Part 3

No one approves more than I the removal of the causes of disease. It is no more necessary to extract a tooth at the root of which an alveolar abscess has formed than it would be to amputate a limb for the cure of an abscess of the medullary substance of its bone. Disease of the eye sometimes requires that it be enucleated, but the honest, skilled ophthalmologist _would not_ remove the eye when he _knew_ he could restore it to usefulness. The spirit of the teachings of Dr. Sexton's articles is far from being progressive. Nor is this all; many assertions are not based on fact, but on erroneous impressions. Our duty to our profession and the laity is not to destroy but to save; and while ignorance is ever working its mischief in all vocations in life, it is not just to accept the results of such work as a basis on which to found a law.

ARTICLE IV.

DIAGNOSIS AND TREATMENT OF DENTRITIC CYSTIC TUMORS OF THE JAWS.

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

_Diagnosis._--Cystic tumors may be confounded with other affections which occasion swellings about the jaws, as enchrondromata, sarcomata, and myxomata, abscesses, and the collections of fluids in the antrum. Dental alveolar abscess may be distinguished by its acute course, and when in a chronic, condition by the discharge of its contents through the fistula, either upon the gum, or within the oral cavity. The tumor formed by an abscess is never so sharply definite as is the case with cysts; with dropsy of the antral cavity the distention of the facial wall of the jaw is more uniform than it is with cysts.

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.

_Pathology._--Cysts of the jaw may be either simple or compound; whether they be cysts of retention, exudation cysts, or extravasation cysts belonging to the jaws, is a matter not as yet fully established. The exudation cyst is a secretory cyst; in a generic relation, however, it is just the opposite of the retention cyst. Serous sacs form the foundations of the exudation cysts. "The mode of development of cysts of the jaws," says Wedl, "has not yet been determined; it therefore becomes necessary, in order to throw more light on the subject, to pursue further anatomical investigations in that direction."

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.

_Treatment._--The removal of all dead teeth involved. Other teeth whose pulps are living may be loose, and to a casual observer appear to be complicated, but a careful examination will reveal the fact that they should not be disturbed but retained in their places; only one tooth may be the offender, being a dead one which has caused the trouble. After the removal of the cause, let it be either one or more dead teeth or fangs of teeth, cyst walls may be punctured with a sharp instrument, and the contents of the sac released, this being done by carrying the instrument through the alveoli, and not through the bony parietes of the jaw. After the contents of the sac is let out, and the sharp spicula of bone trimmed, with engine burs, tincture of iodine full strength may be forced into the cyst sac, by saturating tufts of cotton-wool and allowing them to remain, again repeating the treatment at intervals of a day. If necrosis of bone be present, it is good practice to alternate the iodine treatment with aromatic sulphuric acid. Cases generally yield to this treatment in from six week to three months. I have seen cases not yielding to treatment for nine months. There are other and shorter methods in the treatment which perhaps some would prefer--the cutting down through the body of the tumor, by making a crucial incision and scraping out the contents of the sac, afterwards allowing nature to do the rest--but I do not believe it is the best or safest way. There is surely a much greater loss of structure, which is never restored as in the former method by granulation, after the secreting cells have been destroyed by medicinal applications of iodine and sulphuric acid treatment.--_Medical and Surgical Reporter._

ARTICLE V.

THOROUGHNESS.

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

[Read before the South Carolina Dental Association.]

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.

Just as the tillers of the soil sow their seeds, watch their crops, and reap their harvests, so must we do our duty, advise our patients as to the best means of preservation, and would that I could say, reap our harvest. There has been so much written upon this subject that I have nothing _new_ to say, but will touch upon several points, and in giving my idea of thoroughness, as there applied, I may draw out some discussion.

The first step towards the preparation of the mouth for dental operations is the removal of calculus and decayed fangs. Let this be done in a manner that will _insure future cleanliness_, where the proper after attention is given on the part of the patient.

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.

Such is the importance of thoroughness in dental operations. This paper does not half express it, but for fear of trespassing too much on your valuable time, I commend these ideas to your criticism.--_Southern Dental Journal._

ARTICLE VI.

WHAT FILLINGS SHOULD WE USE?

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

When I look back at my commencement and reflect that my early practice was founded on what the older men in authority had published and taught, and how I feared to do other than they demanded, I shudder at the many teeth I extracted I now know might have been saved, with even the amalgam of that day. And I tremble at the advice _now_ given by the authorities that _gold_ only should be used as a permanent filling. Young men knew no better, but the older do. God forgive them, I cannot. While I do not belong to the disciples of the new departure, _so far as their theory is concerned_, I stand side by side with any person _who can save teeth by plastic materials_, where gold cannot be used. Better do this than persist with gold indiscriminately, and lose teeth, rather than stoop to conquer with _any article_ that is _not gold_. The public are demoralized on the subject of _gold_. "Are you not going to fill my teeth with gold?" says nearly every new customer; "Dr. ---- would not think of using anything else." A city operator must have more than the usual quota of courage to stand before the societies and state "he has been using _amalgam_ more freely of late." For the first eight years of my practice I would not touch it, because Doctors Elisha Townsend and J. D. White passed their anathemas on everything but gold and tin. I worked myself nearly to death with tin to find it preserves from caries but not from attrition. Since 1862, I have been feeling my way, and while I think I have reared many beautiful and substantial monuments of gold, and have perfected machinery with which to do it, yet I consume more amalgam than ever before.

A gold filling _properly_ impacted, with cavity judiciously prepared, and the walls shaped as to forbid future decay, _will save_, irrespective of the frailty of their bony structure? But as thousands of teeth _cannot be so prepared_, both of strong and of frail organizations, and the circumstances _cannot_ be controlled, we should resort to something that will enable us the more surely to meet the issue.

To enumerate the many cases of peculiar character that forbid the use of gold, would be too great a task. Physical impossibilities lie in the way of every undertaking; and it is for the successful engineer, who is well acquainted with his material, and their relative strength and _adaptability_ for his purposes, to so use each, that his design will be consummated, and which shall not by future wear, prove a failure. There is a fitness in every material that experience has proven to be specially adapted for a given work, and when this general law is recognized and we become first-class engineers, we shall the better see where we can adapt our materials to the work to be done, and we can be the more certain of success, for it is founded on the logic of mechanics and physical law.

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

As well say everything should be made only of iron, or steel, or wood, as that every tooth should be filled with gold; or, as _equally ridiculous_, that the amalgam or some one of the plastic fillings should be the only material used.

It is not _necessary_ to found a _creed or departure_ on a law of _incompatibility_ to tooth substance. We need not look so far into the unknown and unknowable. We poor, short-sighted creatures must have the tangible; not a hypothesis on a _supposed theory_. Any one with half an eye can see just where the incompatibility is; not between gold and dentos, but between dentos and untutored and unskilled brain and hands to _carry out the law of adaptibility_--the correlation of forces involved.

One skilled in the use of the mallet, with the rubber-dam and a substantial starting point, with walls ever so frail, can perfectly impact and complete the work in gold filling, _provided the surroundings are there_. But allow _one little vacuum_ between the tooth substance and the filling, and a _capillary tube_ will be formed to suck up _fermentable material_; and the _acid generated_ will act on the tooth whether it be filled with gold, amalgam, oxyphosphate, or gutta-percha. A thousand capillary tubes making porosity in the gold or the amalgam, will not do it; but if there is one, however small, between dentos and filling, destruction is sure.--_Transactions of the Odontological Society of Pennsylvania._

ARTICLE VII.

SOME METHODS OF SEPARATING TEETH WITH WEDGES.

BY DR. DWIGHT M. CLAPP, OF BOSTON.

[Read at the joint meeting of the Massachusetts and Connecticut Valley Dental Societies, held at Worcester, Mass., June, 1885.]