The Pathology of Dental Infections and Its Relation to General Diseases WESTON A. PRICE, D.D.S., D.Sc. CLEVELAND, OHIO Director ot the Research Institute of the National Dental Association Annual Meeting Canadian Oral Prophylactic Association INDEX Aims and Objects of the Association 2 . . The Pathology of Dental Infections and Its Relation to General Diseases 3 President's Address 22 Secretary-Treasurer's Report . . . • r .24 TORONTO 1916 Aims and Objects of the Canadian Oral Prophylactic Association IN the year 1905 a committee of dentists of Toronto was formed to communicate with the manufacturers of the tooth preparations then on the market to ascertain the composition of each, because they believed that a dentist should not recommend any preparation of which he did not know the ingredients. Finding there was no satisfaction to be obtained in this direction as to the formulae of these preparations, arrangements were made to have them chemically analyzed, thus ascertaining that in most of the samples were ingredients which should not exist in an ideal mouth preparation. The Canadian Oral Prophylactic Association was then organized to have manufactured preparations which should contain nothing which was not beneficial. After much consideration and consultation a paste was manufactured under the registered name "Hutax" (meaning mouth health). Later a powder was placed on the market, and last a tooth brush. These articles are the result of frequent consultations with many of the leading practitioners, not only in Toronto, but of the Dominion of Canada and the United States. The shareholders of the Canadian Oral Prophylactic Association origin- ally subscribed $5.00 each for "the good of the cause," and the charter of incorporation provides that the profits are to be expended for educational and philanthropic purposes, such as (a) bringing prominently before the public important information, which the dentist has, as to the influence of conditions of the mouth on the general health. (b) Care of the teeth of the poor, (c) Assisting the indigent in the profession of dentistry. Thus no director or shareholder receives directly or indirectly any dividends or other remuneration. Every dentist may recommend "Hutax" preparations with a confident consciousness that there is nothing better on the market, and that the profits will be utilized for the good of the profession and of humanity. The Pathology of Dental Infections and Its Relation to General Diseases Weston A. Price. D.D.S., D.Sc. Cleveland. Ohio. Delivered before the Annual Meeting of the Canadian Oral Prophylactic Association and their guests, the Academy of Medicine, Toronto, February 14, 1916. — Mr. President, I want to assure you that I come with a very deep sense of my inability to-night to live up to the standard and desire and hope that has been thrown out by Dr. McDonagh. I think it is a very unfair handicap to put upon a man to make such extravagant statements which of all men I certainly cannot live up to. It is, however, a very great pleasure to be here, and I come with a mingled feeling of joy that I am privileged to come back to Toronto and be with you again, and feelings of helplessness akin almost to discourage- ment when I realize the responsibility that is being thrust upon the dental profession to-day, and the utter inadequacy of the dental profession to meet that responsibility. One week ago this evening we had in Cleveland the opening of the Research Institute of the National Dental Association, and had as one of our speakers Dr. Charles Mayo, of Rochester, Minnesota. That splendid orator and magnificent physician and surgeon reviewed to us in detail the development of modern science as it relates to the healing arts. He reminded us of the splendid contributions of the Chinese, of those great contributions of the Greeks, and finally came down to the present decades and reminded us how one after another the great scourges, the great besoms of death, had been taken from the earth by medical science, and then as his climax, said the great mass of people to-day would not die of one of those plagues, they would die of a simple infection, that 90 out of every I00 probably would die because of some simple infection, the result of a focal infection, which focus itself would give them no trouble. He then referred to the fact that 90 per cent, of the lesions, of the focal infections, are above the collar, and of those above the collar which would include the tonsils, the antrum, the nasal passages and sinuses, that for the largest part come from dental infections, oral in- fections, and then accepted the challenge of the dental profession that they are going to take that responsibility. Are you going to do it, brothers? Recently I have been corresponding with the deans of the universities and the dental colleges of the country, with the editors of our best journals, and advertising in our dental journals to find if we cannot get one dozen, or even one-half dozen, men who are competent to go into the department of 4 Report of the Canadian Ural Prophylactic Association. research to determine the relation of mouth infections to systemic infec- tions. How many do you suppose we could find? I am ashamed to let you know. There are a few good men who are doing research work, but we cannot pry them loose from where they are, but alas, the tragedy is we haven't men in the world to-day; we haven't enough to even do one per cent, of the work that is demanded right now in interpreting the relation of mouth infections to systemic infections, and vice versa. Dr. Mayo said last month that at this moment we should have four dentists to every one that exists now in order to look after the interests of humanity. Not only for their own sakes, but for the State's sake. What does that mean? Well, my dear brothers in the profession, it means we must put our shoulders to We this wheel. have a great responsibility as a dental profession, namely, to help interpret the relation of these mouth infections to systemic infections. He also said to me on that occasion, as he did in Boston some weeks ago, we have learned as a medical profession doing research as we are in our institution, that these problems cannot be solved by medical men; they must be solved by men with a dental vision. Where are the men with the dental vision? Unfortunately, when we try to pick out the men with dental vision^ that is all they have got. Oh, the men with the medical and dental vision are the men that are wanted; the man who is—big enough to see all the physician sees, and also see what the dentist sees these seeing both at once are the men we need. I visited a hospital in Chicago not long since, and one of the leading bacteriologists took me through one ward after another and showed me the many cases that were being treated and helped, because they had treated the mouth infections, and then we came to a room, and We he said: "There is a great joke in this hospital. have got to get a new room to store the teeth in. As a matter of fact we are ex- tracting so many teeth in this institution we have really got to get a new place to store them." I said to him, "What proportion of the teeth that are extracted in this hospital are in your judgment related to the other infec- tion that the removal of the teeth did cure or did relieve?" He said, "I have thought of that many times, and I have thought that three or four out of a dozen." The average number of teeth extracted in that hospital under the direction of the medical men, he said, was about twelve, and in his judgment as a bacteriologist not more than three or four of the twelve ever should have been extracted. We are honored, I understand, and I am glad it is so, to have a number of the medical men with us to-night. I don't know what your practice is here, but I do know that I go to cities where the feelings of the medical men sometimes are so extreme as to even demand that every tooth that has a dead pulp is a menace and should be removed, and if it isn't giving trouble it may give trouble. Now, that is almost as extreme as a physician as perhaps are 70 per cent, of the dental profession, who rather plume themselves and say. "Well. Report of the Canadian Oral Prophylactic Associatioi perhaps so and so is not competent to save this root, but I can put a bridge on that will be all right." I say the dental profession are taking the other extreme and—are saying, or thinking, and are allowing themselves, perhaps, to be misled or else they have not informed themselves of the danger and they are going right ahead and putting dental work on teeth that are already shortening the lives of those patients. I believe and know, just as much as I know I am standing here, that a lot of my dental operations have helped to shorten the lives of patients. I would give a great deal if I had not done some of the work that I have been doing. I believe absolutely that I have put bridges on to teeth that already had an infection, and that were undermining the health of those patients, and I did not suspect it. I have had the privilege of undoing some of that work, and if God will spare me I hope to undo quite a lot more of it. To show you that I have not been a gold crown advocate I may say I have never put a gold crown in any person's mouth forward of the second bicuspid. So you see I have not been a slave to the gold crown habit. I have refrained from devitaliz- ing pulps where I could accomplish the result in some other way, but I have felt I was so skilful that I could attach bridges to teeth that had deep pyorrhea pockets beside them. I thought I was so skilful that the patient ^vas wonderfully fortunate to be in my hands, but I know very well that they would have been better off in the hands of some man entirely unknown to the community, but who ^vith his conservatism was satisfied to practice a great deal less scientific dentistry perhaps but would use the forceps more frequently than I would. Well, some medical people will say, "That is what I expected, and that tooth should be extracted." That is just as far from the mark as the other statement, for the time has come when we can distinguish the type which is a dangerous type of infection from one which is not. Now, which is the greatest tragedy which has de- veloped in this entire field of research during this last two or three years? I know of none that is so significant and so appalling, because of its subtle- ness, as the abscess. The dental abscess that is causing trouble in the mouth of the patient is, as a rule, not the one that will be causing arthritis or myelitis, or a heart affection, not nearly so as that type of dental abscess that produces no local trouble. Let me repeat: Of the last dozen cases that we have studied and treated for arthritis there has not been a single exception to the fact that the lesions which we relieved and treated impro\- ing the patient's condition were giving no local trouble. Why? The very type of infection answers the question. What do I mean by the type of infection? Here we have a rapidly developing abscess with a great deal We of inflammation and pus formation. have not got a simple strep- tococcus infection; we have a stercoremia infection, with some of the ancillary contaminations with it. But when we have a pure streptococcal infection of the type that produces lesions that I referred to, almost in- variably, if not invariably, they give the patient no trouble. Now, this 6 Report of the Canadian Oral Prophylactic Association. seems like a contradiction, but if that organism produced a very much more severe—reaction in the human body it w^ould be a great deal better for the body if it was worse it would be better. That seems like a strange thing, but what does that mean? If an organism growing in your body starts up some trouble in the body and brings forward the resisting powers of the body a new element is created, a chemical substance that reacts against that organism, and the body politic, our united body, drives it out. We build up a resistance, I say, and we destroy the organism. Why? Because it irritated our bodies. But when it grows within our bodies without producing an irritation the body does not react, and therefore there is no anti-body built up to destroy it, and consequently it lives on and on and the body is almost indifferent to its presence. Here is another strange but rather important apparent contradiction. The lower the virulence of the organism the more subtle it seems to be in producing these grave lesions like the arthrities. The lower the virulence of the organism the less ten- dency it has to produce a reaction on the body, and the more certain it is to produce those lesions like the arthrities. Now, we will see some reason for that. If we were to go down to a restaurant to-morrow morning, and if you—would take along with you several other species b—esides the human species let us say a porcupine, a grasshopper and an ant you all go into the restaurant, and we will assume you are all going to order from the bill of fare. What would be the difference in the meal you would order? As a matter of fact you would all order nearly the same thing. What would it be? It would be largely protein. Why? You have a digestive ap- paratus that would digest a nice piece of chicken, like we had this evening, and I found my digestive apparatus inside could dissolve that chicken splendidly. Now, the porcupine would not take that. He would select a nice piece of bark, and another of the organisms would select a piece of horn. You could not digest the horn, and you could not digest the bark, so those various forms of life would select the very thing that they could digest. The point I am trying to emphasize is that the only differ- ence between you and every other form of life, including those streptococci, for example, is that your digestive apparatus is just a little different to theirs, and yours changes and theirs changes. They have the property of living on certain tissues of your body, and your body has the power of taking in food, and can select certain of those products for different organs of the body. Let us assume you have taken your piece of chicken. How- does that chicken become part of your muscle tissue? You have two different kinds of digestion, and the micro-organism has also. You have two kinds of digestive fluids, one in the stomach, another in the arteries and veins, in the blood stream, a digestive circulation, and the protein you take into your body, as, for example, the piece of chicken, is split up. It does not go into the body as a whole protein; it is divided up as you take an axe and split up the wood into fibres, and.afterwards it goes into that — Report of the Canadian Oral Prophylactic Association. 7 other circulation. Then each cell of your body has digestive fluid, and these take the particular pabulum that it wants, just as your body, which is a multiple of cells, and each streptococcus has one digestive fluid outside its body and one inside its body. All liviiig things must do three things; they must eat, they must assimilate, and they must excrete, and you and the'pabulum are precisely alike, as we will see from different viewpoints as we go along. When you take into your body some protein which gets into your circulation, which has not been properly split up in your stomach, what happens? Why, immediately the chemistry of your body is called forward and you build up a new enzime, a new chemistry, to dissolve or digest that very thing; and the thing that happens is this: If, for ex- ample, you have got, we will say, an overdose, you have overeaten, in other words, bananas or eggs or milk, or any kind of food, in so large quantities that some of that protein gets from your stomach through into the circulation without having been properly split up, the blood immedi- ately produces a chemistry that splits up and digests that protein that has gone through, and ever after that if you eat eggs or bananas, or whatever the thing is that has poisoned you, immediately that chemistry is ready and splits up that protein, and that protein when split up in your blood is part poison, and that poison is the thing that is making you sick, and you can't eat those things. When you get typhoid fever, for example, the organism grows in your body, and that is precisely what happens. You react that organism in your blood has called forth the new chemistry which tears down and splits up those organisms, part of which are poison, and that poison makes you sick. You are walking up and down the country with those organisms in your body; they are incubating in your system, but it is not until your body reacts that you are sick. What does that mean? Simply the time comes when this chemistry is so perfectly de- veloped that immediately the new organisms come into the body the defensive forces rush to the rescue and produce a large amount of this chemistry and destroy that organism. Now then, what happens when the bacteria of your mouth, for ex- ample, get into your blood system? They do not stop there, and con- sequently a resistance of the body has not been stimulated, but pretty soon your body builds up that chemistry, and immediately it does you are sensitized to it, and day after day your body is reacting to that very thing to which it is so sensitive. Now, what is the significance of this? Many of you know this, but for those who do not I will call it to your attention. If you were to ta—ke a little of the white of an egg and inject it into your circulation to—-day just the ordinary white of egg which your stomach would digest if you inject it into your blood system circulation to-day it would not do you much harm; it would be in there as a foreign substance, but your body immediately builds up the chemistry to destroy that pro- tein, and in ten or twelve days if you put a little bit more white of egg S Report of the C\uuidian Oral Prophylactic Association. in it will kill you. Why? \ ou have been sensitized to that white of egg, and even so small a fraction of any of the proteins as sometimes the millionth part of a dram \\ill be enough to sensitize the body so that when the subsequent dose of that gets into the blood system the reaction is most violent on the part of the whole body, because it so rapidly splits up that protein. You all have seen this illustrated, for it is the man that is appar- ently the strongest that dies with typhoid. "Why is that? Because he had to tear down so many of those organisms immediately that his reaction has been stimulated. So it is the strong men that die of this disease, because nature reacts so vicriently and so much of the poison is set free. There are scores and scores of people that are going up and down our streets suffering from a poison that is going into their body by absorption of protein from the bacteriological infection of their mouths, and they are sensitized to it; the dental operators know what I speak of so well. You know that if we undertake to scale too many of the teeth the same day they are violently sick. I remember one woman where I simply took care of about one-quarter of the teeth, removing the debris from the teeth, because in that operation we open up the circulation slightly and let in more of these toxine poisons, and I said to her, "This is all we had better do to-day; let us stop now and you telephone me to-morrow and let me know if you have had a reaction, ' and although that woman had walked to the office and walked away ap- parently in her normal health, which was much below par, the next day, even with the telephone within arm's length of her bed, she reached to get it to telephone me, as she had promised she would tell me how she felt, and she was—so sick she threw herself back on the pillow and said, "What is the use? he told me I would be sick anyway." She was simply reacting to the toxine, to the protein that was being absorbed from that poison. Now, that is going on in a large degree in so many bodies, and there are probably hundreds and thousands of us that are beginning to die at 40 and 50 years of age because we are over sensitized to those mouth protein poisons. Now, I will not have time to go very far into that discussion, and I \vill take the slides at this time and discuss first some of the typical kinds of lesions, and because of the impossibility of covering the ground I should like to limit myself very largely to streptococcus infection. The first slide which we will put on will be one showing the Research Institute of the National Dental Association, a building that has been purchased for the dental profession of the United States, a building which contains some- thing like thirty rooms, and I am glad to say that within six weeks after the call went out to the dental profession for assistance to buy that building one-third of the entire cost of the property was in our hands, either in cash or pledges. It-is also significant that these researches that have been going on now for about three years, and which have entailed an expense of some- thing like $75,000. 90 per cent, of that amount has come from the dental Rtport of the Canadian Oral Prophylactic Association. 9 profession as voluntary contributions. This building which you see has something like 30 rooms, and has another building at the rear with a splendid auditorium, and we have facilities for taking care of a large amount of research work. I will be glad to furnish anybody who is inter- ested with a more detailed description by mail. In this picture we have a typical infection of a streptococcus type, pro- ducing no general disturbance. This patient was out of business for four years, and for two years of that time ^v'as in sanitariums and hospitals. He had symptoms of gall-stone and peptic ulcer, or stomach disturbance of various kinds, and twice was taken to the hospital for operation. On both occasions it was decided not to operate, because it was so uncertain that there were gall-stones present. He had fallen off in weight from 156 pounds to about 120. TAventy years pre\ious to the time of the presenta- tion of the patient he had a boil on his chin, which in all probability was an external fistula to a dead pulp in a tooth. It was not recognized that the pulp in the adjoining lateral was dead. Our examination with the radio- We gram showed the presence of the abscess. opened into the right lat- eral and removed some of the infection and inoculated it, and studied the organism with our various methods, and were able to produce in animals the typical liver infections. By typical I mean corresponding to the infec- tions that Ave get consecutively with that type and strain of streptococcus. With no other treatment than obliterating the area of infection at the two roots, opening up the canals and thoroughly cleansing, this gentleman gained 25 pounds in twelve weeks, and went back to his business. He lived in another city, and his physician has written me that he has no doubt but vvhat we did remove \.hp entire cause of this man's trouble. The last time the man called on me he said he worked from seven in the morning till eleven at night, and looked as stout and well as could be. The next slide shows the typical lesions in the animal, and the section of the liver shows a typical focal abscess, which we get with this strain of streptococcal infection. I want you to note that the blood vessel is entirely blocked. The kidney of this animal shows a cloudy swelling, but \vithout an abscess, that is very characteristic of this type of infection. Here we have the picture of a young man who was treated in the clinic of Dr. Hart- zell, who is one of our directors of research supported by the Research Institute, and working in the University of Minnesota and in the hospitals. This man had not been without pain for nine months, and could not walk, could not feed himself, could not put on his own collar and could not dress himself. At the time this picture was taken, as you can see, he could put his hands behind his back and up over his head. The next picture shows us the lesion that \\as found. This man had been in the hospital for nine months, and the treatments given him were doing him no good, and he was turned over to our department. The medical men were not able to satisfactorily find relief for the infection. The area of absorption is 10 Report of the Canadi-aii Oral Prophylactic Association. shown around the molar. The removal of the dental infection and the making of a vaccine entirely removed the trouble, or sufficiently so that he was dismissed from the hospital in six weeks. He could then run up five flights of stairway in the Donaldson building, one foot above the other, where five weeks before he couldn't put his foot to the floor in the hospital, and no other treatment than the removal of the infection and the vaccine made from this culture. Here we have another case from Dr. Hartzell's clinic. This woman had suffered for three years. You notice the ankles are swollen, and the knees and the hands, and she is very much emaciated. She suffered very great pain, and month after month they were placing on record "present treatments doing patient no good." The next picture shows us the dental infection at the apices of some old roots, and with no other treatment than the removal of these roots and the making of the We vaccine the trouble was removed. do not emphasize the vaccines much. We believe they are helpful in certain cases. In a few weeks this woman was able to stand erect on those knees that had not been straightened for many months. She was dismissed from the hospital and went back to her family of several small children who needed her very much. She has had no recurrence in twelve months. Here is a case from my own practice. We had watched this patient getting worse for fifteen years and we came to the conclusion that some dental trouble was the cause. The next picture shows us the area of infection around the bicuspid. With very little other treatment than the treating and removing of that infection and the imperfectly filled root which I had filled some twenty years before. The radiogram which has done splendid service showed the imperfection, and that woman now has thrown away her crutches. This picture shows a patient that is being carried to my office. The woman could hardly move her head or elevate her hands, but with no other treatment than treating the dental abscesses in that woman's mouth those joints that were so tied up that her knee joint could not be flexed one-eighth of an inch will now swing through quite a large arc, and^ very soon she will be on her feet. The pain is entirely gone and she has gained a number of pounds in weight. I think she will be walking around by midsummer at the rate she is improving. When that woman was put in the chair she could only move her head half an inchwithout moving her position on the chair, so rigid were her vertibrae, and now she can turn her head from side to side and look over her shoulder, and that is from the treatment that has taken place since November. I am sorry that I failed to bring the slides showing the infections in that woman's mouth. There were five abscesses all at the apices of teeth that had had dental treatment, some with gold crowns and some with fillings. Only one of the five had a fistula. Every one of those teeth except the one v^rith the fistula gave us a pure culture of the strains of streptococcus, and the one with the fistula gave us a mixed infection. Now, what is the significance