Part 2

Implanted teeth can never be successful for these reasons: First, teeth are developed from a different structure than bone. If dried pericementum took on new life and performed its functions as before, it would be a success. If we could implant immediately after a tooth is extracted, success is more probable. It would be equal to skin or bone graft. If the cementum becomes reorganized, it can grow only at the expense of the dentine. If resorbtion takes place in vital tissues it certainly is so in dead tissues. So it would be but a few years until the whole root would be replaced by a new material, probably bone, since it is produced by bone-producing tissue.

The experiments of Drs. Hopkins and Penrose were reviewed in this connection and the following deductions drawn. First, sterilized bone in favorable conditions undergoes organization. When acted upon by periosteum is absorbed, and when in a narrow cavity, and not too large in bulk, organization and absorbtion both take place. Second, these processes go on most actively between five and eight weeks.

According to Dr. Wm. Savory, tight ivory pegs were more quickly absorbed than loose ones. He draws the following conclusions:

First—the operation of implantation has fallen into disrepute, either from failure or loss of confidence.

Second—when the root is covered with dried periosteum the membrane is absorbed before union takes place, and when union does occur it is probably that of ankylosis between vascular cementum and the surrounding bone. In view of which, teeth with much thickness of cementum are to be preferred, and should be denuded of the membrane before the operation.

Third—organization takes place better when the tooth is moderately tightly fitted in solid bone, and for this reason the cicatrix of bone formed after the extraction of a tooth is the most favorable place for implanting teeth.

Fourth—that the resorbtion and rebuilding of the tissues of the body necessitate the absorbtion of the dentine of the roots of implanted teeth, and thereby their loss. But that as a temporary replacement of lost teeth, the operation of implantation is justifiable to those who comprehend it to be such.

_Discussion_—DR. BUTLER:—I have not performed this operation, as I was doubtful of its final success. The question now is whether it is justified by its duration of three to five years, and the patient's liability to disease, etc.

DR. SAGE:—I wish to know what was considered large or small ivory peg.

DR. FLETCHER:—The experiments of the men go to show that bone will become organized when ivory will not. The only part of a tooth that may be organized is the cementum. The line of reorganization or absorbtion is a softened tissue, so when the process reaches the crown and is about complete, the crown drops off. If a very fresh tooth is implanted, the membrane may be accepted.

The following officers were elected for the ensuing year:

President, E. G. Betty, Cincinnati, O.; First Vice-President, J. R. Callahan, Cincinnati, O.; Second Vice-President, G. H. Wilson, Painsville, O.; Secretary, Otto Arnold, Columbus, O.; Assistant Secretary, Henry Barnes, Cleveland, O.; Treasurer, C. Q. Keeley, Hamilton, O.

H. T. Smith re-elected member Board of Examiners.

DISCUSSION OF DR. BLAISDELL'S PAPER.[1]

DR. SMITH:—Mr. President, the essayist this evening has presented a paper which is a resume of the methods of practice of many practitioners throughout the country, but although they have given their methods of capping exposed pulps, I do not see that they give their results, and he cites but one case and pronounces that a failure.

The most important thing to avoid in the treatment of exposed pulps, as held by the authorities, is pressure, and I endorse that opinion most thoroughly. I believe a large proportion of failures in the capping of exposed pulps is due to the lack of skill on the part of the manipulator. We speak of accidental exposures in excavating; I believe that that exposure is almost inexcusable. I don't believe any graduate of the dental school of Harvard College has any right to punch an excavator into a pulp unless he intends to do it when he starts. It may be a little personal to say that my experience in accidental exposures is very small, but such is the fact. I have had cases where perhaps the exposure was excusable. In cases of a malformation of the pulp or tooth, but under ordinary circumstances, in cases that we usually meet, such exposure of the pulp I believe to be wholly inexcusable. The practitioner of to-day in opening into a cavity knows, or should know, that he is liable to come into contact with the pulp, and he therefore ought to excavate with the greatest possible care, and with the careful instructions given in the schools to-day there is no excuse for his exposing that pulp.

The method cited of using gutta-percha, I do not believe in, and the placing of gutta-percha directly on the pulp, I condemn, not from my own experience, but from my observations of cases treated by other practitioners, the patients have come into my hands afterwards. Trouble has resulted in every case that I have seen, but they may have been cases which should not have been capped, and perhaps it is hardly just to deny that some were successes.

The pulp, while it is an organ of great sensitiveness and extreme delicacy of structure, I believe to be most persistent in its vitality. The capillary circulation of the pulp, as you all know, arising from the vertical vessels forming loops, prevents a combination near the surface, and the absence of lymphatics in the pulp prevents medicaments from doing much good, as would be the case upon serous membrane. Where the trouble is diffused through the entire membrane, in many cases the application of arsenious acid will only destroy a part of the pulp, and has to be re-applied again and again.

If a tooth has been aching, and there is congestion about the pulp, or an exuding of pus, I invariably destroy it. I don't believe a pulp can be brought to a healthy condition to stand capping after it has reached that stage. But there are many cases where patients have neglected their teeth and had a little pain, or after taking sweets, they have a severe toothache that soon passes off, so that at the time of examination there is no soreness nor inflammation; or if we have a strong, robust, healthy patient, and in excavating carefully around the pulp we remove a layer of decalcified dentine and find just a point of the pulp exposed; in such cases I do not hesitate to cap, and my mixture is as follows:

I take oxide of zinc, and mixing it with oil of clove or creasote, flow it carefully over the pulp, then fill out the cavity with either oxychloride, or oxyphosphate of zinc.

It is true, Mr. President, that I have kept a record of the pulp exposures and my method of treating them, and the condition that they were in, but in looking over my records I found that when I wanted to get at the results, it was not a very easy matter, and it has taught me in the future to keep a little book and enter the cases of pulp exposure and treatment of dead teeth, so I can turn to a person's name and find the result at once, but, you come to look through your record-book for a case which was treated twelve or fifteen years ago and follow out the record of the patient to find whether the pulp has since died, you will have an endless job. I have one case where I had five exposures of pulp in one mouth, of a right superior molar, mesial cavity, and of the bicuspids on the same side, and the bicuspids of the left superior. They were capped eight years ago, and last year—I have not seen the patient this season—they were all tested with warm instruments or ice, and every one of them was alive. How soon they will die, of course, I cannot tell, but they were apparently in good condition when I last saw them. Another case of which I have a record, was an exposure on the mesial surface of an upper right molar, which was exposed in such a manner that with a magnifying-glass you could look into the cavity and see distinctly the pulsations in the pulp. At that time I was with Dr. Shepard, and I called him to see the case. It was extremely interesting, more so perhaps to us than to the patient. As the patient was strong and healthy, the pulp was capped in the manner I have just described, and that pulp is alive to-day.

That is all the data that I can give you, Mr. President, excepting that I know, in my own practice that a majority of the pulps that I have treated and capped in that way are still alive, and I am a believer in capping certain exposed pulps. This is an exception: A patient came to my office something over two years ago. On a lower right second bicuspid was an exposure near the margin of the gum, which was capped, and that patient had not been in to see me since that day until yesterday, and would not have come then had there not been a pain in that locality. In examination I found that decay had started below the gutta-percha, upon the cervical wall, which I had placed there for protection, after the first capping, and had again exposed the pulp. The patient had suffered for two or three weeks with neuralgia before coming in. I thought it was useless to try to preserve any exposed pulps for that patient, so a new opening was made and the pulp devitalized.

I do not hesitate, however, in destroying a pulp to-day so much as I did some years ago, when we were taught to believe that the devitalizing of an exposed pulp was almost a certain forerunner to the total destruction of the tooth. There has been a radical change in that theory, Dr. Atkinson, of New York, has written a paper in which he speaks of the amputation of a pulp. If I remember rightly, he claims that you may amputate a pulp up to the bifurcation of the roots, that it is good surgery and it will live. I do not agree with him; and yet when I have been trying to destroy pulps up in the canals, I have sometimes thought they would live, no matter what you did to them. I do not hesitate to destroy pulps to-day, because we have such an excellent knowledge of the structure of the tooth, and we now know that simply because the pulp is lost we must not suppose the tooth to be entirely dead, but there is still life from the membranes of the root. So I am now inclined to cap only those pulps which present the best conditions for capping. If a pulp presents any symptoms of congestion or inflammation, I believe you had better dispatch it at once, in order to give the best results to the patient, but I am not a believer in the wholesale destroying of pulps. I believe, gentlemen, in conservative treatment.

DR. EDDY:—Mr. President and Gentlemen: I am a firm believer in treating exposed pulps, with arsenious acid. I have tried almost everything else during the last fifteen years and have found nothing that will especially preserve the life of a pulp. I have had cases apparently benefited by some kinds of treatment; but I think it has been due fully as much to the temperament of the patient and general condition of health. I believe that oxyphosphate will destroy a pulp just as surely as arsenic, only not as soon. I believe this because I used it nearly eight years, and have seen some of the results. I have also had cases where I have used oxyphosphate of zinc underneath amalgam fillings, as a cement, a non-conductor, but not in direct contact with the pulp, and the pulps have died, and I laid it to the oxyphosphate of zinc. Of course, I have had my experience with fresh exposure, which I suppose was due to my being a graduate, and in those cases I think I have had good results by doing nothing more than touching the exposed pulp with carbolic acid and packing gold directly over that, and it seemed to work very well. I have tried almost everything that has come before us; and in those cases of exposure resulting from decay, or even in cases where there is no exposure, but a zone of softened tissue remains, which is liable to break down, I think it will give the patient the most satisfaction to devitalize the pulp. It may be a little more painful at first, but it is better than having the neuralgia every now and then for from one to five years and then destroy the pulp.

Another thing, Mr. President, when a pulp is destroyed by an oxyphosphate filling it makes one of the dirtiest heaps of debris that I have met. It goes all to pieces and makes a very bad mess. I have used oxychloride for capping and had better results than with the oxyphosphate.

DR. BLAISDELL:—I would like to ask if Dr. Eddy has ever used oxysulphate?

DR. EDDY:—I have not.

DR. GILLETT:—I would like to hear more about this idea of oxyphosphate destroying the pulp. As I understand the gentleman, he makes the statement that he has ascribed the death of certain pulps to oxyphosphate used either as a lining, or as a filling in cases where there has been no exposure. Am I right?

DR. EDDY:—Yes, sir. I had one to-day, Mr. President, that I can attribute to nothing but oxyphosphate. There was no exposure.

DR. NILES:—Mr. President, I used to cap pulps, but I seldom perform that operation now. When I do, I feel that death will occur sooner or later. I never cap with oxyphosphate unless I wish death to take place. It has been said by one of the speakers to-night that the nerve has no means of absorbing dead matter, as the pulp has no absorbents. Even if it had, I should not want it to come in contact with the oxyphosphate. Phosphoric acid is an escharotic, and I don't know why a creamy mixture of it and the oxide should be flown over an exposed pulp, unless to destroy it. If a pulp stands this treatment and lives, it is tough. An acid that will etch glass, or dissolve silver, will destroy soft tissue. It seems to me out of reason to use such things on exposed pulps. Phosphates or chlorides mixed to the consistency of cream make an unstable, strongly acid compound, that when hard very soon dissolves in water, or to a large extent will become deteriorated in water or moisture. In my opinion, the best treatment to save a pulp, provided the patient is strong and robust enough to help out any treatment, is to relieve it from all irritation, disinfect it, and let nature take care of it. Any non-irritating mechanical means you can use to that end will be more beneficial than stimulating, bleeding, etc. I would not use strong carbolic acid or creosote to disinfect an exposed pulp, for they also destroy its surface, and the dead matter remaining decomposes and irritates the adjoining tissue. Sooner or later that pulp dies. The most of the patients who come to us with exposed pulps have a debilitated state of the system. It is not the best vitalized class of people, but those who are sickly and delicate, and who have not much reserve force for the body, to say nothing about the teeth. The question of conservative treatment, in a large majority of cases, with the hope of any lasting results, I shrink from. If I can painlessly treat my patient and take him past the trouble by destroying the pulp and filling the cavity and canal, I feel that I have done the best that can be done for him.

DR. TAFT:—In my own practice I think I have been reasonably fortunate in saving what exposed pulps I have had to deal with. I suppose I have my proportionate share of them, and my practice has been almost invariably to cap them. I think I am safe in saying that I have not used arsenious acid half a dozen times for the purpose of destroying pulps in the four years that I have been out of the school—I do not think I have used it _four_ times. In those cases where I have used it, the pulps have come to me in a highly inflamed condition, have been aching a long time, and trying to save them by capping has seemed at once to be out of the question, and in those cases—and in those cases only—have I devitalized them at once. I do not believe in flowing oxyphosphate directly over the pulp; neither do I believe it a good plan to put carbolic acid over it. My method is either to mix oxide of zinc with oil of cloves and apply it carefully, or to apply the oil of cloves directly to the exposed portion, then dust the oxide of zinc on that; afterwards flowing oxyphosphate in a creamy condition, and waiting until it hardened, then fill the rest of the cavity with oxyphosphate or amalgam.

I keep a record of all the pulps that come to me exposed, or that I expose myself, and some I treat differently from others, but the majority of them, when seen subsequently, are alive. Occasionally I find one that comes back after a time, showing signs that the tooth is dead, and of course the tooth is then opened and treated; but the proportion of them is so very small that I believe in a conservative treatment of them, and think the first thing to be done is to get rid of whatever congestion there may be, if any, and I do not see why a pulp should not then live as well under a careful and skillful capping as it should against the hard, bony wall of the pulp cavity. I have had such good success in the treatment of them that I do not believe in destroying them at once.

DR. GILLETT:—Will Dr. Taft please to outline his treatment of congested pulp, by which he brings it back to normal condition?

DR. TAFT:—I must say that I do not have a great many cases of congested pulp, but where I do have one which has been exposed for some length of time, and has given pain, I first apply local treatment, using something of the nature of oil of cloves, then fill the cavity with cotton and let it go for a few days. I had a case about three weeks ago of a tooth that I had filled, a year ago, with gutta-percha. At the time the tooth was filled I was unable to decide whether there was an exposure or not. The tooth had been previously filled by a well-known Boston dentist with gutta-percha, and was very sensitive to excavating. The cavity extended far up under the gum, and I refilled it with gutta-percha and it kept quiet for about a year. Three weeks ago the lady came to me, complaining of great pain. I took the gutta-percha out, and upon re-excavating I exposed the pulp and found it alive. It had been troubling her then for about a week. I thought at first I would try to save it, and began treatment by putting a pledget of cotton, dipped in oil of cloves, into the cavity, sealing it up temporarily with gutta-percha, and applying the little capsicum plasters to the gum, hoping to reduce the inflammation in that way, but after working over it a week I destroyed it. I think congestion of the pulp can be reduced by internal treatment much better than by any local treatment, and if we were physicians and had the knowledge of materia medica that we should have under those conditions, I think we would find it possible to easily and quickly get rid of the inflammation and bring the pulp around to a healthy condition, so that it could then be successfully capped, provided there had been no suppuration. When it has reached that stage, the only thing to be done, in my opinion, is to apply arsenious acid and destroy it.

DR. WERNER:—I look upon the treatment of a pulp principally from the standpoint of whether such pulp is absolutely necessary for the welfare of the tooth. The pulp is a formative organ. Its function decreases as the tooth develops. In young persons it is largest; grows smaller and smaller, and in old age it is nearly ossified or obliterated; that is, its retrogressive stage begins materially after the crown of the tooth erupts through the gum. I have seen three different times what Dr. Smith spoke of—the actual pulsation of the pulp—which in a large exposure, in a favorable light, is easily seen. All of those three pulps were capped and they seemingly are alive to-day, but I think the teeth would be quite as serviceable had the pulp been destroyed. From a surgical standpoint the amputation of part of the pulp may at times be successful, for we know how resistive they often are to any kind of arsenious acid treatment, yet I should never do it unless it were in a partially developed tooth, where the life of the pulp is essential. What the surgeon does after trepanning the skull, we should do in capping or bridging over the pulp cavity. He does not flow escharotics like oxychloride or oxyphosphate of zinc over the brain. He mechanically covers and takes good care not to press on the contents of the cavity. The tooth pulp must be treated in the same way; a simple mechanical covering over it being all that is necessary. Whether you put a metallic cap, or whether you put court plaster, or one of gutta-percha (though I should hesitate about using the latter), makes little difference, only be sure that you do not press upon the pulp. With the knowledge we have to-day in treating devitalized teeth, there seems little reason for a young man to risk trying to save bad cases of exposed pulps. It is in extreme practice successful only for the time being—sooner or later ending in failure. To me many so-called successful records are only apparent successes, the operations only hastening the pulps to degeneration. The flowing over of all escharotics, I think, is highly unscientific.

DR. CLAPP:—The last speaker has made the statement that after the tooth is formed it no longer requires the presence of a pulp. I would like to ask him when he considers a tooth formed?

DR. WERNER:—In many cases the pulps of teeth are very large at twenty-five years. A tooth, however, is usually formed and the apical foramen closed up at from three to five, or, at the latest, ten years after the eruption.

DR. CLAPP:—I had occasion yesterday to cut off two central incisors for a lady eighteen years of age. The pulp chamber was entirely obliterated, entirely filled. I imagine that the pulps near the apex of the root are still alive, and it seems to me that the presence of the pulp is a great advantage to the teeth as long as they are in a healthy condition, and I must say that I hesitate to destroy pulps. As Dr. Taft says he has not destroyed the pulps in half a dozen teeth in four years, I do not believe that my proportion is greater than that in eighteen years.

I would like to inquire of the Society its opinion of the advisability of removing softened dentine over the pulps that would be undoubtedly exposed by the removal of such softened dentine.

DR. BIGELOW:—I do not rise to relate any experiences in capping pulps, but there is one question that has come up in my mind many times that I would like to have answered, if possible, by some of these gentlemen that believe in capping, and practice it regularly. We were taught in the school that in an inflammatory condition we might expect to find heat, pain, redness, swelling—we might expect to find one or all of these symptoms in an inflammatory condition of the tissue. It is said of the bones, that an inflammatory condition might exist and yet have neither swelling, redness, nor pain, but there might be heat. Now the question that comes up in my mind is, how are we to know, really, when the pulp is in an inflamed condition, and what treatment to give it before capping? Very often patients come to us with teeth that have been aching, and there is perhaps a swelling of the pulp and a certain redness; I say swelling—the throbbing generally indicates a swollen condition, in which cases the pulps are evidently inflamed; but what I would like to know is, how are we going to tell whether these pulps are in an inflamed condition or not? I would like to know the proper treatment for an inflamed pulp. In cases where I have attempted to subdue the inflammation, I have not had great success.

DR. SMITH:—In the absence of all symptoms, I should conclude that there was no inflammation.