dental history
What Happened to the Bismuth Line? Qing C. Zeng, D.D.S.; Louis Mandel, D.D.S.
ABSTRACT The historical use of bismuth in the treatment of syphilis is reviewed. Attention is called to a patient’s development of dark blue/black bismuth deposits that involved the marginal gingiva and lateral ventral tongue surface. A mechanism is described to explain the presence of bismuth deposition in these two oral areas. The explanation for the deposition is based on modern concepts of the pathophysiology of inflammation. Before penicillin was discovered to be a safe and efficacious treatment for syphilis, many treatment modalities were promulgated, each with its own adverse effects. In the late 19th and early 20th centuries, when syphilis affected a significant portion of the population, mercury was the treatment of choice. Many mercurial preparations were utilized, but it soon became apparent that the drug’s serious side effects outweighed its benefits. Patients often developed kidney failure, neuropathies and mouth ulcers. Mercury poisoning also could occur and lead to death.1,2 Following the discovery of the causative spirochete, Ehrlich’s investigations resulted in the use of arsenics for the treatment of syphilis.3 Ehrlich was awarded the Nobel Prize for the introduction of the therapeutic arsenical Salvarsan. Salvarsan proved to be more effective for the treatment of syphilis than the previ-
32 JUNE/JULY 2020 The New York State Dental Journal ●
ously used mercury formulations. Nevertheless, it, too, caused side effects, and soon reports of liver failure and seizures were received.3 The more successful use of bismuth in the treatment of syphilis was first advocated by Balzer in 1889 and then confirmed and popularized by Salzerac and Levaditi in 1921.4 Almost immediately after the introduction of bismuth for syphilis therapy, it was widely adopted by syphilologists as a substitute for mercury, and for patients who had problems with the arsenicals.4,5 Bismuth proved to be an effective agent for the treatment of congenital and acquired syphilis.6 Unfortunately, bismuth also proved to have side effects with its prolonged use. These included excessive salivation, stomatitis, diarrhea and albuminuria.5 The side effects were usually transient and hardly necessitated discontinuing treatment.7 A major objection of patients focused on the formation of a blue/black line along the gingival margins. The bismuth gingival line was first reported by Balzer in 1889, and then in 1921 by Salzerac and Levaditi.4 Reports indicated that 56% to 70% of patients undergoing bismuth treatment developed this gingival manifestation of bismuth therapy.8-10 The line was also observed when the bismuth was administered for conditions such as chronic discoid lupus erythematosus, lichen planus, scleroderma and granuloma annulare.10 An increased bismuth line incidence is directly correlated with increased dosages of bismuth.11 Of interest is the
