Read Ebook: The American Journal of Dental Science Vol. XIX. No. 6. Oct. 1885 by Various Gorgas Ferdinand J S Ferdinand James Samuel Editor

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The remedy of course is to remove the cause, and assist nature in affecting a cure, and to do this the pulp chamber must be opened, its contents removed, the canals cleansed and disinfected, the abscess healed, and the roots filled to the exclusion of all fluids and purulent matter. But how often this is not done. How many thousands of suffering mortals are to-day dragging out miserable lives because of these drainage tubes emptying themselves into the oral cavity--into the maxillary sinus or into the meatus of the nose. Such an abiding nuisance in the mouth cannot long exist without ruining health. But how few of the unfortunate sufferers realize the cause of their nervous irritability, their loss of appetite, their feeling of lassitude, their lack of energy, and their general prostration. And here let me say, that but few, in comparison to the number of these unfortunate sufferers seek relief at the hands of the dental practitioner. The patient is neither sick nor well, but debilitated and "good for nothing." The family physician is consulted, nervines and tonics are administered, but to no avail. The septic matter is vitiating the air that is breathed, and poisoning the food that is eaten. The saliva that is poured into the mouth from the various glands must mingle with this poisonous matter and carry it into the stomach.

Sanitary means are being employed in all our cities at the present time, in view of the cholera scourge that it is feared will sweep over our land the coming summer. Our physicians wisely talk and write about the baneful influences of impure water, about miasma arising from the decomposition of vegetable matter, and about unwholesome food, and it would be well if the public would heed their timely warnings. And as dental practitioners, I feel that we, also have an important duty to perform, in enlightening our patients, and the public so far as we are able to do so, in the direction I have above indicated.

The subject is of paramount importance, and as the opportunities come to us in every day practice, let us not fail to impress upon the minds of our patient , the fact that a clean mouth is essential to health.

The agitation of this subject, by the medical profession, is a step forward. Hitherto medical men have not given the matter the attention its importance demanded.

And now that this new light has dawned upon Dr. Sexton, it is not strange that, in hastily drawing his conclusions, he should have mingled much of error with the truths he has discovered. Possibly some of the cases that have come under his notice may have been the result of bad practice on the part of incompetent dental practitioners, but to charge the dental profession with their short-comings would be a matter of great injustice. Dr. Sexton is too hasty in his conclusions. First, he discovered that certain pulpless teeth had caused certain ailments, hence he condemns all pulpless teeth. He has discovered that certain dentists have failed to treat such teeth successfully, hence he condemns the dental profession for attempting to save teeth, it would be equally fair to condemn the whole medical profession, because of the incompetency of some of its members. But before dismissing the subject of pulpless teeth, it may be well for us to examine the subject a little more carefully from the standpoint of the medical writers above referred to. We cannot afford to make a mistake with regard to so important a matter. The higher a man stands in his profession, the more serious the mistakes he makes, and the more important it is that his practice be sound. An enthusiast or an extremist may injure a good cause. There are such men in our ranks.

A few years ago a prominent dentist said, "The tooth's pulp is its soul, and it is criminal to destroy it."

I heard another prominent dentist say, "If I find a part of the pulp dead, I amputate the dead tissues, and save the balance of the pulp alive."

A dentist has just moved away from Burlington, who has been in practice there for fifteen years, and during that time he has been using arsenic for obtunding sensitive dentine, and he has succeeded in accomplishing his purpose admirably. I have found in one month half a dozen filled teeth containing dead pulps, and, of course as many alveolar abscesses in active operation. The evils arising from such abominable methods of practice are simply appalling.

I have less frequently met with cases where those fistulous openings were on the neck or chest. In those cases the roots of the teeth are usually long, and when the abscess breaks through the lower border of the jaw, and the pus comes in contact with the soft tissues, it follows the course of the muscles and forms a sinous as it gravitates to some point on the neck or chest. I have known of a number of such cases being under medical treatment for years, where the affection was supposed to be of a strumpous nature, and the real cause was not suspected, and in every case a rapid recovery has followed the extraction of the offending tooth.

Gentlemen, I have no doubt but the most of you are disappointed in the nature of this paper. I have scarcely alluded to the treatment and filling of pulpless teeth. That had not been my purpose. But I have wished to call attention to the fact that a large majority of the ailments above referred to have been due to diseased teeth that have never received any attention whatever at the hands of competent dentists.

DEAD TEETH IN THE JAWS.

TRUMAN W. BROPHY, M. D., D. D. S.

In reply to Dr. Sexton on this subject, Dr. Brophy makes these pertinent remarks in the journal of the American Medical Association:

Dr. Sexton says: "The retention in the jaws of teeth which are diseased, have become irredeemably sensitive to thermal influences, or deprived of adequate periosteal nourishment through calcareous formations about the roots, very frequently gives rise to nervous diseases about the head. I am convinced that these reflected nerve influences manifest themselves much oftener since dentistry has come more extensively into practice during the present generation, and greater efforts are made to retain defective teeth in the jaw."

That diseases of the teeth are often the center from which pain is reflected to the eyes, ears and other parts, all experienced clinical observers must admit. But that these pathological conditions of the teeth, from which reflected pain has its origin, can be and are successfully treated and cured with rare exceptions, as effectually as any other diseases, is a fact too well-established to be set aside.

Again: "The dead tissues of the dentine will sooner or later, most likely, be transmitted through the tissues of the cementum to the periosteum." Communication between the lacunae canaliculi of the cementum with the tubuli of the dentine is not free; indeed, it seldom exists, hence it cannot be "that through the periosteum alone the dentine may long derive some nourishment."

About 22,000,000 teeth are annually extracted in the United States, and I regret to say this enormous loss of teeth is to no small extent due to the indifference manifested by physicians in the anatomy, physiology and pathology of these organs. It is a fact, no one will attempt to gainsay, that hygienic measures directed toward the preservation of the deciduous set, if understood, are seldom recommended by the general practitioner to the families under his charge. The premature loss of these teeth paves the way for early lesions of the permanent set. The pain resulting from advanced caries of the deciduous teeth, owing to the difficulties encountered in controlling the patient, is not easily treated; moreover, the injurious impressions thus made on the system of the child abide through life. There is no doubt hundreds of thousands of teeth are unnecessarily extracted each year, and then drugs are given with a view of curing the patient of the disorders of digestion and other abnormal conditions which follow, and which in turn arise from imperfect mastication of food, verily for the want of teeth.

We need to know "what's the matter" in the treatment of these "nervous diseases about the head," as in all others, and apply a remedy which will bring the abnormal tissues back to health. Too often, indeed, has it happened that patients, by advice of their medical attendants, have submitted to the loss of many, and, in some instances, to all their teeth, in the vain endeavor to be relieved from trigeminal neuralgia. You may ask, Why this useless loss of teeth, and all the resulting evils? Because the advice given was not wise; the etiology of the affection was not understood.

There are certain pathological conditions of the teeth which have not been mentioned in this discussion, and which give rise to reflected pain of the eyes, ears, and other parts.

Among these may be mentioned exostosis of the roots of teeth and nodules of calcific matter within the pulp canals in contact with a living pulp. The former of these conditions has been regarded incurable, the removal of the tooth with the united bony tumor being indicated. In favorable cases, however, this tumor may be excised and removed without removing the tooth. The pulp nodules of calcified deposits within the pulp chamber may be, in a large majority of cases, successfully removed without sacrificing the tooth.

DIAGNOSIS AND TREATMENT OF DENTRITIC CYSTIC TUMORS OF THE JAWS.

BY JOHN S. SMITH, D. D. S., LANCASTER, PA.

In some cases of cystic tumors, they present so formidable an appearance at first sight, that they may be taken for solid tumors; especially is this so when their walls are compact and well organized, nearly if not altogether obliterating the sense of fluctuation when pressure is made upon them.

Cases have come under the observation of the writer where it required the most delicate touch to detect any fluctuation when pressure was made upon the apex of the tumor.

In some cases the diagnosis cannot be determined accurately until after one or more teeth are removed that are involved with the tumor. After such operation, a probe carried through the alveolus will usually reveal the true condition of the lesion. One or more dead teeth are found involved--one, however, being the rule in most cases which have come to the notice of the writer, while two, and sometimes three, are implicated with the tumor. The dead tooth may be easily distinguished from the living ones by its opaque appearance. Such tooth may be carious, and it may not.

Primarily the dentritic cyst originates from what pathologists call a "cold abscess," that is, an abscess which has never opened; subsequently, having developed into a tumor. The interior of the cyst has a fibrous lining, and being compact in structure, is the seat of an inflammatory process. The cyst contains a pyriform fluid; it may attain such magnitude as to invest several teeth and extend beyond the alveolar process. The tumor is usually oval in shape, with its apex on a line with the diseased tooth directly involved. The size of the tumor may be as large as a hulled walnut or as small as hazel-nut; crepitates under pressure, and feels like parchment. In cases of long standing, considerable resorption of the alveolar process takes place, and the teeth immediately connected will be loose; especially will this be the case if the alveolar borders are broken; these teeth should be removed. These tumors are found painless, as a rule. I have met with cases, however, where an acute inflammatory condition was present, with all the symptoms of acute periodontitis manifested. So that it could have been readily mistaken for the pointing of an alveolar abscess.

Rindfleisch says: "The accumulation of the fluid is not produced by the continuance of the normal secretion, but by an exudation surpassing the normal measure of the serum of the blood with salts, albumen, fibrinogenous substance, and extractives, in the most varying proportions. The exudation cysts have little to do with pathological new formation. Of extravasation cysts," he says, "a parenchymatous bleeding can very well be the point of departure for the formation of a cyst. The hemorrhagic depot can present itself primarily as a cyst, namely, when the blood is poured out between two surfaces in themselves smooth; for example, bone and periosteum, cartilage and perichondrium, and thereafter remains fluid. As a cyst may also be formed when upon the one hand the limitary parenchyma furnishes a connective tissue membrane, upon the other hand, the blood itself is resorbed through a series of metamorphoses up to a small remainder, and is replaced by a clear fluid."

The above-mentioned condition is liable to manifest itself within the body of the jaw, the bone and periosteum, after severe mechanical injuries to the bone, and the rupture of blood-vessels within the parenchyma. There can be little doubt that many of the so-called dentritic cysts of the jaws have their origin primarily from causes brought about by falls, strokes and mechanical violence, causing rupture of blood-vessels. It is quite true, history of cases fully confirms such facts.

Clinical observations leads us to believe, however, that only in cases where the abscess does not open, we find the pathological new formation taking place within the jaws. Pulpitis, and as has been observed, followed by pericementitis and periodontitis, is a prolific cause of the development of the dentritic cystic tumor.

THOROUGHNESS.

BY L. P. DOTTERER, D. D. S.

Though scarcely more than a novice in the vast field of Operative Dentistry, I have gleaned sufficient experience from observation and practice to know that THOROUGHNESS is the surest means of success.

As regards the preparation and filling of cavities, there are so many conflicting conditions, that we must be governed entirely by the case before us; but to be thorough in our preparation, we must so shape the cavity as to have the walls nearly plumb, uniform margin, slightly undercut. In proximal cavities there may be a groove or pit at cervical wall, but do not have it too near the margin, on account of its liability to produce fracture, and consequent failure at that point. On grinding surfaces, cut out all fissures leading into cavity, and be careful to have no angles.

The margin, after all, is the most important point; for just here failure begins, especially at the cervical wall, and care should be taken to thoroughly remove all softened structure, and aim to reach a solid foundation. These margins should be carefully trimmed and burnished, and thus our cavity is ready for the filling.

We often hear practitioners decry the rubber-dam, and boast of their skillful use of the napkin; but, gentlemen, many are the failures consequent! For in deep proximal cavities, the dam is invaluable in keeping guard against oozing moisture from the gums, which, without this precaution, will flow upon the filling without our knowledge. The dam adjusted, we proceed to form a mass of non-cohesive gold, and where the walls are strong enough, we can continue with this material throughout. But where cohesive gold is necessary, we should cover our borders, as far as possible, with soft foil; for this is more adaptable to the walls. Another advantage to be found in non-cohesive gold, is its pliability, ease of starting, and rapidity in finishing. We should thoroughly condense from beginning to end, whatever may be the kind of foil used.

Filing and finishing is too often hurried through, leaving a surplus of material at the cervical wall, or lapping the edges--another sure cause of failure; and every care should be directed to finish in such way that an instrument passing over the line of demarkation cannot detect it. After filing, we would use pumice, either on a strip of orange-wood, or by some other convenient means, and then polish. The same general rule holds good in amalgam work, and the main cause of failure in these cases is that lack of thoroughness in finishing.

In grinding surface cavities, where the enamel leading thereto is funnel-shaped, we often introduce too much amalgam, extending it beyond the margins of the cavity, and finishing to a fine edge. This material, when hard and bit upon, will fracture perpendicularly around the margins, giving the finishing a bulged appearance, and exposing a V-shaped crack, which will invite decay. Consequently, we should remove all surplus material, and finish at the very margin of the cavity. When gold is used, this precaution is not so necessary, as the edges of a gold filling will not fracture. Since we do not have to mallet amalgam, it is natural to suppose we don't require firm margins, but this is a mistake; and as much, or even more care should be exercised in the preparation of a cavity for amalgam than gold, as tooth-structure seems to waste away more rapidly from the former.

Let our motto be, "Whatever is worth doing at all is worth doing well." If applying arsenic or a disinfectant, cover it with gutta-percha, for the patient may be delayed a few days longer than we anticipate; and what is worse than removing a foul piece of cotton, and finding the tooth in a poorer condition than we left it? If we introduce a temporary stopping on account of exposure or frailty, let it be done thoroughly; and after relating its importance to the patient, caution her to return at a certain time for its removal and permanent filling.

We must be teachers at our chairs, if we wish the public to appreciate us, and we should instruct patients in the proper care of their teeth by an intelligent and thorough use of the brush, pick, etc.

WHAT FILLINGS SHOULD WE USE?

DR. W. G. A. BONWILL, PHILADELPHIA.

Where is the dentist that first lays out his design and orders materials best adapted for specific portions of it?

SOME METHODS OF SEPARATING TEETH WITH WEDGES.

BY DR. DWIGHT M. CLAPP, OF BOSTON.

COCAINE.

WALTER W. ALLPORT, M. D., D. D. S., OF CHICAGO, ILL.

The introduction of cocaine as a local anaesthetic, and the more general use of peroxide of hydrogen in the treatment of dental and oral diseases, are the principal advance made in the medical department of this practice during the year for which this report is made.

The two forms of cocaine which have been most generally used in surgery are the hydrochlorate and the oleate.

In operations in the mouth, involving the mucous membranes, together with the immediately subjacent tissues, these preparations have proven so efficient there is little question of its value as a local anaesthetic in such cases. But its action on deeper structures, such as involve the roots of teeth, is so uncertain as to render its practicable benefits questionable in the operation of extraction. In the surgical treatment of pockets caused by pyorrhea alveolaris, the anaesthetic effect of this agent is often so great as to render this sometimes very painful operation comparatively painless, and its employment in such cases should rarely be dispensed with. In the treatment of hypersensitive dentine, as well as in the removal of tooth-pulps, its action as an anaesthetic has, under some circumstances, seemed to be all that could be desired. But in far the greater number of cases it has proved of little practical value. More recently, however, a new form of cocaine, known as the citrate, has been introduced in Germany by Merck, and is now being manufactured by McKesson & Robbins, of New York. In a series of experiments, conducted by Dr. John S. Marshall, of Chicago, it has been shown that for operations on sub-mucous tissues, or in the extraction of teeth, it seems to possess no special advantages over the preparations previously named. But when applied to dentine or the pulp, its action--though not always positive--seems to be more reliable, especially on the dentine, and gives promise of better results. Under favorable conditions it produces anaesthesia of the parts in from five to ten minutes, and the duration of the effect is of sufficient length to afford time for the preparation of the cavity. This effect has, in some cases been prolonged for more than an hour. The pulp has been extirpated without pain after the drug has been applied in from three to twelve minutes.

If the citrate of cocaine be kept in solution for more than three or four days it decomposes and loses its active properties. As introduced by Mr. Merck for dental purposes, it is made into pills by incorporating it with gum tragacanth dissolved in glycerine, each pill containing 1/8 grain of the citrate. In this form it keeps well. A pill is applied to the sensitive cavity and covered with a cotton pledget, moistened in tepid water. It should be allowed to remain from five to twelve minutes, when--if at all--the desired result is produced. In twenty per cent. of the cases where this remedy has been employed it has proven unsuccessful, but it is hoped that this percentage will be reduced by a better knowledge of the drug and the improved methods of its preparation and use.

Editorial, Etc.

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