Part 3

DR. BIGELOW:—I don't know whether all the symptoms were absent or not, and that is just the point; there may have been heat, but not knowing positively there was an increase in temperature, an inflammatory condition might exist, and we might work blindly.

DR. SMITH:—I know of a prominent physician who treated a woman for the "Grippe" when her real trouble was fatty degeneration of the liver. He worked as near to the symptoms as he could get, but he diagnosed the case wrong. He is a prominent, eminent physician, and I simply speak of it to show the uncertainty of symptoms in a diagnosis. So in this case, there might be inflammation, but if there was an absence of all the symptoms, I should conclude that there was no inflammation and should treat it accordingly.

DR. BIGELOW:—Suppose there was an absence of all the other symptoms, how are going to get at the heat?

DR. SMITH:—Well, I don't know of any thermometer that has been made to register the amount of heat in a pulp. The only way you can get at it is by the symptoms which the patient gives you. Of course we can suppose lots of things, but we must act on the actual facts presented.

DR. CLAPP:—The gentleman has answered Dr. Bigelow. I would like to have him give his opinion on my question.

DR. SMITH:—Mr. President, it is hardly fair to consider me the encyclopedia of the Society, especially when we have the professor of materia medica of the school here. He ought to be able to answer all these questions.

I don't speak as an authority, but if decalcified dentine is soft and punky, I don't believe in leaving it. I believe you had better take it out and destroy the pulp at once, but if by decalcified dentine you refer to dentine that can be easily removed with an excavator, and yet has a certain amount of hardness about it, I should leave it rather than expose the pulp. I had a case—the patient was a child—where this soft dentine was left in the cavity. It was treated by a dentist whom I knew, and at first I was surprised that he should have left it, but when I found what a subject he had to deal with, I did not blame him; in fact I think I can compliment him for getting out as much as he did. I took occasion to speak to him about it, and he said he could not do much with the patient, so he left this punky condition, treated it with antiseptics and put in an oxyphosphate filling over the surface; but yet it set up an irritation, and it would have been better if the tooth, a six-year molar, had been extracted at the time. As the better way out of it, I had the tooth extracted, and the twelve-year molar came right into place. So if you mean decalcified dentine of that nature, I believe in removing it and destroying the pulp.

DR. CLAPP:—The gentleman has answered my question completely; I did mean just this leatherly condition that we often find in the deep portions of the cavities, and it is just this soaked condition of the dentine that I wanted his opinion concerning the advisability of removing it, but I referred more particularly to the teeth of adults than of children.

DR. SMITH:—Now that I have given the gentleman my views on the subject, I would like to have his.

DR. CLAPP:—I have left this softened dentine in a great many cases, and so far as my experience goes, I have not afterwards had very much trouble. I think that, rather than expose a pulp in a patient of good health, the surrounding conditions being favorable, I should prefer to leave a small layer, disinfecting and drying as much as possible before filling. It appears to me to be a great calamity whenever I expose the pulp in this way or in any other way, and I do the best I can to avoid doing so. It has been my practice, where I thought I should expose the pulp, to leave this softened dentine, but I have seen a few cases where decay has undoubtedly continued underneath the oxyphosphate or oxychloride fillings. I think it is a matter of great importance, and one where the best judgment will sometimes go astray.

DR. EDDY:—I would just like to mention that hydronapthol may be fearlessly used in all cavities without causing any escharotic action.

With regard to the spongy condition that Dr. Clapp speaks of, it must be thoroughly dried out with a hot air syringe. If it cannot be thoroughly dried, it is better to remove it.

DR. WERNER:—In regard to the question asked by Dr. Clapp, I should say that it would depend on the amount of sensibility yet left in the partly decalcified leathery part of the dentine spoken of. If that still has sensibility, I should believe in treating it not so much escharotically as antiseptically. Again I wish to assert my opinion, that after the foramen was closed and the tooth well developed, it would not be a great calamity for a tooth if the pulp were devitalized and the pulp cavity well filled. I am much of the opinion that a tooth in a devitalized condition resists better than a live tooth the attacks of caries. This is perhaps an extraordinary statement to make, and I know is contrary to the teachings of good authority, yet the many pulpless filled teeth I see free from decay, while their living neighbors do decay, leads me to this opinion.

DR. REILLY:—I would like to state a little experience that might cover Dr. Clapp's case partly. Some time ago a young lad came to my chair whose father had great difficulty in getting to go to a dentist's office. There were two enormous labial cavities in the central incisors. I did not attempt to excavate at all. I had been cautioned before that it would be hazardous to try it, as he was a fearful little fellow to get along with, and his teeth were very sensitive. I simply wiped out the cavities as well as I could, getting them dry without causing pain, and filled them with gutta-percha. He came again a few weeks ago, and the dentine was all there, much harder, as I remember it, than it was on the first visit. I removed it the last time and filled them without any trouble. Now, I do not think it is any risk to leave decalcified dentine in the bottom of a cavity, providing it is tightly sealed; but, as Dr. Eddy says, I should depend more on the drying process than on the use of antiseptics.

DR. WERNER:—Dr. Reilly brought up a very important point. Much less excavation than is generally done is necessary for the absolute control of decay, and that all excavation that gives pain is, in one sense, unscientific. It is only necessary, from a mechanical standpoint, to retain metallic fillings, but I think some day we will have a plastic filling that will require very little excavation—simply the wiping out of the cavity and the thorough removal of the actual decayed portion, leaving all that has sensation—treating the cavity antiseptically, and when in an aseptic condition, fill it with this plastic filling. The surgery of to-day is very much modified. Muscles and bone are not cut away as they were forty, or even twenty years ago. To-day ivory is inserted and made useful in the place of bone, and why should not tooth substance that has sensation be preserved? We have to cut it away simply because we have to shape the cavities to retain the metallic fillings; that is, we treat mechanically instead of therapeutically. In the near future I hope we shall know better than to cut away that which should be saved. I have a very hard little patient whose parents wish me to save his teeth but not to give him pain, and the little fellow will not stand any excavation. His teeth are being preserved at the only disadvantage of having to have a great many temporary fillings.

DR. SMITH:—I do not quite understand the logic of Dr. Reilly's conclusions. I may misunderstand him. He tells of a case coming to him where he did not see fit to excavate; he placed in that cavity some gutta-percha; the gutta-percha after being in a while was removed and the cavity excavated. Now, how did he know the depth of decay at the first sitting? and not knowing the depth of the cavity, how did he know that decay had not gone on in that cavity?

DR. REILLY:—I think I was cautious about that statement. I said, to all appearances, it had not decayed. Of course, I could not tell absolutely, only from my experience in excavating I judged it was about the same as when I first saw it, perhaps a little harder. If we were not able to judge something of the depth of decayed dentine, we would be in constant danger of exposing the pulp. If you cannot tell by the feeling of your excavator when you are near the pulp, I would like to know what you are going to do in those cases where you cannot see the bottom of the cavity?

DR. SMITH:—Yes; but you say you did not use your excavator in this case.

DR. REILLY:—I reached my conclusions while wiping out the cavity with the forceps and cotton, and I thought then, and it is my feelings now, that decay had not gone on in that cavity at all. I think it is possible for such a condition of affairs to exist; I think that things stand still in such a condition. I had a case the day before yesterday which was treated some ten years ago, and on removing the filling I found the pulp canals filled with cotton. There was no odor at all—perhaps the cotton was slightly discolored, but the cavity was in apparently the same condition in which it had been left; and it seems to me that if a tooth would remain in that condition with cotton, why wouldn't it be preserved under gutta-percha in just the same condition? I don't know why the gentleman should conclude that it would decay? What leads him to think that it would decay?

DR. SMITH:—I don't know that it is so, but I have read somewhere that in decayed dentine there exists "pesky little bugs," and if a cavity is stopped up and these micrococci, or bacteria, cannot get at the oxygen which comes to a cavity from the outside, they will work in to the dentine and decalcify the tooth substance in the search for that food which they live on. It is not my theory, but I read it somewhere, and in my practice I either kill the bugs or take them out.

DR. REILLY:—That theory may be all right, but it does not work out in my practice. The experience that I had with this young man has been repeated over and over. I do not excavate carious dentine as far as it can be, and I don't think that theory will work out in all cases. If bacteria are there after the cavity has been thoroughly cleansed and tightly stopped, they must find an early death in some way.

DR. NILES:—I am very glad to hear Dr. Reilly speak as he does. It is perfectly consistent with the accepted theory of decay. Decay does not progress where moisture and oxygen are excluded; therefore a cavity thoroughly dried out and hermetically sealed is good treatment and sound in theory. Nature has formed a covering to the nerve, and although nothing but the matrix of that covering may remain, I would not tear it away if an attempt is to be made to save the nerve. I would retain it with its odontoblastic connections with the pulp. I believe it is the only reasonable theoretical and practical course to follow. Let the nerve alone; nature has provided a covering, why should it be torn away? If there is any irritation, it is very easily removed. In my opinion, a pulp is never inflamed to an extent that needs treatment when it is free from soreness by percussion. If there is inflammation at all in the pulp there will be periosteal disturbance to give warning; but if the periodental membrane is not inflamed, it may be concluded that the pulp is free from irritation; provided, of course, it has never been painful or previously inflamed.

DR. REILLY:—I would like to relate my experience with cases of this kind which have been right under my eye and care for some two and one-half years. When I first began to fill my babies' teeth, I made it a point that they were not going to be frightened. The eldest is six years old, and has been under treatment for nearly three years, and during that time she has never experienced any pain in the chair, and she will come to my office any time with confidence,—in fact she seems to like it. Her teeth are very poor, and in the first ten cavities I did not do any excavating whatever. I practically did not remove any decayed dentine. I simply stuck in fillings wherever there was a cavity and depended entirely on dryness, and I have had good results from it, with no dead pulp up to the present time. After the first dressing of cement I endeavor to remove carious dentine.

DR. TAFT:—Did you use a rubber dam?

DR. REILLY:—No, sir. The teeth were too short and it could not be done without causing some pain. My principal object was to avoid pain.

DR. WERNER:—Did you put in any gutta-percha fillings?

DR. REILLY:—Yes, sir. I put in some at first; then cement, and I have used copper amalgam in crown cavities.

DR. GILLETT:—It seems to me that the case which Dr. Reilly has related is merely the ordinary temporizing with children's teeth, the object being to save them pain, and the case would be somewhat different with adult teeth in which there has been a large amount of decay, and when we expect to do permanent work. I do not see how that decayed, diseased matrix can be non-irritating, as Dr. Niles claims.

DR. NILES:—If it was irritating you would have inflammation.

DR. GILLETT:—A pulp will sometimes stand much irritation without showing evidence of inflammation. An inflamed pulp is not always painful. My experience with decalcified dentine under fillings has been gained chiefly from removing fillings which other dentists have inserted over such decalcified dentine, and I have seen many cases where the results were anything but satisfactory.

DR. NILES:—I have had some experience in that line myself during the last thirty years, and I have generally found decalcified dentine under good fillings to be in as good condition as when it was left there. In most cases it was left there, not with any idea of conservative treatment, but because the dentist was too lazy to take it out. I do not believe that decalcified dentine, thoroughly cleansed and dried, and hermetically sealed, can do any harm whatever to a nerve, or create any irritating effect. I would not leave a sloppy piece of dentine in the bottom of a cavity, which could not be well dried; neither would I leave the cavity half-full of decay, because in that case I could not reasonably expect that there would be no irritation.

DR. EDDY:—If my memory serves me right, Dr. Niles once read a paper before the American Academy of Dental Science, in which he stated that in those cases of decalcified dentine in the bottom of the cavity he invariably used arsenious acid, and treated them the same as he would an exposed pulp, and it went on record. Now, to-night, he seems to be advocating an entirely different method.

DR. NILES:—I should like to see that statement. I have written a paper on the subject—you will find it probably in the _Independent Practitioner_—but I don't think you will find the statement there that I always destroy the nerve in cases where there is decalcified dentine at the bottom of the cavity. Of course, where I have inflammation in the pulp and the tooth is sore, I should destroy the pulp.

DR. BRIGGS:—Rules have their exceptions, and when I make the statement that I do not believe in capping pulps, I still claim the privilege of having certain exceptions. It seems to me that in all the cases of actual exposure, the question of capping the pulp is merely one of expediency for the purpose of keeping the tooth along. You do not wish to destroy the pulp at that time, perhaps, because it is a young tooth; or perhaps you dread the trouble and inflammation which is likely to ensue from the use of arsenious acid at that time, or possibly the patient is going away. In those cases I have had no trouble in putting a dressing in, which has kept the tooth quiet for a long time, but I always expect that sooner or later I will have a dead pulp to attend to. In fact, the most of the pulps that I have capped to preserve, are pulps that are not exposed, but are protected by a thin layer of dentine, perhaps decalcified, but which I could easily make aseptic. Many cases of pulp stones are the result of putting a filling too near the pulp, which is irritating and causes a formation. In those cases I remove the irritant and put in a dressing. That dressing is made by mixing the oxide of zinc with an antiseptic which has some anæsthetic property—say some essential oil; then covering that with a thin layer of copper plate, and then putting a hard filling over that. There is always an uncertainty about it, and four, eight or even twelve years is not always time enough to prove the success of capping the pulp. It may be that after twelve years you find a pulp stone formed that will give all the trouble and exhibit all the symptoms of neuralgia. If your tooth is fully formed, it is better to get the pulp out of the way and to fill it properly, and have a good, healthy tooth. It has been said this evening that the office of the pulp is to form the tooth, and when the tooth has been fully formed its usefulness is, to a greater or less extent, over, and the tooth can do good service without it, and this opinion I agree with.

Perhaps right here would be a good place to mention something which I intended to speak of later on, under the head of "Incidents of Office Practice." We have, all of us, more or less trouble from applying arsenious acid, and I have lately found that where the pulp is exposed, I can, by wiping a 20 per cent. solution of cocaine over the surface, inject without pain a twenty per cent. solution of cocaine, and after a few moments remove the pulp entirely, also without pain. My brother and myself have operated several times on such cases lately with satisfaction to ourselves and our patients. I say several cases, because we have disposed of some old cases which had resisted the arsenious acid and had been hanging along waiting for "something to turn up."

DR. GILLETT:—Dr. Briggs' remarks concerning injecting cocaine solution, and removing pulps in this way, brought to my mind that the chief use that I make of cocaine is in connection with arsenious acid, when I am going to destroy a pulp. My method is to moisten the end of an instrument, and pick up with it some of the cocaine crystals, making a pellet the size of two or three pinheads, and seal it in with the arsenious acid. I find it very helpful in controlling the pain in connection with such application.

PRESENTATION OF SPECIMENS.

PRESIDENT COOKE:—Dr. Gillett will show a warm-air apparatus.

DR. GILLETT:—I was prompted by the note on the card, saying that an apparatus for obtunding dentine would be shown, to bring up this apparatus, which some of you have seen before, as Dr. Brackett exhibited it at the last meeting of the American Academy of Dental Science. This is an apparatus for obtunding sensitive dentine, of which there are but a few of its kind in the country, and this particular one was sent to Dr. Brackett by Dr. Bogue, of New York. I have used it some for the last two or three weeks, and find that it is possible to produce very good results without hurting the patient. Those who have used Dr. Waite's obtundent, and have gotten satisfactory results with it, will perhaps appreciate my explanation in this way. I have used that with considerable success, and like it very well, and I find that I can do the same work with this apparatus, with the additional gain that its application is not painful, as a rule. It is simply a means of obtaining dryness in the cavity by the use of a continuous current of warm air.

H. L. UPHAM, D.M.D., _Editor Harvard Odontological Society_.

PHOSPHATE OF ZINC CEMENT AS ANCHORAGE FOR PERMANENT FILLINGS.[2]

BY C. J. PETERS, D.D.S., SYRACUSE, N. Y.

About six years ago I read a paper before the Syracuse Dental Society on the subject, "Oxy. Phosphate," in which my main object was to bring forward the idea of its use as anchorage for amalgam fillings in particular. After the experience I have had with the method, I have nothing to retract, but can reiterate with emphasis every word said then. This, now, is no new untried thing I bring before you. For the last two years it has been talked of more or less throughout the country. I conceived the idea early in 1884 when a lady came to me for treatment in whose mouth were four teeth which two years previously she had been told were beyond saving, but had neglected having them extracted on account of the dread of the operation. I treated three of these teeth and filled the roots, but could think of nothing that would be retained in the crown but cement. I wondered if amalgam would stick to cement as the cement does to tooth structure. I tried it, and was successful, and those three fillings are in to-day and can be produced at any time.