PYORRHEA ALVEOLARIS.
[Footnote: Abstract from a paper lately read before the Southern Dental Association, Baltimore, Md.]
By Dr. J. M. RIGGS, of Hartford, Conn.
A gentleman, a physician, aged thirty-two years, strong and vigorous, with no lack of nerve-energy, calls to have his teeth attended to, with the disease in the first stage throughout the mouth. Upon examination, he observes upon the gum of one of the lower cuspids a dark purplish ring encircling the neck, from one-sixty-fourth to one sixteenth of an inch in depth; the tooth in situ is white and clean. With the aid of the mouth and hand mirror he shows the condition to the patient, and, taking up an excavator, endeavors to pass it down between the tooth and gum, on the labial surface. After it gets down a little way the instrument meets with an obstruction, over which, calling the patient's attention to the fact, he carefully guides the instrument until it drops down on the tooth-substance beyond it; then, turning the instrument and pressing it upward, he breaks off a portion of the concretion; which proves to be what is ordinarily called lime-salts, or tartar. That is the cause of the purple ring on the gum, which is merely the outward manifestation of the disease. Take it off thoroughly, polish the surface of the tooth, and in three days' time the gum will show a perfectly healthy color. The condition described is the first stage of the disease, and the treatment given is all that is required for a cure of the case at this time. But take the same man and let him go for ten years without the simple operation detailed. The disease spreads, and causes inflammation of the process, and, finally, its absorption--sometimes on the labial surface for one half or two-thirds the length of the tooth. It runs its course, the tartar accumulating, all the time following up the line of attack. At the end of ten years what has become of the line of tartar? Sometimes it will be found extending clear around the tooth. Sometimes it will not be found at all; it has done its work--the tooth is loose, but the concretion is gone, in whole or in part. In this case the patient wants the tooth out, but, he asks, what has become of the tartar? The answer is that the natural acids found in the oral cavity have dissolved it, and it has passed into the stomach or out of the mouth in the saliva. But the tooth is so loose that it is a torment to the man; it lies in its socket, entirely loose, almost ready to drop over. It hurts so that he cannot bear the pain. The tooth is taken out. There is no tartar on it, or very little; there is a little speck near the point that looks like a foreign body; but the point of the tooth--the apex--is as sharp as a needle. After the disease has done its work of separating the tooth from its socket, the destroying agent begins to absorb the tooth at the point, irregularly, causing the sharpness described. Now, because no tartar is found upon the tooth, does that argue that it has never been there? Not at all; the loosened tooth shows simply that it has been there and has been absorbed. The speaker has never seen a tooth in that condition on the point of which he could not show patches or specks; we may not see the tartar, but it certainly once existed there, and has accomplished its work.
Now suppose we find a patient with all the teeth loosened; he has neuralgia pains in the face, for which medicine seems to furnish no remedy; he has also catarrh, and the malar and nasal bones are all affected. In the third and fourth stages a low inflammatory action pervades all the bones of the face, accompanied by neuralgic pains, extending to the brain itself. In such a case the disease of the teeth intensifies the catarrh. A medical man called upon him for treatment for pyorrhea alveolaris; the patient was also afflicted with catarrh. He cured the pyorrhea alveolaris, and cured the catarrh, too, at the same time.
Another case.--A lady called in great distress. Nearly all her teeth were affected, and the discharge was most offensive and abundant; if she lay on her side in bed, the pillow would be covered with large splotches of the discharge in the morning; if she lay on her back, the mass was swallowed, and the result was that the whole alimentary canal was demoralized by the pus, blood, and vitiated secretions. When she arose she wanted no breakfast, only two or three cups of strong coffee and some crackers. She was nearly blind, could only see a great light, and was totally unable to see to read. He told her that the trouble with her sight was caused by the diseased condition of the teeth; that unless that was remedied, she might live three months, but she would die suddenly. He treated three or four teeth at a time at each sitting. This consumed three weeks. The teeth became firm, her appetite returned, her sight was restored, and she was able to walk a mile or two without disturbance. He was called to Brooklyn, where they had a live society, and an infirmary for the treatment of dental diseases, at which members of the society were delegated to attend from day to day. He was invited to give a clinic upon pyorrhea alveolaris, and he told them of this patient, whom he showed to some fifteen members. The woman was apparently in fair health. It was not loss of nerve-energy which started the disease in this case, but the disease caused the loss of appetite and the vitiated condition of the whole alimentary canal. Her physician would have sent this woman to the grave, not recognizing the disease and its management.
He maintains that it is not lack of nervous energy that causes this disease, but the disease will lead to loss of nerve-energy. That small purple ring on the gum of the cuspid in the case first mentioned would eventually have led to the loss of the whole set, if left to work its way unopposed. He had tried in these remarks to controvert the old ideas, and to present the cause of the disease and its treatment as he sees it. You may see it differently; if so, give us your information, in order that we may correct our views, if wrong.
One gentleman says he finds it is only those who are strong and vigorous who have this disease. The speaker finds some cases of this kind; he also finds consumptives who have not a trace of it, but he would take the strongest man in the room and cause a beautiful case of pyorrhea alveolaris in his mouth in three weeks, with a fine cotton thread tied around one of the lower front teeth at the line of the gum. The thread will work its way under the gum, and the gum will become inflamed; it will work its way down between the gum and the tooth, and in the meantime the flour and the particles of food will also work down under the loose gum, finding a rallying-point on the thread; the mass will become impregnated with lime-salts, and will then begin to harden, and in a very short time you will have an excellent example of the disease under discussion. Patients suffering from salivation fall an easy prey to this disease, due to the action of the drug on the glands and the hard and soft tissues of the mouth, the gums in such cases affording a ready pocket under their edges for the deposits.
When you find a tooth with the characteristic concretion of tartar upon it, the first principle of surgery demands that you clean that tooth thoroughly. Go down beyond the line of the disease, go around the tooth thoroughly, and break up the diseased tissue, and apply tincture of myrrh, and in three days you will notice a marked improvement for the better, and if the patient takes proper care of the teeth the disease will not return. Practitioners should watch the teeth of the young people under their care, and see that the mouth is kept scrupulously clean and healthy.
In reply to a question, Dr. Riggs stated that whenever absorption goes on irregularly, unless the inflammatory action is extreme, it will sometimes absorb one or two bone-cells, and then skip one or two, and these last, being isolated, naturally die, or become necrosed to some extent. In treating this disease you must break up the line of disintegrated tissue. You must, as it were, transfer your eyesight to the end of the instrument, so that when you strike dead bone you will know it. Live bone will feel smooth and greasy.
It requires some years of experience to treat this disease properly, because you have not your eyesight to aid you, but must depend absolutely upon the sense of touch. With experience, however, you will learn to give a great deal of relief in one of the most annoying conditions to which the teeth are subject. The reason the profession are not familiar with the treatment of this disease is, they fail to recognize it until it reaches its third or fourth stage, and then they treat it by depletion and therapeutic remedies. Some treat it by stippling in acids underneath the gum, thinking thereby to dissolve away not only the tartar, but the necrosed bone. Another writer takes off patches of the diseased tissue, and another a strip of the gum, from wisdom-tooth to wisdom-tooth. This treatment he could only characterize as simply barbarous. The treatment of this disease is purely surgical. Any therapeutic treatment is to alleviate the pain and soreness immediately after the operation.
Dr. W. N. Morrison, St. Louis, referring to the method of treating pyorrhea alveolaris described by Dr. Riggs, said he cheerfully bore testimony to the importance of loosening the scales of tartar, and teaching patients the value of cleanness of the mouth. In his experience he had found that all instruments will occasionally fail to dislodge the deposit. In such cases he used as an assistant a little ring of para gum about an eighth of an inch wide. This was sprung on the tooth at the edge of the gum. If this is done and the ring allowed to remain a few hours, you will see an entirely new revelation, and you will readily be able to get at the tooth to clean it. He had found it advisable to give patients practical showing how the brush should be used.