirpated the impacted third molar without disturbing
the second molar. The granulomata were removed at
once, after which the bone was thoroughly curetted. Local
conductive anaesthesia was used for the operation, which
also relieved the pain in the ear while it was in effect.
During the after treatment the patient improved rapidly
and was freed from the aural pain and inflammation.
(Figure 149.)
Case VIII. (Otalgia.) The patient, a young lady,
referred to me by another patient, complained of earache
102 ORAL ABSCESSES
on the right side; occasionally also had what she called
faceache on the same side. She consulted two dentists,
who failed to locate the cause of the trouble, and was about
to go to an ear specialist when her friend, who had a simi-
lar experience, the cause of which I was able to locate and
remove, advised her to consult me first. I took radio-
graphs of the teeth on the affected side, and found that
the right lower second bicuspid had a large obscure cavity
at the distal side, underneath the cervical margin of a
gold filling. The pulp was involved and a granuloma had
developed at the end of the root. There were no symp-
toms that indicated this condition. The tooth was
extracted and the bone curetted, which resulted in per-
manent relief of the otalgia. (Figure 150.)
4. Lymphatic Infections.
There are two groups of lymph glands which drain
the jaws and teeth and their mucous membrane. The sub-
mental glands take care of the region of the lower incisor
teeth. They are situated behind the chin, beneath the
fascia, and between the two geniohyoid muscles. The
other group are the submaxillary lymph glands. They
are three in number. The anterior one lies internally to
the lower border of the mandible and anterior to the
external maxillary artery. It is connected with the re-
gion of the superior incisors, cuspids, and bicuspids, also
the lower cuspids, bicuspids and the lower first molars.
The middle submaxillary lymph gland lies posterior to
the external maxillary artery at the anterior part of the
submaxillary salivary gland. It drains the parts contain-
ing the maxillary first molar, but also partly the upper
bicuspids and second molar. In the lower jaw it takes
care of the three molars, but principally of the second
molar. The posterior gland is situated at the posterior
pole of the submaxillary salivary gland and is connected
with the upper wisdom tooth exclusively, and also with
SECONDAKY COMPLICATIONS 103
the lower third molar, which is to small extent drained by
the middle gland.
These just described lymph glands are tributaries of
the deep cervical lymph glands which accompany the ex-
ternal and internal jugular veins.
In a perfectly normal condition these glands are of
very small size so that they are hardly noticeable ; they are
seldom larger than the size of a pea, but in diseased con-
dition they may become greatly enlarged. Lymphatic
infections occur most frequently in children, but are not a
rare occurrence in adults.
Lymphangitis is an inflammation of the
GUIS " lymphatic vessels, and also gives rise to
inflammation of the tissue immediately
surrounding them. It is rarely a primary condition and
usually extends from the focus to the nearest lymphatic
gland, but may continue from there to the next group of
lymph glands.
Etiology: The cause is always a septic condition. It
occurs in the mouth occasionally from abscesses or other
infections. The bacteria or their toxins are absorbed
from the focus and cause inflammation while passing
along the lymph channels.
Symptoms : "We can easily recognize a lymphangitis by
the pink or reddish colored streaks clearly visible on the
skin. There is usually more or less pain along the lym-
phatic vessels and a rise of the temperature. Lymphan-
gitis from lesions in the mouth is only recognizable if the
lymphatic channels beyond the submental or submaxillary
lymph glands are affected, in which cases there is also
swelling of these glands. The affection therefore does
not point directly to the lesion and the cause has to be
ascertained by radiographic examination. The affected
gland, however, indicates the location of the focus.
Treatment: The finding and removing of the cause is
imperative and if this is done the inflammation will dis-
appear in a short time. Hot applications can be applied
as soon as the focus has been thoroughly opened and
drainage established.
104 ORAL ABSCESSES
ILLUSTRATIVE C ™\ /X (Lymphangitis.) The pa-
c s tient, a woman 01 middle age, presented
a lymphangitis extending from the left
submandibular region to the left axilla and breast. The
lymphatic channels were distinctly outlined in reddish
color. The submaxillary and cervical glands were
slightly enlarged and tender on pressure. "No pain in the
mouth. Radiographic examination revealed a large area
of lessened density around the left lower second bicuspid.
(Figure 153. ) Examination showed slight swelling on the
gum and pus discharge at the gingival margin if pressure
was applied. The treatment consisted in extraction of
the tooth, thorough curettage, and insertion of iodoform
wick for drainage. This was changed until the discharge
stopped and then left to heal up. Bacterial examination
showed a streptococcus and staphylococcus aureus
infection. The inflammation of the lymphatics grad-
ually diminished and disappeared entirely after three
weeks.
lymph a- Lymphadenitis is the term applied to the
denitis" inflammation of the lymph glands. We
distinguish acute, chronic, and subacute
lymphadenitis. Submaxillary, submental, and cervical
adenitis are common complications of diseased teeth, es-
pecially in children, and unfortunately it occurs fre-
quently that the glands are removed without investigat-
ing the unsuspected cause, which almost always is an
acute or chronic abscess, from a temporary, permanent,
or impacted and unerupted tooth.
acute Acute lymphadenitis usually occurs in
cervical LYM-connection with acute periodontitis and
phadenitis acute abscesses.
Etiology : Acute lymphadenitis is usually secondary to
a septic infection. The focus for the submaxillary and
submental lymph glands may be found in the orbit, zygo-
matic and temporal fossae, the nose, the cheeks, palate,
lips and especially the alveolar process and teeth of both
jaws. Alveolar abscesses and stomatitis are the most
PLATE XLV
Fig. 153
Fig. 154
Fig. 153. — Radiograph showing the tooth (second bicus-
pid) causing lymphangitis of Case No. 9.
Fig. 154. — Radiograph showing the lower second molar
causing lymphadenitis in Case No. 10.
PLATE XLVI
Fig. 155
Fig. 155a
Figs. 155 and 155a. — Eadiographic plates of Case No. 11, showing the un-
erupted third molars causing chronic lymphadenitis. There was a
,„„^ ,T„,.„V.l,
SECONDARY COMPLICATIONS 105
frequent causes. The toxins or bacteria themselves may
be absorbed.
Symptoms : The glands in acute lymphadenitis become
only slightly enlarged, they feel elastic and soft, and are
very sensitive on palpitation. But also the tissues sur-
rounding the glands become affected by the process of in-
flammation, the skin looks red and swollen, and in extreme
cases the pus may burst through the capsule of the gland
and force its way through the skin.
Treatment: Find and remove the focus and use cold
poultices and hot mouth wash until the abscess in the
mouth has healed, then apply hot poultices to the glands.
If suppuration has progressed beyond the stage where
nature can take care of the condition, the glands should be
incised.
illustrative @ ase ^. (Acute Lymphadenitis.) A
case 7 oun g man, a medical student, con-
sulted me for tenderness directly
under his lower jaw. Upon examination, I found
the middle lymph gland of the right submaxillary
group slightly enlarged and very tender ; there was also
enlargement of one or two of the cervical glands. The
examination of the mouth revealed nothing except large
amalgam fillings in the posterior teeth. I took a radio-
graph of the right lower molars first, and was at once
rewarded in finding a large area of lessened density ex-
tending from the roots of the right lower second molar.
A radiograph of the upper molars showed all teeth in
normal condition. The pulp of the right lower molar had
never been touched before, but apparently was infected.
The reason why there were no other symptoms was prob-
ably due to the thickness of the outer and inner plate of
the mandible in this region, not allowing the pus to pene-
trate quickly to the large cancellous inner portion, allow-
ing the pus to accumulate without causing pressure or
pain. When I opened into the pulp, I found what I ex-
pected, namely, an extremely putrescent pulp. After the
local condition was treated, the glands became normal in a
very short time. (Figure 154.)
106 ORAL ABSCESSES
CHRON8C If the lymph, glands are swollen and re-
cervical main so on account of persistent infection
nrUmc" ^ or a l° n g time, we have chronic lymph-
adenitis.
Etiology: Chronic lymphadenitis is a secondary infec-
tion. It is caused by continuous absorption, such as
bacteria from chronic abscesses or pyorrhoea.
Symptoms: The glands are usually much larger than
in the acute condition. They are hard, are easily palpi-
tated, and are not tender on touch. They are not adherent
and seldom suppurate.
Treatment : The focus should be removed because there
is always danger of a secondary infection such as tuber-
culosis, reaching the gland via the primary lesion.
subacute Subacute lymph glands occur from sub-
cervical acute attacks in the primary lesion.
lymph A- Symptoms: Besides the symptoms caused
denitis about the focus, we find the lymph glands
very large and extremely tender. This is characteristic
for subacute attacks.
Treatment : The treatment is the same as for the acute
condition.
illustrative Case XI ' ( Cnronic lymphadenitis.) A
CASE yo un g lady of about 18 years, was sent
to me with radiographs showing four im-
pacted wisdom teeth. She complained of swellings in the
submaxillary region, which from time to time became
very tender and painful. On examination the gums
around the wisdom teeth are found red and inflamed, dis-
charging pus on pressure; the posterior submaxillary
lymph gland on each side is much enlarged. I extracted
all four impacted teeth under ether anaesthesia, and after
the wounds had healed the glands diminished gradually
to their normal size. (Figure 155.)
tubercular Tubercular cervical lymphadenitis is more
cervical frequent in children under six years, but
lymph A- is not a rare occurrence in adults. That
denitis y. occurs independent of general tubercu-
losis due to septic infection from the mouth was
shown by Professor Cantani in fifty clinical ob-
SECONDARY COMPLICATIONS 107
servations at the Institute of Medical Clinic of the
Royal University of Naples.
Etiology : The cause is the tubercle bacillus, which may
find its way to the glands via the lymph system or circu-
lation from the tonsils or the teeth. Carious teeth with
open pulp chambers are an ideal place for the entrance of
such microorganisms.
Symptoms : The glands first are enlarged and firm, and
it is characteristic that in a short time other glands are
involved and the structures in the vicinity of the glands
become fused together. (Peri-adenitis.) It is also
characteristic that the swelling of the glands does not go
back after removal of the focus. In cases where the in-
fection is secondary to tuberculosis of the lungs, bones,
etc., the glands do not become excessively enlarged, but in
primary infections we have large glands which tend to
break down.
Treatment : The treatment more or less depends on the
question whether the patient suffers from general tuber-
culosis or whether the cervical lymphadenitis is only a
local infection. If the patient's general health is poor, it
should be improved by outdoor life and plenty of good
nourishment. In treating local conditions we should
ascertain and radically remove the cause. Radiographic
examination is necessary to ascertain abscesses resulting
from teeth, because chronic abscesses give no symptoms
or signs to indicate the condition. The removal of the
cause, however, does not cure a cervical tubercular ade-
nitis and many treatments have been advised for this
condition.
Extirpation: Surgical removal according to many
writers is not justified in cases of moderate size because
they claim that tubercular adenitis is liable to recur. I
think the reason for the recurrence may rather be found
in the neglect or insufficient treatment of the cause than in
the method. However, it may be advisable to try one or
more of the other methods before resorting to radical
means.
Heliotherapy: This treatment consists in exposing the
glands to direct sunlight.
108 ORAL ABSCESSES
Radiotherapy: A series of X-ray treatments has been
found to give good results. The X-rays are carefully
filtered to prevent burning and the dosage is regulated
according to the patient and the condition. About twenty
treatments applied twice a week are said to be sufficient.
This treatment is also advised in cases where suppuration
occurs. The abscess may be punctured if a sinus does
not already exist. X-ray treatment is also beneficial
after extirpation to prevent recurrence.
Injections of Antiseptics : Injections into the glands of
iodine or carbolic acid have been advocated. De Vecchis,
an Italian physician, has used the following method which
had not failed him in a single case, and has the advantage
of not causing a permanent scar or fibrous thickening,
which fact is important from an aesthetic viewpoint,
especially in women. After careful search for and
removal or treatment of the focus or possible foci in the
mouth and throat, he injects the following solution :
Synthetic guaiacol Merck 6.0
Metallic iodine 3.0
Sodium iodid 6.0
Glycerine 30.0
Saccharin 0.5
Aqua dest 10.0
Mx et solve.
Sig. for injections.
With needles of special size he makes parenchymatous
injections with this solution, turning the needle in all
directions in the gland and liberating the drug drop by
drop, using 1 to 2 c.c. in all. The injection is followed
by slight massage and by application of tincture of
iodine and warm cotton for twenty minutes. When
suppuration has begun, he aspirates all pus-like liquid,
and if the patient can be seen daily, he also uses gluteal
injections of 1 c.c. each day. In regard to the paren-
chymatous injections the operator should be particu-
larly careful in regard to asepsis, so as not to cause
mixed infection. After each injection the gland becomes
SECONDABY COMPLICATIONS 109
more tumid, warmer and more reddish, but after one or
two days it begins to diminish in size. The injection is
repeated twice a week for three to four weeks ; the patient
is directed to use an antiseptic mouth wash and gargle, to
avoid smoking and drinking of intoxicating beverages,
and is advised to live in the fresh air and sleep with the
windows open, to eat as much as he can of the most
nutritious food.
illustrative ^ ase ^^' ( TuDercular lymphadenitis.)
CASE (Case reported by Stark in Revue de la
Tuberculose, July, 1896.) A youth who
had always been healthy previous to his eighteenth year,
developed at that age enlarged glands. Carious molars
were present on both sides. The glands were removed and
the teeth extracted. The glands proved to be tuberculosis
and the cover slip preparations from the teeth revealed
tubercle bacilli.
5. Diseases of the Alimentary Canal.
The mouth and teeth have a very close relation to the
rest of the alimentary canal both in health and disease.
There are three ways in which digestive disturbances
occur.
1. Insufficient Mastication. The mouth is the place
where the food should be properly prepared for digestion
by crushing it into small pieces and mixing it with saliva.
A full set of teeth, especially bicuspids and molars, is
necessary to accomplish this. Lack of chewing surface,
sore and carious teeth or malocclusion mean imperfect
mastication, and consequently increased and unnecessary
work for the stomach. "While such a condition leads to
various ills connected with impaired digestion," says
Hunter, "it is not the most important relation of dental
diseases to general health."
2. Swallowing of Bacteria and Pus. Most serious
gastric and intestinal disturbances are liable to result
from continuous swallowing of pus and bacteria, which
are either mixed into the food during mastication or
110 ORAL ABSCESSES
reach the stomach between meals. Oral diseases pro-
ducing such conditions are numerous and common, oral
abscesses discharging through sinuses into the mouth,
stomatitis and pyorrhoea are of greatest importance. Ill-
fitting crowns and fixed bridges, which often cause most
contaminating unsanitary conditions, are also a source of
gingival inflammation and ulceration.
The discharge from these diseased conditions is con-
tinuously taken into the stomach. For a long time the
acids of the stomach have been looked at as destructive
to such bacteria, but Smithies,* in a microscopic ex-
amination of gastric extracts from 2,406 different
individuals with "stomach complaint," showed that
irrespective of the degree of acidity of such gastric
extracts, bacteria were present in eighty-seven per cent.
Hunter says there is a limit to the power of the stomach
to destroy such organisms. Even in health it is never
complete and is solely due to the presence of free HC1.
But these powers become progressively weakened, when
through any cause an increased and continuous supply of
pus organisms is associated with a diminished and contin-
ually lessening acidity of the gastric juice. During the
intervals between digestion the acidity of the stomach
reaches normally a low level which also gives bacteria a
good chance to live and multiply in the stomach.
These conditions lead eventually to deeper seated
changes in the mucosa of the stomach, and also pass
through into the intestinal tract. They pass through the
small intestine, where they also may enter into the blood
stream to the large intestine where they may exist in large
numbers. In this fashion enteritis, colitis and appendi-
citis may be caused.
3. Haematogenous Infections of the Alimentary Canal
Due to Oral Foci. Rosenowf writes that hemorrhages,
superficial erosions and definite ulceration of the mucous
membrane of the stomach and duodenum occur in man
not infrequently during severe infections. He produced
* Cited from Mayo : Mouth infection as a source of systemic disease.
t Eosenow: The production of ulcer of the stomach by injection of streptococci.
SECONDAEY COMPLICATIONS 111
ulcers in the stomach or duodenum, or both, of eighteen
rabbits, six dogs, and in one monkey by intravenous in-
jections of certain streptococci, which have a certain
grade of virulence.
septic Many writers describe only acute and
gastritis chronic catarrhal gastritis and mention
bacterial infection invading the stomach
from the nose and accessory sinuses, the throat and oral
cavity as one of the causes. Hunter, however, distin-
guishes a septic gastritis due to pyogenic infection of the
stomach. The term acute and chronic is principally used
to indicate a case which is temporary in its course or of
a case which shows little tendency towards spontaneous
recovery.
Etiology : Professor Miller already recognized the fact
that indigestion may be associated with foul mouth, and
he brought a charge against the physicians that "their
custom of disregarding dental diseases altogether as a
factor in pathology is as unjust to their patients as it is
discreditable to their profession."
Septic gastritis is caused by continuous swallowing of
pus organisms such as are discharged from oral abscesses
with sinus and pyorrhoea pockets, infected tonsils or
septic diseases of the nose. Not all these bacteria are de-
stroyed, as has already been explained, and the mucosa
becomes eventually infected, a septic catarrh is set up
which is continuously sustained by influx of pyogenic
bacteria.
Symptoms : Clamminess of the mouth, distaste of food,
coated tongue and bad taste in the mouth are not so much
manifestations of gastric catarrh as the direct result of
oral sepsis. The real symptoms are indigestion, gastric
discomfort, and nausea.
Case XIII. (Subacute gastritis.) Re-
case ported in Hunter's "Pernicious Ane-
mia," page 231.) A lady, aged sixty-two
years, suffered from subacute gastritis. The patient had
severe intermittent sickness and gastric pain of eight
months' duration, necessitating the use of morphia, with
112 ORAL ABSCESSES
loss of weight and increasing weakness. Cancer was sus-
pected, but on examination no sign of malignant disease
was found in the stomach, the abdomen, the rectum or the
uterus. Constant complaint was made of a bitter taste
in the mouth, nausea, with loathing and distaste for all
food. The tongue was coated with a dirty moist fur.
The patient had false teeth both in the upper and lower
jaws. The plates were scrupulously clean, and the gums
beneath the plates were perfectly healthy. There were
four remaining teeth, three of them decayed, suppurating
around the roots, with pus welling up on pressure. There
was no other sign of disease. A provisional diagnosis
was made of gastritis caused by continual swallowing of
pus. The roots were ordered to be extracted. A week
later, the tongue was clean, the sense of taste returned
for the first time for eight months, and there had been
only one attack of pain. In another week, there was a
return of the sickness, with vomiting on pain and slight
fever. The vomit obtained two weeks later was watery,
with rusty flakes consisting of mucous, fibrin, catarrhal
cells, leucocytes and blood, the whole being loaded with
streptococci, staphylococci and a few bacilli. A diagnosis
was made of infective (septic) gastric catarrh. As a
local antiseptic, three grains of salicylic acid were given
thrice a day, with peptonized milk as food ; counter irri-
tation was applied. There was complete cessation of all
pain, and a steady recovery from that time onward. The
patient gained weight rapidly and has since remained
well (two years).
Similar to septic gastritis Hunter distin-
enteritis guishes a special form of the disease,
namely, septic enteritis, which is in his
experience a very common result of prolonged oral sepsis.
Etiology: The bacteria which continuously enter the
stomach and escape destruction naturally find their way
into the intestine, where they finally infect the thin epithe-
lial layer of the mucous membrane.
Symptoms : There is more or less abdominal pain and
diarrhea containing undigested food and mucous, whitish
in color, and sometimes semi-solid.
SECOm)ARY COMPLICATIONS 113
Case XIV. (Case of Enteritis.) Dr.
case TRAT,VE Hunter's case reported in the British
Medical Journal, November 19, 1904, page
1361. The patient, aged thirty-seven. Foul oral sepsis ;
most intense gastritis, enteritis and colitis, chronic renal
disease, pericarditis, uraemia. Patient died, and micro-
scopic examination of the stomach showed: intense gas-
tritis with invasion of mucosa by masses of streptococci.
The bacterial invasion descends along the
coLms > ' CmS a l mien t ar y canal and may cause appen-
proctitis dicitis, colitis and proctitis. The appen-
dix is predisposed to infection on account
of its poor blood supply (appendicitis is most commonly
caused by the bacillus coli, the staphylococci and strepto-
cocci). Haematogenous infection is also supposed to
cause appendicitis, Poynton and Paine have caused it
experimentally in rabbits with the organism isolated from
rheumatic cases. If the colon is involved, the disease is
called colitis, and if the mucous membrane of the rectum
becomes infected, we speak of proctitis.
Rosenow's work shows that in gastric and
gastric intestinal ulcers the mucosa is attacked
duodenal from behind through the blood stream.
ulcers K is therefore a disease due to haemato-
genous infection.
Etiology: The bacteria causing these ulcerating con-
ditions are supposed to have a selective affinity for these
particular areas. Predisposing factors, however, may
have a good deal to do with the localization of the disease.
Clinicians have observed aggravations of symptoms in
ulcer of the stomach following sore throat, and the asso-
ciation of these conditions with septic foci in the mouth
have been emphasized by various writers. Experimental
evidence has been furnished by producing ulcers when
injecting bacteria into the gastric artery by Rosenow's
experiments on rabbits, dogs, and monkeys with the strep-
tococcus. Steinharter* produced gastric ulcers experi-
mentally in rabbits by injecting staphylococcus cultures
* See Bibliography.
114 ORAL ABSCESSES
of a special virulence and a weak acetic acid solution into
the wall of the stomach. In the forty animals used for
the experiments typical peptic ulcers were produced vary-
ing from one quarter of an inch to one inch in diameter.
He concludes: "In the light of the above results, it seems
possible that the staphylococcus is responsible for certain
cases of gastric ulcer in human beings. If by some means
(through an erosion or trauma, etc.) a hyperacid gastric
juice enters the tissues of a limited area of the stomach
wall, and if the staphylococcus of proper virulence finds
lodgment there, it does seem quite probable that the
necessary conditions used in producing the experimental
ulcer would be duplicated.
Symptoms : About the first symptom of intestinal ulcer
is the occurrence of pain lasting for an hour or two after
the ingestion of a hurried meal, or after the taking of food
that needs unusual activity of digestion. Hyperacidity
and over-secretion, vomiting, and hemorrhages are other
symptoms of this disease. The blood may be found in the
vomitus or stool.
Case XV. (Gastric ulcer.) (One of the
cas1 TRAT,VE cases reported by Hartzel in the Journal
of the National Dental Association,
November, 1915, page 341.) The patient, a laborer,
thirty-one years of age, of Irish descent, weighing on the
average 160 pounds. Previous history, habits, and fam-
ily history negative. His present illness began in October,
1913, with heavy burning pains in the epigastrium after
eating. In November he noticed blood in the stools and
occasionally vomited blood clots. He went to the hospital
for two weeks, where he was partly on a bread and milk
diet, and then stayed at home for eight weeks before
going back to work. After four weeks the pain reap-
peared with the same symptoms. He was admitted to the
University Hospital of Minnesota (Case No. 5356), on
September 15, 1914. At this time the pain was absent,
but an area of tenderness was noted over the stomach.
He was thin, weak, unable to work, was constipated, with
blood occasionally in the stools and blood clots occasion-
SECONDABY COMPLICATIONS 115
ally in the vomitus. Physical examination showed him
fairly well nourished, with marked anaemia, palpable
cervical glands, submerged tonsils, had pyorrhoea and
many old roots. The diagnosis was made as that of gas-
tric ulcer, marked secondary anaemia, mitral insuffi-
ciency, apical abscesses and pyorrhoea. Hemoglobin
35%, red blood cells, 3,500,000, and leucocytes, 8,000.
Between September 15 and October 1 oral infection was
eradicated. All remaining upper teeth were extracted,
also the abscessed lower molars. The remaining lower
teeth were treated for pyorrhoea.
On November 2 the physician in charge made the fol-
lowing note: "Patient's condition has remarkably im-
proved. His weight has increased twenty-three pounds.
There is no abdominal pain. ' '
He was discharged on November 11, 1914, greatly im-
proved, with no other treatment than a bread and milk
diet and the elimination of the oral foci.
He again presented for examination in March, 1915.
He had been working and living as a lumber man, eating
a full mixed diet and doing the heaviest kind of work, and
has been perfectly well since leaving the hospital. He
states that for one and a half years before admission here,
he had been troubled almost continuously with stomach
symptoms and has never had so long a period of freedom
as this before. A blood count at this time showed the
hemoglobin to be 77%.
6. Diseases of the Blood.
Today we know that infections are never entirely local-
ized. Bacteria, their toxins and protein poison, produced
during the process of infection and inflammation, or both,
are always absorbed into the circulation, not only from
the primary focus, but also from secondary lesions.
The presence of bacteria and of protein poisons in the
blood may cause diseases of violent and acute symptoms,
or may be very latent in character, according to and de-
pending on the number, virulence, and species of the
116 ORAL ABSCESSES
bacteria, as well as the reaction and resisting quality of
the defending blood cells.
septicemia Septicemia is an acute general infection
of the blood caused by bacteremia which
occurs if living pyogenic bacteria exist and multiply in
the blood.
Etiology : Septicemia often results from cases of exten-
sive acute suppuration or from absorption of bacteria in
open wounds. It is predisposed by high virulence of the
bacteria and lowered resistance of the patient. It occurs
especially after surgical interference in septic conditions
in patients with lowered resistance, and from persistent
toxic and bacterial absorption, as from acute abscesses
without outlet from the pus. In patients who are feeble
from a long standing infection it is therefore advisable
not to remove all foci at once, or the result may be
fatal. The streptococcus which is found in almost all
oral infections is the cause of septicemia, but also other
pyogenic bacteria may produce the disease.
Symptoms: After the inoculation the patient suffers
from repeated chills, and the temperature rises to 105° F.
The appetite is lost and the patient apathetic and de-
lirious. The pulse becomes weaker and irregular and the
temperature falls quickly before the exitus. Death usu-
ally occurs in a few days, but sometimes the end is drawn
out for several weeks. The diagnosis of septicemia is
made by the severe and rapid constitutional symptoms
and is differentiated from toxemia and sapremia by the
blood test. A blood culture should be made at once,
using great care to disinfect the patient's skin. Blood
is withdrawn from the median basillic vein by means of
a sterile aspirating syringe, and cultures are made in the
ordinary manner. If bacterial growth is obtained, we can
make a sure diagnosis of septicemia.
Treatment : A great deal depends upon prompt, active
and thorough treatment of the local lesion. A few hours
make a great difference in the outcome. Free drainage
should be established by a wide incision ; hot, moist, and
large dressings should be applied and changed every few
SECONDARY COMPLICATIONS 117
minutes. Saline infusions (1000 to 3000 c.c.) are ex-
tremely useful; the diet should be regulated; and later,
after the infection has subsided, tonics and stimulants
should be given.
pyaemia Pyaemia is an acute infection of the blood
characterized by the presence of infected
emboli in the blood, which in turn cause metastatic ab-
scesses wherever they lodge.
Etiology : The bacteria causing the infection in the pri-
mary focus produce coagulation of the blood. This clot
soon becomes infected, and portions of it are broken off
and thrown into the circulation. It follows the venous
system, where it may cause thrombosis or be carried to
the heart and be distributed into any part of the circula-
tion. The streptococcus is the commonest cause of this
disease, but like septicemia it may also be caused by the
bacillus coli, staphylococcus, pneumococcus, and bacillus
typhosus.
Symptoms: The symptoms are the same as of septice-
mia and usually start with a severe rigor followed by
profuse sweating. The temperature is of intermittent
character and rises up to 105 ° F. Abscesses usually make
their appearance after a week and affect any part of the
body. In chronic pyaemia the symptoms are less marked.
Treatment : The radical treatment of the primary focus
is to be undertaken at once. The lesion should be freely
opened, the septic material removed without disturbing
the leucocytic area, which would allow absorption and
further contaminate the blood stream. Establish free
drainage and irrigate often. Anti-streptococcic serum
may be used and also autogenous vaccine as soon as it can
be made. The outcome of the disease depends upon the
resistance of the patient and virulence of the bacteria
and is often fatal.
Case XVI. (Pyemia.) (Reported by C.
CASE TRAT,VE ^- Haman, Wisconsin Medical Jour-
nal, March, 1903.) Patient, a man
of forty years, seen in consultation with Dr. W.
E. Bruner. An upper molar had been extracted a
118 ORAL ABSCESSES
week preceding, the face was swollen from an alveolar
abscess. The right eye was very prominent. He had a
high evening temperature of 104 to 106° F., with morning
intermissions. In a few days the other eye became promi-
nent, which is quite characteristic of cavernous sinus
thrombosis, and is accounted for by the venous connection
between the teeth and periodontal structures and the cav-
ernous sinus. The veins from the teeth empty into the
pterygoid plexus. The pterygoid plexus communicates
with the cavernous sinus directly by means of small veins
passing through the foramen Vessalii, foramen or ale and
foramen lacerum medium, and indirectly through the
facial vein which empties into the sinus. The diagnosis
of sinus thrombosis was confirmed. The patient lived
about a week.
Toxemia is a term which expresses a con-
dition due to the absorption of toxins.
Toxin in its strictest meaning is produced only by a small
number of bacteria, as we have already seen, such as the
diphtheria and tetanus bacilli. Generally, however, we
speak of toxemia as a condition which may be caused by
the absorption of any poisonous substances originated
from bacteria or bacterial activity. If the poison is pro-
duced by saprophytic bacteria which live on dead
material, we speak of "sapremia."
Etiology : Toxemia is due to the absorption of poisons
created by bacterial activity and tissue reaction. In true
toxemia toxins only are absorbed from the focus, but the
term is also applied to all those conditions where bacteria
also have entered the circulation as long as these produce
no acute general infection (septicemia).
Foci which cause toxemia are found in the intestinal
tract, the genito-urinary system, and nose, and adjacent
sinuses, the throat, and the oral cavity. Oral abscesses
play the most important role in the mouth, but toxic
absorption is also caused from unclean crown and bridge
work, stomatitis, and pyorrhoea on account of the absorb-
ing quality of the mucous membrane. All lesions in the
mouth are caused or inhabited by the largest variety of
SECONDARY COMPLICATIONS 119
pathogenic and saprophytic bacteria. They grow in com-
binations, inhabiting the diseased tissue simultaneously
or acting at different stages of the decomposition, which
makes possible the production of a large variety of chemi-
cal substances, as has already been described in the first
part. These poisons may have special actions on certain
tissues. It is well known that the diphtheria toxin, for
example, is especially prone to attack the nervous system
and to cause peripheral neuritis.
Symptoms: Toxemia may be very severe, beginning
with chills, a rapid rise of temperature reaching 104° F. ;
there may be anorexia, headache and prostration, and
later delirium, stupor or coma. In the less severe or
chronic cases, which are of very frequent occurrence, the
principal complaint is malaise.
Malaise is a condition caused by a certain
or 'chronic amoun ^ °f toxin or bacteria, or both, en-
toxemia tering the circulation. The disease is not
acute and violent as in acute septicemia
and acute toxemia, probably on account of insufficient
number and virility of the bacteria absorbed, and of the
small amount of poison liberated to cause severe intoxi-
cation. The blood pressure is lowered and the symptoms
are best expressed by the complaint of the patient of the
inability of doing mentally or physically the accustomed
day's work. Slight exertions cause disproportionate
fatigue. An abnormal amount of rest is required, the
appetite is often poor, the skin has usually a grayish,
sallow appearance, the lips lack the color of health, there
is loss of weight, constipation, and benumbed mental
activity.
Treatment : The foci may not be apparent, and it may
require a thorough search to locate the lesion from which
the absorption takes place. It should be remembered that
a very small focus may, on account of its persistence and
its chronic nature, cause a small but continuous infection
of the blood. The radical removal of such foci is the first
step in the treatment ; there is frequently more than one
focus and it is important to remove all the septic con-
120 OEAL ABSCESSES
ditions. If the tonsils are diseased, it does not mean that
oral abscesses may not participate. The treatment of the
cause is often sufficient to result in a cure ; in other cases,
it is advisable to give tonics and stimulants.
Case XVII. (Toxemia.) Patient, a
CASES RAT,VE y ourL £ l a( ty? a college student, consulted
me about a tooth which had been unsuc-
cessfully treated. She had no symptoms of discomfort
in her mouth, but upon questioning, complained of a tired
feeling and frequent intermittent fever of about eight
months standing. A radiograph showed a lower six-year
molar with poor root-canal filling, but no pronounced
periapical destruction. The second bicuspid, which is the
tooth in question, presented a very large area of lessened
density at the distal side of the apex. The tooth was at
once extracted and the bone curetted. The patient im-
proved rapidly ; the fever did not recur. (Figure 156.)
Case XVIII. (Toxemia.) Patient, a man of middle
age, asked two years ago for a careful examination of his
teeth. He complained of an intoxicated feeling in his
head, which manifested itself principally in the morning.
His ability to think was greatly decreased, smoking made
him ill, while before he was able to smoke a moderate
amount. Radiographs of his teeth showed abscesses on
the upper right incisor, upper left cuspid, first and second
bicuspid. I opened these teeth; a vile odor came from
the canals. Apiectomy was performed on the lateral in-
cisor after the root canal was properly treated and filled.
The cuspid and two bicuspids I cleaned thoroughly with
the sulphuric acid method, and treated the canals with
f ormocresol, and ionic medication. The root canals were
filled, but the points projected through the apical fora-
men. During the treatment the patient improved
greatly and at the end his head felt perfectly clear so
that he could again do his ordinary day's work. He also
said that he was again able to smoke without discomfort.
After eight months he came back saying that the old
trouble recurred in a mild form. A new radiograph
showed the areas of lessened density the same as before
SECONDARY COMPLICATIONS 121
the treatment. I amputated the roots of the two bicus-
pids at once, and later I performed the same operation
on the cuspid. The patient reported an almost imme-
diate change, and so far, permanent improvement. He
later told me of another condition which apparently came
from the teeth. He had the upper bicuspid tooth treated
in Paris some time preceding and remembered distinctly
that from this date he was afflicted with constipation.
After the first treatment of the teeth he got rid of this
condition entirely, and did not need any drugs until it
returned with the toxemia. Again it was permanently
relieved after the surgical removal of the abscesses. The
interesting part about this case is the fact proven that
root canal treatment neither with antiseptic nor ionic
medication cured the abscess permanently, although the
treatment was thorough and much longer continued than
was necessary according to general rules. The bacterial
growth and production of toxin was inhibited for a few
months, but was only lying dormant until the infectious
process slowly recovered. (Figures 157, 158.)
anaemia Anaemia is a reduction in the amount of
blood as a whole or of its corpuscles, or of
certain of its constituents. There is primary or idio-
pathic anaemia due to increased destruction due to some
existing disease. Among the primary anaemias belong
chlorosis, a disease of young girls, and pernicious anae-
mia, the cause of which is not definitely understood.
Among the secondary anaemias belong acute and chronic
secondary anaemia. Hunter separates a special class
which he calls septic anaemia.
Pernicious anaemia, or Addison's anae-
anaemia m ^ a ' Hunter says, is characterized by
imperfect action of the blood-making or-
gans, the absence of haemalytic and bone marrow changes,
and characterized by pigment changes in the liver, kidney,
and spleen. The disease is usually fatal.
Hunter, who has done so much good work on this sub-
ject, thinks that a large number of cases grouped as
pernicious anaemia are really of an infectious nature with
122 ORAL ABSCESSES
no bone marrow and pigment changes. The true per-
nicious anaemia, however, he regards as a chronic infec-
tive disease in which gastric disturbances, altered
digestion, absorption and auto-intoxication, as well as
oral abscesses and pyorrhoea alveolaris, may be a most
important antecedent and concomitant, but not the only
etiological factors. They precede the disease-creating
conditions which permit the contraction of the specific
(haemalytic) infection underlying the real characteristic
features of the disease.
Septic anaemia is a term used by Hunter
anaemia ^ or a ^ cases °^ secondary anaemia which
are of a septic infectious nature. Many
of the cases diagnosed as pernicious anaemia, and espe-
cially all anaemias comprised within Biermer's definition
of progressive pernicious anaemia, show a predominant
septic factor. These are distinguished from pernicious
or Addison's anaemia by the absence of haemalytic and
bone marrow changes and absence of pigment changes in
kidneys, liver, and spleen.
Etiology: Septic anaemia is caused by absorption of
bacteria or the poisons of bacterial activity and may come
from foci in the nose, sinuses of the oral cavity (abscesses,
pyorrhoea) , and infections in the stomach and intestine,
or chronic suppuration in any other part of the body.
Prognosis is favorable if the cause is removed in time,
but the disease may have a severe and fatal course.
Symptoms : Dirty yellow, anaemic complexion, loss of
bodily and mental vigor, with loss of weight. Not infre-
quently there is slight fever. The red blood corpuscles
are reduced, but seldom below two millions, and haemo-
globin is about forty-five per cent, on the average.
Case XIX. (Anaemia.) (Eeported by
case TRATIVE T " B> Hartzel > Journal of the Allied Den-
tal Societies, October, 1914, page 52.)
This is one case out of four which came under the obser-
vation of the writer. The patient, a Scandinavian of
fifty-three years, presented himself with a history of his
illness, having started seven years ago with slight at-
PLATE XLVII
Fig. 156
Fig. 157
Fig. 158
Fig. 156. — Radiograph showing right lower second bicuspid
causing toxemia in Case No. 17.
Figs. 157 and 158.— Radiographs of Case No. 18, showing four
granulomata.
PLATE X LVI I I
Fig. 159
Fig. 159a
Figs. 159 and 159a.
-Radiographic plates of Case No. 20. The arrows
indicate the granulomata.
SECONDARY COMPLICATIONS 123
tacks for a few minutes each day of chills and fever,
followed by vomiting. These attacks had no relation to
his meals. Since this time he had gradually, but inter-
mittently, grown weaker. He had trouble for some time
with swelling of the limbs and with dizziness. His color
became pale and yellow, and he grew dull and listless.
When admitted to the Eliott Hospital in Minneapolis,
Minnesota, he was weak, yellow in color, with constant
pain in his stomach, and seemed only dully conscious.
The case was diagnosed by the medical staff as pernicious
anaemia, with slight cardiac enlargement, mild pyorrhoea
alveolaris and rarefaction about two root ends. He was
put on iron and arsenites, and there seemed to be but
little improvement, except a slight improvement in the
blood count, until his mouth was put in good condition by
the dental staff. Since that time he has been steadily
improving. His consciousness had returned to normal
and his other symptoms have been much improved. The
most striking picture, however, is presented by his blood
count, which has steadily risen from 900,000 red blood
corpuscles and 15% haemoglobin to 2,630,000 red blood
corpuscles and 61% haemoglobin. The only serious set-
back occurred June 16, which was coincident with the
occurrence of a dental abscess, at which time the haemo-
globin dropped back from 61% to 55%, and the red blood
cells from 2,630,000 to 1,800,000. After extraction of the
abscessed tooth, the last blood count jumped from
1,800,000 to 2,500,000, and the haemoglobin is the highest
it has been since commencing his record, namely, 65%.
7. Diseases of the Heart.
The infective diseases of the heart are caused by haema-
togenous infection due frequently to the streptococcus
viridans, but may also occur in connection with typhoid
fever, pneumonia, influenza, diphtheria, tuberculosis,
and syphilis. Dr. Richard C. Cabot, in an analysis of
six hundred successive and unselected cases of heart dis-
124 ORAL ABSCESSES
ease, found that he could group 93% of these six hundred
cases under four etiological headings : 1, Rheumatic, that
is, presumably streptococci, 46% ; 2, Nephritic, 19% ; 3,
Arteriosclerotic, 15%, and 4, Syphilitic, 12%. The
streptococcic infections of the heart have their origin in
a large majority of cases before the twenty-second year.
It begins young, it is essentially a chronic disease, and if
severe or progressive, handicaps those afflicted during
the prime of life, and often causes death before maturity.
On account of the severe prognosis, every effort should
be made to eliminate all septic foci in the body as a pre-
ventive measure, especially the ones which are liable to be
caused and harbor the streptococcus. Streptococcic in-
fections of the tonsils and teeth are of very frequent
occurrence in children and form an ideal entrance for
disease. At this place it is necessary again to call atten-
tion to the importance of removing both tonsilar and
dental foci, both on account of the intimate relation
between these organs and the danger of the persistence
from a see min gly unimportant lesion after the principal
ones have been removed. The temporary teeth, especially
the temporary molars, are very often pulpless and ab-
scessed and suffered to remain in the mouth, partly
because they cause no pain and partly for orthodontic
reasons. It is, however, much better to sacrifice those
temporary teeth and take a chance on the possibility of
malocclusion rather than on the possibility of heart in-
fection and life itself.
The pericardium, myocardium, and the valves, have the
same general blood supply and therefore they are all
liable to haematogenous infection resulting in pericar-
ditis, myocarditis, and endocarditis (valvular and mural).
pericarditis P er i car ditis is an infection of the pericar-
dium occurring in children at an early
age. Its most frequent etiological factor is systemic in-
fection from infections in other parts of the body, but it
also may occur as a continuous infection from diseases of
the pleura as well as the myocardium.
SECOm>AEY COMPLICATIONS 125
myocarditis ^e car( ^ ac musculature very frequently
becomes attacked by secondary infections ;
it may be due to the streptococcus, the gonococcus, the
pneumococcus, or other microorganisms. The microscope
reveals lesions in the heart muscle which explain cardiac
irritability and later indications of cardiac distress from
infective diseases.
-*.r*«^ „ nrMT.r- Endocarditis is the inflammation of the
ENDOCARDITIS ,. . , « ., -, , ■, .
lining membrane ot the heart, and is
usually confined to the valves (valvular endocarditis) and
rarely to the walls (mural endocarditis). It is princi-
pally caused by the streptococcus and especially by the
streptococcus viridans (rheumatism), which may be
transported from a primary focus, such as the tonsils,
abscesses on the teeth, etc. The streptococcus causing
endocarditis grows best in high oxygen tension, and is
usually extremely virulent. The circulating blood fur-
nishes oxygen in abundance and furnishes an ideal con-
dition for an abundant vegetative growth on the valves
and walls of the endocardium. Syphilis, that is, the spiro-
chaeta pallida, is another important etiological factor.
Typhoid, scarlet fever, pneumonia, influenza, diphtheria,
and tuberculosis occasionally involve the valves, but show
a marked predilection for the myocardium.
Endocarditis occurs in two forms: acute endocarditis,
characterized by the presence of vegetation with loss of
continuity (simple endocarditis), or of substance in the
valve tissues (ulcerative endocarditis) ; chronic endo-
carditis is a slow sclerotic change, resulting in thickening
and deformity.
Treatment : The infectious diseases of the heart are of
a very grave and often fatal nature. Careful study leads
specialists to believe that in a large number of instances
heart disease in the adult originates in childhood, and all
energies should be put into the recognition and treatment
of these diseases in the early stages. Eustis* says that
endocarditis in its earliest stages is not surely recogni-
* Endocarditis in Children. Boston Medical and Surgical Journal, September
Zy 19i0
126 ORAL ABSCESSES
zable, but that it is important to begin treatment, in order
to be effective, before a diagnosis can be made. This
means that infections diseases as rheumatic (the term
used in its broadest sense) attacks, and chorea in children
should be treated as cases of acute endocarditis. In these
cases of suspicious heart disease, we should remove septic
foci, such as diseased tonsils or abscessed teeth. It should
be remembered that absence of pain in the mouth or
teeth is not a sign of healthy condition, but on the con-
trary, that the most dangerous septic foci, chronic ab-
scesses, are often entirely symptomless and unsuspected
by the patient, and that sometimes, if the removal of
diseased tonsils does not give the desired result, there
may be an unknown focus on one or more teeth which
can only be discovered by the radiograph. Such a focus,
although small, may be the cause of persistent infection.
In removing such foci it is of greatest importance not to
go about it in a wholesale manner; this might result in
absolute harm. Eustis reports a heart case where a
severe relapse of chorea occurred immediately after the
extraction of several teeth. The practice of removing
tonsils, adenoids, and abscessed teeth, all at one time, is
very frequently undertaken in order to save the patient
repeated shocks of general anaesthesia, but is poor policy,
as it is liable to cause exacerbations of the disease we try
to cure. The foci should be removed gradually, the ton-
sils separately, and the teeth one by one ; this can be done
easily and without causing great shock if local anaesthesia
is used, which is a most excellent method for operations
in the mouth. It also gives the operator a much better
chance to curette and inspect the abscess cavity, a most
important part of the operation.
The recovery from heart diseases is extremely slow;
strict rest in bed for weeks or months is almost univer-
sally advised in these cases even for several weeks after
the temperature and pulse have reached normal. This is
a most difficult thing I find for many dentists to under-
stand ; they think the patient should recover immediately
after the foci in the mouth have been removed.
SECONDARY COMPLICATIONS 127
Case XX. (Subacute endocarditis.)
case TRAT,VE ^^ e V&tieiat, a D °y> a S e( i thirteen, born in
Russia. He had been in this country for
two years. He had had the measles when very young and
scarlet fever some five years before coming to this coun-
try. He never had had any sore throat.
Seven months ago he started to have pain in the joints,
mostly in the shoulder region, associated with fever.
Shortly afterwards he complained of pain over the pre-
cardia and of dyspnea upon exertion. He was kept in
bed except for meals.
Physical examination showed lungs negative; heart,
apex visible and palpable in fifth interspace, 11 cm.
from the midst ernum. Over the apex was felt a distinct
presystolic thrill. Sounds of a fair quality but rapid.
At mitral area is heard a presystolic murmur. Over aorta
is a diastolic murmur and over pulmonic area is a systolic
murmur. Abdomen is full, soft, and tympanitic
throughout. No masses or tenderness. Knee jerks pres-
ent. No glands in neck, axilla, or groin. Pulse equal,
regular, of waterhammer variety. Capillary pulse
present.
Patient was admitted to the Robert B. Brigham hos-
pital on November 6. Temperature 100.6° F. ; pulse,
140 ; respiration, 28 ; blood pressure, 125-80. He was put
on a light diet and kept in bed. I ordered X-rays taken
of his teeth, which showed shadows representing granu-
lomata at the roots of the two lower first molars and one
upper first molar. I extracted the upper first molar on
December 11, and the right lower first molar on December
14, both under local anaesthesia. Cultures from the
upper molar revealed a streptococcus and staphylococcus
infection. From the lower molar a pure streptococcus
infection was demonstrated. On December 23 a slight
downward tendency of temperature was reported, the
pulse still being variable. He received vaccine treatment
beginning January 10, 1915, which, however, did not
improve his condition. On February 3, the third six-year
molar was extracted, and yielded a streptococcus culture.
128 ORAL ABSCESSES
The patient improved materially after this and was ad-
vised to have his tonsils out, as they were enlarged, but
left the hospital on February 28 at his father's request.
He was again examined at the hospital in June, 1916.
He was greatly improved : no temperature, better pulse,
is able to go about and to attend school. Regurgitation
and mitral stenosis are still present and will probably re-
main as permanent defects. (Figure 159.)
8. Affections of the Nervous System.
Nerve affections due to oral conditions are either local,
remote, or general. The local conditions arise from
direct infection of the branches of the maxillary or man-
dibular division of the fifth nerve by septic condition, or
are caused by pressure, such as is frequently caused by
impacted and unerupted teeth. The pain is usually
referred to other branches of the fifth or to communi-
cating nerves which may result in complaints in other
organs such as the ear and eye, where not infrequently
aural or ophthalmic disturbances are produced by the
referred irritation. These conditions have already been
described under their respective headings. If nerves in
other parts of the body are infected, we speak of remote
infection, and if a large number is involved, we speak of
general nerve infection. The two latter conditions are
caused by haematogenous infection or intoxication. The
bacteria and poisons created by bacterial activity or the
latter alone are absorbed from the primary focus and
certain toxins are thought to have a special affinity for
the nervous system. The poisoned blood irritates the
nerves and causes certain disturbances such as neuritis,
chorea, insomnia, and mental depression.
neuritis Neuritis is an inflammation of the nerve
trunks ; it may be in a single nerve local-
ized, "or involving a large number of nerves,' ' called
general or multiple neuritis.
Etiology : Localized neuritis is usually caused by cold,
traumatism, or extension of inflammation from neigh-
SECONDAEY COMPLICATION'S 129
boring parts. This condition is of frequent occurrence
in the mouth. Alveolar abscesses, or impacted teeth,
maxillary sinusitis, and osteomyelitis often involve in-
flammation of parts of the second or third division of
the fifth nerve. Postoperative pains after operations on
the jaws are also well known and are due to traumatic
injury of or continuous traumatic inflammation of the
nerves.
General neuritis has a very complex etiology : organic
poisons, as alcohol, ether, lead, arsenic, mercury, etc., and
poisons caused by infections, such as streptococcus, infec-
tions, diphtheria, typhoid fever, smallpox, scarlet fever,
syphilis, and others.
Hunter and other authors think that oral sepsis plays
a great role in the etiology of toxin neuritis. Hunter*
gives three well-studied cases of typical general neuritis
prevailing for many years (Case 3 for fourteen years),
and in all cases there resulted immediate improvement
from the removal of the septic oral conditions.
Symptoms : In localizing neuritis there is pain of a bor-
ing or stabbing character felt in the course of the nerve
and in the parts supplied. In general neuritis there is
no constant intense pain in the nerves, but there is numb-
ness and tingling in the hands and arms or part supplied,
a so-called paresthesia, which is often described as the
"pins and needles" sensation. There may also be altera-
tions in the muscular power and abolition of deep reflexes.
illustrative Case XXI. (Local neuritis.) The pa-
case tient, a woman of about thirty-seven
years, complained of local neuritis in the
lower jaw. An X-ray plate was taken and showed a large
area of lessened density about a root in the lower jaw.
The inflammatory process involved in this case the in-
ferior alveolar nerve and was the direct cause of the
neuritis. After removal of the root and curettage, fol-
lowed by occasional treatment, the condition disappeared
^completely. (Figure 160.)
* Hunter: Pernicious anaemia, pp. 303-305.
130 ORAL ABSCESSES
trifacial Neuralgia is a pain in a nerve or nerves
neuralgia °^ radiating character. Trigeminal neu-
ralgia attacks mostly only one branch of
the nerve, but in rarer cases two or all divisions may be
involved. It is characteristic for the disease that no
inflammatory conditions occur in the part where the pain
is located.
Etiology: The cause of trigeminal neuralgia is fre-
quently of obscure character and often cannot be located
even after the most painstaking search. It is said to occur
from general and local causes. The general causes are a
result of toxemia such as produced by infectious diseases.
The local causes are more important. They may be due
to diseases of the eye, middle ear, nose and accessory
sinuses, or especially the oral cavity and teeth.
The diseases of the oral cavity most commonly cause
trifacial neuralgia. Pulpstones or nodules often occur
in the pulp chamber of a tooth, causing pressure upon the
nerve fibres of the pulp. Impacted and unerupted teeth
are also an important factor. The pressure exerted by a
developing tooth which grows in a wrong direction may
be extremely great and sometimes even causes absorption
of parts of the permanent tooth which stands in its way,
even exposing its nerve. Pieces of alveolar process are
sometimes fractured after extraction and escape dis-
covery, or such pieces or ends of roots may be forced into
the cancellous part of the bone and cause, especially in the
lower jaw on account of the mandibular canal, pressure
upon the nerve. Abscesses on unerupted and impacted
teeth and chronic abscesses in general may, besides being
a focus from which toxic absorption takes place, be the
cause of trigeminal neuralgia. They usually give no local
discomfort, but may be causing irritation and inflamma-
tion of branches of the fifth nerve, causing in turn a reflex
neuralgic condition.
Synrptonis : The pain many times is only a slight and
bearable one, but in other cases it is of most excruciating
character. Some patients have a continuous mild pain
with severe attacks at irregular intervals. The interim,
PLATE XLIX
Pig. 160
Fig. 160. — Eadiographic plate of Case No. 21, showing a large osteo-
myelitic area caused by the root which remained under a bridge. The
diseased area extends into the mandibular canal causing neuritis of the
inferior alveolar nerve.
PLATE L
Fig. 161
Fig. 162
Fig. 161. — Eadiograph of lower molar with cavity beneath the gum (dark area around
the filling) of Case No. 22.
Fig. 162. — Kadiographie plate showing impacted lower third molar which caused
neuralgia in Case Xo. 23.
SECONDARY COMPLICATION'S
131
during which the patient is either free of pain or where
there is only a dull aching, may last minutes, hours, or
days. The attacks sometimes are of such terrible charac-
ter that the patient is tempted to commit suicide.
The attacks occur either spontaneously or may be in-
duced by movements of the mouth, washing of the face,
or touching the lips or cheek with the fingers.
Diagnosis : Diagnosis of trigeminal neuralgia requires
the most painstaking search for general as well as local
causes. It is principally a process of elimination of one
possible cause after the other. The use of the radio-
graph is imminent for examination of the oral cavity.
Plates should be taken first to make sure that there are
no impacted, unerupted, or supernumerary teeth or odon-
tomas in remote parts of the maxillary or mandibular
bones. The plates also give us a general idea about the
teeth. Films from different angles should then be taken
of all the teeth for a more detailed diagnosis, and only the
very best negatives are good enough to ascertain the pres-
ence or absence of abscesses and pulpstones.
Dr. Henry Head believes that neuralgic pains resulting
from teeth have definite areas of reference in relation to
the tooth involved. These areas have been ascertained by
gently pinching the loose skin, and if the right spot is
touched, there is often a distinct exacerbation of pain
from the tooth. The following table is from Behan's
book on "Pain."
Tooth
Reference Area
Maxill.
Incisors
Fronto nasal region
Maxill.
Cuspid
Naso labial region
Maxill.
First Bicuspid
Naso labial region
Maxill.
Second Bicuspid
Temp '1 or maxillary
Maxill.
First Molar
Maxillary region
Maxill.
Second Molar
Mandibular region
Maxill.
Third Molar
Mandibular region
Mand.
Incisors
Mental region
Mand.
Cuspid
Mental region
Mand.
First Bicuspid
Mental region
Mand.
Second Bicuspid
Hyoid or mental
Mand.
First Molar
Hyoid ) Also in ear and just behind
Mand.
Second Molar
Hyoid > angle of jaw and tip of
Mand.
Third Molar
Sup. Laryngeal ) tongue on same side.
132 ORAL ABSCESSES
Treatment : Treatment of neuralgia consists of removal
of the cause and treatment of the symptoms. In cases of
obscure persistent nature, alcohol injection into the main
trunks or the Gasserian ganglion are recommended. Neu-
rectomy of the terminal branches or of the whole second
or third division is advocated by the believers in the
surgical methods, and as a last resort the removal of the
Gasserian ganglion.
Case XXII. (Trifacial neuralgia.) Pa-
cases RAT,VE tien t> Mrs. S., was referred to me for
radiographic examination to find the
cause of an obscure neuralgia, which was referred to the
right upper side of the jaws. A diseased condition of the
bone in the upper jaw was suspected by her dentist. The
radiograph, however, revealed an obscure pus condition
about the root of the lower second molar concealed by the
gum, causing necrosis of the root. The extraction of the
lower molar stopped the neuralgia entirely. (Figure 161.)
Case XXIII. (Trifacial neuralgia.) Patient, a young
lady, complained of faceaches on the left side, which
sometimes were very severe and interfered with her
studies. X-ray showed an impacted lower wisdom tooth
as well as abscesses on both ends of the first molar. I
extirpated the impacted tooth, extracted the first molar,
and curetted the abscess cavities. The patient made quick
recovery and has been free of pain ever since. (Figure 162.)
~..^_~. Chorea, or St. Vitus 's Dance, is a disease
chiefly affecting children, characterized by
irregular, involuntary contraction of the muscles, and a
marked association with acute endocarditis and rheu-
matism.
Etiology: The disease is most common in children be-
tween the age of five and fifteen. Fright, injury, and
mental worry are named as etiological factors ; the prin-
cipal cause, however, seems to be of an infectious nature.
It has already been said that chorea is closely related to
endocarditis and rheumatism, which diseases we know to
be due to streptococcemia, thanks to our modern under-
standing enlightened by the splendid work of Rosenow.
SECONDAEY COMPLICATIONS 133
The foci which are looked for in the streptococcus infec-
tions (arthritis, endocarditis) are therefore also possible
foci for chorea, and practical experience confirms this
supposition. Eustis* mentions two relapses, one of arth-
ritis and one of chorea following tonsilectomy, and also
reports another case where a severe relapse of chorea
followed immediately after the extraction of several
teeth. These relapses are due to an increased amount of
bacteria absorbed from the unprotected wound and again
teaches us to remove such foci one by one with an interval
of several days between each extraction or operation.
Case XXIV. (Chorea.) (Eenorted by
case TRA M ' T ' Schamberg, Journal of the Allied
Dental Societies, December, 1915.) A
young girl, about fifteen years of age, was sent to the
hospital with the following complications of diseases:
chorea, muscular rheumatism, and a valvular lesion of the
heart. She was observed in the medical ward and treated
for some time without material improvement. When she
was finally sent to Dr. Schamberg's clinic, the jactitation
and convulsive movements of her body almost interfered
with a thorough examination of her mouth. Yet, staring
us in the face was a gold crown upon an upper front tooth.
An X-ray was made of this part and an infection detected.
The removal of the tooth and curettage of the bone was
promptly followed by an improvement in the chorea, and
at the end of several weeks the patient walked with
scarcely any evidence of the disease. There was likewise
such a pronouncd improvement in her other conditions
that she was considered well enough to be dismissed from
the hospital.
Mental depression and melancholia are
M ^b A i^£iJ-°h ,A diseases or perhaps symptoms of a more
AND MENTAL , -, x \ -vm i i.
DEPRESSION or l ess obscure nature. While it seems a
far cry from oral infections to mental dis-
eases, we have reliable reports from sincere men who
have seen profound depression and melancholy disappear
*Ettstis: Endocarditis in Children. Boston Medical and Surgical Journal,
September 2, 1915.
134 ORAL ABSCESSES
after the treatment or surgical removal of septic foci in
the mouth. Such cures are convincing arguments that
chronic intoxications from septic foci are some of the etio-
logical factors in these conditions.
Case XXV. (Mental depression with
CASE oral sepsis as an important factor.) (Re-
ported by C. Burns Graig.) The patient
a woman aged fifty-nine, well preserved, and of more
than average mentality. She came from a long-lived,
non-nervous stock. The father died three years ago, the
mother two years ago. During the week of the mother's
death she had a nasal operation. Soon after this, finan-
cial losses caused considerable worry. The patient con-
tinued in reasonably good health for over a year. At
this time she went to a fashionable sanitarium, more as a
pleasure resort than for treatment. While there, she
began to have attacks of dizziness. A physician told her
she had mild heart disease and prescribed Nauhehn baths.
After she had taken eleven baths a nervous breakdown
began.
When first seen, the patient was greatly depressed and
nearly always in a state of agitation, at other times she
spoke in a mournful tone without being able to give the
exact cause of her depression. She said she was con-
vinced she would not recover.
Physical examination was entirely negative except
pulse of 100 and condition of her teeth. Radiograms
showed two abscesses on the roots of crowned teeth and
a collection of pus beneath a faulty bridge. The stools
when examined proved normal, except slight evidence of
catarrhal colitis. Haemoglobin, 78%. Red blood cells,
4,869,000. White blood cells, 6,500 ; differential showed
mild increase in the lymphocytes. Urine normal. A test
breakfast showed diminution in the hydrochloric acid con-
tent. A serum Wasserman was negative and the spinal
fluid was normal in every respect.
A week of tonic measures was without noticeable im-
provement. It was then decided to have the bridge work
removed and the abscesses cured. During the following
SECONDABY COMPLICATIONS 135
week the cloud began to lift and the patient began to have
moments of better humor, and saw some possibility of
looking at the brighter side of things. She was then sent
to the country for two weeks from whence she returned
in a comparatively happy state of mind.
Case XXVI. (Melancholia.) (Reported by Van
Doom, Dental Cosmos, June, 1909.) The patient, a young
lady, was referred to Dr. Yan Doom as a case of melan-
cholia. The patient had as little cause for mental depres-
sion as one could possibly imagine, of which she was as
well aware as the doctor. She had wealth, friends, a
beautiful home, and the education and culture that should
go with such a happy environment. Examination of
the mouth revealed nothing serious. Radiographs taken
by Dr. Lodge revealed a number of teeth with areas of
absorption about their apices, of the existence of which
she had not the slightest idea. Some of the teeth were
extracted, others could be saved by treatment. Within
a short time after the septic foci in the mouth had been
removed, the patient was in normal condition. She had
no recurrence of her melancholia up to the time of the
essay (about one year).
9. Diseases of the Joints.
ACUTE Acute infectious arthritis, or rheumatic
infectious f ever ? is an acute infection of the joints
a dtuditic to focal disease. In children, carditis and
chorea otten occur simultaneously; in
adults, the systemic infection involves the heart less fre-
quently.
The disease usually starts with irregular pains in the
joints and slight malaise. There is slight chilliness, the
fever rises quickly and within twenty-four hours the
disease is fully manifest. Temperature between 102 and
104° F. Pulse soft and usually above 100. The affected
joints are painful to move, soon become swollen and hot
and present a reddish flush. The disease is seldom limited
to a single articulation and the joints are usually attacked
136 ORAL ABSCESSES
successively. The course of the disease is extremely vari-
able and depends whether there are also cardiac (endo-
carditis, myocarditis, pericarditis), pulmonary (pneu-
monia and pleurisy), and nervous (chorea, meningitis,
polyneuritis, coma) affections.
Etiology: The newer methods of bacterial culture
(Eosenow) have proved the presence of infectious organ-
isms in the joint fluid, in the synovial membrane and
proximal lymphnodes where it may always be found dur-
ing the height of the disease. The organisms belong to
the diplococcus, streptococcus class. The focus is prin-
cipally found in the throat (tonsils), nose, and accessory
sinuses, and the oral cavity.
Case XXVII. (Acute Infectious Arthritis.) Patient,
a man, about thirty-four years of age, was sent to me for
treatment. Had had measles followed by mumps, but no
other childhood diseases. A month before consulting me
he had rheumatic swellings and pain in the knees. The
shoulders were next attacked, and after a short time all
the large joints became involved. He took electric baths
but did not improve.
He was able to walk only with crutches. He showed
me radiographs which had been taken of his teeth. There
were areas of lessened density on the right upper central
incisor and the left upper first molar. The broach which
the dentist had inserted into the root canal extended
directly into the antrum and a frontal plate of both an-
tra showed an opaque area on the left side. I operated,
opening through the canine fossa ; there was a large ab-
scess at the floor of the antrum. I extracted the trouble-
some molar and removed by curettage the diseased bone
and abscessed areas. The antrum was washed daily.
Apiectomy was then performed on the central incisor.
The patient suffered an exacerbation in the knee joint
and had to stay in bed for three days. After a week he
started to improve gradually and after seven weeks, when
the antrum had healed, he was entirely rid of arthritis.
He walked into my office without difficulty ; his joints were
PLATE LI
Fig. 163
Fig. 164
Fig. 165
Figs. 163, 164 and 165.— Radiographs of Case No. 27. There is
an abscess on the upper central incisor and upper first molar,
which infected the antrum causing acute arthritis of all the
joints.
PLATE LI
Fig. 166
Fig. 167.
Fig. 167
Fig. 166.— Normal Land.
-Hypertrophic Arthritis. Note the bo.iy overgrowth of many of the phalangeal joints,
especially the terminal of the first and fifth phalanges.
SECONDARY COMPLICATIONS
normal. He received no general treatment while I took
care of him, and the improvement in the condition of
the joints was wholly due to the removal of the infectious
focus. (Figures 163 to 165.)
Hypertrophic arthritis is the term used
hypertro- by Goldthwaite, Painter, and Osgood for
arthritis those cases in which the chief lesion is
an outgrowth of bone in or very near the
joint, but without destruction of joint tissue as a charac-
teristic or important change. Most writers agree to
classify these cases as hypertrophic, except Billings, who
would deny this condition a class by itself, placing it in
the group with atrophic arthritis as a result of joint
infection. (Figure 167.)
It is a disease of the latter half of life. There is usu-
ally a history of trauma, or static disturbances. The
disease does not show a tendency to steady progression.
There is no true ankylosis, motion is limited only by
interference of the exostoses. The X-ray shows the pres-
ence of osteophytic outgrowths and marked marginal
lipping of the joints.
Etiology: Painter, who also recognizes the type of
hypertrophic arthritis, believes it is not due to infection,
but to a combination of trauma and faulty metabolism.
gouty Glouty arthritis should not be confused
arthritis with true gout, for many of the charac-
teristics are lacking. It is a disease of the
metabolism which may attack any damaged joint. It
derives its name from the fact that the bones show the
small pouched out spots called " Bruce 's nodes," which
are also found in true gout. (Figure 168.)
Painter divides the chronic infectious
chronic IN- type of arthritis into infectious and atro-
A ^.pQ l p H '^ AND phic. It has been established that the
arthritis infectious group is found in earlier life,
while the atrophic type is seen in
persons of older age. In the Robert B. Brigham Hos-
pital Painter classified twenty-five cases and showed that
the average age of the infectious type is thirty-two years,
138 ORAL ABSCESSES
of the atrophic type forty-nine years. "It seems, there-
fore, logical to suppose," says Lawrence, "that atrophic
and infectious arthritis are but different stages of the
same process. ' ' The chronic infectious type, which occurs
in early life, is called Still's disease in children.
Etiology : Chronic infections and their sequel, atrophic
arthritis, are much more common and more serious than
the hypertrophic form. The two main causes of these
two types are now generally held to be autointoxication
and infection. (Figures 169 and 170.)
Autointoxication is by some writers believed the etio-
logical factor, because many investigators (Phillip, Cole,
Beattie, and others) failed entirely to demonstrate bac-
teria in the diseased joints. The toxin material may
come from any part of the body and may be due either
to continuous, persistent bacterial activity in some focus
discharging toxins into the blood (toxemia), or to meta-
bolic or digestive derangements.
Bacterial infection of the joint tissue is believed to be
the cause by other writers, S chillier, Poynton, Paine, and
before all, Rosenow isolated three organisms belonging to
the streptococcus pneumococcus group from the joints.
Each of these organisms is convertible into the other types
by cultural methods. These bacteria have a characteristic
low grade virulence and grow best in a low oxygen tension
and even grow anaerobically. Such a condition is found
in the infected joints caused by the method by which the
bacteria invade the tissue ; the vessels supplying the joints
are closed by endothelial proliferation at the site and
stimulated by the bacterial embolus. Injected into animals
they produce arthritis, endocarditis, pericarditis, myosi-
tis, and myocarditis. Steinharter* undertook such animal
experiments, injecting staphylococcus cultures into rab-
bits and dogs intravenously. The material used was pre-
pared by suspending an agar slant culture in about 10 c.c.
of normal salt solution. The usual dose of such an emul-
sion was 1 c.c. for a rabbit and 3 c.c. for a dog. The re-
sults as shown by the published protocols, indicate that
the staphylococcus is apt to localize in the joints and pro-
* See Bibliography.
PLATE LI I
Fig. 168.— Gouty Arthritis. Note hypertrophic changes of the phalangeal joints and the
small areas having a pouched out appearance just posterior to the distal end of the second
portion of the phalanges, characteristic of gout.
PLATE LI V
Fig. 169
Fig. 170
Fig. 169. — Infectious Arthritis. Note the periarticular swelling and irregular joint atrophy with
thinning of the cartilage.
Fig. 170. — Atrophic Arthritis. Note the general bony atrophic destruction of several joints with
corresponding deformity.
SECONDAKY COMPLICATIONS 139
duce the typical lesions and symptoms (lameness) of
arthritis. The organisms recovered from the arthritic le-
sions have a decided tendency to again localize in joints.
In some cases the arthritis was the only lesion found at
autopsy, but in other cases it was associated with duodenal
ulcer, appendicitis, cholecystitis, myocarditis, pericar-
ditis, endocarditis, nephritis, colitis, and myositis. ' ' The
results of localization obtained in connection with studies
of staphylococci," says the writer, "are singularly sug-
gestive of Rosenow's results with streptococci."
The causative focus, is, according to Billings, usually
found in the head, but may be found anywhere in the
body. The most important places for infectious foci are
found in the nose, throat (tonsils), oral cavity, the intes-
tinal tract, and genito-urinary system. Septic foci may
occur in different parts of the body simultaneously, as
the tonsils and the teeth, or the teeth and the intestinal
tract, and even may have a pathological connection. It
is rather seldom to find a true condition where, for ex-
ample, the only foci are found in the mouth, but it is
evident that the sufferers from chronic arthritis have
almost always an abundant number of septic lesions in
the mouth, which without question may have been respon-
sible for the disease. The lesions in the mouth from
which haematogenous infection may take place are
principally the different varieties of abscesses, pyorrhoea
pockets, and septic bridgework. The streptococcus is
most frequently found in oral abscesses, as has already
been mentioned, and septic processes are found in the
mouth of a very large percentage of people. At the
Robert B. Brigham Hospital I examined eighty-seven
patients, from which number seventy-two or eighty-nine
per cent, had abscesses on from one to thirty-two teeth.
The seventy-two patients had three hundred and forty
abscesses and many suffered from pyorrhoea besides.
Treatment : The treatment consists in general improve-
ment of the metabolism by suitable diet and open-air
existence. Then comes the search and removal of all
possible foci of infection and absorption to eliminate
140 ORAL ABSCESSES
radically any source which was originally responsible for
the disease and may cause reinfection. The removal of
the focus does not necessarily result in a cure, as the
secondary joint lesions have developed to a certain extent,
but it frees the system from the burden of continuously
taking care of those conditions and gives the patient a
chance for an effort towards recovery from other diseased
conditions. Abscesses, as well as other pus conditions in
the mouth, should therefore be radically removed, not
only because the system absorbs from them bacteria and
toxins, but also because many have sinuses into the mouth
through which pus is discharged, which deteriorate the
food and cause gastric and intestinal sepsis. It is also
important to restore the masticatory apparatus to full
efficiency. The teeth, which are missing, should be re-
placed by plates or by removable bridge work, because
it is not fair to expect that the stomach of a weakened
patient will digest food which has not been properly pre-
pared in the mouth. Local treatment of the diseased joints
and consists of hydrotherapy and electric baking and
massage.
illustrative Case XXVIII. (Infectious arthritis.)
(From a report by Dr. Proctor.) The
patient, a young girl, aged twenty-one,
had always been in very good health. As a child she had
mumps and measles. Has not had scarlet fever, diph-
theria, or pneumonia. Eleven years ago the patient suf-
fered considerably from nasal catarrh, with sore throat
and swelling on the side of the neck. This was operated
on and discharged for three or four months. Has not
been subject to colds or sore throats since; the swelling
on the neck did not recur. No tuberculosis or arthritis
or carcinoma in the family history.
On Sunday, August 16, 1914, the patient had an ul-
cerated tooth (right upper central incisor) which was
giving her some trouble. The following morning the
pain had increased and the face was swollen. She went
to the dentist to have it attended to. He lanced an
abscess on the gum and gave her another appointment
SECONDARY COMPLICATION'S 141
for the following Friday, August 21. During the interval
between these visits the girl suffered very great pain and
could not sleep nights. The dentist, however, filled the
tooth with a gold filling and told the girl that she would
have to expect more or less pain, but that the swelling
would soon go away. When she went home from this
visit her face was so swollen that her mother hardly knew
her. After four or five days the face started to become
normal and at the same time the left ankle began to get
stiff, and shortly afterward the right ankle became
affected, then the elbows and thumbs became stiff and
swollen. The joints had not been particularly tender,
but the condition showed a tendency to steady progres-
sion until the patient could hardly walk on account of
stiffness and pain. The first physician who took care of
her thought that her trouble might be due to a run-down
condition, and as she grew gradually worse under his
treatment (she saw him two or three times for ten weeks),
she was advised to consult another physician, who diag-
nosed her case as infectious arthritis, with the abscessed
tooth as the causative factor. He sent her to the Rhode
Island Hospital, where she was admitted November 28,
1914. Physical examination showed nose and throat
negative, heart in good condition, lungs clear. Abdomen
no masses, no tenderness. On December 22, the jaws
started to get stiff, especially the right side, so that her
eating was limited to well chopped or soft solid foods. On
December 28, the terminal joints of the thumbs were
swollen and a dull grating was produced on manipulating
the joint. In March, 1915, the patient went home ; at this
time the girl was perfectly helpless and unable to feed
herself; she had to stay in bed. Dr. Painter, who saw
the patient in December, 1915, found all the larger joints
involved and the small joints of the hands. She was
unable to sit up and could not move any of her joints
without a great amount of pain. Figure 171 shows a
radiograph of her fingers ; Figure 172 shows the condition
of the devitalized tooth. Dr. Painter ordered massage,
regulated the diet ; Dr. Proctor performed apiectomy on
142 OKAL ABSCESSES
the upper central incisor on December 24, and removed
the scar tissue, which yielded a streptococcus staphylo-
coccus culture. The patient improved very much during
the following three months, she was able to get up and
go about, the mouth could be opened wider. In April she
took cold and had a relapse. Dr. Proctor operated on
her again on April 17, having better access to the mouth
at this time. The root of the right lateral incisor, which
was found devitalized, was amputated, and at the same
time he removed the left lower third molar and second
bicuspid, which showed abscessed condition. The pa-
tient improved again and is now able to sit up in a chair.
Case XXIX. Atrophic arthritis. Patient, a house-
wife, of sixty-nine years, was admitted to the Robert B.
Brigham Hospital on July 3, 1914. Had had measles,
pertussis, scarlet fever and lung fever, when a child. Her
present illness started two years previous. Both hands
became swollen. This swelling was white and painless;
later the feet became affected, and the eyes were inflamed.
The process subsided slowly and she had not wholly re-
covered when a second attack was suffered one year before
entering the hospital. This time the hands, shoulders,
neck and knees were affected and she has not recovered
from this attack. Examination showed pupils equal and
of normal reaction, tonsils not enlarged, throat negative.
No glandular enlargement in neck, axillae or groin.
Lungs negative, heart action irregular and systolic mur-
murs heard at apex and transmitted to axilla. Spleen
not palpable, kidneys not palpable, abdomen soft and full,
no masses nor tenderness.
Diagnosis: Infectious arthritis with atrophic changes.
The patient received house diet and was kept in bed on
account of the cardiac condition. X-rays of joints were
taken. X-rays of intestine with bismuth meal were taken.
The knees, elbows, and hands showed atrophic changes.
These were contracted so as to make the patient appear
as bent over.
On October 2 the patient was ordered to the hydro-
therapy room for electric treatment. On April 29, 1915,,
PLATE LV
Fig. 171
Fig. 171. — Badiographic plates of one hand of Case No. 28, showing atrophic destruction of
sev ral joints. Note the periarticular swelling.
Fig. 173
Pig. 172. — Radiograph showing the bone changes about the incisor which origin-
ally had caused the infectious arthritis of Case No. 28, the radiograph had been
taken about sixteen months after the patient had acute symptoms.
!FiG. 173. — Radiographic plate of Case No. 29, showing areas of disease about the
roots of the upper first molar and lower first and second molars.
SECONDAKY COMPLICATIONS 143
X-rays of her teeth were taken and showed areas of bone
absorption on the upper left first molar and the upper
right second bicuspid. There were also large areas on
the left lower first and second molars, and the right lower
second molar. (Figure 173.)
I extracted the teeth and curetted the abscess cavities.
After two weeks the patient had more motion in the
fingers and wrists, although there were still areas of
swelling and tenderness. Soon after, walking for a few
steps was successfully attempted. Improvement con-
tinued, and after three months she was able to walk up
and down stairs, and made considerable gain in the use
of her fingers on the piano. At the time of writing, May,
1916, she is in good condition, up every day, eats and
sleeps well, walks every day, and has considerable motion
in her fingers. She will leave the hospital shortly.
CHAPTER IX
EXAMINATION OF THE ORAL CAVITY
The mode of examination of the mouth is perhaps today
the greatest shortcoming of the average dentist. The
patient who trusts his family dentist entirely takes it
for granted that the dentist's examination is complete
and thorough, and believes that the mouth has been
restored to a normal and healthy condition when being
dismissed. The radiologist's exa min ation reveals many
unsuspected abscesses in the mouths of patients, to whose
mouths dentists have given conscientious if mis-
taken attention. It often takes a good deal of explana-
tion to righten the dentist's position in such cases and to
sooth the patient's anger at having been deceived. While
the dentist, of course, is not to blame for conditions which
have been caused and have developed without his knowl-
edge, the situation must be properly explained. The
patient will be quick to realize that the dentist had only
the best intentions in trying to save every tooth as an
important organ of mastication and that he surely is not
to blame for not having been able to accomplish the im-
possible in correctly treating many abnormally devel-
oped teeth and obstructed root canals, and for not know-
ing that such dangerous septic conditions can exist in
his patient's mouth without giving any symptoms. But
today, with our modern means of examination, where
X-ray machines are especially adapted for our purposes
and where radiologists are to be found in almost every
street, where there are professional men, there is no
excuse for a dentist to neglect to ascertain the condition
of all devitalized teeth in his patient's mouth. But he
who only fills cavities, constructs bridges and makes
PLATE LVI I
♦ -w
Fig. 174
Fig. 175
Fig. 176
Fig. 177
Fig. 178
Fig. 179
Fig. 174, 175, 176, 177, 178 and 179. — Radiographs of a mouth showing a large amount
of crown and bridge work of recent date and a great many abscess areas.
PLATE LVI II
Fig. 180
Fig. 181
Fig. 182
Fig. 183
Fig. 184
Fig. 185
Figs. 180, 181, 182, 183, 184 and 185. — Radiographs of a neglected mouth showing
broken-down teeth and abscess areas.
EXAMINATION OF OEAL CAVITY 145
plates and neglects other abnormal or diseased conditions
which the patient does not particularly complain of,
renders poor service to the public. The dentist is the
man who has charge of the mouth and he has a great
responsibility. It would put the dental profession back
to the age of the mechanic should we undertake to con-
cern ourselves only with mechanical restoration instead
of investigating and treating every disease found in the
region of our domain. What would we think of an
ophthalmologist who would only correct abnormal condi-
tions of the lens and would pay no attention to co-exist-
ing iritis or other inflammatory diseases of the eye % But
we find exactly parallel cases in the practice of many
dentists.
The physician often has occasion to in-
method OF quire into the condition of his patient's
P^fh.K. A-n.sN*. mouth, especially when in search of a
EXAMINATION # i • A ' n t
for the iocus or ioci oi the disease concerning
physician which the patient is consulting him. Some
medical men still have the idea that the
mouth is a thing apart from the body which cannot have
any influence upon the general health, others are too easily
satisfied with the patient's statement that the dentist is
visited regularly and that there is absolutely nothing
wrong with the teeth, but the thorough physician will not
be satisfied except with a report based upon a careful
examination and radiographic diagnosis made by a den-
tist or radiologist in whose judgment he can trust.
A superficial examination of the mouth by the physician
should include the following :
1. Examination of the soft tissues of the mouth. The
tongue, floor of the mouth, palate and gums should be in-
spected. Stomatitis is easily detectable and in pyorrhoea
the gums are inflamed and spongy, and pus can be
squeezed out from underneath the gum.
2. Examination of the teeth. Neglected teeth can be
recognized at a glance ; there are many cavities and broken
down teeth causing abscesses with or without visible
sinuses on the gum.
146 ORAL ABSCESSES
Overdentristried teeth are of a most deceiving nature.
Teeth of dark appearance, gold and porcelain crowns and
bridges always come under suspicion, because these are
generally signs of devitalized teeth, and it makes no
difference whether the gums are inflamed or normal, with
no sinus, and no symptoms of inflammation whatever.
Radiographs should be secured of such teeth as this is the
only means of finding out their condition.
Impacted and unerupted teeth should be investigated
by the X-ray. If some teeth are missing and the patient
does not remember that they were extracted it is possible
that they are in malposition and cause disturbance.
3. Enlarged Lymph Glands. If the submental or sub-
maxillary lymph glands are enlarged, it is almost always
a sign that some septic process is going on in the mouth.
Abscesses, however, may occur without the involvement
of the glands.
The old method of dental examination has
METHOD OF already been criticized in the first part of
°v^h.*,A-n,Mu this chapter. But worse than the method
for™ he of examination is the way the dentist
dentist keeps his records. The card systems and
books which are on the market are abso-
lutely inefficient, for besides a place for bookkeeping they
provide only for records of the fillings placed in the teeth
and the crowns and bridges made for the patient. There
is no arrangement that provides for the marking of root
canal operations, for indicating abscess and pyorrhoea
conditions, not to speak of other diseases which may be
directly or indirectly connected with the conditions found
in the oral cavity.
The dentist should inquire into, examine and record the
following conditions :
..„_. 1. General Health of the Patient. The
examination dentist should inquire into the general
condition of the patient's health and if a
history of systemic disease is found in connection with
septic processes of the mouth, the patient should be en-
PLATE LI X
Fig. 186
Fig. 187
Fig. 188
Fig. 189
Fig. 190
Fig. 191
Fig. 192
Fig. 193
Figs. 186 and 187,
-Badiographs revealing deep cavities causing obscure pain,
distal side of the first molar.
Both on the
Fig. 188. — Badiograph shows a large amount of unsuspected trouble.
Figs. 189, 190, 191, 192 and 193. — Badiographs showing the value of X-rays before undertaking
root canal work. In Fig. 189 note bent apex of second bicuspid with gold crown. In Fig. 191,
cuspid with root bent at right angle. In Fig. 192, the foramina of some teeth are still widely
open. In Fig. 193 there is a pulp stone in the pulp chamber of the first molar.
PLATE LX
Fig. 194
mm i
Fig. 195
Figs. 194 and 195.— Radiographs of a mouth which was examined for foci and report chart
indicating the granulomata and root canal fillings.
EXAMINATION OP OKAJL CAVITY 147
couraged to consult a physician, whose cooperation should
be secured to find out whether there is any connection
between the two conditions and what further treatment
besides the treatment of the oral condition could be of
benefit to the patient.
2. Diseases of the Soft Tissues. The tongue, palate,
floor of the mouth and gums should be examined next.
Abscesses, ulcers, cancers, gummata, palatal perforations
and clefts, benign and malignant tumors, cysts, diseases
of the salivary glands and ducts, inflammation of the
throat, stomatitis and pyorrhoea may be noticed.
3. Diseases of the Teeth. Malocclusion should be no-
ticed in children, missing teeth and lack of masticating
efficiency in adults. Cavities may be in plain view or may
only be discovered after most careful exploration. If the
patient complains of pain the teeth should be tested to
find out diseased conditions of the pulp. Applications
of ice or hot instruments to the various teeth, as well as
the galvanic or high frequency current are useful aids
to diagnosis. Acute periodontitis is recognized if a tooth
is tender and pain is caused on percussion, acute abscesses
and parulis are noticed in like manner, the latter causing
noticeable swelling of the face and gum. Sinuses on the
gum without complaint of pain and tenderness lead to
chronic abscesses caused by devitalized teeth, and all de-
vitalized teeth whether they cause apparent trouble or
not should be recognized ; these are usually darker in ap-
pearance, have large fillings or large cavities, porcelain
crowns or gold crowns which may also serve as abutment
of bridges. Such teeth should be radiographed to find
out the periapical condition and the quality of the root
canal fillings. Finally, the dentist should be on the look-
out for impacted and unerupted teeth, which usually
sooner or later become a source of serious trouble. In
children they may cause malocclusion ; in adults, various
abnormal and diseased conditions, as we have already
seen.
148 ORAL ABSCESSES
It is impossible to make a thorough exam-
graphic ination of the mouth without the use of
examination radiographs in patients who have devi-
talized teeth. If the dentist has not
an X-ray machine of his own, he can easily secure
radiographs of the suspected teeth from a dental
radiologist, who will not only take the radiographs,
but will also give valuable advice as to the in-
terpretation of the pictures. It is indeed a great ad-
vantage to be able to consult a man who as a specialist
sees many cases and therefore has a much greater expe-
rience in radiographic diagnosis than the general prac-
titioner, and the fee for such services with the modern
improvements has been reduced to a level which is in the
realm of almost every person.
Radiographs are principally taken to find obscure
causes, to ascertain physical diagnosis, to diagnose ob-
scure conditions, to prognose the outcome of therapeutic
measures, the possibilities of treatment and the course of
surgical technique.
1. Obscure pain may be diagnosed by means of radio-
graphs and found to come from decay under the gingival
margin or under fillings, from impacted and unerupted
teeth or cysts and acute abscesses.
2. Diagnosis of Condition of Devitalised Teeth. The
use of radiographs to find out the conditions of pulpless
teeth has revolutionized the attitude towards devitaliza-
tion of teeth. It made us realize the difficulty and value of
good root canal fillings and the consequences of neglect
and inability to perform perfect root canal work. Radio-
graphs show whether the root fillings reach the apex or
whether the canal is only filled part way. Broken root-
canal instruments are detected as well as perforations at
the side. The apex may show a ragged appearance, which
is a sign of necrosis of the root ; or it may appear enlarged
and bulging on account of exostosis of the cementum.
There may be an area of lessened density around the apex
showing loss of bone ; this indicates an abscessed condition
or a granuloma. Similar areas occur sometimes on the
PLATE LX1
f i I /i
( ffl (
) h
(1
(W
Fig. 196. — Eeeord chart as used by Dr. Potter and reproduced with his permission.
%
EXAMINATION OF ORAL CAVITY 149
side of a root or between the roots of multirooted teeth.
There may also be absorption of bone at the cervical part
of the alveolar process surrounding the bone, indicating
pus pocket.
3. Prognosis Before Boot Canal Treatment. It is of
great importance to make sure of the probable outcome
before involving the patient in lengthy and expensive
root canal treatment. The radiograph may show normal
canals, open apical foramina, accessory foramina, bent
and curved roots, inacessible canals on account of sec-
ondary dentine, pulp stones or broken root-canal instru-
ments. Abscess formation and necrosis of the apex may
be discovered which would indicate the necessity of sur-
gical interference and generally gives an idea whether a
tooth can be saved or not, whether the root canals can be
treated with medicines, and the canal filled to the apex,
whether apiectomy is practical and indicated to save the
tooth or whether the tooth has to be extracted.
All these findings should be recorded on a
charts CASE chart. Professor William H. Potter, who
realized the shortcomings of the ordinary
dentist's examination charts, took much pains in arrang-
ing a practical chart on which all dental conditions can
be marked down. Figure 196 shows an examination re-
corded on his chart. The plates also have historic
interest: they are copies of originals from Carabelli*.
The back of the chart is arranged for book-keeping.
Similar but simpler charts have been made up by the
author for reports of radiographic examination. This is
sent with the radiographs and gives the dentist a better
idea and clearer picture of the condition of the whole
mouth, which can be verified by the radiographs. In this
chart the radiologist can interpret the radiographic
findings so that they are plainly visible. Such a chart
is seen in Figure 195.
* Carabelli : Die Anatomie des Mundes.
CHAPTER X
TREATMENT OF ORAL ABSCESSES
The treatment of oral abscesses varies with the ana-
tomical location and with the condition of the inflamma-
tion. The treatments of the various conditions will be
discussed under the following headings :
1. Treatment of acute and subacute conditions.
2. Treatment of chronic conditions.
3. Treatment of abscesses due to diseases of the gums.
4. Treatment of abscesses from impacted and un-
erupted teeth.
5. Treatment of abscesses of the tongue.
6. Treatment of abscesses of the salivary glands and
ducts.
7. Treatment of systemic conditions.
1. Treatment of Acute and Subacute Conditions.
In treating acute conditions we should carefully differ-
entiate between acute and subacute inflammation. In
acute inflammation, especially in the beginning stage
where there is little destruction of tissue, the tissue reacts
easily to treatment and complete regeneration is possible.
In subacute cases, however, a chronic condition has pre-
viously existed, the root may be necrosed, and the reaction
of the tissue is therefore not sufficient to produce com-
plete recovery when the acute symptoms subside. The
inflammation passes back into the quiescent and persis-
tent chronic stage. It is therefore important to diagnose
the cause correctly, and distinguish between the acute
condition which occurred as a primary infection of the
periapical tissue, from an infected pulp, and the subacute
TREATMENT 151
condition, which can be recognized by the history or by a
radiograph showing that the root canal had been treated
or filled previously. In the subacute cases, extraction is
indicated unless the conditions are favorable for apiec-
tomy, but before this operation can be performed, the
same treatment is indicated as for the acute conditions
until the symptoms quiet down, when the tooth can be
filled and surgically treated.
Acute periodontitis sometimes can be
the cause topped and extensive alveolar abscess
prevented by prompt removal of the
cause. In the later stages of acute abscess it is of equal
importance to eliminate the causative factor, which is a
suppurating pulp. When opening into the tooth use a
good sized round burr, holding the tooth firmly by making
a plaster cast for each side, so as to decrease the jarring
and to prevent further irritation. If there is much pain,
conductive or general anaesthesia is indicated. Remove
the largest part of the pulp in a gentle manner so as not
to press infected material through the apical foramen.
If the radiograph indicates that abscess formation
has already begun, it may be advisable to enlarge
the root canal and apical foramen so as to get reasonably
free access to the abscess. All this is done under aseptic
precautions. A mild antiseptic dressing is placed into
the tooth, such as :
Buckley's Modified phenol:
Mentholis gr. xx
Thymolis gr. xl
Phenolis F3 iij MX
Black recommends :
01. cassiae 1 part
Phenolis 2 parts
01. gaultheriae 3 parts
Mx oils and add melted crystals of phenol.
Close the opening of the tooth with cotton dipped in liquid
petroleum ; this prevents saliva from entering, but allows
152 ORAL ABSCESSES
gases which may be formed in the canals to escape.
Change the dressing daily until the tooth feels more com-
fortable, when the dressing can be sealed into the tooth
with base plate gutta percha. After the root canals have
been cleaned and sterilized, they should be filled, so as to
seal the apical foramina hermetically. Only by scru-
pulous asepsis, careful treatment and technique can re-
currence or chronic continuation be prevented. This tech-
nique will be described in the chapter on prevention.
To avoid further irritation the affected
d Leased™ E e l° n g a ted tooth should be put at rest.
tooth This is best done by building up the occlu-
sial surface of all the teeth of one jaw
with copper cement except in the position of the tender
tooth.
Counter-irritants are beneficial to help
of counter^ a ^ sorD the abscess. Apply on both sides
irritants °^ ^ ne g um > over the affected root, tincture
of iodine, tincture of iodine and aconite,
or chloroform; these are the most common counter-irri-
tants. They should be applied to the dried mucous mem-
brane. Suction cups containing counter-irritants are
applied on the gum opposite the apex of the root.
In some cases of acute abscess, we can
latomy £ a ^ n sufficie^ drainage through the root
canal to affect a cure. This is true for
upper teeth if treatment is started before the destructive
process has progressed too far. In lower teeth this is al-
most impossible, because the process is not aided by gravi-
tation. The abscess in the mandible is also of much more
severe nature, more pain is produced, and a longer time is
required, because of anatomical conditions, till the pus
burrows an opening through the bone to the surface.
Great relief and good drainage can be secured by an arti-
ficial opening through the alveolar process. Under con-
ductive or general anaesthesia we incise the gum, retract
it to both sides, and with a large round burr drill through
the process to the apex of the tooth. The opening should
be made at the lowest level. The root canal can be opened
TREATMENT 153
at a future sitting, though I prefer to do it at once. If the
apical foramen can be penetrated, irrigation through the
tooth is indicated. Normal salt or mild antiseptic solu-
tion should be used. Put a mild antiseptic dressing into
the tooth, as already described, and a wick into the arti-
ficial sinus to prevent premature closing of the wound.
I prefer to use a cigarette wick made of rubber tissue;
this does not disintegrate. The abscess should be irri-
gated daily until no more pus is discharged, when the
root canal can be filled. The wound should heal from the
bottom ; this is accomplished by shortening the wick. If
suppuration persists we must ascertain the cause. Usu-
ally this comes from necrosis of the tooth and can only be
cured by amputation of the diseased part.
In cases presenting a subperiosteal or subgingival paru-
lis, an early incision will quickly relieve the pain. The
pus, which has already penetrated the outer plate of the
bone and collected in large quantity under the periosteum
or gum, cannot be expected to drain back through the
bone and root canal of the tooth. Therefore we should at
once, under conductive or general anaesthesia, secure a
large incision at as low a level as possible. In case of
subperiosteal parulis, which is particularly liable to cause
extensive necrosis, especially if it is of long duration, this
incision should be very extensive so as to give free drain-
age. Some authors recommend leaving the tooth alone
until the acute symptoms have subsided, but I prefer to
remove the cause at once. If conductive or general an-
aesthesia is used, this may be effected when the abscess is
incised. An opening should be drilled into the tooth and
the bulk of the diseased pulp is removed. The incision
is made on the gum as described. The pus should be taken
up with a sponge, especially under general anaesthesia.
The point of a piston syringe or fountain syringe is in-
serted into the root canal and the whole area is washed
out thoroughly with normal salt or mild antiseptic solu-
tion. Under general anaesthesia this solution should be
taken up by sponges and not left to run into the mouth.
154 ORAL ABSCESSES
Under conductive anaesthesia the management is much
simpler and the whole treatment can be done more success-
fully. The incision should be kept open by means of a
wick made of rubber tissue, and the washing should be
repeated until the discharge of pus stops. The opening
in the tooth can be closed temporarily after an antiseptic
dressing has been placed into the root canal. After the
root canal has been cleaned and sterilized it can be filled,
and if this is correctly done, the abscess will not recur or
continue as a chronic lesion unless the periodontal mem-
brane has been destroyed at the apex of the root or become
necrosed during the period of suppuration. In such
cases we have to resort to apiectomy or extraction.
extraction ^e most radical, but usually also the
quickest relief is extraction of the offend-
ing tooth. If the patient's resistance is low so that a
speedy healing by the application of any one of the above
methods cannot be expected, or, if high fever or com-
plications set in, it is almost always advisable to resort
to more radical means. If extraction is decided upon, it
should be undertaken at once, because nothing is gained
by waiting. It is an erroneous idea that a tooth should
not be extracted during the acute stage. Nothing gives
a more spontaneous result than elimination of the cause
and establishment of drainage through the alveolar
socket. The extraction should be performed under
general or local conductive anaesthesia. Spray the mouth
thoroughly and paint the tooth and surrounding gum
with iodine to prevent secondary infection. The extrac-
tion should be followed by curettage, after which the
wound is freely irrigated, treated with iodine, and lightly
packed with gauze. Antiseptics and anodines can be ap-
plied on this dressing; iodoform, orthoform, or the fol-
lowing preparation is of benefit :
Eur of orm paste :
Orthoform 40
Europhen 60
Add liquid petroleum to make a paste.
TREATMENT 155
The wound should be irrigated daily and granulation
should be allowed to fill the cavity from the bottom. An
antiseptic mouth wash should be used freely and often
and held in the mouth for five to ten minutes at a time.
If the socket does not fill in with granulation tissue
speedily it is advisable to procure a slight hemorrhage
with a sterilized instrument. The socket is then filled
with a blood clot which organizes in a very short time.
In cases where the disease has progressed to the stage of
parulis, an incision should be made on the gum in addi-
tion to the extraction and communication established from
the gum to the socket. Curette the diseased process and
irrigate profusely. The socket is treated with tincture
of iodine placed into the wound of the gum to drain the
abscess and permit the socket to fill in with a blood clot.
The dressing is changed every day until suppuration is
stopped, when the wound is left to heal.
For Palliative Effect. A hot foot-bath
treatment an( ^ cathartic should be ordered. Pre-
scribe the foot-bath as follows : A tub is
partly filled with warm water and the feet immersed.
Hotter water is added to raise the temperature of the bath
to the greatest degree that can be tolerated. Powdered
mustard may be dissolved in warm water and added to the
foot-bath. (Do not dissolve the powder directly in the
hot water; it would defeat the action necessary to pro-
duce the irritant volatile oil.) Keep the feet in the water
five to ten minutes. The effect is dilation of the blood
vessels in the lower extremities, reducing the blood pres-
sure in the head. After the foot-bath the feet should be
thoroughly dried and the patient should go to bed, which
has been warmed beforehand. It is essential not to step
on a cold floor with the bare feet, or to chill the feet in
any way, because this would contract the vessels again
and spoil the effect.
For a cathartic prescribe castor oil in gelatine capsules.
Six 2y 2 gram capsules should be taken before retiring.
156 ORAL ABSCESSES
Other laxatives are:
Tab. Caseara Sagrada a.a. 0.3 chocolate coated.
Sig. One to two tablets before retiring.
or,
Aloini gr. 1/5
Strychnia gr. 1/120
Ext. Belladonna Fol gr. 0/8
S. Take one to two pills before retiring.
An alternative may also be given in certain cases :
Potassii iodidi 6.0 g. — 3 jss.
Syrupi sarsaparillae comp. 90.0 — f3 iij.
Sig. Take a teaspoonful in water every 2 hours
till 3 doses are taken, then a teaspoonful after meals.
For Belief of Pain. Phenacetin and aspirin have
been found by the author the most effective antipyretic
for pain in the trigeminal region. Give gr. V of each and
repeat after one hour if necessary. Trigeminin gr. V or
pyramidon gr. II s.s. sometimes prove of value. To tide
the patient over a very severe attack or to give a night's
rest a hypnotic may be used. Tab. Bromural (Knoll &
Co.) a.a. 0.3 (gr. V) two to three tablets before retiring
should be given. In extreme cases :
Morphiae sulph 0.015 gr. 14
Kalii Bromid 2.0 gr. xxx
Aquae 30.0 3i
Sig. One half to be taken at once ; balance in three
hours, if needed.
For prompt relief give % or % E r - morphine hypo-
dermically.
Diet. Order a light, easily digestible diet which is
strengthening at the same time.
TREATMENT 157
treatment "^ a smus ^° ^ ne ^ ace exists we always
of sinus have to resort to extraction of the respon-
TO face s ^ e tooth. The discharging of an ab-
scess in the face is often invited by
poultices or hot applications to the face. This should be
avoided; poultices if used should be applied to the gum
and cold applications only to the face. If a sinus exists
it should be curetted and washed. After extraction of
the tooth and curetting of the diseased area the sinus will
close up speedily; unfortunately, however, not without
leaving a permanent mark. This scar can be improved
somewhat by excision of the fibrous connection which
fixes the skin to the bone and closing of the wound by a
plastic operation.
2. Treatment of Chronic Condition.
Chronic abscesses in all stages are of very persistent
character and the fact that they cause none of the car-
dinal symptoms makes it extremely hard to ascertain in
a general way whether the lesion is yielding to treatment
or not. Even the radiograph for this special purpose
is not always a safe means of finding out, because lighter
and darker shadows, smaller and larger areas can be
obtained by variation in the exposure, the quality of the
ray, the depth of the development and the angle at which
the exposure is made. Generally we may say that as long
as there is any area of lessened density at all and as long
as the root end is necrosed we cannot claim to have cured
the abscess.
Antiseptic treatment of chronic abscesses has for a
long time been the treatment per se. A large number of
drugs have been and still are in use. They are either
forced through the apical foramen but more frequently
are only applied into the root canal of the tooth by
means of cotton dressings, and it is left to their power of
evaporation to penetrate into the diseased periapical
tissue and cure the abscess. Ionic medication has been
recommended to carry the antiseptic into the diseased
158 ORAL ABSCESSES
tissue. Careful experiments with these methods and a
variety of drugs proved to my satisfaction that there is
today no antiseptic known that has sufficient penetrating
and sterilizing power to destroy bacterial life completely
in the periapical granulomata. I have treated blind ab-
scesses of medium size from the root canal with all known
methods and found such treatment extremely uncertain,
if not entirely insufficient. Grieves,* whom I consider
one of the most thorough investigators, makes the follow-
ing statement about treatment of pericemental condi-
tions: "There is to my knowledge no medicament nor
method, germicidal, oxydizing or electrolytic, that will
revivify the pericemental apex. If it be vital, the tooth
is healthy ; if it be diseased, the tooth is next to doomed.
This is the point in treatment where materia medica stops
and good surgery begins. ' '
This is exactly my opinion, based upon histopatho-
logical study, as shown in Chapter VI, and investigations
especially undertaken to study the value of the different
popular methods of medication.
Original Investigation of the Efficiency of Medication
for the Treatment of Granulomata.
Five teeth in different patients have been used for ex-
periments. All cases showed an area of about pea
size and were of long standing. I first used antiseptic
dressings until there was no more odor. Teeth 1 and 2
received no further treatment. Teeth 3 and 4 received
zinc ions, milliampere for ten minutes on two different
days, the fifth tooth received iodine ions % to 1 milliam-
pere for fifteen minutes on two days. Tooth 1 was ex-
tracted ; on tooth 2 apiectomy was performed. Cultures
were made both from root apex and abscess and showed
bacterial growth. Tooth 3 was extracted. No growth
from the root apex, slight bacterial growth from the ab-
scess. Apiectomy was undertaken on tooth 4 and bac-
* Grieves, C. J. : Dental Periapical Infection as the Cause of Systemic Disease.
Dental Cosmos, January, 1914.
TREATMENT 159
terial growth was received from both abscess and root.
Tooth 5 was also a case of root amputation; the abscess
yielded a culture of staphylococcus albus and a few very
small chains of streptococci.
Another case showed the inefficiency of ionic medica-
tion in the treatment of the chronic abscess ; Mr. R. suf-
fered with arthritis and especially complained of toxemia
and decreased mental capacity. He had to stop smoking
as the system was not able to take care of the nicotine.
From radiographic examination I concluded that there
were chronic abscesses on left upper first and second bi-
cuspids and proliferating periodontitis on the left upper
cuspid. The root canals were carefully cleaned and
treated with medicines, zinc ions were used twice and
iodine ions once, then I filled the canals. Much care was
taken in condensing the root canal fillings which resulted
in forcing the root canal cones through the foramina.
During the treatment the patient received great relief
and finally got rid of the systemic conditions, his head
was clear in the morning, and he was especially pleased
that he could again smoke "like a chimney." After five
or six months he returned, however, saying that his old
symptoms were returning. I delayed treatment for four
or five weeks longer, when he was almost as bad as before.
Radiographs showed about the same amount of decreased
density about the two bicuspid roots. Apiectomy was per-
formed and cultures procured. These yielded a bacterial
growth and the symptoms disappeared almost entirely
several days after the operation.
From these observations I conclude that in cases where
we do not deal with a purely local condition, but where
the patient's health is involved, more radical treatment
than medication is recommendable.
A chronic alveolar abscess or granuloma looked at from
the viewpoint of the bone instead of the tooth is, as
already mentioned, an osteomyelitic condition; the dis-
ease occurs in the bone and at the expense of the bone,
and the only reason why the disease does not spread more
160 ORAL ABSCESSES
easily is due to the abundant blood supply of the jaws and
the protecting reaction of the tissues which form a fibrous
layer at the periphery of the lesion enclosing the seat
of suppuration. In cases where there is necrosis of the
root, and necrosis occurs in most all roots surrounded for
a long time by chronic inflammation, it is impossible to
cure the condition without getting rid of the diseased
part by surgical means. In cases where the disease has
not progressed beyond the apical part, the usual condi-
tion, we can separate the necrosed part of the tooth sur-
gically and curette the bone, which will induce prompt
healing of the condition. This operation permits us to
extirpate the abscess radically, remove the necrosed root
end surgically, and still save the tooth.
removal of J ^ so ™ c ^ ron ^ c di seas e it is imperative to
the CAUSE remove the primary cause. The principal
cause of proliferating periodontitis and
granulomata is the condition of septic and imperfectly
filled root canals. Our aim therefore ought to be to
thoroughly cleanse the root canal and remove all infected
tissue. Root canal treatment and root canal filling are
operations which require considerable skill and patience.
The technique will be described in the chapter on pre-
vention.
Antiseptics applied into the root canal
treatment have, as already discussed, been used for
with anti- a i on g time to render the tooth aseptic.
placed ■*■ ^° no ^ think that they ever were meant
into the to be used for treatment of chronic ab-
ROOT canal scesses, and their insufficiency for this
purpose has already been enlarged upon,
but it may be wise to say also that formaldehyde,
either alone or combined with other drugs, has never
been meant to be the cure of all pulp and periapical dis-
eases. Dr. G-. Y. Black has described at length its irrita-
ting action and its power of destroying periodontal mem-
brane, and Buckley himself has stated that formaldehyde
acts only on the surface and has no penetrating power.
TREATMENT 161
IONIC
MEDICATION
Ionic medication is advisable in all those
cases of short standing where the prolif-
eration of the periodontal membrane is of
small extent and where the apex has not been affected by
necrosis nor the periodontal membrane destroyed. The
effect of ionic medication is to distribute into the sur-
rounding tissues the antiseptic placed in the root canal.
The dentinal tubules, as well as accessory foramina, are
sterilized by this method, which prevents later reinfec-
tion. The therapeutic action depends on the drug used ;
zinc, copper, silver, and iodine are most commonly em-
ployed.
Zinc Ion. A zinc electrode is used with a three per
cent, solution of zinc chloride applied on a few fibres
of cotton. Place the zinc broach into the root canal.
The positive pole is used in the tooth, the negative pole
is held in the hand, or applied to the cheek, and one-half
to three milliamperes are applied for from five to fifteen
minutes. The action of zinc chloride is tissue destruc-
tive. It is used by some men to destroy the granuloma,
which is then thought to be resorbed.
Copper Ion. A two per cent, solution of copper sul-
phate is used with a copper anode on the positive pole.
One milliampere seems to give a good dissociation of ions.
Its action is similar to zinc chlorid.
Iodine Ion. Tincture of iodine is used and applied
on the negative pole, preferably on an iridium platinum
electrode. Use one half to three milliamperes for five to
fifteen minutes. To be safe the treatment should be
repeated.
Action of Antiseptic Ions. The effect of ionic medica-
tion is to distribute the antiseptic deeper into the tissues.
Its action is destructive to bacteria. The zinc ion seems
to be the most effective, but like the copper ion, it seems
to have a decidedly irritating and tissue destructive, if
not escharotic or caustic effect. Symptoms of swelling
and pain have been observed after the treatment in several
cases by the author, and for this reason the iodine ions are
more commendable. It has only a bactericidal action
162 ORAL ABSCESSES
and does not destroy the tissue, and is well known as the
great antiseptic. I have used an aqueous solution of
iodine lately. It has all the iodine properties minus the
irritating action, and also penetrates more profusely in
moist tissue. Ionic medication with iodine is of great
importance for root canal sterilization and is to be highly
recommended for routine practice to sterilize in a proper
way the dentinal tubules and accessory foramina of a
tooth, as will be described in the chapter on prevention.
apiectomy Apiectomy is an operation by which we
can positively eliminate a chronic abscess
without sacrificing the tooth. It is the only sure method
of treatment if the apex of the root is diseased, if the
apical periodontal membrane is destroyed, if the root
canal cannot be treated and filled to the very end, if the
side of the root has been perforated near the apex by a
root-canal instrument, or if an instrument has been
broken off in the end of the root. It can also be per-
formed on teeth that carry crowns or bridges if the root
canal is accessible and properly treated and filled previous
to the operation. Not all teeth, however, are favorable
cases. The operation is impossible on third and almost
always on second molars. The first molars are frequently
accessible, and all the remaining teeth can easily be
operated upon.
The operation consists in opening through the side of
the alveolar process, amputation and removal of the dis-
eased root apex and thorough curettage of the diseased
bone. It is a strictly aseptic, surgical operation.
Radiographic examination: A careful examination of
the condition of the occlusion and a study of the length
and shape of the root by means of a good radiograph is
imperative. The condition of the root canal should be
investigated ; from the radiograph we can judge how well
we shall be able to fill it. Observe also the position of the
neighboring teeth and how much alveolar process to hold
the tooth there will be left after the operation. A tooth
with pyorrhoea or with an apical periodontitis extending
almost to the alveolar border is not a favorable case, be-
PLATE LX I I
Fig. 197
Fig. 198
Fig. 199
Fig. 200
Figs. 197, 198, 199 and 200.— Apiectomy, on the left upper cuspid. Fig. 197 shows incision,
Fig. 198 gum and periosteum retracted, Fig. 199, cutting of a window into the alveolar process
to expose the root end, Fig. 200, the root end and granuloma exposed.
PLATE LXI V
Fig. 205
Fig. 206
/m
Fig. 207
Fig. 208
me none cavity Figs 206 and 207 show the first horse-hair suture Fio- 208
shows the completed operation.
TREATMENT 163
cause after the operation there would not be enough
periodontal membrane or bone left to give firm attach-
ment to the tooth ; neither should a tooth be operated on
if the tooth next to it has also a chronic abscess which
will either directly or indirectly reinfect the healing
tissue.
Treatment of the Root Canal. Apiectomy is only suc-
cessful if the root canal has been sterilized and properly
filled previous to the operation. It is not sufficient
simply to amputate the root where the old filling ends ; but
the root canal and dentinal tubules have to be sterilized,
or there will be reinfection from the tubules exposed
where the root is cut. If it is not worth while to remove
a crown and treat the root canal, the tooth should be ex-
tracted or there will be recurrence (with or without
symptoms) and the patient is as badly off as before. It
is not justifiable to leave a crown on a tooth because it is
a masterpiece of art, if the foundation upon which it is
built ruins the patient's health. The root canal should
be rendered aseptic by application of antiseptics or by
ionic medication. It should be filled with the rosin-chlo-
roform-gutta-percha method, which has the advantage
of making the point adhere firmly to the root canal. Dr.
William H. Potter, Professor of Operative Dentistry,
Harvard University Dental School, inserts root canal
fillings with pure lead points. That pure lead is accep-
table to the tissue has been proven by the encapsulation
of bullets in almost any part of the body. It has the
advantage of being burnishable from the abscess cavity,
of not disintegrating, and of safely staying in place dur-
ing root-canal reaming for fitting of a post and crown. I
use the following method for lead fillings : Dehydrate the
root canal with acetone and hot air, dry with electric root
canal dryer until the patient feels the heat. Fill chloro-
form and resin (dram I to gr. IY) with a sub-Q syringe
into the canal and insert a gutta-percha point or cone,
pumping it forty times up and down. Remove the re-
mains of the point and insert a lead cone, previously steri-
lized by boiling it or immersing it for five minutes into
ORAL ABSCESSES
phenol and five minutes into alcohol. Condense the filling
as well as possible with root filling condensers so that it
adapts itself to the walls. Any filling or crowning of the
tooth is performed before the operation so as not to dis-
turb the healing process.
Preparing the Patient for the Operation. If local an-
aesthesia is used, it sometimes is necessary to use pre-
operative treatment, especially in nervous, apprehensive,
and hysteric patients. Bromural-Knoll (alphabrom-
isovaleryl urea) is an excellent sedative; one tablet is
given to children, two to adults (in water thirty minutes
before the operation), or ^4 gram of morphia hypoder-
mically one hour before the operation.
Preparing the Field of Operation. The mouth should
be sprayed out with an antiseptic solution, and the mu-
cous membrane should be cleaned with a cotton roll in the
area where we intend to operate.
Anaesthesia. Local anaesthesia, applied by the im-
proved technique* with novocain suprarenin is best
adapted for this operation. The amount of suprarenin
should not be too large, because too much local anaemia
is undesirable, making it almost impossible to procure
enough hemorrhage at the end of the operation to fill the
bone cavity with blood.
Radiograph. A new intraoral radiograph can be taken
at this stage, while we wait for the anaesthesia to take
effect. This is essential to ascertain the extent of the
root canal filling.
Preparation for the Operation. The operation should
be performed on the principles of aseptic surgery. The
instruments have been selected beforehand, have been
boiled and put on a sterile table, and are covered with a
sterile towel until they are used. A sterile table is pre-
pared to deposit the instruments for use, the patient is
covered with a sterile sheet, and in order to exclude the
hair, the head is covered with a sterile towel except over
* See Thoma : Textbook on Oral Anaesthesia.
PLATE LXV
Fig. 209
Fig. 210
Fig. 211
Figs. 209, 210 and 211. — Radiographs of three cases
which are not favorable for apieetomy because the bone
and periodontal membrane has been diseased from the
apex to the neck of the tooth.
PLATE LXV
Fig. 212
Fig. 216
Fig. 213
Fig. 218
Fig. 217
Fig. 219
Fig. 214
Fig. 215
Fig. 220
Fig. 212 and Fig. 216. — The patient has five devital : zed teeth w'th granuloma. Ore
tooth had to be extracted on each side. The treatment, filling, hr'd^ework nM
apiectomy which was finally performed is seen in Figs. 213, 214 and 215, for one side,
Figs. 217, 218, 219 and 220 for the other side.
TREATMENT 165
the eyes, nose, and mouth. It goes without saying that
the operator wears sterile gowns and gloves.
Operation. The saliva ejector is put in place by the
assistant and the lip is retracted with a lip retractor. One
sterile syringe is placed on either side of the part that is
to be operated so as to prevent saliva entering the field
of operation. The mucous membrane is dried with
sterile gauze and painted with 3y 2 per cent, iodine or
aqueous solution of iodine.
Incision. With a flap knife make a "U "-shaped in-
cision, as shown in the picture. Lift the periosteum and
gum from the bone with the sharp periosteal elevator.
Insert a suitable gum retractor and use sterile gauze to
remove the blood.
Amputation of the Root. The alveolar process is now
visible if it has not been destroyed by the granulation.
A good-sized opening is cut with the chisel and mallet, or
by aid of the burr to get a clear view of the apex of the
root. Resect the apex with a fissure burr at a point fur-
ther down than the extent of the root-canal filling and as
far toward the cervical part as is necessary to remove all
parts which are necrosed. Remove the resected apex
with a suitable elevator.
Curetting of the Abscess Cavity. The most important
part is still ahead. This is the removal of the granulation
tissue and curetting of the alveolar process with a round
burr, until all granulation and osteomyelitic bone is re-
moved and healthy bone is visible on all sides.
Treatment of the Wound. Smooth carefully with the
burr all sharp points and margins of the alveolar process.
Do not shape the distal part of the tooth like the end of
a root, as it is sometimes advised, because this still de-
creases the amount of attachment with the bone. Also,
I prefer to have one round, clean cavity without anything
projecting into it. Wash with normal salt solution, re-
move all the debris, sponge, and sterilize the whole cavity
with 3% per cent, iodine or aqueous solution of iodine.
Remove the excess with sterile sponges and stimulate
bleeding with a suitable instrument. When the cavity is
166 OEAL ABSCESSES
filled up with a blood clot, draw the flap over the opening
and sew it carefully with three horse hair stitches.
Healing. If proper aseptic care has been taken, a
good union of the gum is obtained in a short time. The
stitches are removed after three days and if horsehair has
been used, this causes little or no discomfort. In my
mind, the sewing in the mouth is of greatest importance ;
it prevents reinfection from saliva and the fluids of the
mouth. The healing of the bone cavity occurs by organi-
zation of the blood clot, and bone is later formed from this
tissue. In some of the radiographs it can be seen how
the trabeculae of bone grow into the cavity. Ultimately
the tooth becomes ankylosed at the end to the newly-
formed bone. The patient should be told that the face
may swell up the following day as a result of the mechan-
ical injury, for which dry heat can be applied. After
three or four days the face is normal again. After-pain
is very seldom noticed.
Failures and Dangers.
The anatomical relations of the jaw should be kept in
mind: in the upper jaw the proximity of the antrum, in
the lower bicuspid region the mental foramen, and if
operating on the lower molars the relation to the man-
dibular canal. If the operation is performed with per-
fect aseptic precautions there is very little danger.
Failures, however, may occur either because the granu-
lation tissue has not been entirely removed, because a
neighboring tooth may be involved, because the tooth has
not been sterilized, or because the cement of the root may
be discolored and necrotic almost to the cervical margin.
The last two reasons are the most important ones and
always cause reinfection, which can only be cured by
extraction. I want to make it very plain that this opera-
tion is not a short cut to save the removal of a crown, and
proper treatment of the root canal, and it is only success-
ful if that work has been previously accomplished
satisfactorily.
PLATE LXVI I
Fig. 221
Fig. 222
Fig. 223
Fig. 224
Fig. 225
Fig. 226
Fig. 227
Fig. 228
Fig. 229
Fig. 230
Fig. 231
Fig. 232
Fig. 233
Fig. 234
Fig. 235
S?ectomv'on 2 »' l^ra^'nw' *l? ^ ? 2 - 7 '~ R adio S r aph? showing the different steps of root canal treatment and
apiectomy on a lateral incisor, which had imperfect root filling and apical granuloma. Fig. 226, taken directly after
Vtcs 9o« o9q ,qn a oo-, t> j,- operation. Fig. 227 four months later.
taken two month* »ft»r tiT « f- ° g *?l ph i S sho ?' in S th .e treatment for apiectomy on another lateral incisor. Fig. 231 is
taken two months after the operation, the bone is starting to fill in. The excised granuloma of this case is seen in Figs!
Figs. 232. 233, 234 and 235.— Radiographs showing the process of' apiectomy on two teeth, the lateral incisor and cuspid.
PLATE LXVIII
Fig. 237
Fig. 239
Fig. 241
Fig. 236
uU: I
Fig. 238
Fig. 240
Fig. 242
Figs. 236, 237 and 238. — Eadiographs showing apiectomy on a first bicuspid. Fig. 23
immediately after the operation. Fig. 238 shows the process of healing, six months later.
Figs. 239, 240, 241 and 242. — Apiectomy on a cuspid. Fig. 241 directly after the
operation. Fig. 242, nine months after the operation.
TREATMENT 167
If apiectomy is ruled out as the advisable
anTT ACT,ON treatment for one reason or another, we
CURETTAGE still have the most radical treatment
left; this is extraction of the tooth and
curettage of the bone. This treatment radically and
positively removes not only the lesion, but also its cause.
I lay great stress on the removal of the chronic abscess
with the curette or surgical burr. After washing the
wound, the alveolar socket should be inspected and curet-
ting is repeated if all has not been removed. Very fre-
quently we find a definite abscess in the radiograph, but
after the tooth has been extracted, there is no abscess
attached to the tooth, and if we inspect the socket there
is only bone to be seen. This may be due to the fact that
the lamella of the alveolar socket has not been destroyed
by the disease and that it has to be broken through at the
bottom if we want to reach the granulation. After the
curetting has been completed the wound is again in-
spected, and if all the bone looks healthy, I sterilize the
wound with 3%% iodine or aqueous solution of iodine,
and then allow the socket to fill with blood. The blood
clot will organize and form new tissue.
After the bleeding is stopped, the patient is instructed
to use a mouth wash, and is asked to return for inspection
of the healing wound and for treatment.
In severe systemic disorders, if the patient has a low
resistance, or in any weak person, it is necessary to use
proper judgment in determining the number of teeth that
are to be extracted at one time. I have in many cases
noticed an exacerbation after surgical treatment, and
Hartzel reports that he has noted an exacerbation of
joint inflammation in all arthritic patients following
surgical treatment of pyorrhoea or curettage of abscesses.
A sudden extensive removal of a large number of lesions
may cause positive harm, especially in weakened patients
who have suffered a long time, and where the protective
cells have been worn out from long-continued chronic
focal infection. It is therefore not advisable to extract
a large number of teeth at one sitting, or to remove all
168 ORAL ABSCESSES
the teeth, and the tonsils the same day, while the succes-
sive removal of the foci will benefit the patient ; the action
of this process will be described later under surgical auto-
inoculation.
FYTiRPATinM ^e ex ^i r P a ^ on °f teeth with chisel or
OF TEETH burr, or both, is an operation performed
as the last resort, if extraction by forceps
and elevator have failed. But often it is indicated as a
typical primary operation, if the case is diagnosed as a
difficult one by means of radiographic examination.
Indication. Extirpation of roots and teeth is specially
indicated in cases of extensive exostosis of the root apices,
or in cases of broken down roots, partly or entirely
covered by the gum, and especially if the distal teeth have
moved forward so that the root is too large for the space.
Anaesthesia. Local anaesthesia or local and general
anaesthesia combined can be used. The decreased bleed-
ing obtained by local injections is desirable, especially in
the back of the mouth.
Preparation. Sensitive and apprehensive patients
should receive a sedative, such as Bromural-Knoll, two
tablets to adults, in water, thirty minutes before the
operation, if local anaesthesia is used. One hour before
the operation % gram of morphia with or without atropin,
as required, hypodermically, is used before a general an-
aesthetic.
Preparing the Field of Operation. The mucous mem-
brane should be dried and the area to be operated on is
painted with tincture of iodine or aqueous solution of
iodine. The saliva is taken care of by the saliva ejector.
Incision. Several types of incisions are used accord-
ing to location and condition. It should be large enough
to prevent laceration of the soft tissue and give a clear
view of the field of operation.
Operation. After the retractors are inserted remove
the outer part of the alveolar process, so as to expose the
entire root or roots ; in molars the roots should next be
separated, and this is best done with a fissure burr. The
root or roots are then luxated with an elevator, after
which the sockets are curetted and the edges of the bone
PLATE LXIX
Fig. 243
Fig. 244
Fig. 245
Fig. 246
Fig. 251
Fig. 252
Fig. 253
Figs. 243, 244, 245 and 246. — Apieetomy on a cuspid which is an abutment for a bridge. The
pulp had died. No root filling. Fig. 244 shows root filling. Fig. 245, immediately after the
operation. Fig. 246, after eight months.
Figs. 247 and 248. — Apieetomy on a lateral incisor.
Figs. 249 and 250. — Apieetomy on a central incisor.
Figs. 251, 252 and 253. — Apieetomy on two teeth, central and lateral incisors. Fig. 251,
directly after the operation. Fig. 252 shows the healing process after two months. Fig. 253
shows the bone completely filled in after ten months.
PLATE LXX
Fig. 254
Fig. 255
Fig. 256
Fig. 257
Fig. 258
Fig. 259
Fig. 260
Figs. 254 and 255. — Apiectomy on a lower incisor.
Fig. 256. — Apiectomy on two lower incisors.
Figs. 257 and 258. — Apiectomy on a lower incisor with broken root instrument in
apical part of the root canal.
Figs. 259 and 260. — Apiectomy on a lower bicuspid, the molar was extracted at
the same sitting.
TREATMENT 169
smoothed with the surgical burr. It is important to re-
move all pieces of process which are fractured or pro-
jecting so as not to prolong or hinder the healing process.
Care of Wound. The gum should be placed back and
sutured to its original position. The wound is washed
with normal salt solution until all debris is removed, and
then treated with 3% per cent, tincture of iodine or
aqueous solution of iodine. In cases of chronic abscesses
the wound can be filled in with a blood clot if the curettage
has been performed properly, but in cases of active sup-
puration, I prefer to pack the socket with iodoform
gauze, saturated with orthoform or novocain powder to
prevent pain. A mixture of orthoform powder, novocain,
and campho-phenique is also most excellent for this pur-
pose. The wound should be irrigated and dressed until
filled in with granulations.
3. Treatment of Abscesses Due to Diseases of the Gum.
Abscesses Due to Injury of the Gum. The abscesses
which start at the gingival part of the gum respond easily
to treatment as soon as the cause is removed. Foreign
substances, irritating fillings or crowns should be taken
care of, the abscesses should be incised and washed out.
Iodine is most effective as a therapeutic agent.
Abscesses Due to Pus Pockets. Abscesses caused by
the closing of a pyorrhoea pocket should be incised to
evacuate the pus. The tooth is scaled until all debris
attached to it are removed. After washing with normal
salt solution, treatment with iodine is found beneficial.
Ionic treatment is also highly recommended. Most of
these cases are due to pyorrhoea and the treatment of
pyorrhoea will not be considered in this book.
4. Treatment of Abscesses Due to Difficult Eruption,
Impaction and Unerupted Teeth.
Radiographic examination is imperative in all cases
of impacted and unerupted teeth, not only to make sure
of the diagnosis, but also to find out the position of the
tooth and to determine the course of treatment. Intraoral
films often give good results, but generally I prefer a
170 ORAL ABSCESSES
plate. With many patients it is hard to use an intraoral
film on account of trismus or a sensitive throat, and often
we get only the crown of the tooth in the picture, and
while it is possible to determine from this how the crown
is interlocked, it leaves us in doubt about the formation of
the roots. From this radiograph we should be able to
ascertain the number of roots, their form, as well as the
location of the tooth in regard to the ramus and mandi-
bular canal.
extirpation -^ i m P ac ted teeth which give rise to
OF II mp acted pathological conditions, such as abscess
and pockets or pain caused by pressure, neural
UN erupted anc [ mental irritation, should be promptly
teeth extirpated. This involves a difficult and
serious operation in which sometimes the skill of the oral
surgeon is taxed to its highest degree. The technique of
the operation I shall not mention here, but a few words
about pre-anaesthetic medication, anaesthesia and after-
treatment may be of use. The physician has not yet gen-
erally appreciated the difficulty of this operation, and the
dentist has not until lately recognized the value of proper
preparation and the after-treatment necessary for the
extirpation of impacted teeth, as well as other oral sur-
gical operations. If the operation is performed under
local conductive anaesthesia, which is the anaesthesia of
choice, it should be preceded by administration of an
hypnotic or narcotic, such as Bromural-Knoll, two tab-
lets in water half an hour before the operation, or in more
serious cases, morphine gr. 1/6 to gr. *4, or morphine, gr.
y±, and atropine, gr. 1/150. This stupifies the patient so
as to take away the terror of the operation, and appre-
hension of the instrumentation. It also relieves the
after-pain associated with such an operation. Many pa-
tients, however, prefer a general anaesthetic, which also
should be preceded by the usual preanaesthetic medica-
tion. General and local anaesthesia may be combined
to great advantage to overcome the physical as well as
psychic shock. All depends of course a good deal upon
the attitude of the patient and the difficulty of the case.
A good many impacted or unerupted teeth can be extir-
PLATE LXXI
Fig. 261
Fig. 264
Fig. 267
Fig. 262
Fig. 265
Fig. 268
Fig. 263
Fig. 266
Fig. 269
Figs. 261, 262 and 263. — Series of radiographs showing healing of the bone cavity. Fig.
262, immediately after operation. Fig. 263, after about one year.
Figs. 264, 265 and 266. — The condition before the operation is seen in Fig. 264. Fig. 265
shows the healing after a few weeks. Fig. 266 shows complete filling in of the bone
cavity after about fourteen months.
Figs. 267, 268, 269. — Radiographs showing the healing process after apiectomy. Fig.
268 shows bridges of bone growing into the cavity. Fig. 269 the condition after about
one year.
PLATE LXXII
Fig. 270. — A selection of curettes.
TREATMENT 171
pated without great effort, and in a comparatively short
time, while others call into action the greatest operating
skill. The easy cases can easily be performed in the
office, while hard cases, in apprehensive and neurasthenic
patients, should be done at the hospital, where the patient
can receive proper preanaesthetic treatment and have
proper care and medication for a few days. After the
operation great pain is usually experienced, especially
after the removal of lower impacted wisdom teeth, which
frequently extend into the mandibular canal. To com-
bat the pain, give morphia gr. 1/6 to gr. ^4 hypoder-
mically, later, if the pain is less severe, the following
powders have been found excellent by the author :
Phenacetin 0.7 gr. xii
Sodium bicarbonate 1.03 gr. xx
Codeine sulphate 0.06 gr. i
Caffeine citrate 0.24 gr. iv
Mx et devide chartulas in powders No2 iv.
Sig. One powder every three hours until relieved.
If there is only a small amount of pain prescribe :
Phenacetin —
Aspirin aa. 2.0 gr. xxx
Mx et devide chartulas in powders No2 vi.
Sig. Take one powder every hour until relieved.
5. Treatment of Abscesses of the Tongue.
The treatment of abscesses of the tongue depends very
much upon the duration of the lesion and the differen-
tiation of the simple, the phlegmonous, and tubercular
type.
In simple abscesses of the tongue with
tuber- on ty moderate infiltration, a small deep
" incision is all that is necessary. The ab-
scess cavity is drained and kept open by
an iodoform wicking, which is changed
until suppuration has stopped and the wound healed. In
the severe type of phlegmonous abscess of the tongue, it
172 ORAL, ABSCESSES
is important to incise as early as possible. General an-
aesthesia is usually necessary to open the mouth, which
is locked by muscular trismus, so that the tongue can be
properly palpitated and the cause ascertained. The an-
aesthetic should be given by a method which makes
aspiration of pus and blood impossible. If an abscess
is the cause of the disease, this should be widely opened
first, and if due to a tooth or teeth, these should be ex-
tracted without hesitation. The tongue then is drawn
forwards and pressed towards the healthy side. Its
muscle is deeply incised with a crescent-shaped knife by a
horizontal cut, which should start as far back as possible
and reach way forward near the point through the thick,
ungainly, deformed substance of the tongue. There may
be not much discharge of pus from the tongue, except a
small amount of badly smelling liquid, which almost al-
ways flows from the wound. This is, however, enough
to lessen the dangerous increase of the swelling and give
relief to the angina, feared more than anything else by
the patient. The mouth gag should stay in the mouth
until the patient has awakened, when the danger of aspir-
ing blood and pus is passed.
Small tubercular lesions should be
OFSMALL thoroughly excised and the wound sutured
tubercular immediately. Lactic acid is used by
LESSONS Brophy to sterilize the wound, and the use
of the X-rays is recommended as post-
operative treatment.
This operation is recommended by Krause
E)^siON OF arLC ^ Seymann for tuberculosis, gumma,
the TONGUE Den ig n tumors and selected malignant
tumors which involve only the tip of
the tongue. Under anaesthesia the tongue is drawn
forward and a thread of heavy silk is then drawn
through each side as far back as possible. These
hold the tongue in position . A V-shaped incision is
now made in the healthy tissue, a good distance
away from the diseased part. In order to lose
the least amount of blood, the incision is only made two-
PLATE LXXII
Fig. 271
Fig. 272
Figs. 271 and 272.— Excision of tip of tongue as
described in text.
TREATMENT 173
thirds deep, the anterior part is held with a tongue for-
ceps and drawn forward, and silk sutures are inserted at
once to draw the two sides together. After several
stitches are inserted, the incision is continued towards
the floor of the mouth on one side. When the lingual
artery is divided, the vessel should be seized with a haem-
ostatic forceps and ligated. The same thing is done on
the other side. The sutures are continued while the two
sides are drawn together. A new tip is thus formed by
the dorsal part of the tongue; this is drawn up so that
the lower surface becomes accessible. The diseased part
of the tongue is now hanging down and the suturing is
continued while the tip is resected, bringing the surfaces
in exact contact. Finally the excised part is severed and
the remaining wound united. The two large pieces of
silk which served to draw the tongue forward are re-
moved, but two of the threads from the sutures are left
and fastened, one on each cheek, to pull the tongue for-
ward in case of post-operative oedema. Liquid diet
should be prescribed, which is to be given through a glass
tube.
Large tubercular abscesses of the tongue, especially
those on the side and extending down to the reflection of
the mucous membrane of the floor of the mouth, cannot be
operated upon as just described. These should be curet-
ted. Brophy recommends application of lactic acid and
the X-ray. He says that the results of treatment of
tuberculosis of the tongue are not gratifying, and that
this is primarily due to the fact that the patient is much
debilitated by the presence of tuberculosis in other parts
of the body, therefore one should be guarded in his
prognosis.
6. Treatment of Abscesses of the Salivary Glands and
Duets.
Abscesses of salivary glands and ducts are almost al-
ways associated with salivary calculi, which are ascer-
tained and diagnosed by means of radiographs. Surgical
interference therefore is always necessary.
174 ORAL ABSCESSES
Abscesses and calculi, which are formed in the glan-
dular ducts, can almost always be excised from the inside
of the mouth, except in Wharton's duct, which we can
only trace as far back as the myohyoid muscle from this
region. Also the sublingual gland is accessible from the
inside of the mouth, while the submaxillary gland, how-
ever, and the posterior part of its duct, as well as the
parotid gland, can only be reached by an incision through
the skin.
After the mouth has been opened under
operation ether the tongue is seized with a pair of
floor T of tongue forceps and drawn towards the
THE MOUTH corner of. the mouth on the healthy side,
the lower part turned up. The tongue
now can be retracted so that we get good access to
the field of operation. Pack the pharynx with gauze and
apply iodine for sterilization. Ajo. incision is made half-
way between the f renum of the tongue and the inner sur-
face of the jaw, and parallel with the latter. The mucous
membrane is carefully dissected away and retracted.
Part of Wharton's duct is now visible, and if it harbors
the stone it should be dissected (lingual nerve towards
the mesial side). Split the duct lengthwise directly over
the stone. This is then removed, after which a fine probe
may be inserted through the ranuncula salivaris, over
which the opening of the duct can be closed with a few
sutures. If the stone, however, is not found to be in
this duct, or if it had been diagnosed from the beginning
to be in the sublingual gland, we should first ascertain its
exact location by puncturing the gland with a straight and
fine steel needle. If we draw pus or feel hard resistance
we know that we are near. The way to the stone should
be secured by a blunt instrument injuring as little of the
glandular substance as possible. A fine haemostatic
forceps serves well for taking hold of the stone, and
after it is removed the pus should be washed out with salt
solution, tincture of iodine may be applied, after which
the mucous membrane is closed by catgut sutures. In
TREATMENT 175
the experience of the author great relief and speedy im-
provement follows this operation.
In cases where the stone cannot be re-
of^the 01 ^ nioved from the inside of the mouth, ex-
G lands cision of the whole gland is advisable to
prevent salivary fistulas. The same is
true in cases of extensive destruction of any of the glands.
If a fistula exists already it is sometimes due to obstruc-
tion in the excretory duct, the relief of which has been
found to cause speedy healing of the fistula.
7. Treatment of Systemic Complications.
The important factor in treatment of systemic compli-
cations is the early removal of the focus. If foci have
been in an active state for a considerable period of time
the disease becomes firmly fixed, the secondary infection
may be well established, and in the persistent stage tissue
destruction may have occurred ; this condition is beyond
repair. Elimination of the focus then does little in the
way of repair, although it prevents reinfection and re-
moves a septic condition which is a great burden to the
system, wearing out the organs, the duty of which is to
protect the body by destroying the bacteria and neutral-
izing the foreign ferments and protein poisons.
If a result is expected from the removal of the focus of
a disease, it is of utmost importance not only to find and
remove the primary focus, but also others, namely, the
secondary foci caused by hematogenesis from the primary
focus, as these are new factors which will continue the
trouble. A streptococcus infection of the tonsils may,
for example, have been the primary cause of an endocar-
ditis or acute arthritis, but they also may have produced
a streptococcus infection in two chronic alveolar granu-
lomata which heretofore had been caused by staphylococci
albi. After the removal of the tonsils, the infection con-
tinues from the streptococcus infection of the dental
granulomata and we fail to get a cure. No time there-
fore should be lost in acute hopeful conditions to ascertain
176 ORAL ABSCESSES
all foci, whether primary or secondary, and promptly
start in with their radical removal.
This, however, should be undertaken in a
autSnoc- systematic way, and not as one multiple
ulation operation, as such procedure could, under
certain circumstances as we have seen,
bring positive harm. The surgical interference neces-
sarily inoculates the patient with a large number of or-
ganisms, inducing an effect similar to that of an efficient
vaccine, with the added advantage that the constant
supply is shut off from the disturbed focus. This sur-
gical auto-inoculation stimulates the production of anti-
bodies benefiting the patient after each operation, bring-
ing about a gradual gain. It can readily be seen that a
too large inoculation would cause positive harm,
especially in a patient who is weakened and has lost his
resistance by long standing disease. The removal of the
foci should, therefore, be carefully planned; three to six
days should elapse between each operation. Not only
should foci in different parts of the body be removed at
different times, but also foci in one region should, if pos-
sible, be operated on with intermission. In the mouth,
for example, abscessed teeth should be extracted and
curetted one at a time, leaving three to six days between
each operation, and here again I want to impress the im-
portance of thorough curettage, because it not only
removes the principal part, the real focus, which other-
wise may continue to feed the infection, but also surgical
auto-inoculation is wholly dependent upon thorough dis-
turbance of the focus.
In most diseases treatment of the secondary manifes-
tations is to be undertaken hand in hand with the removal
of the focus, because we can not expect that pathological
changes in the new lesions disappear without the proper
care and attention. Medical therapeutics, massage, hy-
drotherapeutics, surgical interference, rest, or exercise,
fresh air, cheerful surroundings, regulation of diet and
improvement in digestion and assimilation, all will fur-
ther improvement and cure of the disease.
TREATMENT 177
restoration ^ ne °^ ^ e ^ ac ^ ors which improves the
OF masti- patient's digestive process, and with it his
gating health and strength, is proper mastication
efficiency °^ ^* e ^°°d- We cann °t expect that the
stomach of a weakened patient, whom we
desire to build up, will digest food which has not been
properly prepared in the mouth. It is therefore of
greatest importance to replace all teeth, those which have
been previously lost and those which had to be sacrificed
to get rid of a primary or secondary infectious focus. The
mouth should as soon as possible be restored to its full
and important physiologic action by plates or removable
bridge work.
CHAPTER XI
PREVENTION
Gigantic studies have been made both in medicine and
dentistry in the last twenty or thirty years. The most
important advances, perhaps, are those of preventive
medicine and hygiene, and from all the specialties of
medicine there is none in which prevention is more im-
portant than in dentistry. Disease of a tooth means
invariably loss of substance; whether it is hard or soft
tissue, restoration to normal is seldom possible, a decayed
tooth will never fill in, an inflamed pulp will not yield
to any treatment, and the result is always loss of part of
the tooth or of the whole organ. The treatment is a re-
placement of the lost organic substance by inorganic
material, metal or porcelain, and the result is a com-
promise of a more or less temporary character.
The importance of the oral hygiene movement has been
acknowledged by the physician, the schools, and the pub-
lic, and it is general knowledge that teeth should be saved
for masticating purposes and that insufficient mastication,
from lack of teeth, often causes malnutrition. Today,
however, there is connected with oral hygiene a still
greater factor than saving teeth for mastication; this is
prevention of septic conditions in the mouth. We have
seen that the mouth is the very gateway through which
disease may enter and proceed through various channels
to almost any part of the body. In our practical hospitals
and clinics we have occasion to see patients where disease
is well on the way, so that it is too late for a cure of the
secondary chronic disease; we see a large number of
patients where we can stop disease by removing the septic
condition, and in still others we shall be able to prevent
septic oral foci by judiciously selecting favorable cases
PREVENTION 179
only for root canal treatment, advising extraction of those
teeth which cannot properly be taken care of. Our great-
est effort, however, should be directed towards educating
the public to make them realize the importance of pre-
serving the vitality of the tooth and prevent decay, which
is almost always the primary cause of pulp disease and
dental abscesses. The gums should be kept in healthy
condition so as to prevent pyorrhoea, which is a disease
of almost equal frequency.
Prevention of Secondary Diseases from Oral Abscesses.
At another place we have discussed the privilege and
duty of the dentist to participate in the diagnosis of the
cause of secondary disease and the aid in treatment, by
judiciously and radically removing such foci, if abscesses
or other septic conditions are found in the mouth. The
difficulty in obtaining a speedy cure by the removal of
the focus after the secondary disease has passed into a
chronic stage, has been pointed out at various places, and
the advantage of removing such foci for prevention is
therefore obvious. Each individual mouth should be
examined most carefully by means of instrumentation and
radiographs, and all septic conditions should be radically
removed. If it seems advisable to treat these teeth in
a conservative way by carefully sterilizing and filling the
root canals, subsequent examination by the radiograph
at regular intervals is indicated to note whether there is
improvement or whether the condition is getting worse.
It may be hard for a man who has practised for years the
saving of every tooth at any cost, to make up his mind
to advise extraction or expensive root-canal treatment if
there is no apparent local trouble in the mouth, and it
will be hard for a patient to understand why this or that
tooth which does not ache, could be a factor of present
or future ill-health, and should be treated or removed,
unless the dentist is able to explain the condition in a con-
vincing manner, which can only be based upon a thorough
understanding of the condition. But he who does not
tolerate septic conditions in his patient's mouth practises
180 ORAL ABSCESSES
good dentistry as far as the teeth are concerned, and most
excellent preventive medicine from the standpoint of the
whole body.
Prevention of Periapical Infection.
The question whether or not abscesses on devitalized
teeth can be prevented has not yet been entirely solved.
The men (Ulrich*) who believe that these abscesses are
caused principally by haematogenous infections of the
periapical area of pulpless teeth, which represents tissue
of lower resistance, think that it does not matter how well
the root canals are filled, abscesses may be caused in any
case, if there are infectious foci in other parts of the body,
which cause a mild bacteremia. They claim that it is
especially the streptococcus to which the lesion may be
attributed and look at most apical abscesses as secondary
infections. However, we need not search for very remote
modes of infection when there are other causes nearer at
hand. If we consider the anatomy and pathology of the
dental pulp, if we remember how hard it is to render asep-
tic the root canal, the dentinal tubules and the apical fora-
mina, and how often careless methods of technique are
employed, we find the causes may be practically obvious.
However, I do not doubt that in some instances abscesses
start as a secondary infection, and furthermore, that
subacute attacks of abscesses which have been in the
quiescent stage of inflammation for many years may per-
haps be explained in this way, although here again we
have other factors to consider.
RADIO- It is well to radiograph a tooth before
GRAPHIC undertaking to treat a root canal, no
DIAGNOSIS matter what condition it is in. Abnormal
before ROOT formation of the roots and obstructions
CANAL such as deposits of secondary dentine and
tment pulpstones can in this way be determined
beforehand, and the patient and the dentist save much
time and expense if it is determined, whether or not
we can mechanically achieve a perfect result.
* Ulrich, Henry L. : The Blind Abscess. Journal of the American Medical As-
sociation, November 6, 1915, p. 1619.
PLATE LXXiV
Fig. 273. — Microphotograph of the apex of a tooth showing multiple
foramina.
Specimen by author and stained with Mallory 's Phosphotungstic
acid and Hematoxylin.
PREVENTION' 181
Grieves* points out that arsenic used for
FOR E rulf^ SBA devitalization of a pulp is very apt to
extirpation cailse necrosis in the periapical tissue on
account of its vascularity, the drug being
absorbed by the pulp. Pressure anaesthesia with novo-
cain or cocaine as first described by Professor Edward C.
Briggs of Boston, is of greatest value for pulp extirpa-
tion. Local anaesthesia with novocain suprareninf is
also very excellent, and many times the only method that
gives results, as in cases of diseased pulps with persisting
nerve fibres or partly extirpated pulps. General anaes-
thesia is not recommended except in front teeth where
the procedure is comparatively simple.
If a pulp is infected or disturbed by sur-
pulp PLETE gi- ca l interference, it strangles itself at
EXTIRPATION ^ ne a pi ca l foramen on account of the hy-
peremia produced. It is therefore
important to remove every particle of it, or later it will
become a source for periapical infection.
In pulp extirpation a fine broach should be inserted as
far into the root canal as possible so that the entire pulp
is removed at once. A fine wire with a loop should then
be inserted with the mild antiseptic dressing, and another
radiograph should be taken to find out whether we have
reached the end of the root.
If the root canal is not large enough to
and A enlarg- a ^ ow eas ^ P assa g e to its end, and if dis-
ING the " ease d oi" healthy tissue remains, this
canal should be taken care of by the sulphuric
acid or sodium potassum method. Both
of these drugs are valuable for root canal work, but care
should be taken not to force any through the apical fora-
men. The sulphuric acid should be neutralized with
sodium bicarbonate; both drugs are best used in Luer
syringes with root canal hub. The sodium potassium
paste is used on smooth broaches; its great affinity for
organic matter draws the drug through obstructed places,
* Grieves, Clarence J. : Dental Cosmos, October, 1915, p. 1118.
t Thojia, Kurt H.: Oral Anaesthesia, p. 107.
182 ORAL ABSCESSES
making passage way for the broach. The result, however,
depends a great deal upon patient and continued instru-
mentation. The Rhein picks are the most valuable in-
struments for this purpose. The strong caustic alkali
which is formed by this process should be neutralized by
sulphuric acid, and this in turn by sodium bicarbonate.
An important factor in root canal operations is easy
access, for the crown of the tooth should be so reduced
as to allow straight entrance into the canals.
Failure of achieving the desired results in
medicatIon root-canal operations has gradually led to
the use of highly oxidizing, tissue obstruc-
ting drugs with great penetrating power, in the age when
older antiseptic methods have almost entirely yielded to
good surgery, and where it is an important principal to
destroy as few cells as possible, and where we know that
any cell which is rendered necrotic adds only another
place where infection may find media of its liking.
Drugs, such as formaldehyde and all its numerous prepa-
rations, should not be placed into a root canal under any
condition. Formaldehyde preparations should only be
used as the first dressing upon a putrescent pulp, placed
into the pulp chamber, and covered with cotton saturated
in petrol oil or with temporary stopping, as the case re-
quires. After the pulp has been extirpated, this drug
should no longer be applied into the pulp chamber nor
into the root canal, as it would penetrate through the
foramen and do harm to the periapical tissue. Zinc
chloride, copper sulphate, concentrated phenol, tri-
chloracetic acid are other root-canal drugs of great tissue
destroying action. Their use as well as the use of sul-
phuric acid and sodium potassium for root-canal cleaning
should be carefully controlled, and great care should be
taken to confine their action to the root canal. Gr. V.
Black* describes at length experiments made by appli-
cation of the different drugs for use in root canal treat-
ment. The different medicaments were applied to the
skin on cotton in small rubber cups, held in position by
* Black, G. V. : Special Dental Pathology, pp. 291-298.
PLATE LXXV
Fig. 274. — Microphotograph of the end of a root.
A, showing root filling extending into a remnant of pulp which
may give a symptom of pain which often is mistaken for the
pain caused when emerging through the apical foramen.
B, Necrosed area of the dentine. D, Pulp remnant.
C, Secondary dentine filling the canal.
Specimen prepared by the author. Stained by Mallory's
Phosphotungstic acid and Hematoxylin.
PREVENTION
court plaster. Oil of cloves and Blackwood creosote each
produced practically no inflammation, Black's 1, 2, 3 only
slight irritation, oil of cinnamon a large blister, creosol
and formalin in each instance a very deep inflammation
which was painful and so unbearable that it had to be
removed after seven hours ; the tissue formed no blister
but was of yellowish color as though it would slough
away ; needles could be stuck into the tissue one-third of
an inch before sensation was felt. Six weeks later a scar
was visible which looked as though the area had been
burned. It is evident that such an injurious drug should
not be sealed into root canals.
To avoid injury of the periodontal membrane and bone
surrounding the apex of the tooth, the operator should
put his effort into perfecting his technique rather than
relying on strong drugs to sterilize what he neglected to
remove. Mild antiseptics and anodines are sufficient as
dressings in most cases, ionic application of iodine will
take care of bacteria in dentinal tubules and accessory
foramina, and if a healthy condition cannot be obtained
by mild medication, the cause is to be looked for outside
the tooth. If a radiograph was not taken beforehand, it
is now time to find out the condition of the periapical
tissue, and in most cases it will be found that the reason
of not making any headway is due to a granuloma or
chronic abscess, a lesion which does not yield to medicinal
treatment. Mild antiseptics of reputation are :
Black's 1, 2, 3.
01. cassiae 1 part
Thenolis 2 parts
01. Gaulteriae 3 parts
Mx the oils and add melted crystals of phenol.
Buckley's Modified Phenol.
Mentholis gr. xx
Thymolis gr. xl
Phenolis f 3 iii
184 OKAL ABSCESSES
Ionic medication has already been consid-
medicatson ere( ^ -^ or treatment of periodontitis. Zinc
chloride and copper sulphate should not
be used for sterilization of dental structures on account
of their tissue destroying action, upon which some men
base the treatment of the apical granuloma. This is be-
lieved to be dissolved by this method so that it can be
resorbed by the tissue. Such applications, however, also
destroy the periodontal membrane, and as we have seen
that the success of root canal treatment depends upon
preservation of this most important structure, it would
be unwise to apply an agent which has exactly the oppo-
site effect.
Iodine ions are, however, to be recommended for root
canal or rather dentine sterilization. Tincture of iodine
3y 2 per cent, or aqueous solution of iodine, a recent prepa-
ration without the irritating action of the alcohol, is
applied into the root canal by means of a Luer syringe.
The negative pole is applied to a platinum broach, with
cotton saturated in the same solution attached, the posi-
tive pole is placed under the rubber dam in the form of a
sponge electrode, or held in the hand. The circuit of a
direct current, reduced by a special rheostat (there are
several well made ionization machines in the market) and
measured by a milliampere meter is now closed and the
amount is gradually increased until from % to 3 milliam-
pere is used. The treatment should be applied for ten
minutes in each canal. Iodine should be added from
time to time, as it is used up quickly, which is indicated
by the white color of the peripheral part of the dressing.
After ionic medication with iodine the pulp chamber
should be washed out with alcohol or acetone to remove
the brown stain. A mild aseptic dressing is inserted and
the canals filled at another sitting.
The most important factor which has to do with poor
root-canal filling and following periapical infection is
unsuccessful dehydration. Acetone should be applied by
means of Luer syringe and broach, and dried out with
hot compressed air. An electric root-canal dryer is then
PLATE LXXVI
Fig. 278
Fig. 275
Fig. 279
Fig. 280
Fig. 276
Fig. 281
Fig. 282
Fig. 277
Figs. 275, 276 and 277. — Radiographs showing the process of root canal treatment.
Fig. 275, shows a wire which was inserted to see whether the apex was reached.
Fig. 276 shows an unsuccessful root canal filling. Fig. 277 the final filling.
Figs. 278, 279 and 280. — Radiograph No. 278, showing two teeth not filled to the end.
Fig. 279, radiographs with wires inserted. Fig. 280 shows the canal fillings.
Figs. 281, 282. Radiograph No. 281 shows "corkscrew" filling which was replaced
by filling seen in Fig. 282.
PLATE LXXVII
Fig. 283
Fig. 284
Fig. 285
Fig. 285. — On left root treatment attempted through small
cavity, the broach does not go around the curve. On right
mesio-occlusial cavity cut extensively, so as to get proper
access to canals.
Fig. 284 and 285. — Specimen of bent and curved roots, the
root canals of which would be hard to treat and fill.
PREVENTION 185
inserted and if used for the first time the operator mil be
surprised to hear a sizzling noise, indicating that there
was still some moisture left. The heat is applied until
the patient feels the warmth. For root-canal filling
the author prefers the chloroform-resin-gutta-percha
method.* The chloroform and resin (d.i to gr. iv)
is best applied into the canal by use of an ordinary Luer
Q syringe ; with a smooth broach carefully remove all air
bubbles. Select a sterile gutta-percha cone or point and
pump it into the canal forty times. The chloroform dis-
solves the gutta percha, which is forced into the fine canals
and foramina by the pumping action. Other cones follow
the first until the canal is filled, when the filling is con-
densed with a root canal condenser. This method has
several advantages; the most important ones are that
newly-formed chloro-percha can be forced into the finest
canals without the evaporation which spoils the result in
other methods, and that the excess forced through the
foramina is not a sharp point projecting into the peri-
apical tissue, but a soft paste which caps the apex, so to
speak, adapting itself on its surface. A radiograph is
taken immediately, and in case the filling does not reach
to the apex it can be removed before it has hardened, when
the same process is repeated until the filling is satis-
factory.
Sterilization of the instruments and
Ti on and aseptic methods cannot be too strongly in-
ASEPSiS sisted upon. If we consider that the bac-
teriologist sterilizes his smooth platinum
needle most carefully in the flame before he uses it for
inoculation of an artificial medium, we must realize how
much more important it is to sterilize in a most scrupulous
manner rough instruments, such as broaches, so as not to
inoculate the human tissue. All root-canal instruments
should be immersed in alcohol, or in phenol first and
alcohol secondly, each time before they are used. The
field of operation should be properly prepared by use of
* Calahan, J. E. : Eesin Solution in Eoot Canals. Items of Interest, August,
1915, p. 579.
186 ORAL ABSCESSES
rubber-dam and scrubbing of the projecting teeth with
10% formaldehyde, which is dried off by means of air.
If cotton dressings are used for root canal work, or if
broaches wound with cotton are used, a number properly
prepared and sterilized should be kept on hand. The
cavity should be most carefully sealed after each treat-
ment to keep saliva from entering.
summary OF ^ e important factors which should be
important borne in mind in operations of pulp re-
FACTORS TO moval, root-canal work and filling, are, in
prevent short, the following :
periapical i Diagnose the condition first by
means of a radiograph.
2. Treat only cases which promise a good result.
3. Observe strict aseptic precautions.
4. Extirpate all pulp tissue.
5. Avoid injury and necrosis of the periapical tissue
as caused by the use of certain irritating drugs.
6. Avoid infecting of the periapical tissue by instru-
mentation.
7. If a root canal does not yield treatment in a short
time and no radiograph was taken in the first place, take
one now with an indicator in the root canal and find out
what is wrong.
8. Fill the root canals to the very end and ensure a
successful operation by means of another radiograph.
Prevention of Devitalised Teeth.
devitaliza- Our knowledge of the etiology and com-
tion FOR plications of alveolar abscesses and reali-
SrSSi'wiyAMrk zation of the uncertainty of root-canal
DENTINE and . •* .j ,,
prostheses fillings should impress in our minds the
notjusti- seriousness of pulp extirpation. He
fied w h extirpates the pulp of one, two or
more teeth to restore masticating efficiency by bridge
work renders poor services if granulomata develop on the
devitalized teeth, which are apt to endanger the patient's
health. A pulp for such or similar purposes should not
PREVENTION" 187
be sacrificed except after the most careful consideration
and prognostic study of the roots and root canals by
means of radiographs. Prosthetic appliances should be
constructed which do not require devitalization of healthy
teeth, and our efforts should be in the direction of devis-
ing reconstruction work which is not destructive to the
remaining hard or soft tissues of the mouth.
tr e ATM E NT Hyperemia and exposures are frequently
OF hyperemia brought about when excavating cavities
sures of°" ^ insufficient attention is paid to the
THE pulp TO approach to the pulp. The pulp horns
prevent de- are especially liable to become acciden-
vitalization tally involved. Large metal fillings are
liable to cause hyperemia because they are good conduc-
tors of heat and cold. A nonconductor should be placed
into the deepest parts of the cavity beneath the filling.
A pulp in the state of active hyperemia can almost always
be saved if the irritating causes are removed. The
mildest anodines should be applied, such as oil of cloves
or modified phenol slightly warmed, until the irritation
has subsided, when the same treatment as for pulp cap-
ping is indicated. Pulp capping is performed over deep
decayed areas which reach very close to the pulp, and
where there is danger of making an exposure if excavation
is continued. The action then is that of preservation. In
actual small exposures made by excavators in fully
formed teeth in cases where the pulp has previously given
no symptoms of inflammation, and in exposures of teeth
the apical foramen of which is wide open, with pulp nor-
mal or very slightly inflamed, we may attempt to save
the pulp by the so-called capping method. The patient,
however, should be informed of the doubtful outcome of
the undertaking. If there is slight hyperemia of the pulp,
an anodine such as modified phenol or oil of cloves should
first be applied, sealing it into the tooth with quicksetting
cement (not gutta percha) for one week. At the second
visit zinc oxide and eugenol, mixed to a thin paste, is
slightly coaxed over the exposed area ; this is covered with
a layer of quick-setting cement. All depends upon per-
188 OEAL ABSCESSES
feet asepsis, skillful manipulation and prevention of any
pressure or irritation. A temporary filling may be used
until the result is made sure of.
early treat- The prevention of hyperemia, which leads
me NT of to other diseases of the pulp, is best ac-
c aries and complished by filling the cavities when
prophylaxis sma ii an d shallow, or better still, in con-
trolling decay by prophylactic treatment. This is also
prevention in the highest degree against alveolar abscesses
and its many and dangerous complications. The teaching
to the public of oral hygiene, which first was principally
undertaken to combat the loss of masticating efficiency
and its sequels, poor digestion, and ill-health, has now
grown to a still greater importance, namely : the preven-
tion of systemic diseases of the gravest nature to which
the unsuspecting individual is liable to fall prey. With
this point in view, the dentist should educate the public
to the far-reaching meaning of preventive dentistry, and
offer his patients prophylactic treatment at such inter-
vals as seem necessary for each individual case, and teach
each individual how to keep the teeth in good condition
by suggestions as to a suitable diet and practical demon-
strations of how to take care of teeth and gums at home.
Fig. 288
Fig. 2i
Figs. 286, 287, 288 and 289. — Left and right side view and occlusial view of upper
and lower jaw of a patient's teeth who had the four first molars extracted when sixteen
years of age. The four illustrations show the condition when the patient was thirty -five
years of age.
Reproduced ~by the courtesy of Dr. Eugene H. Smith.
CHAPTER XII
THE TRUE VALUE OF A TOOTH
Dean Smith, of Harvard University Dental School, in
his timely paper read before the First District Dental
Society of the State of New York, said: "We all know
how difficult it is to adjust material values. How much
more difficult it is to adjust physiological values, in the
misjudging of which the happiness, health, and frequently
the life of the people is jeopardized!" It is indeed diffi-
cult to place the right value on a tooth; the judgment
depends a good deal on education, education of the dentist
and education of his patients. The value of a healthy
tooth in good occlusion is the easier to determine ; it cer-
tainly cannot be overestimated, but if a tooth is affected
by any of the various dental diseases, there arises a great
difference of opinion. Among the various pathological
conditions I shall consider only those we are especially
concerned with in this book, namely, the oral abscesses and
systemic diseases which are caused by them. One cannot
place too low a value on a devitalized tooth if it causes
conditions which endanger the patient's health.
The tooth which is the most frequent cause of abscesses
is the first permanent molar. This tooth, which plays
such an important part in the health, decays under our
very eyes in children who have the best of care, unless the
fissures are carefully filled as soon as the gum has
shrunken away from the occlusial surface. In the poor,
who do not care for their teeth except if so forced by pain,
this tooth is almost always a ruin when it comes under
our observation, and its pulp is invariably diseased and
very often periapical infection has already set in. The
value of this tooth sinks then from the highest mark to
190 ORAL ABSCESSES
the lowest level. Such badly decayed teeth are contin-
uous expenses, as they would have to be filled and refilled
and finally crowned, and would be sure, sooner or later,
to cause periapical infection. The poison which dis-
charges into the system from such a focus only lowers
the child's resistance to various illnesses, and hampers
the development of the body, but, worse than all, may
cause systemic diseases of the gravest nature from which
recovery may be impossible. How much better is extrac-
tion in such cases ; the twelve-year molars will move for-
ward into place, and while it would not always result in an
ideal condition, the condition which the orthodontist calls
" perfect occlusion," it would, if symmetrically carried
out, be just as good as what the average person has ; per-
sonally, I would say infinitely better, because a first molar
with periapical infection would have to be extracted
sooner or later ; it is only a matter of time ; and when ex-
tracted in later life it will leave a space which cannot then
be filled in by nature, the second molars having been firmly
fixed in the bone at that period of life ; for the patient the
result is worse from any point of view : that of occlusion,
masticating efficiency, chance of systemic infection, and
loss of time and money.
The saving of teeth in children should be of preventive
nature, which is the only safe way of securing and keep-
ing normal occlusion; but if it is too late for prevention,
we must be satisfied with the next best healthy condition.
The results obtained from symmetric extraction of the
badly decayed permanent first molars are very satisfac-
tory if undertaken before the age of twelve ; the occlusion
is in the majority of cases very good, as has been named
" sufficient occlusion" by Dean Smith, a term which ex-
presses the condition fully. Figures 286 to 293 show
models of two patients who had the first permanent molars
extracted at the proper age on account of extensive decay,
and the results are gratifying. These illustrations have
been reproduced with Dr. Smith's consent from his
already mentioned paper. While I want it clearly under-
stood that I do not believe in the wholesale extraction of
PLATE LXXIX
Fig. 290
Fig. 291
Fig. 292
Fig. 293
Figs, 290 and 291. — Left and right view of the teeth of a boy aged thirteen. The
right lower first molar is half decayed, pulp involved, apical foramina open. The left
lower first molar has an exposed pulp. The upper first molars are decayed. All the
first molars were extracted, no appliances had been used and already after three years
the good result shown in Figs. 292 and 293 were obtained.
Reproduced by the courtesy of Dr. Eugene H. Smith.
TRUE VALUE OF A TOOTH 191
children's teeth, and that neither Dr. Smith nor I would
advise the above treatment except in cases where the first
molars are in hopeless condition, I would say this: that
I for one should much prefer to own any of the mouths
shown in these pictures with only "sufficient occlusion"
of twenty-eight healthy teeth, than an ideal occlusion
with a number of devitalized teeth and arthritic joints.
The value of healthy teeth is so inestimably high that
every effort should be made to preserve them. A devital-
ized tooth diminishes greatly in value if an abscess is
formed at its roots, but when it becomes a focus of ill-
health and disease in other parts of the body, its value
becomes decidedly negative and its ownership a curse.
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196 OEAL ABSCESSES
Grieves C. J. — Continued.
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200 ORAL ABSCESSES
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INDEX OF ILLUSTRATIONS
PLATE
FACING
PAGE
I Fig. 1. Predynastic Egyptian Skull, showing loss of bone due
to Abscess 14
Fig. 2. Occlusial View of Upper Jaw of same Skull 14
II Fig. 3. Prehistoric Peruvian Skull, with loss of bone from
acute abscessed condition 15
III Fig. 4. Apical, Lateral and Interradial Abscess 18
IV Figs. 5 and 6. Eadiographs of Abscesses caused by Trauma. . . 20
Figs. 7 and 8. Eadiographs showing Treatment of Case in Fig. 5 20
Figs. 9, 10 and 11. Eadiographs of Abscesses involving neigh-
boring teeth 20
V Figs. 12 and 13. Abscesses due to Pyorrhoea Pockets 21
Figs. 14 and 15. Abscesses from Temporary Teeth 21
Figs. 16, 17, 18 and 19. Abscesses due to Decay of Permanent
Teeth 21
VI Fig. 20. Acute Periodontitis 24
Fig. 21. Acute Abscess 24
Fig. 22. Subperiosteal Parulis 24
Fig. 23. Subgingival Parulis 24
VII Figs. 24, 25, 26, 27, 28, 29, 30 and 31. Sinus Formations 25
VIII Fig. 32. Skull showing Bone Destruction due to Abscesses 26
IX Fig. 33. Ostitis, caused by a tooth 27
Fig. 34. Osteomyelitis of Mandible 27
X Figs. 35 and 36. Photographs of Teeth showing Exostosis of
Eoot 28
Fig. 37. Molar with Scar Bone 28
XI Fig. 38. Central Incisor with Acute Abscess 29
Fig. 39. Photograph of Subgingival Parulis 29
XII Fig. 40. Lateral Granuloma 34
Fig. 41. Apical Granuloma 34
Fig. 42. Interradial Granuloma 34
XIII Figs. 43, 44 and 45. Granulomata caused by Decay of Tooth. . 35
Figs. 46, 47 and 48. Granulomata caused by Incomplete Pulp
Extirpation 35
Figs. 49 and 50. Granulomata due to Broken Instruments 35
XIV Figs. 51, 52, 53, 54, 55 and 56. Granulomata caused by In-
efficient Eoot Canal Fillings 38
Figs. 57, 58 and 59. Granulomata from Decay under Filling. . 38
Figs. 60, 61 and 62. Granulomata on Crowned Teeth 38
202
INDEX OF ILLUSTRATION'S
PLATE
XV
XVI
XVII
XVIII
XIX
XX
XXI
XXII
XXHI
XXIV
XXV
XXVI
XXVII
xxvni
XXIX
TACING
PAGE
Fig. 63. Skull showing Bony Destruction Caused by an Apieal
Granuloma 39
Fig. 64. Skull showing Bony Destruction due to a Granuloma. . 40
Figs. 65, 66, 67, 68, 69 and 70. Badiographs showing Exostosis
of Boots 41
Figs. 71, 72 and 73. Badiographs showing Teeth with Necrosed
Apices 41
Fig. 74 and 75. Badiographs of Teeth showing large Oste-
omyelitic Areas 41
Fig. 76 and 77. Badiographs of Teeth showing Small Areas in-
dicating Periodontitis 44
Fig. 79, 80 and 81. Badiographs of Teeth showing Large Areas
indicating Granulomata 44
Fig. 82 and 83. Badiographs of Teeth with Subacute Abscesses 44
Fig. 84, 85 and 86. Badiographs showing Pus Pockets caused
by Mechanical Injury 45
Fig. 87, 88, 89 and 90. Badiographs of Teeth showing Dark
Areas at the Alveolar Border 45
Fig. 91. Badiograph showing Apical Abscess caused by Pus
Poeket; Tooth Vital 45
Figs. 92, 93, 94 and 95. Badiographs showing Abscesses caused
by Impacted Wisdom Tooth 48
Fig. 96, 97 and 98. Badiographs of Abscesses caused by TTn-
unerupted Molars 48
Fig. 99. Badiograph showing Impacted Second and Third Molar 49
Pig. 100. Badiograph showing Broken Off Impacted Second
Molar 49
Figs. 101 and 102. Badiographs showing Impacted Temporary-
Molars 49
Figs. 103, 104, 105, 106, 107 and 108. Other Impacted Teeth. . . 49
Fig. 109. Badiographic Plate showing an Impacted Upper
Third Molar on Posterior Wall of Antrum 50
Fig. 110. Badiographic Plate showing Unerupted Lower Third
Molar at the Angle of Jaw 51
Fig. 111. Simple Abscess of Tongue 52
Fig. 112. Tubercular Abscess of Tongue 52
Fig. 113. Swelling under Tongue on Left Side 56
Fig. 114. Badiograph showing Salivary Calculus 56
Fig. 115. Badiograph of Granuloma 58
Fig. 116. Smear of Bacteria Contained in above Granuloma. . 58
Fig. 117. Tooth with Large Granuloma 68
Fig. 118. Microphotograph of Section of Above showing Actin-
omycoses Colonies 68
Fig. 119. Microphotograph of Section through Granuloma show-
ing Actinomycoces Colonies 70
Fig. 120. Microphotograph of Chronic Myocarditis produced in
Babbit 72
Fig. 121. Microphotograph of Acute Myocarditis produced in
Babbit 72
INDEX OF ILLUSTRATIONS
203
PLATE
XXX
Fig.
Fig.
XXXI
Fig.
XXXII
Fig.
Fig.
Fig.
Fig.
XXXIII
Fig.
Fig.
xxxrv
Fig.
Fig.
XXXV
Fig.
Fig.
Fig.
XXXVI
Fig.
Fig.
XXXVII
Fig.
XXXVIII
Fig.
Fig.
XXXIX
Fig.
XL
Fig.
Fig.
Fig.
XLI
Figs.
XLII
Fig.
Fig.
XLIII
Fig.
XLIV
Fig.
XLV
Fig.
Fig.
XLVI
Figs,
XLVII
Fig.
Fig.
XLVIII
Fig.
XLIX
Fig.
L
Fig.
Fig.
FACING
PAGI
122. Microphotograph showing Infiltration of Leucocytes
and Lymphocytes in Kidney of Eabbit 74
123. Microphotograph showing Polymorphonuclear Abscess
in Medulla of Kidney of Eabbit 74
124. Microphotograph of Epitheliated Granuloma 76
125. Microphotograph of Simple Granuloma 78
126. Microphotograph of Simple Granuloma showing dis-
tinct Capsule 78
127. Microphotograph of Simple Granuloma showing
Active Pus formation 78
128. Microphotograph of Granuloma with Sinus 78
129. Lithograph showing Construction of Capsule of
Granuloma (Fig. 127) 80
130. Lithograph showing Construction of Granuloma
(Fig. 124) 80
131. Lithograph of Inner Part of Granuloma of Fig. 124 80
132. Lithograph of Inner Part of Granuloma of Fig. 128 80
133. Radiograph showing Granuloma in Lateral Incisor. . 81
134. Photograph of Excised Granuloma 81
135. Microphotograph of same Granuloma 81
136. Lithograph of High-power Drawing of Granuloma
(Fig. 135) 82
137. Lithograph of High-power Drawing of another part 82
138. Antrum exposed to show Abscess 90
139. Radiograph of Case 1 91
140. Radiographic Plate of Case 1 91
141. Cross Section through Eye 94
142. Acute Catarrhal Conjunctivitis 95
143. Simple Ulcer of Cornea 95
144. Normal Eye, and Iritis 95
. 145, 146, 147 and 148. Radiographs of Case VI 98
149. Radiograph of Case VII 99
150. Radiograph of Case VIII 99
151. Position of Lymph Glands beneath Lower Jaw 100
152. Schematic Drawing showing Teeth Drained by Lymph
Glands 101
153. Radiograph Case IX 104
154. Radiograph Case X 104
. 155 and 155a. Radiographs of Case XI 105
156. Radiograph of Case XVII 122
157 and 158. Radiograph of Case XVII 122
159 and 159a. Radiograph of Case XX 123
160. Radiographic Plate of Case XXI 130
161. Radiograph of Case XXII 131
162. Radiographic Plate of Case XXII 131
204
INDEX OF ILLUSTRATIONS
FACING
PLATE PAGE
LI Figs. 163, 164 and 165. Eadiographs of Case XXVII 136
LII Fig. 166. Normal Hand 137
Fig. 167. Hypertrophic Arthritis 137
LIII Fig. 168. Gouty Arthritis 138
LIV Fig. 169. Infectious Arthritis 139
Fig. 170. Atrophic Arthritis 139
LV Fig. 171. Eadiographic Plate of Case XXVIII 142
LVI Fig. 172. Eadiograph of Case XXVIII 143
Fig. 173. Eadiographic Plate of Case XXIX 143
LVII Figs. 174, 175, 176, 177, 178 and 179. Eadiographs showing a
Large Amount of Bridgework and Many Abscesses. . 144
LVIII Figs. 180, 181, 182, 183, 184 and 185. Eadiographs of a Neg-
lected Mouth 145
LIX Figs. 186 and 187. Eadiographs revealing Deep Cavities causing
Obscure Pain 146
Fig. 188. Eadiograph shows a large amount of trouble 146
Figs. 189, 190, 191, 192 and 193. Eadiographs showing the
Value of X-Eays before undertaking Eoot Canal Work 146
LX Fig. 194. Eadiographic Examination of a Mouth 147
Fig. 195. Chart Indicating Granulomata and Eoot Canal Fil-
lings of the above case 147
LXI Fig. 196. Eeport Chart as used by Dr. Potter 148
LXII Figs. 197, 198, 199 and 200. Steps in Apiectomy 162
LXIII Figs. 201, 202, 203 and 204. Steps in Apiectomy 162
LXIV Figs. 205, 206, 207 and 208. Steps in Apiectomy 162
LXV Figs. 209, 210 and 211. Eadiographs of Three Cases not favor-
able for Apiectomy 164
LXVI Figs. 212 to 220. Eadiographs showing the Treatment of Five
Devitalized Teeth 165
LXVII Figs. 221, 222, 223, 224, 225, 226 and 227. Eoot Canal Treat-
ment and Apiectomy on a Lateral Incisor 166
Figs. 228, 229, 230 and 231. Eoot Canal Treatment and Apiec-
tomy on Another Lateral Incisor 166
Figs. 232, 233, 234 and 235. Process of Apiectomy on Two
Teeth shown by Eadiographs 166
LXVIII Figs. 236, 237 and 238. Eadiographs showing Apiectomy on a
First Bicuspid 167
Figs. 239, 240, 241 and 242. Eadiographs of Apiectomy on a
Cuspid 167
LXIX Figs. 243, 244, 245 and 246. Apiectomy on a Cuspid which is
the Abutment of a Bridge 168
Figs. 247 and 248. Apiectomy on a Lateral Incisor 168
Figs. 249 and 250. Apiectomy on a Central Incisor 168
Figs. 251, 252 and 253. Apiectomy on a Central and Lateral In-
cisor 168
LXX Figs. 254 and 255. Apiectomy on a Lower Incisor 169
Fig. 256. Apiectomy on Two Lower Incisors 169
INDEX OF ILLUSTRATIONS
205
FACING
PLATE PAGE
LXX Pigs. 257 and 258. Apieetomy on a Lower Incisor with Broken
Eoot Instrument 169
Figs. 259 and 260. Apieetomy on a Lower Bicuspid 169
LXXI Figs. 261, 262 and 263. Kadiographs showing Healing of Bone. 170
Figs. 264, 265 and 266. Kadiographs showing Healing of Bone. 170
Figs. 267, 268 and 269. Eadiographs showing Healing of Bone. 170
LXXII Fig. 270. A Selection of Curettes 171
LXXIII Figs. 271 and 272. Excision of Tip of Tongue 172
LXXIV Fig. 273. Microphotograph showing Multiple Foramina 180
LXXV Fig. 274. Microphotograph showing a Boot Canal Filling 182
LXXVI Figs. 275, 276 and 277. Eadiographs showing the Process of
Eoot Canal Treatment 184
Figs. 278, 279 and 280. Eadiographs showing the Process of
Eoot Canal Treatment 184
Figs. 281 and 282. Eadiograph showing Poor and Good Eoot
Canal Filling 184
LXXVII Fig. 283. Eoot Treatment through Small and Large Cavity 185
Figs. 284 and 285. Specimen of Bent Eoots 185
LXXVIII Figs. 286, 287, 288 and 289. Models of a Patient's Mouth (Age
35) who had the Four Six-year Molars Extracted
at Age of Thirteen Years 189
LXXIX Figs. 290 and 291. Models of the Mouth of a Boy Aged Thirteen 190
Figs. 292 and 293. Models of same mouth Three Years Later,
All Six-year Molars having been Extracted 190
INDEX
Abscesses
PAGE
acute alveolar 24
acute alveolar, histological
pathology of 77
acute, methods of collect-
ing bacterial specimens. 59
alveolar, chronic 27
bacterial specimens of 59
clinical signs 30
general symptoms.... 30
histological pathology 78
local symptoms 30
radiographic examina-
tion 31
subacute 28
alveolar, due to difficult
eruption, impaction, and
unerupted teeth 47
clinical signs 50
course of disease 47
diagnosis 49
etiology 47
general symptoms .... 50
local symptoms 49
radiographic examina-
tion 50
alveolar, due to diseases of
dental pulp 18
pathological develop-
ment of 18
alveolar, due to disease of
the gum 45
clinical signs 47
course of disease 46
diagnosis 47
etiology 45
general symptoms .... 47
local symptoms 47
radiographic examina-
tion 47
treatment of 169
of salivary glands and
ducts 54
clinical course 56
clinical signs 57
diagnosis 56
etiology 55
local symptoms 56
radiographic examina-
tion 57
PAGE
Abscesses of salivary glands and
ducts. — Continued.
treatment 173
excision of glands 175
operation from floor
of mouth 174
of tongue 51
treatment of 171
varieties 51
phlegmonous 52
clinical signs 53
diagnosis 53
etiology 52
general symptoms. . 53
simple 51
clinical course 52
clinical signs 52
diagnosis 52
etiology 52
local symptoms .... 52
tubercular 53
clinical course 54
clinical signs 54
diagnosis 54
etiology 53
general symptoms. . 54
local symptoms .... 54
oral, history and varieties 15
bacteriology of 58
histological pathology
of 77
review of bacteriologi-
cal study of 61
Absorption, channels of 12
Actinomycosis, investigations of
Thoma 70
Action of bacterial ferments 8
Affections of the nervous system .... 128
Alimentary canal, diseases of 109
haematogenous in-
fection of 110
Alveolatomy 162
Anaemia 121
pernicious 122
primary and secondary.... 121
septic 122
Case XIX 122
etiology 122
symptoms 122
INDEX
207
PAGE
Anaesthesia for pulp extirpation. . . . 181
local 164
Angina 53
Animal inoculation 61
Antiseptic medication 182
Antitoxin 6
Apiectomy 164
failures and dangers 166
healing of wound 166
operation 165
preparing the patient 164
Appendicitis 113
Application of counter-irritants for
acute abscesses 152
Arkovy, bacterial table 62
Arthritis 135
Asepsis and sterilization in root
canal 185
acute infections 135
Case XXVII 136
etiology 136
atrophic 138
Cases XXVII, XXIX 140,142
etiology 138
treatment 139
chronic infectious 137
hypertrophic 137
etiology 137
Aural disturbances 100
Author 'a remark 75
Autoinoculation, surgical 176
B
Bacteria, invasion of, causing prolif-
erating periodontitis .... 38
aerobic and anaerobic, culti-
vation of 60
Bacteremia 11
Bacterial ferments 2
action of 8
Immunity 5
investigations :
Arkovy 62
Author 's remark 75
Gilmer 70
Goadby 62
Hartzel and Henriei 71
Mayerhof er 65
Miller 61
Monier 63
Partsch 63
Schreier 61
Steinharter 75
Thoma 70
Vincent 65
metabolism, by-products of 9
specimens, method of col-
lecting 60
PAGE
Bacteriological study, importance of 59
review of 61
Bacteriology of Oral Abseesses 58
Biological laws of Vaughan 5
Black's 1, 2, 3 152
Blood, changes of, during infection. . 11
diseases of 115
Body cell, the 3
ferments of 3
sensitization of 9
Buckley 's modified phenol 151
C
Calculi, salivary in glands and ducts 55
Cards for examination 146
Case charts, Potter 149
Cathartics in acute abseesses 145
Changes in blood from infection. ... 10
Change in oxygen tension causing
acute periodontitis 26
Channels of absorption 12
Chart, radiographic 149
Cholesterin, degeneration in granu-
loma 83
Chorea 132
Case XXIV 133
etiology 132
Choroiditis 97
etiology 97
symptoms 97
Chronic alveolar abscess 33
clinical signs 34
general symptoms 33
local symptoms 33
radiographic examination 34
Chronic conditions, treatment of 157
Classification of oral abscesses 16
Clinical picture of infection 9
Colitis 113
Collection of bacterial specimens . . 59, 60
Complications 84
of acute periodontitis. 26
secondary 84
systemic treatment of 178
Conjunctivitis 95
infectious 95
etiology 95
symptoms 95
Counter-irritants, application of for
acute abscess 152
Cover glass preparations 60
Cultivation of aerobic and anaerobic
bacteria 60
Curettage and extraction in abscessed
conditions 167
Cyelitis 97
Cysts 41
Cysts in granulomata 83
208
INDEX
D
PAGE
Decay of deciduous teeth causing
acute periodontitis 21
first molar 189
permanent teeth causing
acute periodontitis 22
the teeth causing prolifer-
ating periodontitis 36
Decrease of resistance 4
Defence of the body, protective 4
Devitalized teeth, prevention of 186
Disease, secondary, prevention of . . . 179
Diseases of soft tissues, examination
of 147
the alimentary canal .... 109
blood 115
heart 123
joints 135
teeth 147
Diagnosis of condition of devitalized
teeth 148
abscesses caused by ab-
scesses of tongue, sal-
ivary glands and
ducts 51, 56
abscess of the tongue. . 52
acute periodontitis .... 29
alveolar abscesses
caused by diseases of
the dental pulp 18
alveolar abscesses due
to other causes than
diseases of the dental
pulp 45
phlegmonous abscess of
the tongue 53
proliferating periodon-
titis 29
tubercular abscess of
the tongue 54
unerupted and impact-
ed teeth 49
Ducts, pathological development of
salivary abscesses from .... 51
abscesses from 54
Duodenum
ulcer (see Ulcer) 113
E
Ear (see Aural disturbances) 100
Efficiency of treatment of granulo-
mata, original investigations 158
Electrolytic treatment for abscesses. 161
for root canal work .... 184
Endocarditis 125
acute and chronic 125
Case XX 127
treatment 125
PAGE
Enteritis, septic 112
etiology 112
Case XIV 113
symptoms 112
Europhorm paste 155
Exacerbation 167
Examination cards 146
Examination of oral cavity 144
by dentist 146
physician 145
Examination of soft tissue of mouth 145
the teeth 146
physical 146
Excision of salivary glands 175
small tubercular ab-
scesses of tongue .... 172
tongue V-shaped 172
Exostosis of root 28
Extirpation of impacted and un-
erupted teeth 170
preanaesthetic medication after
treatment 171
Extirpation of teeth 168
anaesthesia 168
care of wound 169
indication 168
operation 168
Extracellular ferments 2
toxins 3
Extraction and curettage of abscessed
condition 167
of badly decayed first molars
in children 190
teeth in acute abscesses. . . 154
F
Ferments, action of bacterial 8
analytic 2, 3
bacterial 2
extracellular 2, 3
intracellular 2, 3
of body cell 3
synthetic 2, 3
Fever, general effects of local infec-
tion 10
Fever in acute abscesses 30
acute sinusitis 116
alveolar parulis 33
pyaemia 117
from impacted and unerupted
teeth 50
rheumatic in acute infectious
arthritis 135
Filling teeth with infected pulps
causing acute periodontitis 30
Focus of infection 13
Focus, removal of 176
Formaldehyde contraindicated 182
INDEX
209
G
PAGE
Galvanic current for diagnosis. . .30, 34
Gilmer, bacterial investigation of . . . 70
Glands, salivary abscesses 51
pathological development of 54
Glaucoma 99
etiology 99
primary and secondary. ... 99
symptoms 99
Goadby, bacterial investigations of . . 62
Granuloma 39
apical 36
clinical signs 43
epitheliated 81
general signs 43
histological pathology... 79
interradial 39
local symptoms 42
lateral 37
methods of collecting bac-
terial specimen 60
with lumen 82
Hartzel and Henrici, bacterial inves-
tigations
table of fer-
mentation... 73
Heart, diseases of 123
High frequency current for diagnosis 30
History and varieties of oral ab-
scesses 15
Hyalin degeneration in granuloma.. 83
I
Idman, bacteriological investigation 66
Immunity, acquired 5
bacterial 5
natural 5
toxin 5
Impacted teeth 48
extirpation of 170
Incision in simple abscess of tongue. 171
Infection, phenomena of 1
from pus pockets causing
acute periodontitis 20
Infections 10
acute and chronic 10
clinical picture 9
continuous 84
from adjacent teeth caus-
ing acute periodontitis. . 20
general 11
general effects of 10
PAGE
Infections, haematogenous 85
causing proliferating
periodontitis 39
influence of quantity on . . . 9
local 10
lymphatic 85
predilection of 13
prevention of periapical . . 180
secondarily transported... 11
virulence 9
Infection through alimentary canal. 85
Infective virus, the 1
Injury of the gum causing alveolar
abscess 45
Inoculation 10
of animals 61
of artificial media 60
Instrumentation causing acute peri-
odontitis 23
Intracellular ferments 2
Investigation, original, of the efficien-
cy of treatment of granulomata. . . 158
Involvement of neighboring parts ... 86
Iodine for root canal treatment. . . . 184
Ionic medication 161, 184
Iridiohoroiditis 97
Iridocyclitis 96
etiology 97
symptoms 97
Iritis 97
etiology 97
symptoms 97
J
Joints, diseases of 135
K
Keratitis suppuration 95
etiology 95
symptoms 95
L
Laxative in acute abscess 156
Lead points for root canal fillings.. 163
Lymphadenitis, cervical 104
acute 104
Case X 106
etiology 105
symptoms 105
treatment 105
chronic 106
etiology 106
symptoms 106
treatment 106
210
INDEX
PAGE
Lymphadenitis, subacute 106
Case XI 106
symptoms 106
# tubercular 106
Case XII 109
etiology 107
symptoms 107
treatment 107
Lymphangitis 103
Case IX 104
etiology 103
symptoms 103
treatment 103
Lymphatic infection 102
Lymph glands, enlarged 146
location 102
M
Malaise 119
treatment of 119
Manifestations secondary 13
Mastication efficiency, restoration of 177
Mayerhofer, bacteriological investi-
gations 65
table 66
Medication, antiseptic 182
ionic 161
for root canal treat-
ment 184
Melancholia 133
Case XXVI 135
Menier, bacterial investigation 63
bacteriological table 65
Mental depression 133
Case XXV 134
Metabolism, by-products of bacterial 8
Metastasis 11
Methods of animal inoculation 61
bacterial study 60
collecting bacterial speci-
mens 59
Middle ear inflammation 100
Miller, bacterial investigation 62
Molar, early decay of first 189
Myocarditis 121
N
Natural Immunity 5
Necrosis 26
of root 29
Nerve communication between ear
and teeth 100
communication between eye
and teeth 94
reference table 131
Nervous system, affections of 128
TAGE
Neuralgia, trifacial 130
Case XXII 132
Case XXIII 132
etiology 130
symptoms 132
Neuritis 128
Case XXI 129
etiology 128
general 129
symptoms 129
intraocular optic 98
etiology 98
symptoms 98
retrobulbar optic 98
Case VI 98
etiology 98
symptoms 98
o
Occlusion, sufficient 190
Ophthalmic disturbances 94
Optic neuritis 98
Oral abscesses, treatment of 150
cavity, examination by physi-
cian 145
examination of 144
Osteomyelitis, acute 26
chronic 41
Ostitis 26
Otalgia 101
Case VIII 101
Otitis media 100
Case VII 101
Overdentistried teeth 146
P
Pain in ear (Otalgia) 101
relief of 156
Papillitis 98
Paresthesia 129
Partsch, bacterial investigation 63
Parulis, alveolar 24
clinical signs 33
differential diagnosis 32
general symptoms 33
histological pathology 78
local symptoms 31
radiographic examination. . 33
Parulis, subgingival 25
subperiosteal 24
Pathological development of absces-
ses of tongue and
salivary glands 51
development of alveolar
abscesses caused by
diseases of the den-
tal pulp 18
INDEX
211
PAGE
Pathological development of alveo-
lar abscesses due to
other causes than
disease of the dental
pulp 45
Pathology, histological 77
Peptic ulcer 113
Periapical infection, prevention of.. 180
Pericarditis 124
Periodontitis 19
acute and its sequels 19
acute interradial 19
acute lateral 19
clinical signs 29
diagnosis 29
histological pathology 77
apical 19
complication 26
course of disease 24
definition 19
etiology 20
Periodontitis, proliferating
clinical signs 42
diagnosis 42
general symptoms 42
local symptoms 42
radiographic examination 42
Periodontitis, proliferating and se-
quels 34
course of disease 39
definition 34
etiology 45
histological pathology 79
termination 41
varieties 35
Pharyngitis 92
Case III 92
symptoms 92
treatment 92
Phenomena of infection, the 1
Physical examination of oral cavity. 145
Poison, protein 7
Potter, case charts 149
Prevention 178
of abscesses by early treat-
ment 188
caries by prophylaxis. . 188
devitalized teeth 186
devitalized teeth by
treatment of hyper-
emia and exposures
of the pulp 187
periapical infection. . . 180
secondary diseases
from oral abscesses. 179
Process of infection, the 6
Proctitis 113
Protective defenses of the body .... 4
PAGE
Protein poison 7
poison caused by bacterial
metabolism 8
poisons 59
sensitization 6
Prognosis before root canal treat-
ment 148
Pulp, death of, without access of air,
causing proliferating peri-
odontitis 38
extirpation incomplete caus-
ing proliferating periodon-
titis 36
Pulp extirpation, anaesthesia for. . . 180
Pus pockets causing alveolar ab-
scesses 46
Pyaemia 117
etiology 117
illustrative Case XVI 117
symptoms 117
treatment 117
R
Eadiographic chart 149
diagnosis before root
canal treatment .... 181
diagnosis important in
secondary infection . 84
examination 148
in acute maxillary
sinusitis 87
in chronic maxil-
lary sinusitis... 88
in trismus of mus-
cles of mastica-
tion 93
of acute alveolar
abscesses 31
of alveolar absces-
ses caused by
diseases of the
gum 47
of alveolar parulis 33
of chronic absces-
ses 34
of granulomata. . . 43
o f proliferating
periodontitis ... 42
of salivary stones. 57
of subacute attacks 44
of unerupted and
impacted teeth. . 50
Eadiotherapy for tubercular lymph-
adenitis 108
Belief of pain 156
Eemoval of the cause in acute and
chronic conditions 160
212
INDEX
PAGE
Eesistance 4
decrease of 4
increase of 5
Resolution of aeute periodontitis. ... 27
of proliferating periodon-
titis 41
Eest of diseased tooth 152
Restoration of masticating efficiency 177
Retinitis 97
etiology 97
symptoms 98
Review of bacteriological study of
oral abscesses 61
Rheumatic fever (see acute arthritis) 135
Root exostosis 40, 28
necrosis 40, 29
Root canal cleaning and enlarging . . . 181
filling 185
drying 185
radiographic examination
before apiectomy 164
treatment, asepsis and
sterilization 185
treatment before apiec-
tomy 148
S
Sapremia 118
Scar bone 27
Schreier, bacterial investigation .... 61
bacteriological table 62
Scleritis 95
etiology 95
Case V 96
symptoms 95
Sensitization : protein 6
of body cell 7
Septicemia 116
etiology 116
symptoms 116
treatment 116
Sequestrum 27
Sinus, active 27
closed 27
to face, treatment of 157
Sinusitis maxillary 86
acute 86
etiology 86
clinical signs - 87
symptoms 86
treatment 87
chronic 88
Case 1 90
Case II 90
etiology 88
clinical signs 88
symptoms 89
treatment 89
PAGE
Sodium potassium treatment 181
Steinharter, bacterial investigation. 75
Sterilization and asepsis in root canal
treatment 185
Summary of prevention of periapical
infection 186
Systemic complications treatment. . 175
treatment for acute ab-
scesses 155
T
Table of nerve reference 131
Teeth, devitalized, examination of . . 148
examination of 147
extraction and extirpation. . . 168
of in acute ab-
scesses 144
overdentistried 146
prevention of devitalized. . . . 186
unerupted and impacted,
differential diagnosis 47
Termination of acute periodontitis . . 27
Thermal shocks causing acute peri-
odontitis 21
Thoma, bacteriological investigations 70
Thrombosis 117
Tongue, abscesses, pathological devel-
opment 51
abscesses, treatment 171
excision of small tubercular
lesions 172
excision of V-shaped part. . 172
incision in simple abscess.. 172
Toxemia 11
Cases XVII, XVIII 120
chronic 119
etiology 118
symptoms 119
Toxins
activity 6
absorbed from granulomata . . 63
definition 3
extracellular 3
intracellular 7
Treatment of acute and subacute con-
ditions 150
abscesses due to diffi-
cult eruption, etc. . . . 169
abscesses due to dis-
eases of the gum .... 169
abscesses of salivary
glands and ducts .... 173
abscesses on tongue . . . 171
caries to prevent ab-
scesses 188
chronic conditions .... 157
INDEX
213
PAGE
Treatment of excision of glands .... 175
hyperemia and expo-
sures of pulp to pre-
vent devitalization of
pulp 187
operation from floor of
mouth 174
root canals in chronic
conditions before
apiectomy 163
sinus to face 157
systemic complications 176
systemic complications
for acute abscess. . . . 155
with antiseptics applied
to root canal 160
Trismus, etiology 93
Case IV 93
diagnosis 93
symptoms 93
treatment 93
Tubercular lymphadenitis 106
Tuberculosis of granuloma 63
PAGE
Trigeminal neuralgia (see Neural-
gia) 130
True value of a tooth 189
U
Unerupted teeth, extirpation (see
Extirpation) 170
Ulcers, gastric and duodenal 113
Case XV 114
etiology 113
symptoms 113
V
Value of healthy tooth 191
Value, true, of tooth 189
Varieties of alveolar abscesses caused
by diseases of the dental pulp .... 18
Varieties and history of oral ab-
sceses 15
Vincent, bacteriological investiga-
tions 65
Virus, the infective 1
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