Dental Sepsis and Its Relation to Constitutional Disease

By W. Marshall Swan, L.D.S.
The diseases attributed to dental sepsis constitute a formidable list. It is not my intention to enumerate them. I therefore propose to give a few notes on the dental aspect of the subject as it appeals to me. Take the two focal points of dental sepsis, namely, the apical abscess and periodontal inflammation. How can these cause any harm beyond the local lesion?
Dangers of Infection in Mouth
It must be evident that a blind apical abscess is a potential source or danger and that in certain circumstances virulent microbes enter the circulation from this source. It is easy to conceive that infection from this area may be carried by the blood stream, and settling on a previously damaged heart valve can cause a seemingly remote condition, such as infective endocarditis. No doubt that tissues and the blood put up a sound defense and are usually successful in establishing natural immunity, otherwise one supposes that the population would be decimated from this cause. Sometimes the defense is not successful and the patient may the show symptoms of toxemia, mild intermittent septicemia and other serious disease.
Infection starting at the gum margin does not operate so directly. The first step is the destruction of the interdental papilla from a variety of causes, such as injury from accumulation of tartar, imperfect fillings, crowns, unfilled cavities, inflammations e. g. untreated Vincent’s infection. From whatever cause lost, these interdental papilla are never renewed in adults, and stagnation areas are thus formed between the necks of teeth where consequently, food debris is not continually removed, the space becomes larger owing to pressure atrophy, and this is followed by infection of the underlying tissues by pyogenic microbes which spread to the bone and cause subsequent loosening of the teeth with enlargement of the neighboring lymphatic glands. When the infection is virulent it may spread by continuity of the mucous membrane to the respiratory tract, even resulting in bronchitis and pneumonia. Opinions vary as to the fate of microbes swallowed. They are usually eliminated, but the opinion is strongly held by some, that swallowed pus and microbes from the mouth do cause toxemia and that they are responsible for some gastric disease. It is also held that in cases of intestinal stasis secondary foci of stagnation occur in the ileum. Here infective bacteria of a mouth type survive, invade the tissues and spread so that secondary infections are established in the bowel. In this way dental sepsis, when combined with some alimentary disorders, such as temporary absence of hydrochloric acid, ileal stasis, &c., may be the cause of many intestinal lesions, including appendicitis, colitis and other inflammatory diseases. On the other hand it is strongly held that toxemia endangered by dental sepsis is the deciding point. By lowering the resistance of the tissues to virulent microbes it is often a contributary factor in the causation of systemic disease and probably in some cases the source.
Coming to dental treatment it should go without saying, that any competent dentist will endeavor by all means to render his patients dentally efficient and orally healthy subject to the limitation imposed on him by the patient’s permission, free-will and endurance. In cases of constitutional disease it seems to me the dentist is often in some degree on the same footing as a consulting surgeon. The patient is now in a medical category, possibly very ill and demands special consideration. In these cases the doctor gives the dentist a short history of the case or at any rate the relevant facts, pointing out the presence of any condition contra-indicating the use of any particular anaesthetic, or any factor demanding care on the part of the dentist. These directions cannot be too explicit, because a dentist may not be expected to possess more than a topical acquaintance with many of the diseases which the doctor is trying to cure. It occasionally happens that there is some difference of opinion between a medical consultant and the dentist. This is usually about the question of wholesale clearances of the teeth and there is usually something to be said on each side.
The Dentist Must Pass Judgment
The dentist is often asked to pass judgment on teeth with slightly receded gums, possibly slightly infected but still capable of doing good service. This problems presents itself repeatedly in the case of elderly patients of the gouty type, in which natural teeth would be a great comfort in their declining years. It is often a difficult question to decide whether or not teeth should be taken out in such circumstances. There are degrees of infection in the mouth that might be described as normal for people beyond the middle age. Take the case of arthritis in an elderly patient. No focus of infection can be found except the suspected teeth, here practically all the teeth show hypercementosis or extosis and sclerosis of the surrounding bone, but no rarefaction. In my opinion this is evidence of a healed lesion and the teeth should be left alone. If, however, the arthritis is getting worse and a tooth is extracted for bacteriological examination and the subsequent investigation indicates the removal of more or all the teeth, then it may be done, for as one high authority puts cannot get movable joints. In the cases extraction is difficult and healing is delayed, and it is usually wiser to extract teeth only one or two at a time. There are many considerations for the prosthetist in fitting artificial substitutes but these should never be weighed in the balance against the health of the patient.
Pulpless Teeth Not Always Dangerous
Regarding pulpless teeth, medical opinion very naturally looks on them with suspicion and it must be conceded that this is justified. Some hold the view that it is impossible even to remove a pulp and fill a root so that it will remain sterile. This view is not justified by facts. It should be possible in any healthy individual, but this entails sound technique and that the treatment be carried out in time, that is before infection has spread from the pulp and permanently damaged the surrounding tissues. Such treated pulpless tetth constantly remain sterile and useful for the greater part of a lifetime and pass the radiological test. It is very different with teeth which are treated when a periapical lesion is established. The difficulty of sterilizing the root canal is great and of the periapical region impossible without the aid of the blood and tissues.
Most dentists now incline to the view that a tooth which has suffered apical periodontitis for say one month, is safer out, unless there is some very strong reason for retaining it. No doubt many such teeth may be rendered comfortable and functional but the result is uncertain and the subsequent radiographic and bacteriological findings are not encouraging. One may say that in medical cases in which the symptoms point to focal sepsis, the extraction of all dead teeth, and the extraction of all teeth affected with periodontal disease which cannot be cured in a reasonable time, say three months, gives the best results whether or not the dental sepsis is the sole cause of illness.
Consultation Necessary in Systemic Disease
In cases where extractions are necessary to consult the patient’s doctor as very unpleasant and dangerous reactions may be produced by suddenly stirring up sepsis. Not a few patients date their chronic complaints to dental extractions, generally multiple. So opinion that in all cases of constitutional disease in people of advanced years, or in any state of lowered health multiple extraction are not advisable. In such cases it is a useful rule to extract one tooth, not the result and proceed accordingly.
Regarding anticipated results in medical cases, one must say that patients are generally very much improved by the removal of all obvious focal sepsis. Sometimes it seems to be the main factor in spectacular cures. In many cases where weight is below par it is quickly recovered and other signs of improvement are evident. Against this there are many cases in which the results are disappointing, therefore it is not wise to promise too much from dental treatment. The difficulty must be realized of establishing a causal relationship between the microbes of a dental focus and disease. This may be too readily assumed by the doctor or dentist. It is obvious that it cannot be proved without much patient investigation by those possessing a specialized knowledge of blood chemistry and bacteriology, along with the clinical study and X-rays. It must be remembered that there are other cavities in the body in addition to the mouth. To quote the words of Sir Kenneth Goadby: “These should be scrutinized carefully as there is considerable danger at the present time of exaggerating the remote effects of trivial mouth disease and thereby overlooking the existence of equally important causes in other regions.” Too often the infection has spread to other regions before it comes under treatment.
In conclusion I would say that the great hope of the future lies in the early inspection and prevention. Too often the dentist closes the stable door –alas! the steed has gone.
(I wish to acknowledge my obligation to the standard works of Colyer, Sprawson and Steadman in preparing this brief paper.)
The Dental Journal of Australi.