674 • T H E J O U R N A L O F T H E A M E R IC A N D E N T A L A S S O C IA T IO N
Pseudomonas aeruginosa
Proteus vulgaris
Aerobacter aerogenes
In 1946, Nichols and Herrell133 re­
ported their experience with the treat­
ment of 41 cases of urinary tract infec­
tions. The organisms detected follow:
Number
Escherichia coli 11
Pseudomonas aeruginosa 10
Gram-negative bacilli 8 o f a nonvital tooth.
Gram-positive and gram-negative
bacilli 5 R O L E O F D E N T A L F O C A L IN F E C T IO N
Aerobacter aeruginosa 4 IN U R IN A R Y T R A C T D IS E A S E
Proteus ammoniae 3
In 1946, Bondi and others134 reported
two unrelated cases o f infection of the
urinary tract by A. aerogenes (a gram-
negative coliform bacillus) in which
chemotherapy was unsuccessful owing to
the development o f streptomycin resist­
ant variants o f the two strains. This and
similar findings have complicated treat­
ment o f infections of the urinary tract
because it now becomes necessary to test
the sensitivity o f the organisms in vitro
before treating the patient scientifically.
In 1947, Carroll, Allen and Doubly135
reported a study o f the sensitivity to
chemotherapy o f bacillary organisms in
the urine of 39 patients who had per­
sistent urinary tract infections. These
organisms were identified as Ps. aeru­
ginosa and its related organisms.
In 1949, Wilhelm and others136 reported
bacteriologic studies from 100 consecutive
patients. These studies showed that A.
aerogenes (B . lactis aerogenes) was pres­
ent in the initial urine cultures o f 50 per
cent o f these patients, and that the or­
ganism was recovered in later cultures in
75 per cent o f the patients at some time
during their stay in the hospital. Bac­
teremia caused by A . aerogenes was
proved in 24 patients, 7 o f whom died.
Hayman,137 in a 1949 textbook, stated:
“ Infections o f the kidney may be caused
by almost any organism but more than
36 9 half of them are due to Bacterium coli.
28 7 Next in frequency are Staphylococcus and
22 5 Streptococcus, more rarely Proteus vul­
garis and Pseudomonas pyocyanea.”
From the preceding review, it would
appear that colon bacteria most fre­
quently have been implicated in the in­
fections o f the urinary tract. Rarely has
an organism been identified which could
have reached the urinary tract o f a pa­
tient hematogenously from the root end
In order to evaluate the role o f dental
foci o f infection in urinary tract disease it
would appear appropriate to establish
scientifically (1) the bacteria that may
be implanted in the blood stream by an
infected nonvital tooth or the extraction
o f such an infected tooth and (2) the
organisms which consistently are recov­
ered from urine samples in cases o f uri­
nary tract infection. Such examination of
the evidence should establish the etiologic
significance o f the nonvital tooth in
urinary tract disease. First an under­
standing o f the nature of renal tract dis­
ease should be helpful.
Lichtwitz,138 in his 1942 textbook,
stated: “ The various forms o f nephritis
always have puzzled pathologists because
they appear following— and probably the
result o f— such diverse, noxious agents as
tonsillitis, colds, scarlet fever, influenza,
other infectious diseases, exposure to cold,
pregnancy, intoxication with various
drugs and allergic states.”
Selye,42 in 1946, while discussing the
clinical implications of the general adap­
tation syndrome o f human beings, stated:
“ Nephritis may be caused by a variety o f
micro-organisms, by exposure to cold or
by treatment with various drugs but it is
particularly frequent in patients suffering
from staphylococcus infection, with ton­
sillitis, scarlet fever or sepsis.”
As Hayman137 outlined rather con­
 F O C I O F IN F E C T IO N IN B O D Y D IS E A SE .
cisely, in 1947, during a discussion of
renal disease in Cecil’s edited textbook,
T h e term “ bacterial infections” is used to
describe diseases due to the actual presence of
bacteria in the kidney and urinary passages.
Bacteria may reach the kidney by way of
the b lo o d stream (hem atogenous in fection ), by
way o f the ureter or periureteral lymphatics
( ascending in fection ) , or possibly directly from
the intestine by way o f the lymphatics. . . .
H em atogenous are by far the most frequent.
It is, then, with hematogenous infec­
tion o f the kidney or urinary passages that
this present evaluation of the role o f non­
vital teeth is chiefly concerned.
Hayman points out further that infec­
tion o f clinical importance occurs when
bacteria come in overwhelming numbers,
or continuously, or are particularly viru­
lent, or because of lowered resistance of
the urinary passages owing especially to
obstruction. Pregnancy and trauma may
predispose to infection.
The discussion by Hayman137 presents
a representative survey o f the organisms
reported in the medical literature as
etiologic factors.
There is rather overwhelming evi­
dence120’ 139’ 101>51>52>122 that the organ­
isms forced into the blood stream by the
extraction of teeth or by the manipulation
of teeth and periodontal tissues are strains
of viridans streptococci in a very high
percentage of patients. At the same time
scientific studies116’ 117’ 118 of root canal
cultures indicate, disregarding contami-
O C U L A R DISEASE
R O L E O F D E N T A L F O C A L IN F E C T IO N
IN E T IO L O G Y OF OCU LAR D IS E A S E
The ophthalmologic literature, certainly
in the 1920’ s, appears to be imbued with
the notion of startling recovery of pa­
tients from uveitis following the removal
of “ foci of infection” in the teeth, tonsils,
nasal sinuses or genitourinary tract. On
the other hand, one reviewing the litera-
V O L U M E 42, J U N E 1951 • ¿75
nants which should not be reported, that
the anhemolytic (gamma type) strepto­
cocci and viridans (alpha type) strepto­
cocci are the organisms usually recovered
in root canal cultures, whereas the hemo­
lytic (beta type) streptococci are most
infrequent.
Lyons,93 in 1946, presented an evalua­
tion of the focal infection theory as a
cause of systemic disease with special
reference to arthritis. In a discussion of
oral bacteriology and renal disease, he
pointed o u t:
Nephritis is another disease w hich is assumed
to be related to foci o f infection. W e are aware
that acute nephritis occurs after infections of
the hem olytic streptococci and that exacer­
bations o f nephritis are associated with re­
infection with hem olytic streptococci. . . . Be­
cause o f the close relationship with hemolytic
streptococci it is indeed difficult to see how
teeth w hich harbor chiefly S treptococcus viri­
dans are necessarily involved. A fter the nephri­
tis is well established and albinuria is presistent
it is difficult to see h ow the removal o f teeth
w ill alter the course o f the disease.
It would appear that infections in the
urinary tract frequently are superimposed
on previous alteration of that tract by
external trauma, developmental anoma­
lies, calculi or growths, and that such in­
fections are developed during altered
states o f resistance in the host. Under
these circumstances, coloform organisms
would be most frequently involved, and
only rarely the normal bacterial residents
of infected tooth pulps.
ture soon becomes conscious o f the fail­
ure to include bacteriologic studies o f the
teeth prior to their removal, careful sub­
mission of data on control groups and the
inclusion of follow-up reports on the pa­
tients treated. Irons and Brown140 re­
ported a follow-up study of 50 of 200 pa­
tients suffering from iritis who were
studied and classified 3 to 12 years
earlier. O f the 40 patients whose condi­