The Relation of Arthritis to Dental Sepsis

By F. W. Broderick

M.R.C.S.Eng., L.R.C.P. Lond, L.D.S.R.C.S.Eng.

            Coste has recently criticized severely the doctrine of local infections and the operative measures for the eradication of loci. He admits that cure sometimes appears to follow the removal of septic foci, though in other cases no such happy results ensue, whilst there are also instances of the arthritis being cured, or it may be dying out, in spite of the continued existence of such loci. He further more denies that there is any proof that the streptococci, commonly regarded as the cause, are anything more than common saprophytes. And a portal of entry for whatever germ may be responsible for the arthritis, he asserts that we are completely ignorant of its nature. He agrees that it is sound practice to deal with infective foci in order to put the system into a better state of defense against infection, whatever this may be, and that the extraction of septic teeth or tonsils is, for this reason, equally indicated in a case of gonococcal arthritis.

Permberton says:

“Although the etiological significance of focal infections must not be minimized, yet it is clear that my series of cases displayed a noteworthy independence thereof. Thus out of 400 cases, 184, or 46 per cent, recovered in the presence of demonstrable surgical foci. This is nearly three times the number which improved (65 cases of 16 per cent) after the removal of foci.”

Further more, he quotes Haden, a member of the American Committee for the Control of Rheumatisms, as having informally expressed himself of the view that the more he sees of arthritis the less he believes that defection is the most important factor.

A Chemical Problem

The great drawback to an intelligent approach to so many pathological problems has been the attitude adopted that when a certain etiological factor has been suggested, the very name given to the offender would seem to have so hypnotized workers on the problem that they hate have thought it unnecessary to consider just how these lying about the changes which they recognize as causing the symptoms, and have been satisfied, in so nay instances, as already pointed out, that we have a chemical problem, the laying down or the taking up of bone are eventually chemical processes; if, they, the defences against, and the causes of immunity from, bacterial, such as might result from focal infection, are chemical and to a great extent non-specific we are prepared to find the underlying factor in such conditions as arthritis, consequent upon the loss of such immunity, to be due a disturbance of the vegetative system which regulates all these chemical processes within the body, rather than in the foci themselves.

Pemberton, considering the pathology of arthritis, refers to this as dynamic pathology, stressing thereby the fact that disease processes, or rather the changes which must have occurred slowly and insidiously leading up to the fully developed clinical entity to which medicine gives a name, are definitely dynamic states, changing perhaps from today, but with a definite abnormal tendency in one particular direction; and that only at a later stage, if at all, does disease assume a static property where medicine recognizes it as an entity.

If this aspect is to be considered then the biochemical changes which occur in the arthritic conditions are far more important than the question of bacterial infection, for this latter, if in any way a factor of moment, can only bring about its consequences through altered chemical reactions.

One Constant Biochemical Change

Permberton found that the one biochemical change that was constant in all cases of arthritis was an alteration in sugar tolerance, a delayed removal of sugar from the blood. Normally on the ingestion of a large quantity of sugar, the blood sugar rises quickly and falls to a normal within a specified time; with arthritics, however, and in certain other conditions of which the presence of focus of infection is one, this fall is delayed for a measurable time.

Pemberton says:

“From the above observations it is, therefore, clear that the delayed sugar removal following ingestion stands in close relation to the phenomena of arthritis, on the one hand, and the influence of frank focal infection on the other. There is some implication that focal infection exists in all arthritics who present delayed sugar removal. This may be the case, and the writer has sometimes interpreted the delayed removal as an index of this end. A delayed removal also follows a variety of inflammatory conditions of which arthritis is one. At present the possibility must be entertained that there is at least one group of arthritics who harbor no foci, but yet present a delayed removal of sugar.”

Sugar Tolerance

He next proceeds to discover the cause of this alteration in sugar tolerance in arthritics and concludes:

“The evidence, therefore, strongly indicates that, whether or not any additional mechanism be concerned, denial to the muscular tissues of their usual degree of contact with the circulating blood interferes with the withdrawal of glucose, so that when sugar is fed a lowered tolerance results. This clearly suggests that circulatory changes contribute to the pathology of arthritis and focal infection with which a lowered sugar tolerance is so closely associated. The marked clinical benefits following therapeutic measures that improve the blood flow emphasize even more strongly the relation of the circulatory changes in arthritis.”

Further, the fact that in those arthritics who are definitely improving under treatment the sugar tolerance returns to normal, still further stresses the truth of this contention, as does the direct observation which:

“reveals that in a high percentage of arthritis the capillaries present a closed or collapsed condition which determines a smaller amount of blood in the given field.”

Thus Pemberton does not believe that the alteration in sugar tolerance is the consequence of changes in sugar metabolism, but rather of circulatory changes which must be under the influence of the vegetative system. Again, we have seen that in the rheumatoid and the osteo-arthritic forms of rheumatism the body changes differ in degree and in kind: in the former there being a resorption, and in the latter a sclerosis of bone. We have seen that Leriche and Policard regard these changes as being brought about by excess of diminished circulation, and we have observed how the removal of sympathetic influences react on bone physiology, so we are back once again to the vegetative system as the method through which the changes come about. Pemberton recognizes this possibility when he says:

“In view of the experiences to be related, which show that cases of the atrophic and hypertrophic types may respond to the same kind of treatment, there is room for the argument that these types have sometimes a common etiology. This implies the possibility of a common pathology. There is at least room for the view that the underlying pathological processes in the various forms of the disease may depend upon a common alteration in physiology. It seems altogether possible that the two great types of the disease may be determined by anatomical and constitutional differences. Thus, for example, the sympathicotonic and the vagotonic types of constitution might afford a broad basis from which the atrophic and the hypertrophic type respectively might arise.”

 

Thus we see that, not only the original dental lesion which made possible the dental infection, not only the presence of the focus itself, but also the development of the arthritis are all dependent upon the same factor, i.e., the disturbance of the vegetative balance of the individual.

This statement, however, requires modifying in so far as periapical sepsis is concerned, as a good defence is unable to do more than quarantine the infection at the tooth apex.

Pemberton concludes that :

“Dispassionate students of the disease (arthritis) are almost unanimous in their belief that other factors also play a role, and that focal sepsis is often only the match to the priming, even when operative. Out of the great mass of information available to us certain principles stand out and constitute a foundation of great value. It is a well-recognized fact that arthritis may follow attacks of ill-health of many kinds, even periods of fatigue, worry and psychic strain. It is true of arthritis, as of many diseases, that anything which interferes with the general equilibrium of health may predispose to it.”

McDonagh contends that all types of rheumatism rest essentially upon changes which the protein particle of the plasma undergo, and that the difficulties associated with this condition disappear if this visualization be accepted. He believes that acute rheumatism, rheumatoid arthritis, and osteo-arthritis, to take the three most common instances of the rheumatic state, are but three stages of one condition, depending upon the condition of the colloidal protein particles and their chemico-physical properties; where dehydration exists alone, acute rheumatism comes about; where this dehydration is accompanied by a certain amount of hydration, rheumatoid arthritis results; and where hydration is excessive osteo-arthritis is the lesion produced. He shows, as the result of blood pictures, in these and other rheumatic states, the there are links between these three outstanding rheumatic conditions, and that this correlation explains why it is that one condition may overlap, or pass into another.

A Three-Dimensional Point of View

An emotional writer in the British Medical Journal sums up the present knowledge of the etiology of arthritis in these words:

“It would seem than in so far as these diseases are concerned we must adopt a three-dimensional point of view. We have to explain why apparently the same sort of conditions produce different effects in different patients; why the conditions held to be responsible for rheumatic disease may obtain in many subjects without in fact producing any symptoms of such disease; and why individuals suffering from apparently closely similar symptom-complexes do not respond to the same form of treatment. To achieve such an exposition we must, in the first place, consider the effects of heredity and constitution; we must go back to the diathesis of our fathers, but not stay there. Endocrine dysfunction, metabolic disturbances, special sensitivities and the like are all important, but not the whole story. We much consider also toxic conditions. but not limit our vision to bacterial toxins alone. We must be prepared to consider all varieties of general and local focal infections, but must realize that when such infections cannot be found it may be that they are not there. Further, we must be prepared to find that even when infections are discovered and removed the trouble may persist, simply because the sources of toxemia were not those causing the symptoms. The responsible toxemia may be chemical in origin rather than bacterial, or it may be deprived from endogenous sources, such as the products of one’s own metabolism.”

Lately both physicians and surgeons have attempted to treat arthritis along the lines of vegetative disturbance. Surgery particularly claims considerable success through the operation of sympathectomy, which was mentioned when considering the physiology of bone resorption and sclerosis. From the physiology of the vegetative system it was thought that the removal of sympathetic influences, thereby giving to the para-sympathetic an unbalanced action, the circulation to the area affected would be much enhanced. It will be obvious, or course, that this operation will only be available in those cases of arthritis which depend upon sympathetic excess.

Ganglionectomy and Trunk Resection

Henderson and Adson record the result of sympathetic ganglionectomy and trunk resection in a group of cases of rheumatoid arthritis. It was found that this method of treatment resulted in improvement of the circulation, and it was therefore assumed that in patients suffering from cold, clammy, pale and cyanotic extremities, an operation affecting the system would improve the blood supply and alter the metabolism and course of the disease. Immediately after operation the skin over the extremities became warm, pink and dry, showing that the vaso-motor fibres had been interrupted, as well as those leading to the sweat glands. After five or six days the skin became normal in color, and the pain and swelling became gradually less. On the other hand, Fischer advocates the administration of acetylcholine both for certain forms of arthritis and also for the prevention of post-traumatic ankylosis as sequels of articular fracture, a disturbance of the sympathetic system being a prominent factor in the pathogenesis of these symptoms. Fisher considers that circulatory troubles are also essential elements. fcetylcholine is a well-known vaso-dilator of the small peripheral, and possibly also of all, arteries. Fischer points out that this action of acetylcholine is dependent upon the calcium potassium ration, which we have considered in relation to vegetative balance, and that this salt appears to have a marked effect on calcium metabolism and the alkalinity of the blood. Its combined vaso-dilating action and favorable effect on calcium metabolism bring about good results. These are similar, according to Fischer, to those obtained by sympathectomy.

Thus all the evidence brought forward points in the same direction: the the main factor in the etiology of arthritis is vegetative imbalance, the two chief forms of arthritis considered, the rheumatoid and the osteo-arthritic variety, being dependent upon the direction in which this balance is upset.

The mixed forms, which are not infrequent, are explained along the lines of McDonagh’s theories, which show that it is rare to find pure dehydration or purehydration, except in acute disease, that there is almost always some type of dehydrato-hydration or hydrato-dehydration present, and that it depends upon this proportion which clinical type presents.

Rheumatism, Caries, Pyorrhea

If, then, we take Weston Price’s clinical experience that with a well-formed granuloma, demonstrating as this will a good defence, i.e., a good vegetative balance, there is an immunity from rheumatism; and with a  poor granulomatous formation, that is with an inefficient defence and vegetative upset in the direction of sympathetic excess, there is a susceptibility to rheumatism, and at the same time a tendency to caries; and that with pyorrhea, which, according to Broderick’s suggestions is associated with parasympathetic excess, the same biochemical findings are present as with a good granulomatous formation, and an immunity from rheumatism; we have only to modify his view in one direction, vis./ that this last is not due to an over-action of the defensive mechanism, but a loss of resistance in another direction, and the immunity from rheumatism is only from the kind of rheumatism that he was considering in the case of periapical sepsis, but that these cases give a susceptibility to osteo-arthritis, which is, indeed, a well-recognized fact.

The Dental Magazine and Oral Topics.