Alveolar Pyorrhea

ALVEOLAR PYORRHEA, pyorrhoea alveolaris (from Greek pion-fat and rhein-flow), a term introduced in 1823 by Tourac and later recognized as unsatisfactory because it describes only one symptom of the disease rather than its essence. In recent years, instead of A. p., the terms paradentosis and paradentitis are more commonly used, indicating that the essence of the process consists in the disease of the so-called paradentium: the gums, alveoli, and root sheath of the tooth. This idea, which remained unnoticed, was expressed more than 20 years ago by Dr. Nesmeyanov, who proposed the term "amphodontitis." Under the name A. p. is known a painful process occurring in the alveolar socket in the presence of a tooth in it and characterized by the following clinical signs: 1) inflammatory redness of the gums with a raspberry hue; 2) loosening of the teeth and their protrusion from the rows; 3) detachment of the gums from the teeth with the formation of deep "pockets"; 4) discharge of pus from under the gums; 5) deposition of firmly adhering tooth stone; 6) a peculiar, not sharp, musty odor from the mouth. X-ray and clinical studies confirm a loss of alveolar bone substance, either uniformly along the entire alveolar crest (horizontal atrophy) or in certain lateral directions along the root (vertical atrophy). In general, the structure of the alveolar bone appears to be rarefied to some extent. Subjective complaints are indefinite and diverse. The disease begins insidiously and imperceptibly. Intense pain is observed only when, due to trauma or infection, the process exacerbates and gives acute gingivitis or pericementitis signs. The patho-anatomical essence of this affliction does not yet have a generally accepted explanation; in general, however, it comes down to the following. The formation of "pockets" is due to the detachment of the pericementum from the surface of the tooth (neck). The epithelium of the bottom of the physiological pocket degenerates and partially necrotizes. At the same time, proliferation of epithelium into the depth of the root sheath is observed; the latter is altered inflammationally to some extent. The contents of the pockets contain shed epithelial cells, disintegration of connective tissue fibers, bacteria, deposition of tooth stone, food residues, and granulation proliferations, the latter of which turn out to be epithelialized. In the gums: cellular infiltration. In the bone tissue, death of bone trabeculae and formation of connective tissue in their place are noted. Due to the death of bone, the interval between the roots of the teeth and the walls of the alveoli, the so-called periodontal space, turns out to be widened, which also causes the loosening of the teeth. There are disagreements regarding the starting point of the process: according to some, the disease begins with the pericementum; others consider the starting point to be the edge of the gum; thirdly, the lesion of the bone substance of the alveoli. The assertion that A. p. begins with gingivitis is not very convincing, since the development of A. p. occurs very often where there is quite good oral care and no signs of initial gingivitis are present. Data on the study of A. p. convince that this disease is not a self-sufficient local disease, but is only a consequence and indicator of an existing disharmony in the whole organism. A. p. develops during various general diseases and at moments of physiological perturbations in the body (sexual maturity, climacteric, old age). Typhus, severe forms of influenza, malaria, chronic diseases of the digestive organs, kidney diseases, inflammation of the ovaries, gout, diabetes, anemia, diseases of the endocrine system, and a whole series of other diseases are moments that provoke A. p. As for local causes, they acquire greater significance in the subsequent stages of the development of pyorrhea. Traumas, in the form of overloading of individual teeth, poor care of teeth, etc., contributing to the creation of secondary phenomena, worsen the pathological process. Various microorganisms found in A. p. should be attributed to secondary phenomena, not causes. A. p., being conditioned by general causes, can also become a purely local process, but only when the general cause that caused it is eliminated; however, A. p., being left without local therapeutic intervention, continues to progress, especially in the presence of secondary factors in the form of infection, deposition of tooth stone, overloading, etc. A. p., left to itself, leads to the death of the alveoli and subsequent loss of teeth. Prevention A. p. consists in the timely elimination of local causes that may contribute to the more rapid development of the disease. Careful removal of tooth stone from under the gums, restoration of disturbed articulation, elimination of overloading of individual teeth, and general oral hygiene slow down the development of A. p. Treatment A. p. is divided into local and general. In order to raise the vitality of local tissues and weaken secondary factors of pyorrhea (microflora, pus), the use of anti-inflammatory and antiparasitic agents (antiformin, resorcin, iotyon, viophorm, chinopyrin, arsenic preparations, emetine, etc.) is useful. At the same time, it is necessary to take care of the most careful removal of tooth stone. Further actions are based on knowledge of the patho-anatomical picture: transformed and shed tissues, flabby, overgrown gum papillae, deeply penetrating tooth stone—all this is subject to removal. This operation is performed in two ways: according to Jung-Sachs or Wiedemann-Neumann. In the first case, scraping of the sockets is performed along the entire length of the formed pockets without detaching the gum flap. The Wiedemann-Neumann operation is performed with retraction of the mucoperiosteal flap of the gum along the entire operative field, followed by returning the flap to its place and suturing. The scraping operation is performed with specially constructed instruments for this purpose. General measures include eliminating the main cause of the disease, i.e., treating the main general affliction. Reports on improvements noted with the use of vaccines, protein therapy, and arsenic preparations (salvarsan, etc.) are very contradictory and require further verification and observation. Appropriate prosthetics and the installation of splints fixing loose teeth is also one of the essential requirements in the fight against A. p.