Part 4

Among the many disagreeable and annoying, not to say painful, things that patients have to suffer at the hands of dentists, nothing, perhaps, is received with greater dread and disgust than the announcement that the teeth must be "wedged" before filling. Some, a small minority among us, I think, always fill without previous separation. In regard to the necessity for it, I will enter no argument here, but only say that personally I am a firm believer in wide spaces between the teeth at their necks, and labor to the best of my ability to obtain this result. It is most likely that many of you are using the same means that I am to get the desired room for filling, but by presenting and discussing the subject, it is possible we may obtain some help in doing what I fear the most of us find, at times, difficult and perplexing. For a long time rubber was about the only thing used for separating. It has some good qualities and many bad ones. It probably causes more pain and annoyance to the patient than any other wedge. Its liability to slide into contact with the gum, causing great pain and soreness, and even suppuration, has caused me to entirely abandon its use, I am willing to admit that it may be used successfully sometimes. The best rubber to use, if it must be used at all, is that of which the most inelastic tubing is made, or the erasers sold by stationers, cut into suitable shape. Wedges of wood are well adapted to cases where the sides of teeth to be wedged are nearly parallel, or where there is less space at the gum than at the points of the teeth. The wedge should be about as wide as the length of the crown, that is, it should extend from the cutting edge to the gum, nearly. It should be so shaped and trimmed as to not irritate the tongue or cheek. One advantage of the wooden wedge is that it is more cleanly than tape, cotton, or silk. This same class of teeth, those with nearly parallel sides, can be separated as successfully, and I think with less pain, with tape. Linen tape of various widths and well waxed is the best. It should be folded so as to be of proper width and thickness, and then drawn into place. A sharp knife is preferable to scissors for cutting off the ends. The tape should be thoroughly waxed, which assists materially in getting it between the teeth, and renders it more cleanly when left in the mouth for several days. In teeth with cavities so situated that cotton can be crowded in with sufficient force, this is one of the best wedges that can be used, as regards both effectiveness and comfort. It is necessary to so place the cotton that the force of expansion will be exerted against adjoining teeth and not expanded within the cavity. By once changing the cotton, space enough can generally be obtained. It is difficult to adjust and keep wedges in place between teeth having more or less space at the gum, and touching only at a small point near the cutting ends. It is in these cases that ligatures of various kinds serve an admirable purpose. Take for instance, the superior central incisors. These usually have but a small point of contact, with considerable space between them at the gum, and it is very difficult to put in a wedge of rubber, wood, or tape, that will not slip up against the gum, or come out altogether. If a ligature is used, the knots can be so tied that the string will clasp the point of contact in such a manner as to hold it quite firmly in place. There are many ways of making the knots; one is to pass the silk once between the teeth, then tie a surgeon's knot; but, before drawing it up, pass one of the ends again between the teeth, and then draw the knot so it will wedge from the gum towards the cutting ends; draw it closely, then finish by tying so that the last knot will be at the labial, or palatal side of the teeth. Another way is to make a series of knots like a chain stitch in crochet work, thus enlarging the silk for a suitable length; draw this between the teeth and tie as before, omitting the first knot that is drawn between the teeth. Another, and a very good way of enlarging the ligature, is, after well waxing it, to roll a little cotton around the silk as you would around a broach for wiping out a root canal, and draw this between the teeth and tie the same as when the silk is knotted. Still another method, easy of application and very effective in almost all cases where there is a cavity in one or both of the teeth, is to secure a pellet of cotton with the ligature. The silk is placed between the teeth in some of the before-mentioned ways; a pellet of cotton is forced into the cavity, projecting against the adjoining tooth, then the silk is tied firmly around the cotton. The swelling of the cotton and silk will make all the space necessary between any of the front teeth with but one application. The bulging of the cotton into the cavity or cavities, caused by tying the silk around it will hold it securely in place. This makes by far the most satisfactory wedge I have ever used, and, so far as I am aware, is original with me. It is sometimes well to open the cavity slightly with an excavator or chisel before wedging, so that the cotton will be more readily retained. For bicuspids and molars more than one application may be needed if much space is required. Quick wedging is sometimes possible, and when it can be done readily is usually desirable. Teeth that move easily may be separated sufficiently for operations by placing a wedge at the point of contact, and another near the gum, applying force gently with the hand, or light blows with a mallet, first on one, and then on the other, until wedged enough. Then remove the wedge that interferes most with the operation, leaving the other in place. Another way that often works well with children and with teeth that move readily, is to insert a large piece of rubber and let it remain from fifteen to twenty minutes, when the rubber will have opened a considerable space. A wooden wedge will keep the teeth from springing together while the work is being done. The appliances designed by Drs. Perry, Bogue and others, for making rapid separations, I have not used, but hear favorable reports in regard to them. Having spoken of rapid and semi-rapid separations, it is left only to speak of a method which works very slowly. It applies, as a rule, to the biscuspids and molars only. In many cases where there are large cavities between these teeth, and often, when it is desirable that they should be filled with what I think is very properly called a "treatment filling," it is well to fill the entire space between the teeth with gutta-percha. In the course of a few months the process of mastication will force the gutta-percha toward the gum, and on removing what has not worn away the teeth will be found well separated, the cervical margins well in view, and the cavities in good condition for a metal filling.--_Archives of Dentistry._

ARTICLE VIII.

COCAINE.

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

The introduction of cocaine as a local anæsthetic, and the more general use of peroxide of hydrogen (H_{2}O_{2}) 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 anæsthetic 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 anæsthetic 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 anæsthetic 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 anæsthesia 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.

With this in view, and at the suggestion of Dr. Marshall, McKesson & Robbins are now manufacturing granules containing one-sixteenth of a grain of the citrate of cocaine, without glycerine or any other saccharine excipient, so that the obtundent may act more promptly than it can in the presence of sugar.--_Address at American Medical Association._

Editorial, Etc.

UNIVERSITY OF MARYLAND, DENTAL DEPARTMENT.--The fourth Annual session of this institution opened with a much larger number of matriculates than ever before in its history, and the number is so rapidly increasing that the present class of seniors and juniors bids fair to be larger than any preceding one.

The reputation of this school has never been sullied by the graduation of students for fees irrespective of professional ability, and the consequence of such a course as has been steadily pursued since its organization, has been to give a professional standing to its diploma which that of no other dental school excels. The present class consists of representatives from all parts of this country, and also Germany, France, South America, Canada, and even Turkey. Many states of this country are largely represented, such as New York, Georgia, Virginia, Pennsylvania, South Carolina and Maryland especially, and also the New England states, while nearly every other state is represented.

Students who have passed a session at other dental schools have entered on a second session at the University of Maryland, Dental Department, to complete their course of study and receive its diploma, and not one of the hundreds of students who have attended a course in this institution, has ever gone elsewhere to graduate. In matriculating the present class, the resolutions adopted by the National Board of State Dental Examiners have been strictly adhered to, and many applicants of this country and Europe have been refused admission who desired to make their attendance obligatory on graduation after ONE session's attendance.

The Infirmary and Laboratory practice is not excelled in size if equalled by that of any other dental school, and the records will show hundreds of gold fillings credited to the individual practice of students for both the regular winter and summer sessions. No other school can offer greater facilities for practical instruction, nor present more complete equipment as to building and appliances than this Dental Department. Dental practitioners are cordially invited to visit the University and inspect the specimen work of its graduating classes deposited in the museum. Large and valuable contributions from all parts of this country and also from Europe are almost daily being received for the Museum, which will compare favorably with that of any other dental school for valuable pathological specimens, which are also utilized for illustrating the lectures of each course.

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CORRESPONDENCE.--The following letter was received from a prominent dental practitioner of Georgia for publication:

AUGUSTA, Sept. 30th, 1885.

EDITOR "AM. JOURNAL OF DENTAL SCIENCE":

DEAR SIR: According to my knowledge of the proceedings of the organizations known as the "National Board of Dental Examiners," and the "National Association of Dental Faculties," it was determined that no dental school would be regarded as reputable that did not after June, 1885, require TWO FULL SESSIONS OF FIVE MONTHS EACH IN SEPARATE YEARS FOR GRADUATION. The only exceptions made being those who after graduation in medicine had passed one year in the study and practice of clinical dentistry, and also those who had attended a previous session at a reputable dental school. I believe that the American Dental Association also adopted the same rule. Am I not correct? I therefore ask how it is that the dental school of Vanderbilt University is permitted to offer graduation at the close of but one session, to a student of this city who has passed one session only, and that very irregularly, at the Georgia Medical College? I also ask how the same school can offer similar inducements to another student from Edgefield, South Carolina, as I understand it has done, and yet be declared reputable? Was it for the purpose of permitting such violations of the rules adopted by the different organizations referred to, that the "National Association of Dental Faculties" allowed the dental school of Vanderbilt University to abstain from becoming a member of that Association for the present year, and accorded to its Dean the privileges of the floor at its late meeting in Chicago? I cannot see why some schools should be compelled to conform to a rule that others may violate with impunity, and I think that the State Boards of Dental Examiners of both my own state and South Carolina should investigate the matter and act accordingly.

Respectfully, &c.,

"JUSTICE."

We can only reply to the above letter by stating that several students who as we had learned from their preceptors, intended to matriculate in the Dental Department of the University of Maryland, on discovering that they would be required to attend two sessions in the institution, had, we are informed, been induced to go to Vanderbilt by the promise of graduation on one session's attendance.

EDITOR OF "AM. JOURNAL OF DENTAL SCIENCE."

Bibliographical.

_A Series of Questions Pertaining to the Curriculum of the Dental Student._--Embracing Dental Histology, Dental Pathology, Dental Surgery, Dental Prosthesis, Dental Metallurgy, Dental Materia Medica and Therapeutics, Anatomy, Physiology and Chemistry. By Ferdinand J. S. Gorgas, A. M., M. D., D. D. S., University of Maryland. Publishers: W. K. Boyle & Son, Cor. Baltimore and St. Paul Streets, Baltimore, Md. 1885. Price, $1.50.

This work comprises leading questions on all the branches belonging to the course of study pursued by the dental student, and its object is to facilitate the study of dental science and its collateral sciences.

Some years ago the author published a small work embracing in an abridged form, questions on Dental Science, and the favor with which it was received by the students of his class, was such as to rapidly exhaust the limited edition, and induce him to prepare, when opportunity offered, a more complete series of questions embracing the entire curriculum of the dental student, and even that of the medical student so far as related to Anatomy, Physiology and Chemistry.

The present work, therefore, is the result of such an intention, and is presented with the hope that it may accomplish the object for which it has been prepared.

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_Practical and Analytical Chemistry._--Being a Complete Course in Chemical Analysis. By Henry Trimble, Ph. G., Professor of Analytical Chemistry in the Philadelphia College of Pharmacy. Illustrated. Publishers: P. Blackiston, Son & Co., Philadelphia. 1885. Price, $1.50.

The object of this excellent work is to place before the student of pharmacy and medicine a compact course of analytical chemistry.

The distinguished author believing that the study of Qualitative Analysis should be preceded by some practical experience such as relates to the preparation of the important gases and a few of the salts, devotes Part First to the consideration of Hydrogen, Chlorine, Hydrochloric Acid, Oxygen, Nitrogen, Ammonia, Nitric Acid, Carbon Dioxide and the preparation of such salts as Potassium Chloride, Potassium and Sodium Tartrate, Ammonium Nitrate and Oxalate, Calcium Phosphate, Magnesium Sulphate, Carbonate and Oxide, Aluminium Hydrate, Ferrous Sulphate, Ferric Sulphate and Hydrate, Copper Sulphate and Lead Acetate. Part Second is devoted to Qualitative Analysis, and Part Third to Quantitative Analysis, together with a description of apparatus, and the processes of filtration, evaporation, crystallization, ignition, etc. The work extends over nearly one hundred pages, and is a valuable text-book for the student.

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_Chemical Problems._--By Dr. Karl Stammer. Translated from the second German edition, with explanations and answers, by W. S. Hoskinson, A. M., of Wittenberg College, Ohio. Publishers: P. Blackiston, Son & Co., Philadelphia. 1885. Price, 75 cents.

The text is in the form of questions to which answers are given at the end of the volume, which comprises one hundred and nine pages. Part First relates to the recognized elements, and Part Second to approximate ratios, temperature, atmospheric pressure and mixed problems, making a compact and useful text-book for the study of chemical problems.

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_Quiz Questions._--Course on Dental Pathological and Therapeutics, Philadelphia Dental College. Prof. J. Foster Flagg, D. D. S. Answered by William C. Foulks, D. D. S. Third edition, Revised and Enlarged. Publishers: The S. S. White Dental Manufacturing Company, Philadelphia, New York, Boston and Chicago.

This excellent series of questions and answers on Dental Pathology and Therapeutics is again offered to the dental profession as a work of reference in daily office practice, and is the only book that contains in a condensed and practical form the facts and principles of these subjects, as enunciated by Professor Flagg. Commencing with General Principles, these questions and answers relate to Deciduous Teeth, Pathological Dentition, Lancing, Permanent Teeth, Dental Caries, Sensitive Dentine, Galvanic Action, Pulp Protectors, Obtunding Applications, Pulp Capping, Pathological Conditions of Pulp, Dental Exostosis, Malformed Teeth, Periodontitis and Alveolar Abscess, the whole constituting a work of great value to all engaged in the practice of dentistry. The work is interleaved with blank pages for notes, etc., and gotten up in a neat and excellent style. We take great pleasure in commending this treatise as a valuable adjunct to the regular text-books of the profession.

Monthly Summary.

PEROXIDE OF HYDROGEN.--_Dr. W. W. Allport, Chicago._--The peroxide of hydrogen (H2 O2), though not a new remedy, has only within the last few years gained much prominence in the treatment of surgical diseases. One of its uses in dental and oral surgery is in blind or deep-seated abscesses, such as arise from roots of diseased teeth. As the tendency of pus is always downward, when these cases occur in the lower jaw it is not infrequent that the abscess, if left to itself, and sometimes even after the tooth is extracted, will point through the external tissues at the lower margin of the jaw, and occasionally downward between the muscles of the neck, and open at various points, even as low down as the clavicle. The usual treatment is to extract the tooth and evacuate the pus through the alveolus, but it often happens that the formation of pus and the continuance of suppuration is not checked, and the abscess points, or is opened through the external tissue of the face or neck, leaving, when healed, a disfiguring scar.

By injecting peroxide of hydrogen into such abscesses before they point through the external tissues, this serious disfigurement can usually be averted, and the suppurative process is materially shortened. It is also a valuable aid for the evacuation of the purulent contents of the antrum of Highmore, in catarrhal and suppurative inflammations, and especially where the sinuses are divided into two or more pockets by bony septi. These cases are often protracted by the inability of the surgeon to perfectly evacuate them. But with this preparation it becomes a simple matter after access has been gained to the cavity by the extraction of a tooth or the perforation of its external wall in the proper place at the juncture of the cheek with the alveolar border. A free opening must always be made for the escape of the contents, in order to avoid pressure from the rapid evolution of gas. Two or three applications of a dram each is usually sufficient to completely empty the sac.

It is used with the most gratifying results in the treatment of pyorrhea alveolaris, and is an invaluable agent in treating pulpless teeth, as by its action all decomposed matter from the pulp chamber and dentinal tubuli is readily ejected, thereby removing the most frequent cause of discoloring of this class of teeth, of inflammation of the peridontal membrane, as well as alveolar abscesses.

The efficacy of peroxide of hydrogen depends on the case with which it is decomposed into oxygen and water. Pus is one of the many substances which causes this decomposition. Hydrogen peroxide acts first chemically and then mechanically. When the decomposition takes place the oxygen is set free and escapes from a liquid to a gaseous form; this expansion of the gas distends the pus cavity, and as it escapes from the orifice, it carries much of the pus with it, and its application should be repeated till all purulent accumulations are evacuated. The liberated oxygen, being in a nascent or active condition, rapidly oxidizes the products of suppuration, and destroys many of the micro organisms of suppuration.[A] Hence it is a disinfectant and anti-septic.

Finally, peroxide of hydrogen, after its decomposition, leaves no material in the system which is foreign to the system, and it is, therefore, one of the most efficient and harmless disinfectants and anti-septics that can be used, in all forms of purulent inflammation.--_Address at American Medical Association._

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