UK ■-'^'- 
 
 301 
 
 UNIVERSITY OF CALIFORNIA 
 
 COLLEGE OF DENTISTRY 
 
 EXTENSION LECTURES 
 UC-NRLF 
 
 *B 175 Tfi? 
 
 THE DISEASES AND TREATMENT OF THE 
 INVESTING TISSUES OF THE TEETH 
 
 BY 
 ARTuriP D. BLACK, A.M., M.D.; D.D.S. 
 
 Pr..f-;<nr .f (^n,■, (ry and Special Demal Pathology, N'^''t^"'-^'"'-n University 
 
 Dental ''chcol, Chicago. 
 
 DECEMBER 27, 1915 — JANUARY 7, 1916 
 
Digitized by the Internet Arciiive 
 
 in 2007 with funding from 
 
 IVIicrosoft Corporation 
 
 http://www.archive.org/details/diseasestreatmenOOblacrich 
 
UNIVERSITY OF CALIFORNIA 
 
 COLLEGE OF DENTISTRY 
 
 EXTENSION LECTURES 
 
 3 
 
 THE DISEASES AND TREATMENT OF THE 
 INVESTING TISSUES OF THE TEETH 
 
 BY 
 ARTHUR D. BLACK, A.M., M.D., D.D.S. 
 
 Professor of Operative Dentistry and Special Dental Pathology, Northwestern University 
 Dental School, Chicago. 
 
 DECEMBER 27, 1915 — JANUARY 7, 1916 
 
 UNIVERSITY OF CALIFORNIA PRESS 
 
 BERKELEY 
 
 1916 
 

 t? ' 
 
INTROD^JOTIO^'* 
 
 Before taking up the work for which we are assembled, I wish to 
 express my appreciation of the honor conferred by the University of 
 California in extending to me an invitation to be one of the lecturers 
 of this Institute. I am pleased also to say a few words in commenda- 
 tion of the action of the University of California in adding dental 
 courses to its extension work. It is a compliment to the profession 
 that the importance of our service to humanity is thus recognized, and 
 I trust that these courses will in future years continue to receive the 
 hearty support of the profession. I wish, before this class, to compliment 
 Dean Millberry for having seen the need of courses under University 
 control, by men without the sphere of influence of commercial interests, 
 and for having suggested the plan to the University authorities. Such 
 courses should stimulate the members of the profession to keep closely 
 abreast of the times and improve the general average of dental service. 
 Thus we see that the University of California is promoting a scheme 
 in which the people of the entire State should be interested, for they 
 will in the end be the beneficiaries. 
 
 The treatment of disease improves with more complete knowledge of 
 pathology. For each disease, we should be able to apply treatment 
 closer to the source, more directly to the cause, or actually to prevent it, 
 as our understanding of the pathology becomes more perfect. We are 
 all familiar with the gradual advancement in the treatment of typhoid 
 fever, especially in the prevention of it by improved sanitation when 
 the methods of transmission became known, and by vaccination after 
 the effect of the infection in the development of antibodies was under- 
 stood. The discovery of the role which the mosquito played in the 
 transmission of yellow fever and malaria made it possible for our govern- 
 ment to carry to completion the construction of the Panama Canal, the 
 failure of the French attempt having been due principally to the ravages 
 of these diseases. 
 
 A careful review of the literature of dentistry reveals little other 
 than very meager statements of the pathology of the diseases of the 
 peridental membrane. The very large majority of writings on this 
 subject concern themselves with names applied by various authors, 
 with theories as to local and systemic causes, and with statements 
 emphasizing the necessity of removing deposits from roots of the 
 teeth. Very few men seem to have made » serious effort to study 
 
 * This course of lectures follows closely the recently published book 
 Special Denial Pathology, by the late Dr. G. V. Black (Medico-Dental Pub- 
 lishing Co., Chicago; Claudius Ash, Sons and Co., London, 1915), credit to 
 which is hereby acknowledged. The illustrations herein were reproduced from 
 the same book, as were about one hundred and fifty stereopticon slides used 
 to illustrate the lectures. Ol Q Q 1^ P f¥ 
 
and pres*ent "in fletaii, 'the pathological changes which take place or to 
 differentiate the various diseases" to which the investing tissues are 
 subject. It is not surprising, therefore, that the many plans of treat- 
 ment have generally been unsuccessful. As a basis for the institution 
 of more rational treatment, this course of lectures will be devoted 
 largely to studies of the histology, physical functions and pathological 
 changes in these tissues. After a time we will come to realize that many 
 of us have been endeavoring to accomplish the impossible. 
 
 The peridental membrane is defined as the soft tissue which serves 
 to connect the root of the tooth with the bone of the alveolar process. 
 We might refer to it as the connecting link between chronic infection 
 of the mouth and the general health, since there is practically always 
 a break in this tissue which permits the infective agent to enter the 
 circulation and be carried to distant parts. We might also think of this 
 tissue as that which must bind together the medical and dental profes- 
 sions in their fight against the ever-increasing list of diseases which 
 are recognized as occurring secondary to focal infections. We are con- 
 cerned chiefly with the dentist's part in protecting the health of his 
 patients, but we will not overlook his duty to conserve the teeth. 
 
 Disease of the peridental membrane does not occur except as a 
 result of (1) a preceding gingivitis or (2) the death of the dental pulp. 
 In the one case there may occur a detachment of the tissue from the 
 cementum beginning at the gingival line of the tooth, with the formation 
 of a pus pocket alongside the root; in the other, the detachment occurs 
 about the apex of the root with the development of a chronic alveolar 
 abscess. It will be noted later that the pathological changes in both 
 cases are similar and that we are confronted with the same difficulties 
 in protecting the general health from the effects of these foci. We will 
 come to realize also that the danger to health demands the elimination 
 of all such foci. 
 
 The chronicity of these diseases has led to much confusion in our 
 ideas and knowledge of the pathology. It is not unusual for cases to 
 run twenty or thirty years before all of the teeth are lost, and few 
 dentists have the opportunity to observe many cases from beginning 
 to end. It is not strange, therefore, that we have failed to associate 
 the early symptoms with those of the well-established lesion. Especially 
 have we failed to recognize the relationship between the apparently 
 harmless gingivitis and the secondary serious and generally incurable 
 pericementitis. We must learn to correlate the clinical pictures presented 
 by many cases in various stages of progress and, from these, make a 
 composite which will give us a better understanding of the progressive 
 changes which occur. 
 
 We must differentiate several distinct diseases of the gingivae and 
 peridental membrane as to their causation, pathology, and treatment, and 
 
in doing this we must have a new nomenclature. Terms which have 
 been applied to a group of diseases must be dropped and others substituted 
 which designate each condition; for the retention of the general terms 
 serves to continue in our minds the confusion which has prevailed. In 
 order to have a clear understanding of the pathology, we require terms 
 which will separate definitelj'' the inflammations of the gingivae from 
 those of the peridental membrane, for it will be pointed out that we may 
 generally cure the one, and practically never the other. Therefore, 
 successful preventive treatment of diseases of the peridental membrane 
 necessitates a clear understanding of the pathology, a recognition of 
 the early stages, and the institution of treatment while there is oppor- 
 tunity to effect a cure. 
 
 FIRST LECTURE 
 
 HISTOLOGY AND PHYSICAL FUNCTIONS OF THE INVESTING 
 TISSUES OF THE TEETH 
 
 The gums, gingivae, cementum, peridental membrane, and the bone 
 of the alveolar process may all be considered as the investing tissues 
 of the teeth. It is important that we have a clear understanding of the 
 histological structure and physical functions of these tissues, in order 
 that we may appreciate the significance of the pathological changes 
 which occur. This will, in turn, lead to more rational treatment. It is 
 especially desirable that we realize the interdependence of these struc- 
 tures upon each other in the performance of their normal functions. 
 
 Gums and Gingivae 
 The gums and gingivae are made up of a pavement epithelium sup- 
 ported by a base of connective tissue. The epithelium of the gingivae 
 is more dense than that of the gums, the cells being very flat and closely 
 packed together on the surface. They are well supported by many long 
 legs of connective tissues, each of which carries one or more blood 
 vessels far into the epithelial covering. Provision is thus made for the 
 rapid regeneration of the superficial cells, which are frequently injured 
 or worn away as a result of the wear and tear to which they are sub- 
 jected in mastication. This arrangement also insures prompt healing 
 of injuries to the gingivae and enables this tissue to withstand long- 
 continued or often repeated irritation without serious harm. The gum 
 tissue is a rather insensitive tissue, offering little complaint to injuries 
 which would excite much pain in other tissues. Occasionally, however, 
 long-continued irritation, as the rubbing of the edge of a denture, will 
 develop extreme hypersensitiveness. 
 
 . i 
 
It will be noted from the above that one of the important functions 
 of the gingivae is that of protecting the underlying peridental membrane 
 and alveolar process. In fact, this seems to be the principal function of 
 the gingivae. In addition, they doubtless are of material service in 
 maintaining the teeth in the line of the arch. 
 
 It is important that we be familiar with the nomenclature of the 
 gingivae and peridental membrane. We may apply the term gingivae 
 to all the soft tissue which rests upon and extends crownwise from the 
 
 .■.',.,;Jl^ 
 
 Fig. 1. Longitudinal section through the gingiva and the gingival 
 portion of the peridental membrane, (E) Epithelium. (D) Dentin. (C) 
 Cementum. (S) Subgingival space. (F) Free gingivae group of fibres. 
 (A) Alveolar crest group of fibres. (H) Horizontal group of fibres. (B) 
 Bone of alveolar process. — Noyes. 
 
 crest of the alveolar process. This may be subdivided into the body, 
 which, encircling each tooth, extends from the crest of the alveolar 
 process to the level of the gingival line of the tooth, the gingival line 
 being the line of junction of cementum and enamel. The free gingivae 
 are those portions which overlie the enamel on the buccal, labial and 
 lingual surfaces of the teeth, and the septal gingivae are the similar 
 portions which occupy the septal or interproximal spaces. We will have 
 occasion to refer frequently to the subgingival spaces— those spaces be- 
 tween the free gingivae and the enamel, or between the septal gingivae 
 
 IT. 
 
and the enamel. Under normal conditions, a thin, flat blade may be 
 passed into the subgingival space, between the free gingivae and the 
 enamel, until it comes in contact with the attachment of the peridental 
 membrane to the cementum at the gingival line of the tooth. 
 
 The gingivae and peridental membrane contain several groups of 
 principal fibres which may be named and briefly described in order, 
 beginning at the gingival line and progressing toward the apex of the 
 root as follows: 
 
 The free gingivae group is composed of those fibres which extend out- 
 ward from the cementum jnst beyond the gingival line and then turn 
 
 Fig. 2. A portion of the ^ i ;. i .me i.ctween two incisors 
 
 of a young sheep, showing the trans-septal fibres extending from tooth 
 to tooth. — Noyes. 
 
 occlusally into the free gingivae. These fibres help to support the free 
 gingivae and assist in maintaining their close adaptation to the teeth. 
 The trans-septal group consists of a strong band of fibres passing from 
 tooth to tooth through the body of the septal gingivae, occlusally of the 
 crest of the interproximal portion of the alveolar process. The principal 
 function of this group of fibres is to maintain the contacts between the 
 various teeth — to keep the contacts tight. It is necessary to appreciate 
 the function of these fibres in order to understand the movements of 
 of the teeth and the progressive involvement of several proximal surfaces 
 from an original pus pocket on a proximal surface. This will be fully 
 explained later. 
 
 A« 
 
8 
 
 The alveolar crest group consists of those fibres which extend outward 
 from the cementum and are attached to the crest of the alveolar process. 
 Their principal function seems to be to steady the tooth against lateral 
 strain. 
 
 The horizontal group consists of those fibres which extend outward 
 at right angles to the long axis of the tooth and are attached to the bone 
 of the alveolar process, just below its crest. These fibres act with those 
 of the alveolar crest group in preventing too much lateral movement of 
 the teeth. 
 
 The oblique group consists of the fibres which make up the bulk of the 
 peridental membrane. They are attached to the greater part of the sur- 
 face of the root, and extend in an oblique direction occlusally to the 
 bone of the alveolar process, serving to swing the tooth in its socket and 
 support it against the stress of mastication. 
 
 The apical fan-shaped group consists of the many bundles of fibres 
 attached about the apex of the root which radiate in all directions and 
 are attached to the surrounding bone. These fibres tend to maintain 
 the apex of the root in its central position in the socket. 
 
 Cementum 
 
 The cementum is one of the most important tissues to be considered, 
 for its peculiar structure is in large measure responsible for the chron- 
 icity of diseases of the peridental membrane. The cementum is contin- 
 uous growing, being gradually built by the cementoblasts which lie upon 
 its surface. These cells are to be considered as an integral part of the 
 peridental membrane, as they occupy the space between the fibres and, 
 by their action, build cementum around the fibres, thus attaching them 
 to the root. 
 
 Cementum is closely analagous to the subperiosteal bone. It is built 
 by cementoblasts lying on its surface, as is subperiosteal bone by the 
 osteoblasts on its surface. The most important difference is that bone 
 has a circulation of blood within and throughout its structure, while 
 cementum has not. This is a very important fact to remember. When 
 there is a suppurative detachment of the periosteum from bone, the 
 underlying bone dies. Then, as a result of the circulation within the 
 bone, a line of demarkation is established and the dead bone is ex- 
 foliated. When the peridental membrane is detached from the cementum 
 by suppuration, the death of the cementum occurs in the same manner, 
 but owing to the lack of circulation within the cementum, the dead 
 portion cannot be thrown off, but remains as a constant irritant to the 
 overlying tissue. This is the principal factor in maintaining the chron- 
 icity of the pus pocket alongside the root and the chronic alveolar 
 abscess. 
 
 §A 
 
Peridental Membrane 
 
 The peridental membrane contains many specialized elements. The 
 various groups of principal fibres have already been mentioned, as have 
 the cementoblasts and osteoblasts. There are also many strings of epi- 
 thelial cells which form a more or less definite network about the root 
 of the tooth. The function of these cells has not been definitely deter- 
 mined. Some investigators think they are the remains of those cells 
 which formed the enamel organ and are liable to break down easily as 
 a result of certain toxins in the circulation. Others contend that they 
 have been so placed for the especial purpose of combating infections 
 of the peridental membrane — that they multiply rapidly and accomplish 
 the encystment and destruction of the infective agents and their products. 
 We are inclined to the latter view. 
 
 The blood-supply of the peridental membrane is unusually good. 
 Vessels enter about the apex of the tooth and pass alongside the root, 
 other vessels enter over the crest of the bony alveolus, and still others 
 pass directly through the bone. With this triple source of supply the 
 practice of removing the pulps of teeth with the thought of diverting 
 an increase of blood to the peridental membrane would seem to be an 
 unwarranted procedure. 
 
 Alveolar Process 
 
 The alveolar process is true bone. However, it should be considered an 
 appendage of the tooth. It is built about the tooth as the tooth grows; 
 it disappears following the extraction of the tooth. It seems logical to 
 state that the physiological process of absorption, by which the peridental 
 membrane and alveolar process are removed following the extraction of 
 a tooth, also plays a considerable part in the changes which take place 
 following suppurative detachments of the peridental membrane from the 
 cementum. We should expect the detached fibres, as well as the bone 
 to which their outer ends are attached, to be absorbed, even though 
 they were not involved in the suppuration. 
 
 It seems, therefore, that there is a physiological interdependence of 
 the various investing tissues which requires that the health of all be 
 maintained; that serious injury to one is likely to impair them all; and 
 that the gingivae stand guard to protect these underlying tissues. As we 
 study the diseases of these tissues we will come to appreciate more and 
 more the importance of preserving the gingivae in good health in order to 
 prevent disease of the peridental membrane. 
 
 L^ 
 
10 
 
 SECOND LECTURE 
 
 STUDIES OF SALIVARY CALCULUS 
 
 INFLAMMATIONS CAUSED BY SALIVARY CALCULUS 
 
 AND TREATMENT 
 
 In view of the fact that the injuries due to deposits of salivary 
 calculus have been recognized since the earliest historical times, it seems 
 strange that so little effort has been made to study the causes and nature 
 of the deposit. Credit is due Dr. Henry H. Buchard for having made 
 the first serious effort in this direction.* Dr. Buchard 's theory was 
 based on the fact that water containing carbon dioxide will dissolve a 
 greater quantity of various salts than it will without the gas, and its 
 ability of dissolving these salts is further increased by the addition of 
 more of the gas under pressure. If water is charged with carbon dioxid 
 under pressure in a closed tank, its power of dissolving the salts will be 
 increased in proportion to the quantity of the gas. Then, if the pressure 
 is released, the excess of gas will be given off and the corresponding 
 excess of salts held in solution will be precipitated. In the human body, 
 the fluids are charged with carbon dioxid under the blood pressure, and 
 are therefore capable of holding excessive amounts of calcium and other 
 salts in solution. When the fluids are discharged (as the flowing of 
 the saliva from Stenson's duct), they are released from the blood 
 pressure, and the excess of carbon dioxid escapes, while a due propor- 
 tion of salts is precipitated. It was reasoned that in the mouth this 
 precipitate would be caught in a curd formed by the action of lactic 
 acid on the mucus, the lactic acid being formed by micro-organisms 
 normal to the mouth, and the precipitated salts and the curd would 
 settle down in out-of-the way places and by additions would finally form 
 a hard mass of calculus. 
 
 It was not easy to prove this theory. Dr. Burchard, in his experi- 
 ments, found that saliva collected in a test-tube, and allowed to stand, 
 would be cloudy within twenty-four hours and it was thought that this 
 cloud was the precipitate of calcium salts. 
 
 This was the generally accepted theory until Dr. G. V. Black under- 
 took his long series of experiments about seven years ago. He first 
 duplicated Dr Burchard 's experiments with the same results. It then 
 occurred to him that it was not proven that the cloud in the test-tube 
 
 Dental Cosmos, vol. 37, 1895, p. 821. 
 
11 
 
 was calcium salts. He contrived to centrifuge the contents of the tube, 
 collecting it on a microscopic cover-glass held in the bottom of the tube, 
 and found that the cloud was composed entirely of a growth of micro- 
 organisms. 
 
 Many new lines of investigations were then taken up. Our time 
 is too limited to do more than recite certain of the more important 
 findings. Systematic examinations were made of artificial dentures 
 and it was noted that the mucus, which gives a denture a greasy feeling, 
 could be readily washed off with the water running from the hydrant, 
 but that there would frequently remain a new soft deposit of calculus. 
 It was observed that this could be easily removed with a brush and plain 
 water if this was done before the deposit had remained as long as fifteen 
 or twenty hours, but that it was difficult or sometimes impossible to 
 remove the deposit with the brush if it remained twenty-four hours. 
 This, of itself, offers a most practical suggestion for the prevention of 
 the accumulation of these deposits on the teeth by thorough brushing 
 twice daily. 
 
 An upper denture was then constructed with a little rectangular gold 
 frame attached to the vulcanite above the buccal surfaces of the molars. 
 This frame was held in place by two screws and was so arranged that 
 a specially ground cover-glass was held under the frame and could be 
 removed and carried to the microscope for examination without disturbing 
 whatever might be collected upon it. It was thus possible to secure and 
 examine deposits in all stages, from the very fresh soft deposits to those 
 which were quite hard. Various staining methods were employed to bring 
 out more clearly the structural characteristics. It was also possible to 
 make photomicrographs of all specimens. 
 
 This line of investigation developed several important facts. It was 
 quickly recognized that the deposit was not a precipitate, as had been 
 supposed, but that the forms were all spherical, and the material con- 
 stituting the deposit was a calco-globulin, and this globulin brings with 
 it the calcium elements which eventually, with the decomposition of the 
 globulin, form the hard deposits. This globulin is called the agglutinin 
 of salivary calculus. Eepeated examinations showed the primary deposit 
 to consist of minute spherules (smaller than red blood corpucles) which 
 gradually coalesced to form larger massses of more or less rounded 
 forms. 
 
 It was also determined that the outpouring of the deposit is decidedly 
 paroxysmal; this is one of the striking characteristics. It was later dis- 
 covered that the paroxysms are of comparatively short duration and 
 occur within a few hours after a heavy meal. If, for example, a heavy 
 meal were eaten at noon, the cover-glass on the denture would remain 
 clear until possibly two o'clock, when the paroxysm of deposit would 
 
12 
 
 begin. It would continue for an hour and a half or two hours and then 
 cease. A new glass placed at this time would remain clear. 
 
 These experiments seem to have established the fact that a heavy 
 meal, especially when well digested, puts into the system more of nutrient 
 material than is required, and that a i)roper balance is restored by the 
 paroxysmal outpouring of the calco-globulin with all the secretions and 
 excretions, each of the body juices and fluids having its due proportion. 
 Persons subject to frequent heavy deposits were able to continue for 
 weeks without any deposits when they reduced the amount of food taken 
 a little below that to which they were accustomed. During such a period, 
 a single heavy meal would result in a paroxysm of deposit. It seems to 
 make no difference what foods are selected for the heavy meal. 
 
 Many other experiments were performed which can not be enumerated 
 in this course. One other thing should be mentioned — a special grinding 
 machine was constructed and a technie developed by which very thin sec- 
 tions of the hard salivary and serumal deposits could be ground thin 
 enough to be available for microscopic study and photographing. These 
 showed the structure of the hard deposits to be similar to the soft deposits 
 caught on the cover-glasses. 
 
 INFLAMMATIONS DUE TO DEPOSITS OF SALIVAEY CALCULUS 
 
 Deposits of calculus always occur on hard substances. In the mouth 
 we find these deposits on the teeth, and on crowns, bridges, artificial 
 dentures, and other appliances. The position of the deposit is most likely 
 to be near the orifices of the ducts from the salivary glands; upon the 
 buccal surfaces of the molars and the lingual surfaces of the lower 
 incisors. The initial deposit is usually at the position of the crest of the 
 free gingivae and occurs because there has been a slight blunting of the 
 normally thin edge. Such a blunting, or some irregularity of form, seems 
 necessary for the initial deposits to become attached. This fact should 
 emphasize the importance of keeping the gingivae in good health with 
 normal thin crests. 
 
 Gingivitis Caused by Deposits oi' Salivary Caiculus 
 When the initial deposit in any position has become hard, there is an 
 irritation of the underlying gingivae. This form of gingivitis, with the 
 gradual accumulation of the deposit, is distinct from others. There are 
 frequent suppurations of the shelf of gingivae which is in contact with 
 the deposit. As the deposit increases, it gradually destroys the gingivae 
 and is apt to replace in contour the lost tissue. The most striking 
 feature of this, in comparison with certain other forms of gingivitis, is 
 that there is little tendency for the inflammation to involve any other 
 tissue than that of the shelf which is in contact with the deposit. 
 
13 
 
 Pericementis Caused by Deposits of Salivary Calculus 
 
 If the deposit is not removed, it is likely to destroy all the gingivae 
 and encroach upon the peridental membrane, gradually destroying not 
 only the peridental membrane, but also the bone of the alveolar process 
 and overlying gum tissue. In all of this there is the tendency for the 
 attachment of fibres of the peridental membrane to be maintained to 
 the level of the tissue destroyed by the deposit. There is little tendency 
 to the stripping off of the peridental membrane from the cementum and 
 the formation of pus pockets alongside the roots. Deposits of salivary 
 
 Fig. 3 
 
 Fig. 4 
 
 Fig. 3. Drawing illustrating a slight deposit on the lingual surface 
 of a lower incisor which has caused a gingivitis only, not having pro- 
 gressed far enough to involve the attachment of the peridental membrane 
 to the cementum. 
 
 Fig, 4. Drawing illustrating a still greater destruction, including 
 also the labial tissues. 
 
 calculus should not therefore be considered a cause of pus pocket for- 
 mation, as has commonly been thought. 
 
 As the destruction of the investing tissues continues, the patient 
 may complain of occasional pain and soreness and the teeth may gradually 
 become loose, so that eventually they are lost. This is a slow process, 
 usually extending over many years, and as suppurations are frequent, 
 the menace to the health is probably greater than has been realized. The 
 thin-walled blood vessels in the granulating surfaces offer micro-organisms 
 easy access to the blood stream. 
 
 ^k 
 
14 
 
 Treatment 
 
 The treatment of the inflammations caused by deposits of salivary 
 calculus should always be undertaken with the possibilities of preven- 
 tion well in mind. It has been stated that fresh deposits are so soft 
 for fifteen or twenty hours that they may be easily removed with a brush 
 and plain water. Therefore, every patient who may be induced to brush 
 the teeth thoroughly twice every day can jjrevent the inflammation and 
 destruction caused by the hard deposit. This has been sufliciently well 
 demonstrated in many cases to leave no room for doubt of its efficacy. 
 
 Our management of cases presenting with deposits should be with the 
 view of gaining the co-operation of the patient to the end that future 
 deposits will be prevented. The removal of the deposits is not difl&cult. 
 They are practically always in sight; not covered by the gingivae. Only 
 a few simple instruments are required. After the removal of the deposits, 
 the surfaces of the teeth should be polished. If there is much inflamma- 
 tion, frequent rinsing of the mouth with warm salt solution will keep 
 the field clear and lessen the patient's discomfort. 
 
 In such cases it is usually best not to advise the patient as to the 
 technic of proper mouth hygiene at the time when the deposits are 
 removed. This should be reserved until the inflammation has subsided. 
 The patient should be given another appointment and should then receive 
 whatever instruction seems necessary to gain his interest and co-operation. 
 This should include a few brief statements explaining the nature of the 
 fresh deposit and the possibility of preventing its accumulation by 
 faithful brushing twice daily. It should also include mention of the 
 danger to the general health, as well as the probable eventual loss of 
 the teeth. Brushes should be selected, their movements demonstrated 
 and instructions given to the finest detail. 
 
 If posssible, a definite arrangement should be made for a subsequent 
 examination, so that we may know how well the home care is progressing. 
 A chart of the mouth, showing locations of deposits, should have been made 
 at the time of examination and each position should be carefully inspected, 
 deposits removed if there are any, and additional instruction given the 
 patient. Considerable diplomacy is necessary in the management of many 
 patients, but one who comes to realize fully the effectiveness of this 
 plan is sure to become more and more enthusiastic and more successful in 
 gaining and holding the interest and co-operation of the patients. 
 
 A-%. 
 
15 
 
 THIRD LECTURE 
 
 GINGIVITIS CAUSED BY DEPOSITS OF SERUMAL CALCULUS 
 WITH TREATMENT 
 
 In considering the inflammations of the gingivae caused by deposits 
 of serumal calculus, we have to do only with the deposits which occur on 
 the enamel of the subgingival spaces. A serum is normally poured out 
 into these spaces to keep them moist. We should expect this serum to 
 contain its proportionate share of calco-globulin, whenever there is a 
 paroxysm. As the quantity of serum is small compared with the amount 
 
 mmm^^ 
 
 Fig. 5. 
 
 Fig. 6. 
 
 Fig. 5. Drawing illustrating a deposit of serumal calculus under the 
 free gingiva on the labial surface of the enamel of a lower incisor tooth. 
 
 Fig. 6. Drawing illustrating a similar deposit on the lingual surface 
 of an upper incisor. Suppuration of the peridental membrane, resulting 
 from deposits in this position, causes the teeth to move labially, and such 
 cases are generally hopeless, after much progress has been made. 
 
 of the saliva, so will the deposits be small and slow of formation. The 
 causes are the same, and the nature of the deposit is the same as salivary 
 calculus. We will often find both deposits in the same mouth. However, 
 proper care or vigorous mastication may prevent the accumulation of 
 salivary deposits, while serumal deposits are being laid down. 
 
 Owing to the fact that the gingivae naturally hug closely about the 
 teeth, the deposits occurring in the subgingival spaces are likely to be 
 
16 
 
 compressed while soft, and harden as flattened scales. If the close adapta- 
 tion of the gingivae is lost as a result of inflammation or detachment of 
 the peridental membrane, the form of the deposit will generally be 
 nodular instead of flat. 
 
 Clinically, these deposits may be divided into two groups: one in 
 which there is a general deposit in the subgingival spaces in the form 
 of narrow bands more or less completely encircling the teeth. The inflam- 
 mation of the overlying gingivae may or may not be apparent. In such 
 mouths deposits of salivary calculus are usually present. In the other 
 group, the deposits will be confined to certain teeth, others being free. 
 In such cases an inflammation of the gingivae about the particular teeth 
 has usually preceded the occurrence of the deposit. An irritation, such 
 as the wedging of food through an open contact, or an ill-fitting crown, 
 causes the outpouring of greatly increased amounts of serum from the 
 inflamed gingivae, thus delivering to these spaces a correspondingly 
 increased amount of calco-globulin for deposit. We therefore find con- 
 siderable deposits in such locations, with little or none elsewhere in the 
 mouth. It is not uncommon to find deposits on the lingual surfaces of the 
 upper incisors, from the irritation caused by food forced against the 
 gingivae by the lower incisors, especially if there is much overbite. 
 
 In all cases in which there are deposits of serumal calculus in the 
 subgingival spaces, these cause inflammation of the overlying gingivae, 
 and occasionally suppuration occurs. The tissues may recover without 
 serious harm having been done. Sooner or later, however, a suppuration 
 will involve the attachment of the peridental membrane at the gingival 
 line and a little pus pocket will be formed. In this way these deposits 
 become the real exciting cause of suppurative detachments of the peri- 
 dental membrane in probably twenty per cent of cases. 
 
 Treatment 
 
 The treatment of inflammations caused by these deposits should be 
 along the same general lines as that mentioned for salivary deposits. 
 More delicate instruments are required, also a higher degree of finger 
 skill. One must learn to feel the deposits and to recognize a surface free 
 of deposit in positions where he cannot see. While proper brushing by 
 the patient will assist in keeping the gingivae in good health, the use 
 of a rubber bulb syringe to wash out the subgingival spaces thoroughly 
 twice a day is much more efficacious. This requires more careful training 
 and instruction and more of enthusiasm to get patients keyed up to the 
 point at which their interest and care will be maintained. A similar 
 plan of recording positions of deposit, of subsequent examinations, etc., 
 should be followed. Even in mouths free from these deposits, nothing 
 
17 
 
 Figs. 7, 8, 9. Three molar teeth showing "rings" of deposits of ser- 
 umal calculus on the enamel of the subgingival space. Frequently these 
 "rings" encircle the crown. Specimens from i>i^orthwestern University 
 Dental Museum. 
 
 Fig. 10. The position of the rubber bulb syringe in washing the 
 subgingival spaces or pus pockets. The end of the nozzle shouJd touch the 
 enamel of the tooth near the crest of the gingivae as it is passed along 
 the arch, the angle being such that the water or solution will be forced 
 into the subgingival spaces. This is the most effective means of prevent- 
 ing deposits of serumal calculus. 
 
18 
 
 will contribute so greatly to the maintenance of the gingivae in good 
 health as the twice daily irrigation of the subgingival spaces with warm 
 water or normal salt solution. 
 
 GINGIVITIS CAUSED BY INJUEIES, WITH TKEATMENT 
 
 In our studies of the histology and physical powers of the investing 
 tissues, the protective function of the gingivae was noted. The gingivae 
 are naturally equipped to withstand severe punishment, which they do in 
 a remarkable way. The fact that they will maintain themselves so 
 long under continued irritation, together with our failure to recognize 
 these injuries as forerunners of more serious lesions of the peridental 
 
 Figs. 11, 12. Photographs of plaster models of a case before and 
 after contact restoration. The patient presented with a slight pocket 
 on the mesial surface of the root of the first molar on account of the 
 open contact. The mesial surface of the first molar and distal of the 
 second bicuspid were free from decay and had not been filled. The 
 separation had occurred as a result of flat fillings in the mesial of the 
 second bicuspid and distal of the first bicuspid. These fillings were 
 removed, and a Perry separator was applied on several occasions to move 
 the second bicuspid back into contact with the first molar, it being held 
 there for a time with fillings of base-plate gutta-percha. Later, permanent 
 fillings were made, restoring normal conditions, as shown in Fig. 12. It 
 was necessary to relieve the occlusion on the distal slopes of the cusps 
 of the second bicuspid as it was moved. 
 
19 
 
 membrane, has led to much abuse and neglect. Yet it seems fair to 
 state, from statistics which will be presented, that possibly seventy-five 
 per cent of the pus pockets alongside roots of the teeth are the direct 
 result of long-continued and neglected injuries to the gingivae. 
 
 With an irritation of the gingivae from any form of injury, there 
 is opportunity for suppuration, with subsequent involvement of the attach- 
 ment of the peridental membrane. As has been mentioned, the irritation 
 is likely to result in a deposit of serumal calculus, which becomes a 
 secondary cause of the further progress of the case. In connection with 
 the more acute suppurations there is often considerable pain. Absorptions 
 of the gingivae occur as a result of the constant irritations* and repeated 
 suppurations. 
 
 It would be almost impossible to cite all the causes of these injuries. 
 Lack of contact of the teeth due to extractions of neighboring teeth, 
 flat fillings, crowns, etc., improjjer contact of teeth, irregularities of 
 contour due to sharp edges of cavities, bad margins of fillings and 
 crowns, etc., abuse of these tissues in operations, and injuries by patients 
 in cleaning, are the most frequent causes. 
 
 In cases in which contacts are not normal, and food is wedged between 
 the teeth, the septal gingivae become inflamed from the repeated im- 
 pactions of food, also from the efforts to remove it. These impactions 
 will, after a time, result in the absorption of the central portion of the 
 septal tissue, while the buccal and lingual portions may be pushed out- 
 ward in their respective embrasures. Their appearance is that of slightly 
 swollen festoons. Later on, as the central portion is further depressed, 
 there is likely to be some absorption of the buccal and lingual portions 
 also. This may continue until the absorption has included much of the 
 bone of the alveolar septum, with deep pus pockets on the proximal 
 surfaces of the teeth. 
 
 Some patients will complain bitterly of the pain caused by slight 
 impactions of food, others will seem unconscious of the presence of con- 
 siderable accumulations in many spaces. Treatment should therefore 
 be undertaken on the basis of the impaction and inflammation, rather 
 than on the complaint of the patient. 
 
 Several years ago, in order to get some reasonably reliable data 
 as to the frequency of the various forms of gingivitis, I requested a 
 number of dentists in various sections of the country to assist me in 
 collecting certain statistics. T sent a number of examination cards to 
 each man with a request that he make a careful record of the areas 
 of gingivitis found in the mouths of young adults, who had no disease 
 of the peridental membrane. I present herewith a brief summary of 
 the results of the examination of 500 mouths of persons between twenty 
 and thirty-five years of age. 
 
20 
 
 Of the 500 mouths examined, but 25 were reported as having no 
 gingivitis. For the other 475 persons, 4265 areas of gingivitis were 
 reported — an average of 8.53 areas per person for the entire 500. Of 
 these areas, 1348 were due to deposits of salivary calculus. These were 
 in the mouths of 39 per cent of persons examined, and represent 31 per 
 cent of all areas of gingivitis. In recording these, each surface of each 
 tooth having a deposit was counted as one area. For example, a deposit 
 on the lingual surface of the lower incisors and cuspids was counted as six 
 areas. 
 
 Five hundred and sixty-three areas were reported as having deposits 
 of serumal calculus on the enamel of the subgingival spaces. These were 
 in the mouths of 15 per cent of persons examined, and represent 13 
 per cent of all areas of gingivitis. Many who had deposits of salivary 
 calculus also had serumal deposits; 140 persons were reported as having 
 either or both, leaving 360 without deposits of either kind. 
 
 There were 2364 areas due to other causes than deposits. Of these, 
 783 were due to bad margins of fillings or crowns, 496 to lack of contact 
 of fillings or crowns, 305 to improper contact of fillings or crowns, 263 
 to malpositions or atypical forms of proximal surfaces, 255 to lack of 
 contact with no decay of proximal surfaces, 233 to caries, and 19 to worn 
 contacts. 
 
 If we add together the number of areas due to bad margins, lack of 
 contact or improper contact of fillings or crowns, the total is 1584. This 
 number of areas, 37 per cent of all, may be properly charged to imperfect 
 dental operations. This is an average of more than three such areas per 
 mouth, and would seem to indicate that fully one-third of the pus pockets 
 are due to lack of care in operative and prosthetic service. 
 
 There was a time when no consideration whatever was given to the 
 soft tissues in the performance of either filling or crowning operations. 
 When files were used to separate the teeth, and wedges were driven 
 between them, the importance of preserving the investing tissues could 
 not have been appreciated. It has only been within comparatively 
 recent years that the attitude of the profession has begun to change. 
 Not until we realize the direct relationship of these areas of gingivitis 
 to the more serious detachments of the peridental membrane which follow, 
 will we be as careful as we should be in the finer technic of all opera- 
 tions so that the number of these injuries will be reduced to the 
 minimum. 
 
 Treatment 
 In the treatment of cases of this kind, it is essential that we should 
 first make careful search for the cause. When this has been found, the 
 treatment will be indicated. If, because of an open contact, food is 
 
21 
 
 wedging between the teeth and injuring the septal gingivae, we must, if 
 possible, learn the cause of the open contact. It may bo that the cusp 
 of a tooth in the opposite arch needs a little grinding, or the extraction 
 of a tooth may have permitted movement of others, opening the contacts. 
 Many times it is a flat filling which did not restore contact, or it may 
 be any one of many things. Most of these are easily corrected and the 
 gingivitis will promptly subside when the cause of the irritation is 
 eliminated. It is not so much the difficulty of correcting these conditions, 
 as it is the necessity of appreciating the importance of it. 
 
 When a contact is too broad, though tight, it should be corrected by 
 trimming to proper form. Other things should be done as required in 
 particular cases. Many require careful study. Close attention to these 
 things will impress the possibilities of prevention by greater care in 
 every operation performed. 
 
 In all of the operations for contact restoration, one of the most 
 important things is proper separation of the teeth without pain or injury 
 to the soft tissues. Notwithstanding all of the more recent devices, 
 I know of nothing so satisfactory as the Perry separators. These seem 
 to meet every requirement. A little experience is necessary to be able to 
 adjust them properly, and thA^ are more expensive than other devices, 
 yet in the long run they are very econon)ical, when one considers the 
 time saved and the benefits gained by their use. 
 
 FOURTH LECTURE 
 
 CHEONIC SUPPURATIVE PERICEMENTITIS 
 
 The term '* chronic suppurative pericementitis" is applied to that 
 disease, the essential characteristic of which is the formation of a pus 
 pocket alongside the root of a tooth. This term was selected because 
 it is closely descriptive of the condition. <")ne of the marked features of 
 this disease is its chronicity, to which reference has already been made. 
 It is also essentially a suppurative disease and it is notable that the 
 suppurative process strips the soft tis^sue from the cementum, which 
 makes the word pericementitis especially applicable. There is room for 
 question in many cases, whether or not the bone of the alveolar process 
 is involved directly by the suppuration, or is absorbed secondarily by 
 purely physiological processes. Therefore, terms which indicate an 
 inflammation of the alveolar process do not place the principal tissue 
 involvement where it really occurs. Whether this term, or some other, 
 comes to be finally accepted and used, it is imperative that a name be 
 found which will a])pl3' to this condition as a pathologic process different 
 from the others to which the investing tissues are subject. 
 
22 
 
 The local causes leading to the formation of pus pockets have been 
 reviewed. We have said that a gingivitis always precedes the peri- 
 cementitis, and have emphasized the fact that deposits of serumal cal- 
 culus and injuries to the gingivae are tJie principal local exciting causes. 
 In doing this we do not overlook the effect of the systemic condition 
 
 Figs. 13, 14. Panoramic radiographic views of the upper and lower 
 jaws in a case of chronic suppurative pericementitis of long standing. This 
 patient had suffered from gout for five years. The right foot was first 
 swollen and was very painful. In subsequent attacks the ankle was 
 involved. The patient stated that except for this, he had never been 
 sick a day. One lower incisor had become so loose that it was removed 
 with the fingers. Pressure upon the gums caused pus to exude about the 
 necks of many of the teeth. It was advised that all of the teeth be 
 extracted. 
 
 in some cases in which local causes are found, and we also appreciate 
 the fact that there are cases in which no local causes are apparent. 
 We are, however, most concerned at this time with conditions which are 
 recognizable and for which definite treatment is indicated. 
 
 Many men have searched for a specific organism which might be proven 
 to be the cause of these suppurations. Up to the present time, all such 
 attempts have failed. Careful clinical study of the progress of cases 
 
23 
 
 contraindicates a specific type of infection, as will be explained later. 
 
 The recent claim of a number of writers that the endameba is the cause 
 
 of this disease seems not to be well founded, and the use of emetine 
 
 has proven a disappointment. It would have been Just as logical to select 
 
 Fig. 15. Normal peridental membrane. The row of cementoblasts 
 may be seen lying along the surface of the cementum. These cells occupy 
 most of the space between the fibers as the latter enter the cementum. 
 Photograph by Dr. F. B. Noyes. 
 
24 
 
 any one of the other organisms which can be generally found in these 
 pockets, and state that it alone caused this disease. 
 
 The symptoms and tissue changes are those of a progressive chronic 
 infection. The appearance of the gingivae may be normal, or the crests 
 may be slightly blunted and swollen, with slight or considerable discolora- 
 tion. The suppuration occurring because of the inflammation of the 
 gingivae sooner or later involves the peridental membrane and cuts it 
 away from the cementum, beginning at the gingival line. When a detach- 
 
 Fig. 16. Section through soft tissue overlying a deep pocket of many 
 years' standing on the labial side of the root of a lower left cuspid; from 
 about the middle of the length of the root. Patient sixty-five years of 
 age. Tissue cut away by Dr. Arthur D. Black on September 29, 1913. 
 Normally the crest of the alveolar process should be present in a section 
 cut in this position. The bone has all disappeared, as have practically all 
 of the fibers of the peridental membrane. Section prepared by Dr. H. A. 
 Potts, photographed by Dr. F. B. Noyes. 
 
 ment has been affected, the general tendency is for pockets to slowly 
 progress. This progress is greatest toward the apex of the root, rather 
 than around the root, so that it is not unusual to find very deep, narrow 
 pockets. The cementoblasts are the first of the specialized elements to be 
 destroyed. This seems to occur as a part of the suppurative detachment 
 of the soft tissue from the root. Subsequently, the principal fibres of 
 the peridental membrane gradually disappear from the overlying tissue, 
 and later the bone of the alveolar process to which these fibres were 
 attached disappears also. As has been mentioned, it should be expected 
 
that these tissues would be absorbed following the detachment, regardless 
 of their possible involvement in the suppurative process. The disap- 
 pearance of the fibres of the peridental membrane may be shown by 
 microscopical examination of tissue cut from these positions; while the 
 absorption of the alveolar process is clearly shown by radiographs. 
 
 The soft tissue overlying the denuded cementum jjresents a granulating 
 surface containing many newly formed, thin-walled blood vessels, which 
 offer favorable opportunity for the many micro-organisms within the 
 mouth to enter the circulation. The cementum itself has necessarily 
 absorbed the products of suppuration and putrefaction, so that a con- 
 dition could hardly be imagined which would present greater difficulties 
 to a normal re-attachment of the tissue to the root. Every specialized 
 element of the peridental membrane has disappeared, and the tissue which 
 remains lies against a cementum which has been rendered negatively 
 chemotactic by absorbing the products of the suppuration. It is for this 
 reason that these detachments are permanent detachments. 
 
 It has been suggested that the outer surface of the cementum should 
 be cut away, with the expectation that an attachment would occur similar 
 to that which takes place when teeth are implanted, transplanted or 
 replanted. We have not time to discuss this point at length at this time, 
 but attention is called to the fact that the attachment in such cases is 
 an unstable one, and it in no sense a re-attachment of the peridental 
 membrane. Where such teeth become firm, the rule is that it is by absorp- 
 tion of the root and building in of the surrounding tissue, a process 
 which, within a few years, results in the loss of the tooth. 
 
 Doubtless many conscientious oi)erators have been misled into believ- 
 ing that re-attachment occurs; this has resulted from their failure to 
 observe cases with sufficient care over a long enough period of time. 
 It is the rule that many cases look very much better following treatment, 
 and that there is close adaptation of the soft tissue to the root, so that 
 one may be deceived. If such cases are kept under close observation, 
 it will be found practically always that the pockets are still there, and 
 that there will be a recurrence of the pus formation. 
 
 Pain is not a prominent symptom, although the tissues about such 
 teeth will occasionally be verj^ painful when the suppurations are acute, 
 or if the pus penetrates deeply into the surrounding tissues. Most 
 patients will complain that the teeth are periodically sore and that they 
 are raised in their sockets. The greater the progress of the case, the more 
 frequently will pain and soreness be noted. 
 
 Deposits of serumal calculus will be found upon the denuded cementum 
 in many cases. These deposits should never be considered a cause, but 
 always a result of the formation of the pocket, as the material for the 
 deposit — the calco-globulin — is brought to the pocket by the serum 
 
26 
 
 escaping from the overlying inflamed tissue. These deposits are fre- 
 quently nodular, as the overlying tissue does not hug closely about the 
 root, and the deposit is not compressed while soft, as is often the case 
 with the deposit on the enamel. When deposits have occurred on the 
 cementum, they cause additional inflammation of the overlying tissue 
 and in this way contribute to the further progress of the pocket 
 
 The cervical lymphatic glands are occasionally enlarged in advanced 
 cases. There is also, as a rule, an excitation of the salivary glands, re- 
 quiring the patient to swallow frequently and possibly to drool at night. 
 
 Pus pockets may be divided into two groups, according to their 
 location. In many cases the pockets will all be on proximal surfaces, 
 with little or no involvement of buccal, labial or lingual surfaces. In 
 others, all the pockets will be on buccal, labial or lingaal surfaces. In 
 the later stages, all surfaces will be involved. It is not uncommon to 
 find a single pocket on the labial or buccal surface, or possibly two or 
 three. The lingual surfaces of the upper incisors are frequently involved 
 as a group. 
 
 The tendency is for teeth having pus pockets on one side to move in 
 the direction away from the pocket. This is partly due to the inflam- 
 mation, but principally to the fact that the balance of pull of the various 
 fibres of the peridental membrane has been disturbed and the fibres on 
 the sound side pull the tooth in that direction. When the pockets are 
 on the lingual side of the upper incisors, these teeth generally move 
 labially and, with the pull of the trans-septal fibres, soon draw the cuspids 
 away from the first bicuspids and open the contacts. The contacts between 
 the incisors and cuspids are also opened by the forward movement, and 
 the septal tissues soon become inflamed from food impactions. When the 
 labial movement of the incisors has once fairly begun, it is seldom 
 checked and after a time the teeth are lost. Very often the forward 
 movement of the cuspids results in the eventual loss of the bicuspids and 
 molars also. 
 
 In cases in which the original pocket is alongside a proximal surface 
 in the bicuspid or molar region, the neighboring teeth are likely to become 
 similarly involved on their proximal surfaces, the buccal and lingual 
 tissues remaining intact. When such a pocket occurs, the inflammation 
 within the septal space, together with the pull of the fibres on the 
 opposite sides of both teeth, tend to open the contact between the teeth. 
 When this occurs, there is usually some pressure on next neighboring 
 contacts, with slight movement of the adjacent teeth. With the subsid- 
 ence of the inflammation, the teeth return to their normal positions. This 
 is repeated again and again, until after a time the frequent movement 
 results in the weakening of neighboring contacts and stringy foods are 
 forced through, causing inflammation of the septal tissues. This continues 
 
27 
 
 until pus pockets are formed on the proximal surfaces of these teeth. 
 In this slow way these cases progress. The movement of the teeth 
 of one arch will often disturb those of the opposite arch and similar 
 inflammations will follow. Thus all the teeth may be lost as a result 
 of a single proximal pus pocket. 
 
 Occasionally the pus formed iu deep pockets is not discharged along- 
 side the root, but involves the adjacent soft tissues and forms an acute 
 abscess at the side of the root. This is a lateral abscess. It may be 
 mistaken for a true alveolar abscess. 
 
 Treatment 
 
 The key to the treatment of chronic suppurative pericementitis is in 
 the statement that suppurative detachments of the peridental membrane 
 are permanent detachments. With this in mind, we may divide the 
 treatment under three headings: preventive, palliative and radical. 
 
 Preventive treatment consists of the carrying out in pactice of every 
 measure which will prevent or cure gingivitis and thus protect the 
 peridental membrane. The methods of doing this have already been 
 discussed. This treatment must be by the general practitioner of dentistry 
 and not by a specialist, for it must come to be a part of every dental 
 operation to conserve the health of the investing tissues. This must 
 be done by careful systematic examinations, properly recorded; by the 
 maintenance of good contacts to promote thorough mastication, and careful 
 training of patients in mouth hygiene. This should come to be a con- 
 siderable part of the practice of each dentist — and it should be the 
 service by which a substantial portion of his income will be earned. 
 Practitioners who follow such a plan will have very few patients in 
 whose mouths pus pockets will occur. 
 
 Palliative treatment should be applied in those cases in which pus 
 jiockets have formed, but are not bad enough to require the extraction 
 of the teeth involved. It is not possible to give a definite rule by which 
 the line may be sharply drawn between those conditions which demand 
 extraction and those which contra-indicate this operation. More will be 
 said on this point later. 
 
 If palliative treatment is undertaken, the first procedure should usu- 
 ally be the removal of deposits from the roots, if deposits are present. 
 It makes little dift'erence what instruments are used, if the operator is 
 able to remove the deposits. A large number of scalers is not necessary, 
 for it is believed that other means should be employed instead of scaling 
 operations if there are deposits in positions of very difficult access. It is 
 certainly of the greatest importance that each operator should develop 
 the best possible finger skill. 
 
The instruments should be sharp and the effort should be made to 
 remove all the deposit and leave the root smooth. In doin^ this, as 
 much as possible of the cementum should be left on the root. The removal 
 of the cementum causes many teeth to become hypersensitive, so that 
 thermal changes or even the mastication of food is painful. It should 
 be borne in mind that there is no physiological provision for transmission 
 of sensation through cementum. Therefore there should be no sensation 
 transmitted through the pulp in scaling operations, so long as the cemen- 
 tum is intact. Sometimes acid formed by organisms growing within a 
 pocket will soften the cementum, so that it is easily removed, or it may 
 be removed by repeated scaling operations. One case has been presented 
 in which the pulp, within the root-canal, was actually exposed by the too 
 vigorous use of scalers. 
 
 If pain is caused in the overlying tissues by scaling operations, novo- 
 cain may be injected. However, in such cases I have generally preferred 
 to remove the bulk of the deposits, which can usually be done without 
 much pain, at the first sitting, and then, by thoroughly irrigating the 
 pockets with salt solution on two or three successive days, bring about 
 sufficient reduction of the inflammation that the more thorough scaling 
 can be done without causing pain. 
 
 Following the scaling, the case should be observed by the dentist until 
 the inflammation has subsided, irrigating all pockets thoroughly at each 
 visit. The patient should then be carefully instructed in the use of the 
 rubber bulb syringe and should be impressed with the necessity of irriga- 
 tion twice daily with normal salt solution. By this plan the pockets 
 will be kept clean and free from accumulations or micro-organic growths, 
 and the recurrence of deposits will be in large measure prevented. After 
 the roots are once thoroughly cleaned, the irrigation by the patient be- 
 comes the most important factor in the prognosis of most cases, and its 
 importance cannot be too strongly impressed. There should of course be 
 an arrangement for subsequent examinations, and further treatment when 
 necessary. 
 
 In a limited number of cases, the cleansing operations, and incidentally 
 the scaling, may be simplified by cutting away the overlying soft tissue 
 and thus materially reducing the depth of the pocket. This treatment 
 is most frequently indicated for pockets on labial or buccal surfaces. , 
 
 Time will not permit a discussion of the reasons for the abandonment 
 of antiseptics in the treatment of these pockets. It need only be said 
 that antiseptics were originally used here for the same reason that they 
 were used in other infected cavities by surgeons, to inhibit the growth 
 of the organisms. Today we should abandon their use for the same reason 
 that surgeons have generally done so, because it has been found that they 
 do more harm than good; that an antiseptic which will be effective against 
 
29 
 
 micro-organisms will also so inhibit the activities of the tissue that noth- 
 ing is gained. By the use of salt solution, most of the organisms are 
 washed away and the tissues are left in the best condition to destroy the 
 remainder. 
 
 Fig. 17. Plaster model of ease in wliich the tissue overlying a pocket 
 on the mesio-buccal root of an upper first molar was cut away to reduce 
 the depth of the pocket and facilitate the cleaning. 
 
 Fig. 18. A case in which the distal root of a lower first molar was 
 amputated. The distal half of the crown of the tooth was also cut away, 
 and a gold crown was made to restore the full occlusal surface. 
 
 This plan of treatment is quite simple, but is very effective if the 
 co-operation of the patient can be secured. So long as the pockets are 
 kept clean, they are practically well, and both the teeth and the health 
 of the patient are conserved. 
 
 Eadical treatment for these cases consists of extraction or root ampu- 
 tation. As a general statement, it may be said that we have gone too 
 far in our effort to save these teeth. When so much of the investing 
 
30 
 
 tissue has been destroyed that the tooth is very loose, it should be ex- 
 tracted. If a tooth has deep pockets and is periodically sore enough 
 to interfere with proper mastication, it should be extracted. If the for- 
 mation of pus can not be controlled, the tooth should be extracted. In 
 most cases, if the disease has progressed to denude the bifurcation of 
 multi-rooted teeth, they should be extracted. Eoot amputation may be 
 substituted for extraction in cases in which a single root of a multi- 
 rooted tooth is diseased, while the other root or roots are not. The 
 lingual root of the upper first molar offers the best opportunity for suc- 
 cessful amputation. It often requires a very careful study of eases to 
 come to a proper decision regarding extraction. We certainly should 
 not be guided by the usefulness of the tooth in mastication alone, as many 
 teeth which are serviceable are a decided menace to health. 
 
 FIFTH LECTURE 
 
 MANAGEMENT OF CASES 
 
 SYSTEMIC EFFECTS OF MOUTH INFECTIONS 
 
 In the previous lectures, we have discussed the several diseases to 
 which the gingivae and peridental membrane are subject, considering the 
 pathology and treatment of each separately. In many mouths several 
 or all these conditions may be present at the same time. An accurate 
 and complete diagnosis is therefore often difficult, as is the determina- 
 tion of the best plan of treatment. For this reason a definite system of 
 making and recording examinations becomes a matter of first importance. 
 In the clinics accompanying these lectures I have demonstrated a simple 
 plan by which each area of inflammation may be recorded by a number, 
 which will indicate the condition of the tissue, the position, and the cause. 
 It requires a little experience to become familiar with any such plan, yet 
 the advantage gained by having made and recorded such complete surveys 
 of the mouth will fully compensate for the effort. The habit of doing 
 this will sharpen one's observation and put one in position to lay out 
 a comprehensive plan of treatment. Every area of gingivitis, the loca- 
 tions of deposits of both salivary and serumal calculus, the condition 
 of contacts, the location and depth of pockets, teeth which are missing, 
 those which are loose, and many other items are necessary to a complete 
 record. In cases in which there are pockets, radiographs should be made 
 for the additional information which they will give and to verify the 
 instrumental examination. In some eases inquiry should be made into 
 the general physical condition of the patient. 
 
31 
 
 With all the facts obtainable, one is ready to lay plans for treatment. 
 It should first be determined what teeth unquestionably require extraction, 
 then those which should unquestionably receive palliative or preventive 
 treatment. There may be several regarding which there is some question 
 and oftentimes it will be wise to reserve one's judgment regarding these 
 for a little time, possibly for several months, until the attitude of the 
 patient towards the technic of mouth hygiene has been observed. It 
 will be possible to retain, without menace to the health, teeth with 
 tolerably deep pockets in one mouth, if the use of the syringe is faith- 
 fully carried out, while in another even quite shallow pockets will con- 
 stitute a serious menace if they do not receive proper irrigation. 
 
 The problem of appearance, and that of replacing lost teeth to pro- 
 vide a means of proper mastication, must have consideration at the 
 same time. Often it will be best to remove some of the ''doubtful" 
 teeth in order to give better abutments for a bridge, or if a denture must 
 be made, there may be an advantage in extracting several such teeth. 
 
 The general attitude of our people in favor of saving every tooth 
 as long as possible presents one other difficulty in the management of 
 these cases. When it has been determined that certain teeth should be 
 extracted, careful dipomacy must often be used in our advice to the 
 patient. I have, on several occasions, given patients what I am sure 
 was sound advice to the effect that they should have many or all of 
 their teeth extracted, with the result that I did not see them again. 
 We should always bear in mind the fact that the loss of the teeth is a 
 serious thing in the life of most persons, and some time is often required 
 to bring them to a proper realization of the situation which confronts 
 them. It is often best, therefore, first to suggest and later to state 
 definitely what seems best, with our reasons. 
 
 The studies by medical men in recent years have brought to us another 
 proposition for very serious consideration; viz., the relation of the local 
 foci of infection to many serious systemic diseases. This relationship has 
 been recognized by a few men for many years, but was not prominently 
 before either the medical or the dental professions until Hunter, of 
 London, wrote his famous article in 1911. 
 
 As early as 1891 our own Dr. W. D. Miller wrote as follows: "During 
 the last few years the conviction has grown continually stronger among 
 physicians, as well as dentists, that the human mouth, as a gathering 
 place and incubator of pathogenic germs, performs a significant role in 
 the production of varied disorders of the body, and that if many diseases, 
 whose origin is enveloped in mystery, could be traced to their source, 
 they would be found to have originated in the oral cavity." 
 
 Dr. Hunter wrote his first paper in 1900, but it was not until eleven 
 years later, after he had seen hundreds of patients improve or fully 
 
32 
 
 recover from those diseases which are now recognized as occuring secon- 
 dary to local foci, as a result of practically no other treatment than the 
 clearing of the mouths from infection, that he wrote a scathing article 
 which brought both professions to their feet. Among other things. Dr. 
 Hunter said in this paper: ''Sepsis in medicine therefore ranks, in my 
 experience, as the most prevalent and potent infective disease in the 
 body. It therefore deserves the particular attention of the whole profes- 
 sion as much as it has hitherto received their particular neglect. It 
 requires this attention at the hands of every branch of the profession." 
 Dr. Hunter's investigations seem to have been confined principally to 
 clinical observations and case histories, yet they are of great value 
 because of the large number and variety of cases reported. 
 
 The studies of Dr. Frank Billings and the group of men associated 
 with him in Chicago have been along more scientific lines, and have 
 given unquestionable proof of Dr. Hunter's observations. Dr. Billings 
 says: "Systemic disease due to a focus of infection anywhere is pro- 
 bably always hematogenous. The study of infected tissues of experi- 
 mentally inoculated animals, and the infected muscles, joint tissues, 
 lymph nodes proximal to infected joints, nodes on tendons, etc., of 
 patients, yield specific bacteria, and histologically there is found em- 
 bolism of the small and terminal blood vessels. Local hemorrhage and 
 endoarterial proliferation result in interstitial overgrowth, cartilagenous, 
 osseous, vegetative and other morbid anatomical changes, dependent on 
 the character of the tissue infected." This one quotation will suffice to 
 impress the fact that Dr. Billings' investigations have been exceptionally 
 thorough. 
 
 Dr. E. C. Eosenow has done most of the bacteriological work for Dr. 
 Billings' cases and his investigations have demonstrated that many 
 changes occur in the morphology of organisms in accordance with their 
 environment, also that they develop as yet unexplained affinities for 
 certain tissues. This was proven by the use of fresh cultures from four 
 groups of cases; appendicitis, ulcers of the stomach, cholecystitis, and 
 arthritis. The cultures were injected into veins of dogs and rabbits, and 
 in each group a very large majority of the animals developed inflammations 
 of the very same tissues as those from which the cultures were made, 
 while there were inflammations of comparatively few of the other tissues. 
 
 In the light of our present knowledge, we are justified in making the 
 following summary of the relation of mouth foci to general systemic 
 conditions: 
 
 1. The mouth contains a large variety of micro-organisms, which may 
 be divided into two groups; those which are normal or constantly present, 
 and those occasionally or frequently found. 
 
33 '.. ■ ■ . '• 
 
 2. Conditions in the mouth are stlahtnat* sHght'iiiflaniraatioils of the 
 gingivae are of frequent occurrence, being present in about ninety-five 
 per cent of mouths of adults. 
 
 3. These slight inflammations, if untreated, may gradually progress 
 to chronic suppurations. The suppurations are caused by organisms 
 normal to the mouth. 
 
 4. All organisms in the mouth, whether normal or accidental, have 
 access to the blood stream through the soft granulations. 
 
 5. The normal resistence tends to prevent systemic effects and is 
 apparently successful in the large majority of cases. 
 
 6. The transmission of infection from the primary focus is princi- 
 pally hematogenous. 
 
 Fig. 19. Lower jaw of a Flat-Head Indian from Columbia River, 
 Oregon, showing destruction of bone by a chronic alveolar abscess about 
 the distal root of the first molar. The bone about the first molar of the 
 opposite side is in practically the same condition. This is typical of the 
 injury which occurs. • 
 
 7. The primary focus is characterized by suppuration, while the secon- 
 dary lesion is non-suppurative. Therefore the secondary lesion is not 
 caused by the principal organism of the primary focus, but by other 
 organisms which enter the primary focus with or after the pus producer, 
 and thus gain access to the circulation; or else the morphology of the 
 pyogenic organism is changed if it produces the secondary lesion. 
 
 8. The organisms entering the circulation through such foci appear 
 to have an as yet unexplained tendency to locate in particular tissues. 
 
 9. The secondary effects include a very wide range of conditions. 
 Chronic arthritis, endocarditis, nephritis, cholecystitis, ulcers of the stom- 
 ach, and appendicitis are the most frequent definite lesions. General 
 impairment of health and vigor, with or without recognizable lesions, is 
 common. 
 
34 
 
 10. T'he sec6Adar;^ effects' ia're usually insidious in their onset and pro- 
 gress and, when cases present to physicians for treatment, are often 
 difficult of management. 
 
 11. It is imperative that the primary foci be eliminated, regardless 
 of the apparent systemic effect or lack of systemic effect. 
 
 12. For the reason that the mouth contains the primary foci in the 
 large majority of cases, a great opportunity is open to the dental pro- 
 fession to prevent grave systemic disease. 
 
 The chronic foci of the mouth may be divided into three groups: 
 (1) Deposits of salivary calculus. There may be included in this group 
 all fillings, crowns or bridges which impinge on the soft tissues and keep 
 them in a constant state of irritation, in somewhat the same manner as 
 does a deposit of calculus. In all cases of this group the rule is that 
 the systemic danger is removed with the relief of the pressure contact 
 on the soft tissue, (2) Pus pockets alongside roots resulting from a 
 suppurative gingivitis. (3) Chronic alveolar abscesses. Each of the 
 latter two causes the detachment of the peridental membrane from the 
 cementum, and the denuded, pus-soaked cementum is the chief factor in 
 maintaining the chronicity of these. 
 
 Today a thorough search for mouth infection is usually undertaken 
 only in cases in which secondary symptoms are manifest, and generally 
 after the physician has been consulted. We know that many such cases 
 will not be benefited by the removal of the cause at this time, because 
 the secondar}^ effect is already too well established. May I suggest that 
 the highest>(i«47— "ofthe dent al profe ssi on today is to search for and 
 e liminal Fethes e foci be??^TTrseconda ry lesions are manifest! If a^inority 
 of tjiese^TCcT'are known to havecatTsecT serious secondary effects, the 
 majority should be eliminated while there is the opportunity to protect 
 the health. This is the opportunity which is before the dental profession 
 today. Such men as Billings, Osier, Mayo, Hunter, and others have ex- 
 pressed it as their belief that the majority of the secondary lesions are 
 from primary foci in the mouth, which means that the dental profession 
 can prevent these diseases if they appreciate the situation and seize the 
 opportunity. 
 
 In giving this course of lectures, it has been my endeavor to stimulate 
 your interest in this subject. What I have presented is necessarily super- 
 ficial and must be supplemented by an extended study of what has been 
 written, together with careful observation and application in daily prac- 
 tice. If I have set some of you to thinking, so that as time passes your 
 appreciation of these conditions will be better, I shall have accomplished 
 my purpose. 
 
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