| “Some Facts Which Physicians Should Know About Maintenance of Dental Health” |
PERIODONTOCLASIA
Periodontoclasia consists of breaking down and destruction of the periodontal tissues - gum, periodontal membrane and alveolar bone. The disease process is usually of long duration. Lesions about different teeth and at different locations around a given tooth progress at variable rates. The lesion may extend only a short distance on one side of the tooth and far down towards the apex on the other, thus producing a deep "pyorrhoea pocket." Or there may be a more uniformly deep lesion in which the parodontal tissues are gradually destroyed all the way around the tooth. The gum recedes exposing more and more of the tooth above the gum, and the bony socket which supports it becomes shallower and shallower, thus greatly reducing the functional stability and usefulness of the tooth. Finally, the lesion extends to the apical region and the tooth is exfoliated or it may be extracted.
The patient may recognize the advanced stage periodontoclasia lesion or lesions ("pyorrhoea") but he does not recognize the early stage of the disease, as such. Neither is this early stage usually recognized and effectively combated by the dentist. However, to prevent this disease we must recognize the early stage and direct our preventive measures against the local conditions which cause the lesion to begin and increase. If we are to prevent further progress of lesions that already exist, our preventive measures must remove or minimize the local conditions, which cause the disease to progress.
The earliest stage periodontoclasia lesion consists of irritation and inflammation at the margin of the gum. This is only microscopic at first but gradually increases in extent. Normally the gingival margin rests against the smooth, nonirritating enamel cuticle. If bacteria are allowed to grow and accumulate at the entrance to the gingival crevice and to advance into the crevice, then the gum there must rest against this bacterial material. Soon some condensation or calcification of the material produces hard concretion, microscopic at first, which is still more irritating to soft gum tissue resting against it. Inflammation occurs and pus cells migrate into the region.
From that time onward the bacterial film and foreign material on the tooth tend to advance farther into the crevice (lesion) making this area of the tooth now a foreign body upon which the inflamed and suppurating gum rests. Specimens of material taken from within the gingival crevice when examined under the microscope, show large numbers of pus cells, diagnostic of inflammation and suppuration.
From this time henceforth, as the lesion progresses towards the apex, the condition consists of suppurating gum tissue on one side resting against a tooth covered with foreign material on the other. An abundance of pus cells are always present in the crevices or lesions around the teeth. Sometimes the amount of pus coming from the lesions can be recognized with the unaided eye, leading to the name "pyorrhea” generally applied to the disease.
The most noticeable symptoms of the early stage of periodontoclasia is "bleeding gums." The inflamed and ulcerated gums tend to bleed easily from brushing or other mechanical irritation. Bleeding from the gingival crevice during functional use of the teeth, mostly unrecognized, continues throughout the course of the disease.
Periodontoclasia is practically a universal disease. Its prevalence is indicated by a survey which I made of the Senior students of our class of 1943. Every tenth student on the printed class list was selected and carefully examined for the disease. Gross examination was made and also specimens were carefully taken from within the gingival crevices of all the teeth.
Lesions and some receding of periodontal tissues was found in every individual, varying from 2 to many. Material from such lesions contained abundant pus cells, establishing the diagnosis of active inflammation and suppuration. In my studies I have also examined a considerable number of other people in different walks of life. Active disease has always been found in all adults, around a part, and usually around all, of their teeth. These observations not only indicate the wide prevalence of this disease, but they also show that the different methods of personal oral hygiene now followed by people in the classes represented, do not prevent it.
Periodontoclasia does not occur about a clean tooth. The bacterial material which accumulates at the entrance to the gingival crevice and initiates the lesion there, is composed of the same type of microorganisms that make up the film pad under which caries lesions develop. If the tooth is cleaned at this location, of film and food material, at night before retiring, there follows a period of several hours of freedom from harmful irritation of the gum tissue by bacterial activity. The growth and accumulation, after food is taken the next day and before time to clean the teeth again, is not sufficient to cause the early stage disease process. To prevent the early stage of this disease therefore, the teeth must be cleaned effectively, at these locations where it originates, every night before retiring. Nothing less will suffice.
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Measures to prevent further progress of lesions that have already been established must be applicable to the conditions that exist within the gingival crevice, now the periodontoclasia lesion. They must be designed to effectively remove and minimize the accumulation of foreign material on the tooth within the crevice, which causes and promotes the inflammation of the gum tissue resting against it.
The microflora in the anaerobic environment within the gingival crevice is quite different from that on the exposed part of the tooth. There is a thick pad of bacterial film consisting of a pile of long rod and filamentous type organisms, one end attached to the tooth or to calculus which is usually present, and extending outward to the surface of the pad within the crevice. At the surface the growing ends and fruiting heads of these rod and filament type organisms are constantly bathed with the ever present pus and inflammatory tissue exudate. This provides a favorable habitat for the more exacting anaerobic spirochetes,7 which are always present, and ameba (Endameba buccalis)2 which are usually present. The bacterial pad extends right down to the very bottom of the lesion and it is here that the spirochetes and ameba, which are dependent upon the other organisms, are most abundant.
Cleaning the bacterial film from the tooth within the gingival crevice is followed by rapid subsidence of the inflammation and healing of the ulcerated epithelial surface. If this is done at night before retiring not enough grows back and accumulates to be harmful, before time to clean the teeth again the next night. In this way further progress of the disease, in most instances, is prevented. It cannot be prevented any other way.
Since the foreign material on the tooth within the crevice extends to the very bottom of the lesion, then the tooth must be cleaned right to the bottom of the gingival crevice. Methods of personal oral hygiene generally taught and practiced do not provide for this. In fact many believe it is important to be especially careful not to injure the gums, in whatever method they follow. Almost none know that they must clean their teeth within the gingival crevices to the very bottom of the space. If they knew it is desirable they could not do it with the toothbrushes, dental floss and other articles which have been available to them heretofore.
Based upon accurate information as to the local conditions which cause and promote both caries and periodontoclasia, I have designed an effective method of personal oral hygiene which is adapted not only to cleaning the teeth within the gingival crevices, but also at other areas where caries originates.
We can state in one sentence the personal oral hygiene every person must know and follow in order to maintain dental health and cleanliness
- "YOU MUST CLEAN YOUR TEETH RIGHT, WITH THE RIGHT KIND OF BOTH TOOTHBRUSH AND DENTAL FLOSS, EVERY NIGHT BEFORE RETIRING." -
Details of the method and specifications of the necessary toothbrush and dental floss have been published4,5,6 together with information upon which they are based.
The individual has not known how to clean his teeth right. He must be taught how to do it, and be shown the conditions by someone who does know*.
An increasing number of practicing dentists are taking the desirable short period of post-graduate instruction to enable them to teach this method of personal oral hygiene to their patients. In at least two dental schools that I know about, members of the faculties are teaching their students this method.
They will know how to maintain their own dental health and cleanliness and later will be prepared to teach their patients.
*I wish the opportunity of instructing and advising in this regard, a still larger number of university personnel, faculty members, students and others.
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SUMMARY
The etiological conditions which must be combated at the locations where caries and periodontoclasia lesions originate and progress are pointed out. Attention is directed to the necessary method of personal oral hygiene for preventing these diseases and for removing or minimizing the conditions which cause and promote them.
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REFERENCES
1. Bass, C. C.; A Demonstrable Line on Extracted Teeth Indicating the Location of the Outer Border of the Epithelial Attachment. J. D. Res., 25:401. 1946.
2. Bass, C. C.; The Habitat of Endameba Buccalis in the Lesions of Periodontoclasia, Proc. Soc. Exper. Biol. and Med. 61:9. 1947.
3. Bass, C. C.; and Fullmer, H. M., The Location of the Zone of Disintegrating Epithelial Attachment Cuticle in Relation to the Cemento-Enamel Junction and to the Outer Border of the Periodontal Fibers on Some Tooth Specimens. D. Res., 27-623, 1948
4. Bass, C. C.; The Necessary Personal Oral Hygiene for Prevention of Caries and Periodontoclasia, New Orleans M. & S. J., 101:52, 1948.
5. Bass, C. C.; The Optimum Characteristics of Toothbrushes for Personal Oral Hygiene, Dent. Items. Int., 70:697, 1948
6. Bass, C. C., The Optimum Characteristics of Dental Floss for Personal Oral Hygiene, Dent. Items. Int., 70:921, 1948
7. Bass, C. C., the Relation of the Inner Border of the Bacterial Film on the Tooth Within the Gingival Crevice, to the Zone of Disintegrating Epithelial Attachment Cuticle, O. Surg., O. Med., O. Path., 2:1580, 1949.
8. Bass, C. C., A Previously Undescribed Demonstrable Pathological Condition in Exposed Cementum and the Underlying Dentin. (In process of publication).
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