Alveolar Pyorrhoea, or Riggs' Disease, is indicated at first by an uneasy sensation; then inflammation of margins of gums; looseness of the gums about the teeth, which form pus-pockets; and necrosis of edges of alveolar process; a tendency to hemorrhage; inflammation extending deeper into gums; small sulci filled with pus; looseness of the teeth and change of positions; disagreeable taste; peculiar fetor of breath; dark livid color of gums, with thick margins, and often extreme sensitiveness to touch; in some cases the gums are denuded of their epithelium, with a polished appearance, in others, with a pimpled surface; the teeth, at length, held in their cavities by a tough, ligamentous attachment, due to the degenerative change occurring in the peridental membrane.

A simple form of this disease may manifest itself at the margin of the gum, indicating its presence by a congested appearance, beneath which may be found a granule of calcified material. While in many cases there is general congestion of the affected gum, and a proneness to hemorrhage, in other cases the gum may present an anaemic appearance - pale and bloodless. This disease may also be associated with syphilis, mercurial salivation and scurvy. The deposit of salivary calculus or other calcified substance is supposed to be secondary to the disease, as a deep-red and denuded gum tissue about the necks of the teeth may be present without any deposit.

Dr. Charles B. Atkinson describes this affection as follows: "Perhaps the earliest condition presented to us is a tumefaction of the margin of the gum - from pearly-red and light lilac to purplish-blue in tint - sometimes puffing to such an extent as to be easily confounded with an alveolar abscess. The tumefied gum bleeds readily on brushing. A probe passed carefully under the gum will disclose a pocket embracing more or less the circumference of the root, in some places nearly or quite to its apical end. Sometimes the gum will be found receded, perhaps on one side only. A purulent discharge more or less marked, may be demonstrated by pressure of the finger over the root, from its end towards the crown of the tooth. A further demonstration of the pressure of pus may be secured by injection, about the necks of the teeth, of peroxide of hydrogen. A general hypertrophy of the oral tissues may be noticed. Suppuration, perhaps preceding, perhaps following, a solution of the dental ligament, which permits the pocket to be formed, and is the antecedent usually responsible for the loosening of the teeth. This loosening may, however, be present as a result of inflammation before suppuration has succeeded. The loosening may be attended with recession of the gum or not, and with or without pain. Locally, aside from the gingival congestions already noticed, the teeth may be found elongated, the breath fetid, tartar freely present (although many cases progress to disaster with no appreciable deposit of tartar), pus sometimes oozing from the sockets, putrid taste in the mouth, tenderness of the teeth, already noted, and many times considerable irregularities, the natural result of the loosening of the teeth. Observation may disclose such systemic conditions as stomach dyspepsia, catarrh (as nasal catarrh or other mucous surface debility), constipation, phthisis, adenoid growths, general congestion due to intemperance, kidney disease, rheumatism, cold feet and other extremities, indicating poor circulation and mal-assimilation. Dr. Rhein has truly said that incurable systemic disorders make only palliation of pyorrhoea disorders.

Causes

Dr. Rehwinkel, who first suggested the name "pyorrhoea alveolaris," ascribed this disease to constitutional and hereditary causes; Dr. G. C. Davis to low vitality and feeble vascularity; Drs. Witzel, Arkovey, and Black, that it is a specific infectious disease; Dr. L. C. Ingersol attributed it to sanguinary calculus; Dr. A. O. Rawls to mercurial taint, and the effects of chloride of sodium; Dr. Talbot to perverted conditions of secretions, low vitality and sanguinary calculus; Dr. J. D. Patterson to catarrh; Prof. C. N. Peirce to its being a manifestation of the gouty diathesis, having found uric acid and its salts at the apical ends of roots. Dr. W. X. Sudduth opposes the uric acid theory of Prof. Peirce, as also does Dr. Younger, who believes it to be of local origin, and due to diseased activity of the pericementum, caused by disturbed nutrition or local irritation: the late Dr. Bonwill agreed with Dr. Younger.

Treatment

The first and one of the most important indications is to sterilize the mouth so that pathogenic organisms will not find access into the deep parts during the subsequent operations; then to remove all deposits from the roots of the teeth, and all necrosed bone from the margins of the alveolar processes. This can be accomplished with what are known as Riggs' instruments. An acquired and acute sense of touch is necessary to determine the thoroughness of the cleansing operation. The pockets formed in the gum may then be sterilized by syringing with a three per cent. solution of pyrozone, or with iodoform and eucalyptus, iodoform and oil of cinnamon, or with injections of chloride of alumina, gr. iij to the ounce of water, also strong tincture of mvrrh, aromatic sulphuric acid, nitrate of silver. Peroxide of hydrogen, and also a solution of iodide of zinc, gr. xii-xiv to the ounce of water, are also recommended by Dr. Harlan, in the form of injections; and for chronic cases the latter is a solution composed of gr. xxiv to the ounce of water, after the parts are cleansed by injections of the peroxide of hydrogen. Another method: After thorough removal of deposits, syringe with aromatic sulphuric acid, diluted with one-half water, and apply night and morning a powder composed of creta preparatae, Treatment 351 acidum boricum,

The use of " Robinson's Remedy " is also recommended, following the use of bichloride of mercury 1 to 500. An antiseptic and astringent mouth-wash should be employed frequently until the gums reattach themselves to the teeth.

Dr. Chas. B. Atkinson recommends first returning loose teeth to place laterally, and securing them with waxed sterilized ligatures. Then, beginning with the upper jaw, such scaling as may be indicated should be performed, after which the pockets should be carefully investigated with proper instruments, all foreign matter removed from them and from about the teeth, having recourse frequently to a 1/500 or 1/1000 solution of HgCl2 in H202. This preparation of peroxide should be first allowed to remain in the pockets and about the teeth for perhaps even three minutes. It may be necessary to reduce the length of elongated teeth, but if direct pressure will answer, this should be resorted to and shortening of the bite avoided. See the patient daily for two weeks. Sometimes no application of medicaments will be indicated - perhaps a little scaling or scraping of overlooked deposit, from time to time. The appearances of the abnormal conditions seem to be best indicated by color, size and texture. A dark blue color of soft and spongv gum should be lanced to relieve the venous congestion, and then injected with aromatic sulphuric acid, full officinal strength. Should suppuration be imminent or present, the pus should be evacuated by incision, or by the injection of peroxide of hydrogen as a first step, followed by a delicate application of "caustic paste" (potassa fusa 2/3, carbolic acid, cryst. 1/3). A cherry-red color of slightly puffed gum calls for salicylic acid solution saturated in 95 per cent. alcohol. The constant exhibition of antiseptic and stimulant mouth-washes is necessary, such as combinations of bichloride of mercury, tincture of calendula and distilled water, or hydronaphthol, tincture of calendula and distilled water; or peroxide of hydrogen and tincture of calendula. Systemic remedies are also indicated, such as tonics and cathartics, the latter in the beginning of the treatment; also digestive stimulation.

Dr. E. C. Kirk recommends a ten per cent. solution of aristol, rubbed up with oil of cinnamon, or oil of gaultheria and introduced into each suppurating pocket, and around the roots of the teeth at the base of each pocket, on wisps of absorbent cotton, saturated with the solution; also saturated solutions of sulphate of zinc and iodide of potassium, equal parts, in turn saturated with crystals of iodine; also, pyrozone five per cent. solution, or peroxide of sodium, or loretin, or trichloracetic acid alone or in combination with pyrozone, or glycozone, or bitartrate of lithia, internally. Dr. Bodecker recommends applying nitrate of silver by making a small platinum wire loop, warming it, and then dipping it into powdered nitrate of silver and carrying into the pockets. Rinsing the mouth before and after the application with salt water will prevent injury to surrounding tissues. Dr. Payne recommends warm distilled water followed by five per cent. solution of pyrozone, and then a concentrated solution of lactic acid. Dr. Gordon White recommends lactic acid, and where roots are very sensitive uses lactate of silver. Dr. Kirk recommends trichloracetic acid to facilitate removal of deposits: also Dr. Jarvie, and also sulphuric acid. Dr. B. F. Arrington medicates with sulphuric acid, campho-phenique, and carbolic acid. Dr. Essig recommends aqueous solutions of chloride of zinc, after all deposits are removed. Prof. Peirce recommends placing patient on an albuminous diet, and tablets of citrate of lithium. The cataphoric current with such medicines as are conductive, and also beneficial in the treatment of alveolar pyorrhoea, it is claimed, will increase their efficiency.