No. 9

W

Part II.

CHAPTER I.

THE ALVEOLAR LESIONS.

ITH the exception of the alveolar lesions, I have reviewed all the lesions which accompany the development of pyorrhea alveolaris. I have indicated the reasons for them. None of them, it appears to me, should be considered as the initial lesion which marks the first step in the development of the disease.

It remains to me only to examine the lesions of the osseous tissue, and, supported by clinical observations corroborated by morbid anatomy, to show that in fact the alveolar lesions antedate all others, and that it is their presence which permits the further evolution of the

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pyorrhea, with its habitual symptomatic cortège and its complex lesions. This subject will form the second part of my work.

(1) Clinical lesions. To study pyorrhea in its initial stage, let us consider the relations of the different tissues of the alveolar dental region in normal man. For this purpose let us consider the mouth of an individual, twenty years of age, healthy, having teeth well arranged, and whose teeth and gums are sound.

If we examine the gingival region of such a subject, we notice that the gum is inserted exactly at the neck of the tooth, where it presents a very minute pad, which forms a space V-shaped in form-a sort of groove, rather than a cavity-which Mendel Joseph calls the

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pericervical space ("gingival trough" of Hopewell-Smith). If we attempt to explore the proximal interdental spaces we shall see that even with the finest instruments we penetrate only with difficulty between the teeth, and there will always be a slight tearing of the gum; for normally this space is completely occupied by the alveolar tissues, ligaments, and gums. This person has little difficulty in cleaning his teeth. They clean themselves spontaneously by mastication, by virtue of the perfect anatomical relations of the dental arches with the cheeks, the lips, and the tongue, which rub against the teeth throughout almost the whole extent of their vestibular and lingual surfaces. He does He does not experience the least need of using a toothpick, for no food. débris will remain in his absolutely closed interdental

spaces.

Let us now examine this same individual at the age of forty years. Let us suppose that his constitution is slightly arthritic. He has taken suitable hygienic care of his mouth. His teeth and gums are always healthy. His teeth are always perfectly placed upon the alveolar arches, and normally occlude. Nevertheless, if we ask him he will tell us that at times he has to make use of the toothpick, because after meals it frequently happens that food débris remains between his teeth. If we explore these interdental spaces, we find that while, twenty years previously, access into these spaces was very difficult, we can now pass into them easily and with instruments of very large caliber. We likewise find in the vestibular and lingual regions of

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Simply because the abuse of the toothpick can produce lesions of the gum and of the ligament of the interdental space, it is not fair to assume, as many practitioners do, that the toothpick is responsible for the creation of interproximal gaps. These are produced spontaneously, and, in the large majority of cases, people begin to use toothpicks only when they feel the need as a consequence of the existence of abnormal interdental spaces, either through alveolar resorption, common in the case under consideration, or through caries, defective filling, or deviation of teeth from their normal positions.

the mouth that the normal necks of the teeth are no longer in relation with the insertion of the fibro-mucous gum, and that the cementum is more or less uncovered.

Nevertheless-and I have assumed that our subject has followed the most efficacious hygienic precepts the pericervical space has followed the gum in its recession, and has not been transformed into a pocket. There is no suppuration at the necks of the teeth.

We have here, however, a patient attacked by pyorrhea alveolaris (understanding this term always in a general sense as we have agreed to use it), since he exhibits the primary lesion of pyorrhea, viz, alveolar resorption. And if the patient were delinquent in the hygienic care of his mouth, if he had some trouble in what Godon has very justly called the articular equilibrium of the teeth, he would present, in the region of one or more teeth, no longer the clinical picture we have outlined, but that of pyorrhea clearly established, with the more or less deep gingival pocket which is characteristic of the disease, and with the complex symptomatic sequence which accompanies the evolution of this affection. What, then, has occurred in this individual, whose tissues are normal in external appearance, and in whom no local pathological cause pathological cause has appeared to intervene ?

If we examined the maxilla of this man by dissection, or if, more happily for him, we contented ourselves with making a radiograph, we should find that the alveolar borders have become notably lowered in height and present the lesions which J. F. Colyer has so well shown upon dried specimens, and presents in his work upon the "Pathological Anatomy of Periodontal Diseases." If we made a section of the alveolar region of this same person, we should find there, in spite of his age, all the signs of senile alveolar atrophy, well described by Hopewell-Smith.†