Periodontal Disease and Overall Health: A Clinician's Guide

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CHAPTER 4 History of the Oral-Systemic Relationship 45envelopes, use of contaminated telephonereceivers, and men with beards.In 1908, Merritt published an article inDental Cosmos with the title “Mouth Infection:the Cause of Systemic Disease.” 13 Inthis article he stated that “there is a generaldisposition on the part of the medical anddental professions to underestimate therelations which exist between an uncleanmouth and many local and systemic disordersof grave nature.” He felt that in many casesof malnutrition, the sole cause was a “filthymouth” and that “no greater good couldcome to humanity than the full recognition ofthe dangers from this insidious, prolific andvirulent infection in the human mouth.” Healso stated that “the adoption of proper oralhygiene practices would result in immediateand marked improvement to general healthand notable increase in the average durationof human life.”On October 3, 1910, Hunter was invitedto McGill University in Montreal, Canada, togive the keynote address at the dedication ofthe Strathcona Medical Building. The titleof his address was “The Role of Sepsis andAntisepsis in Medicine.” In his address, heblamed “oral sepsis” as the cause of a greatmany diseases, and made an attack on conservativedentistry, or as he called it “septicdentistry.” 5 His address was published inThe Lancet, which was the leading Britishmedical journal at the time, as well as in theDental Register. 14,15 Hunter is best rememberedfor the following statement in TheLancet report: “No one has probably hadmore reason than I have had to admire thesheer ingenuity and mechanical skill constantlydisplayed by the dental surgeon. Andno one has had more reason to appreciatethe ghastly tragedies of oral sepsis which hismisplaced ingenuity so often carries in itstrain. Gold fillings, crowns and bridges,fixed dentures, built on and about diseasedtooth roots form a veritable mausoleum ofgold over a mass of sepsis to which there isno parallel in the whole realm of medicine.”He continued with “The worst cases ofanaemia, gastritis, obscure fever, nervousdisturbances of all kinds from mentaldepression to actual lesions of the cord,chronic rheumatic infections, kidney dis -eases, all those which owe their origin to, orare gravely complicated by the oral sepsisproduced by these gold traps of sepsis. Timeand again I have traced the very first onset ofthe whole trouble to the period within amonth or two of their insertion.” It appearsthat Hunter’s condemnation of conservativedentistry was based primarily on its poorstandard. It was fashionable in London at thetime to mimic complicated Americandentistry. However, in many cases the resultswere often of substandard quality. Some wellrespecteddentists at the time, such as EdwardCameron Kirk, the editor of Dental Cosmos,recognized the potential systemic effects oforal sepsis, but felt that Hunter’s criticism ofdentistry was unfair as Hunter’s observationswere primarily based on the disastrous effectsof a very low-standard dentistry. 5In 1911, Billings, the long-servingDean of Medicine at the University ofChicago and head of the focal infection researchteam at Rush Medical College andPresbyterian Hospital, replaced the term“oral sepsis” with “focal infection.” Soonafter that, he was honored with being askedto give the annual Lane Memorial Lectureat Stanford University in 1915. There, hedefined a focus of infection as a “circumscribedarea of tissue infected with pathogenicorganisms” and said that the term focalinfection implied that: (1) such a focus orlesion of infection existed, (2) the infectionwas bacterial in nature, and (3) it was ca pableof dissemination, resulting in systemicinfection of other contiguous or noncontiguousparts. The teeth, tonsils, adenoids,and mastoids were thought to be the usualsources of bacteremia, and certain bacteria,such as streptococcus and pneumococcus,
46 Periodontal Disease and Overall Health: A Clinician's Guidehad special affinities for target organs likethe heart and lungs. 5,16 Billings advocatedthat chronic infectious arthritis was often associatedwith remote foci of streptococcus,gonococcus, or tuberculosis organisms, andsuggested the removal of all foci of infectionand the improvement in patients’ immunityby absolute rest and improvement of population-wideand individual oral hygiene. 17,18One of the first studies measuring the clinicalbenefit of removing focal infection in1917 confirmed his suggestions. The studywas conducted as a retrospective postal survey,and 23% reported a cure for their arthritisfollowing removal of infective foci. Anadditional 46% reported experiencing someimprovement in symptoms. 5,19One of Billings’ research associates wasRosenow. He was a graduate of the RushMedical College where he had been a studentof Billings. He utilized special methods forculturing material from various foci ofinfection. He obtained a number of pathogenicbacteria from patients, including streptococciand gonococci, which he injected in animals.He then tested whether these organisms wouldprovoke lesions similar to the secondarymanifestations noted in the patients fromwhom the foci had been removed. He used theterm “elective localization” to note that certainstrains of pathogenic bacteria (mostlystreptococci) isolated from the oral cavity ofthe patients had localized to the joints, cardiacvalves, or other areas of the animals. 5Physicians like Billings and Rosenowwere prominent and convincing. More and morearticles were published and many other physi -cians, such as Barker and Cecil, embraced theconcept of focal infection. Cecil, best knownfor his textbook of medicine, reported in 1933that “the keystone of the modern treatment ofrheumatoid arthritis is the elimination of theinfected foci.” 20 In an article in 1938, he quotesRosenow who said “the prevention of oralsepsis in the future, with the view to lesseningthe incidence of systemic diseases, shouldhence forth take precedence in dental practiceover the preservation of the teeth almostwholly for mechanical or cos metic pur -poses.” 21 Other leading members of the medicalcommunity, such as Mayo, also advocated thefocal infection theory. He stated that “inchildren the tonsils and mouth probably carryeighty percent of the infective diseases thatcause so much trouble in later life.” He wenton to write “teeth with putrescent pulps mayharbour green-producing streptococci andeven though they show no redness at the gumsthey may be very dangerous to keep in themouth.” 3-5What followed in dentistry as the resultof the “theory of focal infection” was an unprecedentedwave of tooth extractions andthe avoidance of conservative dentistry. 5,22All teeth that were endodontically or periodontallyinvolved were extracted to avoid apossible focus of infection. This approachcame to be known as the “hundred percenter.”The leading spokesperson for thisradical approach was the physiologist Fisher.He regarded a tooth with a root filling as adead organ that needed to be extracted. 5As biomedical research evolved in theearly 1930s, it also started evaluating conceptson a scientific basis. It was then that thestrong belief in the theory of focal infectionbegan to decline. What stimulated this declinewas the work of Holman, who notedthat Rosenow’s work was fraught with contaminationand that his data were incon -sistent. 22,23 Others noted that Rosenowin oculated animals with such high countsof bacteria that it was inevitable that everyorgan or joint would be affected. 24, 25 Grossman,in his book Root Canal Therapy, notedthat Rosenow’s technique “so devastates thelaboratory animal that lesions are sometimesproduced in almost every tissue and organ ofthe body.” The fact that Rosenow’s work inanimal models could not be reproduced byother investigators heavily discredited histheories. 25
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