DISEASE OF THE ANTRUM DUE TO DENTAL 
COMPLICATIONS, AND ITS TREATMENT. 
By FRANK ABBOTT, M.D., NEW YORK, N. Y. 
(Read before the New York Odontological Society, November 20,1888, and reprinted from the 
Dental Cosmos for February,'1889.) DISEASE OF THE ANTRUM DUE TO DENTAL COMPLICATIONS, 
AND ITS TREATMENT. 
FRANK ABBOTT, M.D., NEW YORK, N. Y. 
Mr. President and Gentlemen : Antrum is a name given to certain 
cavities in bones, the openings into which are smaller than the cav- 
ities themselves. The antrum of Highmore was known in Galen's 
time, but it was not until 1651 that a rational description of it was 
given by Nathaniel Highmore, of Sherburne, England. It is a deep 
cavity in the substance of the superior maxillary bone, communi- 
cating with the middle meatus of the nose by an opening (in the 
recent state) about the size of an ordinary knitting-needle, through 
which the Schneiderian membrane is prolonged to line the cavity. 
It is called by anatomists an irregular triangular-shaped cavity. 
Its floor is formed by the alveolar process, and its roof by the floor 
of the orbit. Any further anatomical description of this cavity, at 
this time, would be superfluous, except in a few respects, which 
bear more directly upon the subject before us. The bony covering 
of the antrum is in several places extremely thin, so much so, that 
pressure produced upon it by excessive accumulations in the cavity 
causes it to bulge perceptibly, and unless it is early evacuated, per- 
foration of these thin walls ensues. These localities are-(1) imme- 
diately above the canine fossa; (2) upon the buccal wall, above and 
between the roots of the first and second molars; (3) above and be- 
tween the palatal roots of these molars; (4) the orbital floor. 
A feature of no little interest and importance in studying the 
antrum, especially pathologically, is the variation in its situation. 
It has been said that in the examination of one hundred skulls, no 
two presented this cavity in precisely the same situation. Some 
are large, some small, some are much higher than others, some well 
to the front, others set deep back, and in many instances its situa- 
tion is very different in the same face, one side being very large, 
prominent, and high, while the other is the reverse. 
If the face be short and broad, the indications are that the floor 
of the antrum is penetrated, or nearly so, by the roots of the first 2 
and second molars, and perhaps by that of the second bicuspid as 
well. As far as my observation has gone, the first bicuspid and 
canine seldom if ever penetrate the floor of this cavity with their 
roots. 
Physiology or Function.-This, like the frontal sinuses, being con- 
nected with and forming a part of the air-passages, is made use of 
as a reservoir for air, which is kept at the temperature of the body; 
and in the act of inhalation this warm air becomes mixed with the 
cold, so that upon its entrance into the lungs it is slightly tempered. 
Again, as the cavity is lined with Schneiderian membrane, it un- 
doubtedly serves to a limited extent to assist in the delights or 
otherwise attendant upon the use of the special sense of the nasal 
organ. 
Diseases.-It is an undoubted fact that the great majority of the 
diseases of the antrum are due directly to dental complications. 
Many other diseases of the antrum, such as the different varieties 
of tumors and the 11 troubles common to mucous membrane wher- 
ever situated," occur so rarely as compared with that in which the 
dental organs are especially responsible, that I am disposed to con- 
fine myself to the consideration of that alone, in this short paper. 
It has been stated that to call this disease abscess of the antrum 
was a misnomer, from the fact that but for the close proximity of 
diseased teeth, such a disturbance would probably not have taken 
place. Recognizing the force of this argument, would it not be 
well to speak of it as an alveolar abscess, the pus from which finds 
exit into and through the antrum? By the presence of*the pus, 
however, the entire mucous membrane lining the antral cavity 
often becomes inflamed and more or less hypertrophied, so that if 
of long standing a quite general ulceration takes place, and in some 
rare instances the soft tissue covering the bone in places is altogether 
destroyed, leaving the bone bare. Thus it becomes a disease of the 
mucous membrane lining the cavity itself; and for these reasons 
it has received the name of abscess of the antrum. Abscesses in 
this cavity are spoken of as arising from mal-positioned teeth. Un- 
doubtedly such might be the case, but it has never been my privilege 
to see one. 
Diagnosis.-The means of diagnosing an abscess of the antrum 
are quite numerous, and generally conclusive. The first symptom 
of a disturbance which results in such a disease is a slight soreness 
of a tooth the pulp of which is lifeless; then follows a dull, heavy 
pain (sometimes sharp and darting up the side of the head) in that 
side of the face. This moderately increases in severity, for days, 
weeks, and sometimes for months, before any very especial notice is 
taken of it by the patient, when attention is directed to it more 3 
particularly by a decidedly heavy feeling and increased pain in 
the cheek upon bending forward, or in tipping the head from side to 
side. If the cavity becomes considerably filled with pus before the 
lining membrane becomes sufficiently inflamed and thickened to 
have closed the opening into the nose, an excessive discharge will 
be noticed from that organ upon the affected side. This discovery 
usually takes the patient to the family physician, who at once pro- 
nounces the disease catarrh or ozena, and proceeds in his treatment. 
This often continues for months, and perhaps for years, before the 
real disease is ascertained. 
Should the lining membrane become inflamed and thickened 
sufficiently to close the opening into the nose, the cavity then be- 
comes filled with pus, and in consequence of its continued augmen- 
tation pressure begins upon the surrounding walls. The inflamma- 
tion, together with the pressure, causes absorption, or a melting 
down of the walls progressively until an exit for the pent-up pus is 
effected, unless professional relief is obtained. While this progress- 
ive destruction of the bony wall is going on, a decided bulging of it 
takes place in the localities above referred to. A prominence is 
observed by the side of the nose, over the molar teeth, and in the 
mouth, upon that side, while the orbit is pushed up and out to such 
an extent that the sight of the affected eye is considerably elevated 
above that of the other. By pressing with the thumb upon the 
prominence, by the side of the nose particularly, crepitation may 
very distinctly be heard. With the above diagnostic signs presenting, 
it is generally safe to conclude that an abscess in the antrum is the 
disease in question. 
Differential Diagnosis.-In order to differentiate between catarrh, 
or ozena, and antral abscess, it should first be ascertained whether 
any pulpless teeth are in that side of the upper jaw, and a careful 
observation should be made as to the relative situation of the antrum. 
If pulpless teeth are found, and the face is short from the oral cavity 
to the orbit, the indications are strongly in favor of an abscess in the 
cavity of the antrum, even should no other especial diagnostic sign 
be present except the discharge from the nose. On the other hand, 
should no pulpless teeth be found, or, if present, the face be long be- 
tween the orbit and oral cavity, indicating that the alveolar process is 
very thick between the floor of the antrum and the roots of the 
teeth, it would indicate that no abscess in the antrum existed. The 
absence of pulpless teeth would make the evidence more conclusive. 
Prognosis.-The prognosis in the majority of cases is favorable, 
and with careful treatment they will, within from three weeks to as 
many months, be entirely cured. There are conditions, however, 
which militate against a successful termination of the best-directed 4 
efforts. These are, in both sexes, in patients of advanced age, with 
a generally low physical condition ; those of sedentary habits, poor 
digestion ; and those suffering from chronic malarial poison or from 
some specific disease. In the female the period of cessation of the 
menses (change of life) is probably the most troublesome to combat 
the diseases of this cavity. Dr. J. L. Mewborn, of Memphis, Tenn., 
who has devoted much time to the study of these cases, has arrived 
at the conclusion that abscess from any cause located in the cavity 
of the antrum of a female, at or beyond the " climacteric period," 
is seldom if ever permanently cured. From his report of cases, I 
do not feel disposed to deny his position. However, the first case I 
ever treated, in the mouth of a lady, was a patient over fifty years 
of age. In the course of a month all discharge stopped, and the 
opening healed. I saw the lady frequently, and for some three years 
she had no pain or uneasiness to indicate that all was not well in 
that antrum. Finally, after about three and a half years, an abscess 
made its appearance again, accompanied with all the pains and gener- 
ally disagreeable features attending the formation of the original one. 
When she applied to me I found a second bicuspid, which had been 
pulpless for many years, to be the exciting cause. This I at once 
removed, cleansed the antrum, and treated it for a few times, when 
the lady left the city ; and I have never seen her since, now some 
eight or ten years. She is alive, however, and as far as I know she 
recovered from her antrum trouble the second time as promptly as 
she did the first; but, on the other hand, she may never have recov- 
ered, and this may be one of the cases which would go to prove Dr. 
Mewborn's position. In another case, which I saw first in consul- 
tation some three years ago, the patient being, I should judge, some 
forty-eight or fifty years of age, I made a careful examination of 
the antral cavity, and could find no necrosed bone, nor any condition 
that would preclude the possibility of a cure within a few weeks, or 
months at most. I did not see her again until about eight months 
ago, when she was brought to me by another practitioner. I then 
made another careful examination of her antrum, and found a 
territory of denuded bone, as large (as near as I could judge) as a 
five-cent silver piece, located at the upper posterior wall of the 
cavity. I advised as to treatment, and the patient went away. I 
have since, by request, examined this case, and now believe the bone 
that was bare when I saw her eight months ago has been re-covered 
with the lining membrane of the cavity. The opening into the 
antrum from the oral cavity remains about the same ; it is extremely 
small, however. One peculiar feature presented itself in connection 
with this case, which may be of interest, if not of use, to some one 
who may hear or read this. The lady complained of intense dart- 5 
ing pains in that side of the face, either in or immediately under 
the skin. For some time I was unable to account for it, but finally 
it dawned upon me that probably the denuded and constantly irri- 
tated bone in the antrum was in contact with the infra-orbital nerve, 
or perhaps formed a portion of its immediate covering, so that the 
trunk of the nerve received the injury, which manifested itself at 
its terminal fibers upon the face. The treatment was consequently 
directed to allay the irritation of the trunk of the nerve, which gave 
relief. This is another case which might be cited to sustain Dr. 
Mewborn's position, as 1 believe now, after these years, and a great 
portion of the time under treatment by different dentists, it is still 
open. There appears to be no discharge of pus from it, however. 
Treatment.-The treatment consists in first obtaining a sufficiently 
large, depending opening into the antrum to admit of its thorough 
exploration, the ready application of remedies, and its involuntary 
evacuation of all fluid substances. This is accomplished by, first, the 
removal of the offending tooth. This I know will be objected to by 
some, but I consider it, as a rule, by far the safest procedure. If the 
tooth so removed be the first or second molar, a sharp bur the size 
it is desired the opening should be is placed into the socket of the 
anterior buccal root, and with an engine driven into the antrum, 
cutting all intercepting bone as it proceeds; then with lukewarm 
salt water the cavity is thoroughly washed out, using a spray 
syringe for the purpose. A most searching exploration of the cavity 
is now made with a probe, to ascertain whether any necrosis of the 
bony wall is present. If found, it should be removed. If none is 
found (as it seldom is), the treatment is proceeded with as follows: 
Should there be an unpleasant odor arising from it, it can be controlled 
by the use of a solution of permanganate of potash, two grains to one 
ounce of water. This is not strong enough to irritate the delicate 
lining membrane of the antrum, and will very effectually deodor- 
ize it. The cavity is then washed out as thoroughly as practicable 
with a solution of carbolic acid one to sixty-four. This again is not 
strong enough to irritate the delicate lining membrane of the cavity, 
but in this strength it is a most effective antiseptic. A solution of 
equal parts of Listerine and water is often found very efficacious as 
an antiseptic in the treatment of these cases; a saturated solution 
of boracic acid in warm water is also found of excellent service. 
There is no doubt of the efficacy of bichloride of mercury as an 
antiseptic. I have tried it but once, however, when I used a solution 
of one to two thousand. This produced so much irritation that I 
have since confined myself to more mild applications. I have no 
doubt, however, that a preparation of one to five thousand might 
be used to good advantage. One feature which especially recom- 6 
mends it for use in the mouth is that it has no disagreeable taste nor 
smell. After washing the cavity with any one of the above remedies, 
I apply the same more effectually by means of the spray apparatus. 
As a stimulant, I use tincture of iodine, one drachm to an ounce of 
the carbolic solution. Here I wish to remark that my first idea 
of the use of a spray, as a more perfect means of medicating the 
antrum, was obtained from Dr. J. L. Mewborn, of Memphis, in 1884. 
He, however, uses the remedy warm, and applies it by means of a 
hand atomizer with a single jet. I use compressed air, with a pres- 
sure of thirty to forty-five pounds to the square inch, and a multiple 
spray. The pressure forces the remedy into every irregularity of 
mucous membrane, and the multiple spray reaches all parts of the 
cavity. This mode of applying remedies to the cavity of the antrum 
I consider of incalculable service in the successful treatment of many 
cases, and I cannot, nor do I think dentists in general can thank Dr. 
Mewborn enough for this valuable addition to their armamentarium 
for the treatment of this disease. 
After thoroughly medicating as above described, means must be 
taken to prevent the opening from closing too rapidly. This is done 
by means of cotton wound upon a roughened bit of wood, or a bit 
from a whisk broom, as near as can be judged the size of the open- 
ing. This is dipped into carbolized oil of sweet almonds, one part 
of carbolic acid to fifteen of the oil, then placed in position, and tied 
with a bit of silk to an adjoining tooth. This treatment is followed 
up every day, and as soon as all signs of pus have disappeared the 
plug is each day made smaller, until the opening is closed entirely. 
I never use a drainage-tube. In order to test for the presence of 
pus, peroxide of hydrogen may sometimes be used to advantage. 
In cases where from the history it is evident that a specific 
poison has to be combated, iodide of potassium is given in five-grain 
doses three times a day, and each day the dose is increased one 
grain until the patient becomes perceptibly affected by it, which 
will be manifested by a decrease, and finally a cessation of the dis- 
charge of pus. Many cases yield readily to the effect of sulphide 
of calcium, given in one-tenth grain doses three times a day. 
It is frequently the case that patients are anemic, consequently 
the disease yields slowly, if at all, to local treatment. In such cases 
ammonio-citrate of iron, in from five- to ten-grain doses, three times 
a day, is found of excellent service. Quinine sulphate in two-grain 
doses, three times a day, is found useful. Persons who take very 
little out-door exercise, especially if past middle age, should be di- 
rected to take such exercise liberally and systematically every day. 
It will be observed that I have spoken of but one means of 
gaining an entrance to the antrum. Othei' modes are adopted by 7 
some surgeons, some of which I do not approve of. Some three 
years since, I had the pleasure of listening to the description of 
an operation for this purpose, and saw the patient upon whom 
the operation had been performed. It was before this society, at 
its first meeting, I think, in this room. It consisted in making 
an incision from the corner of the mouth back past the external 
antral wall, dissecting the soft tissues from the wall, and making 
an opening into the antrum over the molar teeth. It was spoken 
of as a great and very successful operation. This may have been, 
as far as the cure of the disease was concerned; but it seems to 
me that the means adopted were altogether too heroic and not at all 
necessary. Here was, from the history of the case, a simple abscess 
from a pulpless tooth, emptying into the antrum, which would have 
been treated, and probably cured, in a few weeks by a competent 
dental surgeon, with no surgical work whatever except the removal 
of the offending tooth and the enlarging of one of the sockets. In 
my judgment, as dental surgeons we ought to openly discourage, in 
the strongest manner possible, such uncalled-for surgical work as 
was shown in this case. Patients suffer quite enough at the hands 
of us all, when such work is done in the most conservative manner 
possible. 
A most interesting and instructive case came under my observa- 
tion some three years ago. A gentleman some thirty-five years 
previously received a scratch on the cheek, by the left side of the 
nose, which, despite all the efforts of the best-skilled physicians in 
this country and Europe, would not heal. It was pronounced a 
rodent ulcer, or flat cancer. It increased in size and annoyance very 
slowly indeed, so much so that at times it was thought to be more 
or less under control. Some twenty years before I saw him profes- 
sionally, he had had the pulp destroyed in the left upper second 
molar, and the tooth filled in Paris. Some ten years later, his 
dentist in this city had refilled the cavity in the crown of the tooth, 
but had done nothing with the roots, they seeming to be filled satis- 
factorily, no trouble having been experienced from them. Three 
years ago the past summer the face on that side commenced to 
swell; the eye became pushed up very considerably, causing severe 
and constant pain. After his return to the city, I was requested to 
go and see him. Upon examination, I concluded that the pulpless 
molar had caused an abscess in the antrum. I was requested by his 
dentist and attending physician to remove the tooth. This I did, and 
found my diagnosis correct. Immediately upon its removal quite 
a discharge of black, fetid matter was observed. This kept up dur- 
ing the following night and a part of the next day. Upon probing 
the antrum, it was found nearly filled with a mass, which proved to 8 
be cancerous. From this time forward the growth of the cancer 
was very rapid. In a few months' time I had removed all the teeth 
in the upper jaw, and several operations had been performed, when 
large masses of the growth were removed, to prevent suffocation- 
Death relieved him of his sufferings finally. The lesson to be learned 
from this case is this : where an incurable disease is present upon the 
face, great care should be taken that the dental organs are not 
allowed to become an auxiliary in its progress, thus increasing, to a 
great extent, the sufferings of the patient, and, in consequence, very 
considerably shortening his life. In this case the seat of the disease 
was apparently changed from his face, outside, to the antrum, caused 
undoubtedly by this pulpless molar. Its more rapid development, 
and consequent increase of suffering and shortening of his life, was 
the result.