RHEUMATIC DISEASES AND MOUTH INFECTION

By ARUN GANGULI, z.d.s. (Vienna), f.d.i.

Visiting Dental Surgeon, Carmichael Medical College Hospitals, Calcutta

The problem of focal infection in relation to rheumatic diseases has received too little critical consideration. The subject must be

approached first from the standpoint of the

nature of systemic diseases. In other words we have got to know what rheumatism and arthritis are. The term ' rheumatic diseases ' embraces a big

group of various illnesses which have their chief characteristic pain in and around joints. '

Rheumatism' is* not a disease but a generic term for many illnesses. These illnesses can be divided into two main divisions : (1) articular and (2) non-articular. In this paper I will discuss only rheumatoid arthritis and osteo- arthritis which occur with about equal frequency, but they differ greatly in setiologic, clinical, pathological and therapeutic considerations.

Rheumatoid arthritis

It is a general progressive systemic disease, the chief manifestations being the articular changes. At the onset the patient usually complains of

malaise, fatigue, poor appetite and loss of weight. Then several joints begin to ache and become

increasingly painful, swollen, tender and some- times red : when the finger joints are involved they become fusiform in shape as a result of the capsular swelling of the proximal inter-

phalangeal joint. If unchecked great destruc- tion and deformity result. The primary and characteristic pathologic change is inflammation ?f synovia which lines the capsule and of the fibrous capsule of the joint, and then secondary changes with destruction of the cartilage, atrophy of the bone, deformity, dislocations and ankylosis. The cause of rheumatoid arthritis is unknown.

The four most popular theories are : (1) infec- tious, (2) metabolic and nutritional, (3) neuro-

genic, and (4) endocrine. I will discuss the first theory here. There is more evidence to support this

theory than any other. In the first place many patients give history that the disease started shortly after infection. The laboratory

changes that accompany this disease, such as

leukocytosis and increased sedimentation rate, support this infection theory. The theory of

' focal infection' started long ago, was

popularized by F. B. Billings of U.S.A. and Priv. Dozent Stein of Vienna, and was warmly received because it suggested a reasonable

approach to the disease. As years passed the enthusiasm gradually died down. Attempts made to produce the disease in

animals by the use of all sorts of organisms were not very encouraging. Arthritis has been

produced repeatedly in animals by the injection of organisms removed from persons suffering from rheumatoid arthritis but it was unlike the

characteristic inflammation in human beings. While working in the house staff at the focal

infection department of the jaw department of the University Hospital, Vienna, under Professor Pichler and Priv. Dozent Stein (focal infection abtielimg der kiefer station der Universitat Zu AVien) I have witnessed many cases of arthritis in animals produced by sealing the organisms in teeth to stimulate a focus of infection,, but at the same time I must confess that it was not the counterpart of rheumatoid arthritis in man. To prove that a focus of infection really causes arthritis we have got to find out whether the

following evidence does exist : (1) a focus must always be found, (2) some substance, such, as bacteria, host cell products of inflammation, must get from that focus to the infected parts, (3) the inflammation in the joints must be proved as a result of some specific substance that gets from a focus to the affected parts. But as these evidences cannot be obtained, the problem remains a theory. After all these one is

naturally left without proof and with many questions as to whether focal infection accounts for this disease. In spite of the above arguments my personal

' clinical impression ' is that the patients benefited

by the removal of infected teeth. I must hasten to add at the same time that the teeth should not be removed just because they are still in the head of the patient suffering from rheumatoid arthritis. This practice should never be encouraged. I advocate that abscessed teeth should be scarified and infected gums should be properly treated. This will also indirectly help the patient, as by such procedures the

patient's general health may be improved and thereby his ability to combat the disease. I feel very strongly that rheumatoid arthritis results from alteration of host's tissue as a

result of '

trigger mechanism ' that in very many

cases probably is localized infection at the roots of teeth, tonsils or elsewhere. Host tissue

damaged by any such irritating illness may liberate antigenic substances which react with

antibodies in joint synovia and capsule causing inflammation. Once initiated in this way, rheumatoid arthritis may continue, recur or

become exacerbated without continuation or

recurrence of the original trigger mechanism.

390 THE INDIAN MEDICAL GAZETTE [July, 1947

Case history Miss S. C., age 22. Before the onset of the

disease, the patient was very active, but

gradually began to feel tired. Loss of appetite and weight. Pain in the spinal column joint and ultimately several joints began to ache and swell especially the fingers. General condition :

irregular menstruation; pain and tenderness of the head; antrum and tonsils good.

Laboratory findings.?Increased sedimenta- tion rate of the R.B.C., mild anaemia and

leukocytosis. Gums.?Healthy. Teeth.?Upper right canine and first molar

(right) filled with amalgam. X.-ray.?Examination of teeth revealed imper-

fect root canal treatment in both. An apical abscess in the molar and some degenerative changes in the apical portion of the canine. Upper first molar was extracted. Old filling

of the canine was removed, apicoectomy per- formed on it and the pulp canal was filled with silver point. The patient recovered amazingly in a very short period.

Case history Mrs. S. D., age 38. The patient was over-

weight, a great pan-chewer (about 100 a day). She felt pain practically in all joints. History <of low and intermittent fever, sub-maxillary glands swollen. Laboratory findings.?Showed increased sedi-

mentation rates of the red blood cells and

leukocytosis. Gums and teeth.?Gums extremely unhealthy,

upper right and left first and second molar teeth loose, formation of gum boil on the palatinal aspect, pus coming out on pressure, the entire area swollen and painful. My first duty was to extract gradually all the upper molars on both sides. It is to be noted that the patient was so bad that I was called at her house for extraction. One week after my last visit the patient was brought to my office. I found her definitely better, the rest of the gums were

treated in the routine manner. Vitamins B and C were prescribed in an intensive'dosage. Four weeks after the patient was as normal as most of us.

Osteo-arthritis

It is a degenerative condition of middle

age and old age which affects the articular

cartilages and weight-bearing surfaces of the

larger joints, such as knee and hips and articula- tions of spinal column. The pathologic changes differ from rheumatoid arthritis and there is no

inflammation of the capsules as in other case.

There are degenerative changes with fibrillation of the articular cartilage at the place of the

greatest weight, bearing or use, usually in the

central portion of the joint. These degenerative changes advance with the progress of the

disease, the cartilage becomes thinned and the

surface irregular. Further progress of the

disease leads to increased articular and osseous

changes and irregularity of joint surface. There is no evidence that oral sepsis is

primarily concerned with the setiology of this

type of arthritis. However it is my clinical

experience that a patient who complains of pain in the shoulders or knees is generally found to have infected teeth or tonsils, and they should be dealt with on their merits.

Conclusion In appraising the problem of infection in

relation to arthritis, the first consideration is to know whether the patient has arthritis, secondly, if he has, what kind of arthritis.

Thirdly, whether a focus of infection is present, if so, whether the infection can reasonably be the cause of that type of arthritis. It is

illogical to expect a cure of gonococcal arthritis by extracting the teeth even if they are infected. It is my clinical experience (though very limited) that patients with rheumatoid arthritis having abcessed teeth as the focus of infection have been cured by their removal. In osteo-arthritis the removal of the infected teeth was of no great help to the patient.

Lastly, I would like to appeal in this connection to the authorities responsible for the medical research that fresh attempts be encouraged for careful reconsideration and further clinical evaluation of this problem in our research institutes in Calcutta.