CHAPTER XXVII DIAGNOSIS OF DISEASES OF THE GUMS (Part 1)

CHAPTER XXVII DIAGNOSIS OF DISEASES OF THE GUMS AND JAWS Diseases of the Gums A HEALTHY gum is of a imiform bright-ijink coloui- with a crenated edge, firm, smooth, and adherent to the necks of the teeth. The evidences of disease are alteration in colour, especially along the free edge, alteration in texture, loss of smoothness, separ- ation from the teeth, recession, escape of pus either irom a sinus or around the neck of one or more ot the teeth, ulceration, a general swelling or a localized enlargement. The guuis are swollen, spongy, and livid in scurvy • they may show petechi^e, bleed easily, and the teeth become loose or fall out. If the gums are swollen, and the edge surrounding the necks of the teeth is slougliy and separated from the teeth, mquire as to whether the patient has been taking mercurv or is exposed to the influence of this metal in anv way J where that is so the affection will be reco/ nizea as mercurial gingivitis; there will also be swellinlr and perhaps ulceration of the tongue salivatio.f loosening o the teeth, a metallic taste in the mout ' and marked fetor of the breath. Where, however' here is no mercurialism, and aphthous sores a'^ iomid on the hps or tongue, the condition will be recognized as aphthous gingivitis. 381 382 SURaiCAL DIAGNOSIS [chap. VVJiere the gum is slightly separated fi'om the teeth, and from between them a little pus can be seen to ooze up, especially when pressure is made with the finger upon the part, the disease is pyorrhoea alveolaris. This is now known to be a very import- ant disease. Its earhest sign is a deep-red hne along the free edge of the gum, with loss of its crenated edge. It begins most often in the iiicisor region or round a stump, and once started is liable to spread widely until it involves all the gum. It causes a disagreeable odour of the breath and a foul taste in the mouth, especially on waking. When it is severe the patient may eject from the mouth a considerable quantity of odorous sero-purulent fluid, and this may dribble from his mouth during sleep and leave a pink staiii on the pillow. A sinus in the gum should be carefully probed, and the adjacent teeth explored, and if the probe leads down to a hard smooth surface it is probably the fang of a tooth. The probe may, however, pass over a more extensive surface of sequestrum, necrosis of tlie alveolar process. The skilled hand can distinguish the sensations given when a probe touches the crown of a tooth, a fang, or bone. As teeth are more opaque to X-rays than is bone, a skiagram will show a tooth or a fang buried in the jaw, and may prove very helpful in diagnosis. If, on looking into the mouth, the siu'geon finds the gum receded from the teeth, and the teeth loose or fallen out, and if the alveolar process is bare and exposed, with pus wellmg up alongside it, he will diagnose necrosis. This may have resulted from injury in tooth extraction, with super- vening pyogenic infection {traumatic), or have fol- lowed one of the exanthemata {exantliematw), m which case it affects the alveolar process only, is often symmetrical, and is insidious in its progress ; XXVII] DISEASES OP THE GUMS 383 or it may occur in oue exposed to the fiimes of yellow phosphorus, when the necrosis is apt to involve the whole depth of the bone, and to be accom- panied by a great amount of swelling, and in the case of the lower jaw by the formation of a shell of new bone aroimd the sequestrum. A sequestrum due to phosphorus poisoning is nearly always rough on the surface, and of a dirty brownish colour. Necrosis of the jaws is also seen as tlie result of cancrum oris. The remaining affections of the gums may be grouped together as tumours. The rapidity of growth, attachment, consistence, and tendency to ulcerate are the facts to be particularly observed in such cases VVhen m an infant or young person the gum is ound growmg up and overlapping the teeth, or even burying them entirely, and projecting in the mouth as irregular lobed masses of firm tissue covered by healthy mucous memln-ane, it is a case of hypertrophy of the gum. This is a congenital affection, though it may not be recognized until some time after birth; It may be associated with hypertrophy of he alveolar process and premature eruption of the teeth A similar condition may be met with in imddle hfe, and is tlien often associated with buried stumps of teeth. If there is a small pedunculated growth from the gum attached between two teeth, and covered with healthy mucous membrane, it is a polypus of the gum. If the growth is papiUated or villous on tile surface, it is biown as a wart. Similar warfs are sometimes seen on tlie ,^alate or on the tonr^ie A soft purph. mass, readily bleeding with nn unev^i surface, growing fron; an aJv^;!,^ is ymnuorua It indicates the presence within the alveolus of an infected root of a tooth. 384 SURGICAL DIAGNOSIS [chap. If a sessile tumour grows frora the gum, being firmly fixed to the alveolus, and is of slow growth, very firm, paiuless, aud covered by healthy mucous membrane, it is a fibrous epulis. Wheu it is of largo size the surface may ulcerate from pressure and friction. This is to be distinguished from a polyp by its deeper and broader attachment, and usually by its greater size. But if the tumour is quite sessile, firmly fixed to the alveolar process, has grown more rapidly, and especially if it has a livid colour, a lobed surface, and soft consistence, and is fomid to spring from within the alveolus, and in its growth to expand the alveolus and loosen the teeth; it is a myeloid epulis. When the gum is found to be the seat of a steadily spreading ulcer, with an indurated base and everted edge, the condition is epithelioma. Enlargement of the lymphatic glands will confirm this diagnosis. In case of doubt a piece of the growing edge should be cut out and examined microscopically. A very chronic solid enlargement of an alveolus is probably caused by an odoiitome in connexion witii the fang of a tooth. Several pathological varieties of odontomata are described, dependira upon the particular element of the embvyonic tootli involved. {See p. 389.) Diseases of the Jaws The acute affectious oi the jaws are inflam- matory, and the most frequent is alveolar abscess. Whenever, therefore, a patient presents himself witn an acute, painful, and evidently inflammaf ory swell- ing of the face, over either jawbone, the first thing for the surgeon to do is to seek for evidence of alveolar abscess. By gentle pressui-e let him find the scat ot most acute tenderness, and observe whether the swell- XXVII] DISEASES OF THE JAWS 385 iug is fixed to the bone ; next he should examine the teeth, looking first of all for carious stumjas and for pus escaping by an alveolus ; and then he should tap each tooth in succession with some small metal in- strument to detect whether any one of them is tender to sharp vertical pressure. Passing his finger between the lip and the gum, he will feel for swelling over the alveoli. If he finds the swelling fixed to bone, and one tooth very tender to pressure, probably' also decayed, with swelling over its alveolus, he will diagnose alveola abscess. It may point at some dis- tance from the diseased tooth which gives rise to it. When, however, the swelling is very extensive, especially if it involves the body and ramus of the lower jaw, and there is no evidence of its connexion with an individual tooth ; or several teeth are found loosened, raised from their sockets, and very tender, It must be diagnosed as acute osteo-periostitis. There is generally high fever in this condition. When a patient with an alveolar abscess or any similar mfective condition of the jaws develops double proptosis with congestion and cedema of the con- junctiva, and immobihty of the eyeballs with fixed dilated pupils, there is thrombosis of the cavernous sinus Exammation of the fmidus will show engorgement 01 the retinal veins. An acutely inflamed gland below the lower iaw may closely simidate either alveolar abscess or acute periostitis, but it will be found to be movable over the bone, if one finger is placed on the floor of the mouth, and fingers of the other hand on the swelling outside. ° If a patient is febrde and complains of pain or a sense of fulkess m one side of the face, examine the antrum care ully. Note any swelling or tender- ness of the cheek, any congestion of the outer will 386 SURGICAL DIAGNOSIS [chap. of the nasal fossa, auy discharge from the uose, and compare the transhicency of the two maxillse when a small electric light is held in the mouth, i.e. by transillumination. If one maxilla is opaque and pus is seen in the nose under the middle turlnuate bone, there is certainly acute suppuration in tlie antrum (sinus maxillaris). In cases where the signs are not conclusive an exploratory puncture into the antrum should be made through the front of the outer wall of the inferior meatus. The chronic aficctious oi the jaws include necrosis, periostitis, eiiusion into the antrum, cysts, and solid tumours. A chronic sinus over either jaw, whether open- ing in the mouth, or on the face, and even in the neck, is usually caused by necrosis either of tooth, odontome, or bone. It should be carefully probed, and the fact of bare tooth or bone determined. A good skiagram will show the position of the seques- trum, dead tooth, or tumour. The surgeon must bear in mind that a sinus in connexion with a dead tooth may open at some distance from it, on the face, the neck, the palate, or into the nose. In all cases of sinuses m these situations, therefore, the teeth must be carefully examined for caries, and a buried fang must be sought for. AVhen there is great thickenmg around the jaw, or the probe leads to the bare ramus or body of the lower jaw, or a large sequestrum is seen in the mouth, the condition is maxillary necrosis. The most extensive variety of this is phosphorus In examining any swelling or tumour of the jaws, notice particuhirly its .>xtcut, its outline, its consist- ence, its eft'ect uium tlir bone and the tecth,^anrt ttio occurrence of luenioiTlKige or discharge. Cysts are XXVII] TUMOUES OP THE JAWS 387 frequently met with in the jaws ; they usually have a globular outline, and in their growth expand the bone over them, and thus a sensation of egg-shell crackling or of the buckling of parchment may be felt on pressing on them. The teeth must be examined not only to see if they have been displaced or loosened by the growing tiimoiu', but also to notice whether one or more is unerupted, shown both by its absence from the alveolus and by its shadow in a skiagram. Ha3morrha,ge occurs particularly from malignant growths ; mu co-pus and pus may flow in large quantities from the nose in empyema of the antrum. In the upper jaw the relation of a tumour to the antrum (sinus maxillaris) is a matter of particular interest. To examine the antrum, first observe the contour of its walls, then compare the translucency of the two ca^aties by placing a small electric light m the mouth, and finally, if necessary, open the cavity and examine its contents. When these are flmd a puncture may be conveniently made throucrh the alveolus of a tooth, preferably the first or second molar, or through the outer wall of the inferior meatus of the nose ; when solid, a larger opening should be made through the canine fossa Distension of this cavity may cause a bulgino- of its outer wall below the orbit and malar bone a flat- tenmg or depression of the roof of the mouth a raising of the floor of the orbit, causing protrusion of the eyeball and, when extreme, bhndness and obstruction m the nasal fossa of the same side' witli epiphora. Expansion of the cavity is not always uniform ; it may occur especially in one direction but It must not be diagnosed unless more than one o the antral walls is found to be bulging. Distension of the antrum may be caused by the growth of cysts 388 SURGICAL DIAGNOSIS [chap. into the cavity, and especially by solid tumours, bony, sarcomatous, or cancerous. In the case of large tumours the surgeon naust endeavour to ascertain whether the tumour is limited to the jaw or involves other bones ; he should examine the temporal region, the nose, and the bone over the frontal sinuses for evidence of sweUing, and then, passing his finger behind the soft palate, should feel whether the tumour is filUng up the pharynx, or is fixed to the base of the skuU. When the surgeon recognizes that he has to deal with a tumour of the jaw he should first decide whether it is inflammatory in nature. If the swelling is on one side of the bone only (as on the hard palate, or outer side of the lower jaw), and if it is painful and somewhat tender, it must be considered as chronic periostitis. If such a sweUing is found to fluctuate it is a chronic alveolar abscess. If the swelHng subsides under treatment the diagnosis will be confirmed ; if it withstands treatment and continues to enlarge without forming an abscess, and particularly if it bleeds, it is a neoplasm. , • , i A smooth globular or ovoid tumom-, which has grown slowly and pamlessly, in a young person, is almost certainly a cyst ; and if to these signs there is added fluctuation or " crackhng," the diagnosis is certain. . . j. j.i If the cyst is single and the permanent teetli are normally erupted, it is a dental cyst ; the presence of a carious fang close to the swelhng supports this diagnosis. If, however, the cyst is single, has gro\Yii slowly in a young person, and one of the permanent teetli is unerupted, it must be diagnosed as a denti- qerous cyst or follicular odontome. Fmding the tootli in the cyst, or seeing it in the skiagram, mU con- clusively prove the correctness of the diagnosis. I a c (i a I 0 t 0 a i 1 i f ! 1 t xxvii] TUMOURS OF THE JAWS 389 Dentigerous cysts are commouer in the lower jaw and around an unerujited third molar. If, however, the cystic tumour is lobulated and more irregular in out- line, and of very slow growth, it is to be diagnosed as a multilocular cyst or epithelial odontome. These cysts are usually met with in young persons, and are com- moner in the lower jaw. (Plate xiv.) Solid tumom's are to be distinguished from each other by the same rules as in other situations. {See Chaps. XVIII. and XXIV.) A circumscribed hard tumour, as opaque to X-rays as the jaw itself, is an osteoma. If such a tumour is found in the alveolus, and is seen to be even more opaque to X-rays than IS the bone, and to have a nodular outline, it is an odontome. When one or other jawbone, or any of the other facial bones, slowly and progressively enlarges, form- ing large nodidar masses of bone without distinct circumscription, and being quite unmodified by treat- ment of any kind, the disease is known as leontiasis. The swelling is as a rule symmetrical. When ad- vanced, this disease causes great distortion of the teatures. A tumour of rapid continuous growth which infil- rates and distorts the jaw, displaces and loosens eeth, and extends into the neighbouring cavities ossfe, or soft tissues, is easily recognized as malig- lant. If the lymphatic glands beneath the mandible -nd along the carotid vessels are enlarged, it is a arcmoma ; where the tumour is large and there is no avasion of glands, it is a sarcoma. In the early tages It is impossible to distinguish between these Towths except by microscopical examination If the patient complains of a dull aching pain 1 the face and of an unpleasant odour in the nostril t the same side, and has a bad taste in the mouth 390 . SUEGICAL DIAGNOSIS [chap. in the morning, and if, wlien he lies down on the opposite side, or holds his head down, odourless pus streams from the nostril, and the antrum is found opaque, it is easy to diagnose empyema of the • antrum (sinus maxillaris). More often, however, the symptoms of this disease are obscure— slight local discomfort, irregular discharge from one nostril, recurrent attacks of naso-pharyngitis, and chronic ill-health— and the diagnosis is only established by the opacity of the antrum and the results of an exploratory puncture. The Temporo-Mandibulae Joint Pain and inability to open the mouth properly are the two leading symptoms of afiectious of this joint. They may be produced by acute inflamma- tion of the joint itself or of neighbouring parts which are pressed upon or stretched by the moving mandible, by osteo-arthritis, by spasm of the muscles of mas- tication, by fibrous or bony adhesions iu the jomt, by cicatricial contraction around the joint, and by tumours near the joint. To arrive at a diagnosis first ascertain whether the trismus is recent and acute, or of long standing. Acute trismus.— If acute, examine for swell- in" of the joint itself immediately in front of the tragus, and for swelling of the parotid gland, or tonsil, or