Part 4

The good results attending its use with amalgam, suggested at once numerous uses to which it might be put, as: anchorage for gold, foundation for any other filling at one operation, lining for thin walls when objectionable color of filling material could show through, cementing fillings which had fallen out or loosened intact, last to place temporarily or otherwise. As an anchorage, its greatest is, I believe, under amalgam fillings in cases of badly broken down molar and bicuspid crowns where, on account of excessive decay and nearness of the pulp, reliable undercut cannot be obtained, and if it could be, would so weaken what remained of the crown as to deprive it of strength to carry the filling. It is especially useful in molars where the buccal surface and a half or more of the grinding surface is gone, in bicuspids whose proximate surfaces are gone with a large share of the grinding, so that the opening of the cavity is the full size of the circumference of the tooth and the remaining walls thin. It is astonishing how many of these latter cases can be shaped and contoured with amalgam without a particle of the amalgam being in sight after the work is finished. If in an anterior proximal filling proper contouring make it necessary for some of the amalgam to show, the anchorage may be thoroughly relied on to permit of cutting out a small portion and facing with gold. The shading of the thin walls by the amalgam is absolutely prevented by the cement. I have in my own mouth a molar in which the filling was loosened by mastication five times on account of the cavity being one of the kind where reliable anchorage could not be obtained. The pulp finally became exposed from frequent cutting away of tooth structure, and the sixth filling was anchored by taking advantage of the pulp chamber, or a portion of it. To use cement as anchorage for amalgam, this is the process: Mix the amalgam according to your custom; place on a slab for mixing cement a small quantity of the liquid and powder ready to mix; then, the cavity being prepared, dry it thoroughly and keep it so while mixing the cement. This being done, place a small amount in the cavity, and at once upon it place a piece of amalgam, which should be so manipulated with the instrument suited to the size and shape of cavity as to force the cement under the amalgam all over the floor of the cavity. Care should be taken to not force the cement entirely to the cervical edge in proximal cavities, and any excess of cement used should be worked out at a point easy of access. By this time the cement is hard enough to be easily chipped off whenever it has been forced beyond the inner edge of the enamel. The filling with amalgam is proceeded with and finished in the usual manner. It is essential that the cement should not be smeared over the edges of the cavity, but carefully worked all over the dentine, closing the mouths of the tubuli, allowing the enamel edge free for contact with the amalgam. The edges of such a filling are better, and remain better than those of the ordinary filling, for the reason, I believe, that the cement controls, or at any rate lessens, the spheroidal tendency in the amalgam. In very deep cavities it is well to work into the cement a piece of hardened amalgam before inserting the fresh, as it lessens the amount of cement necessary, and also of the amalgam, and again prevents the tendency to spheroid. Proximal cavities in children's teeth are very easily filled with amalgam by this method, and without causing pain in cutting tooth structure.

We now come to the use of cements as anchorage for gold. With this material it has a smaller field of application, and in my hands does not yield as good results as in the use of amalgam. I believe that Dr. F. D. Nellis, of Syracuse, New York, was the first to conceive the idea and use the cement as an anchorage for gold. It is useful in teeth having very shallow cavities, and in those cases where, while it is desirable to use gold, the edges chip or shale off at every attempt to make the cavity retentive. The method of use is as follows: The rubber dam, of course, is used. The cavity being ready, a small amount of cement is mixed and placed in it. On the cement put a cylinder of gold large enough to cover the floor of the cavity. Work the gold into the cement, at the same time working the latter all over the cavity. Trim cement from edges and proceed with the filling, making a mechanical anchorage of the gold with that anchored by the cement. Foil or pellet may be used in place of cylinder, and it may be cohesive or not, and the filling finished with soft or cohesive gold, but I think the best results are obtained by using soft cylinder over the cement, continuing with the same and finishing with a few strips of annealed foil. A very good way is to proceed to fill the cavity with gold the same as if cement were not to be used for anchorage, holding the gold in place with another instrument, and when sufficient has been inserted to nicely take the form of the cavity, to take out, place a little cement in the cavity, then force the gold back to place, and after waiting a minute or two for the setting, go on and finish the filling. It is not necessary in this work to confine oneself to the use of the phosphate of zinc cement. In restoring color to very dark pulpless teeth, and wherever extra whiteness is desired, the oxychloride may be used with advantage, but must not be relied upon for strength like the oxyphosphate. In shading, I get the best general results from the yellow shade of the latter. Pulpless teeth generally have a bluish tinge, and yellow seems to neutralize it very effectually. In regard to the effect of oxyphosphate in deep cavities in teeth with living pulps, it does not seem necessary for me to say much here, since the subject has long been worn threadbare by the profession. However, it must be borne in mind that here is a difference. The cement in use I have described is sealed away from the fluids of the mouth and does not have the same effect as when being disintegrated by those fluids. It remains a perfectly inert substance so long as moisture is kept from it, and has the same use in the floor of the cavity as the varnish so often recommended for closing the tubuli of the dentine to prevent ingress of moisture from that direction. In such cases it is a very simple matter to touch the bottom of the cavity with liquid gutta percha before using the cement. In cases of exposure where capping is desired, cap according to your custom and then proceed as described. When extirpation is resorted to, I fill root and pulp chamber with gutta percha.

CAPPING EXPOSED PULPS.[3]

BY A. H. FULLER, M.D., D.D.S., ST. LOUIS, MO.

I will, in a brief manner, give something of a history of the practice of capping the exposed pulps of teeth, with a view of rendering the teeth comfortable and useful, and at the same time preserving the vitality of the capped pulp.

In the early days of the profession, up to and including the time of Hunter, Fox and Bell, the exposure of the pulp was almost equivalent to the absolute loss of the tooth; not from the fact that dentists were ignorant of the conditions necessary for its retention, but from the want of instruments and appliances with which to perform operations for its preservation.

We find them attempting in various ways to overcome the difficulties with which they were surrounded. They attempted to shrink the pulp and render it less sensitive, that they might fill over without wounding or pressing upon it. To accomplish this, astringents and opiates were resorted to; again, acids, alkalies, or the actual cautery were used to destroy it. Any of the above operations were rarely possible, and when possible, still more rarely successful. The extraction and replantation of the aching tooth was resorted to, the pulp removed and the root canals filled in cases where the means at hand would admit. Cleansing the tooth by boiling before replanting, was _suggested_ by Hunter.

Following the above methods, the operation of excision had its day, its advocates and its opponents. This consisted in removing the crown and as much of the root and pulp as possible with cutting forceps, adapted to the different teeth.

The following from "Waite" would lead us to infer that there were those in his day, as well as at present, who would mount a hobby and attempt to ride into prominence by so doing. In discussing this operation of excision, he says: "At the present period, nothing is aimed at but novelty; nor do many productions succeed that follow the regular line of going on; and while men of science pursue honorable and just means to bring themselves into notice, their reputation is frequently surpassed by cotemporaries, brought forward by some lucky coincidence."

This digression may possibly be excused, as it was, in a measure, necessary, in order to continue the history of attempts at conservation of the dental pulp. I will copy from a few of the earlier writers on dental subjects, to show methods of practice, together with results as given:

Jourdan, writing in 1784, says: "I saw a right canine tooth, in a young lady of twenty-three, so worn away as to expose the commencement of the pulp cavity. I enlarged the opening, gave vent to a drop or two of dark, offensive blood, and the pains, which had been very acute, ceased. I destroyed the sensibility of this tooth with cotton dipped with ether, and filled it with gold. It is still in the mouth and gives no trouble, though it has a blueish hue."

"Koecker" gives the method pursued by him from about 1817. He first produced a black scar by burning, with a red-hot wire, the exposed pulp: covered this with a capping of lead foil, and filling over this with gold. He had previously used gold, and afterwards tin foil, as a capping, but with indifferent success. He attributed the later successes to the cooling properties of the lead.

He relates case after case, and adds: "Five out of six teeth can be preserved alive when this operation is _skillfully_ performed." He relates one case where he treated and capped seven teeth, and successfully preserved six of the pulps alive for many years. He further says the smallest error will inevitably cause the destruction and loss of the tooth. He devotes ten pages of his "Principles of Dental Surgery" to this subject.

"Fitch," 1835, recommends the treatment of the exposed pulp with Aleppo galls, scraped up, placed on the exposure and covered with wax; a few weeks or months later, caps with sheet lead or piece of gold plate and fills with gold. He relates numerous cases and complete success of this practice.

Harris, in 1840, arched his gold fillings over the exposure and continued the filling with gold, with some success. Had tried Fitch's method with indifferent success, and thought Koecker's must from necessity result in failure.

In 1841, "Lefoulon," in his work, after giving some of the methods and remedies of his predecessors and cotemporaries, says: "As for ourselves, though we be accused of being controlled by one permanent notion, truth compels us to say that the employment of our ethereal alluminous paste has enabled us to preserve the teeth of our patients, even when these organs were attacked with most intense inflammations. Its sedative and extraordinary anti-spasmodic quality does not fail to triumph over the inflammatory erytheism of the dental nervous system and its appendages to such an extent that all pain and all irritation cease at the end of some days, sometimes on the next day. Let the incredulous put us to the proof and test for themselves the truth of our words."

The above quotations will show about the status of the professional opinion as expounded by the authors of the then works on dentistry. Most of these were written by practitioners who claimed special skill, and were in a measure separated from each other and the profession.

With the exception of Hudson, Maynard and, possibly, one or two others, the practice of removing the pulps and filling the canals was not known or attempted. Harris, in 1840, speaks of their operations, but had attempted it only in a few cases, and with indifferent success.

The necessity for, at least, claiming to succeed in operations of this kind—saving pulps—was almost imperative.

In 1850, Dr. J. D. White, in the _News Letter_, says: "The treatment of the exposed pulp has given rise to great difference of sentiment among well educated dentists, but mainly about the means which should be employed for that purpose, agreeing pretty generally that it is bad practice to destroy it entirely. But as well might we expect to procure a healthy function of the reto-mucosum when denuded of the epidermis by substituting one of our own invention, as to procure a healthy function of the pulp when deprived of its natural protection, the bone."

From about this time until within a comparative recent date, in all methods of capping the ultimate design has been to secure a production of secondary dentine at the exposed point of the pulp. The methods and materials made use of are almost numberless, and the successes claimed are also equally as numerous. For applications in the treatment we have recommended to us in our text-books, pure nitric acid, pure carbolic acid, pure creosote, iodoform, dilute chloride of zinc, iodine, bichloride of mercury, and in fact everything from stimulating it with the electric cautery, to feeding it upon lacto-phosphate of lime and powdered dentine. For capping: the different cements, stoppings, gums, minerals, etc.; and the cases run from the capping of the remaining third of the pulp in the root of a lower incisor upon which a pivot tooth was to be placed, an exposure in the distal surface of a third upper molar, and this suppurating, to a simple exposure from excavating a cavity for filling.

Our dental societies in their reports show that some are very successful in their endeavors to save exposed pulps: that others don't kill babies for the sake of having a funeral, and attempt to save everything: while others, whose experiences are just as extensive, whose observations and opinions are just as much to be respected, claim that an exposed pulp that has ached or been inflamed, can never become healthy by any treatment whatsoever.

There has been, without doubt, a gradual change in practice for the past fifteen years, brought about by sad experiences and the better knowledge of the tissues involved; also by the improved educational condition of the profession as a whole. Dr. Black, in the _American System of Dentistry_, on "The Pathology of the Dental Pulp," has given us, as far as I am able to judge, by far the best and most instructive contribution upon this subject. He concludes his sixty pages of valuable observations as follows:

"PATHOLOGY OF THE DENTAL PULP—GENERAL CONSIDERATIONS."

"In the foregoing pages I have frequently alluded to the fact—which is apparent in a very large proportion of my microscopic preparations—that any of the secondary calcific formations within the pulp of the tooth, result in exhaustion and final death of the pulp. This fact is so prominent that it seems to me that it cannot well be overlooked; and yet, in the capping of exposed pulps, it seems to have been the thought of the profession that to be able to obtain a secondary deposit under such circumstances was to insure the permanence of the health of the pulp. This was my own thought some years ago, but further clinical experience, combined with closer microscopical study of the subject has convinced me that this is a mistake. Secondary deposits may, and do, insure temporary quiet, but so far from insuring health are they, that, as a matter of fact, they bring about the very conditions that we most wish to avoid—the degeneration and final destruction of the pulp.

"In a large majority of cases, however, this result is brought about very slowly, and thus has escaped the notice of most observers; for if an exposed pulp is capped and the cavity filled, and the case seems to do well for a year or two, it is regarded as a success, and is lost sight of. When this returns some years later with a dead pulp, it is treated as one of the great mass of such cases that are constantly presenting themselves, and probably no note was made of the fact that it was capped at a certain time, and was one of the many successful cases.

"Very many cases of capping pass on for years without any deposit whatever, and seem to remain in a perfectly healthy condition. This we must regard as the most desirable result that can be obtained. Enough of these cases have been noted to demonstrate the possibility of rendering the conditions so nearly normal that no disturbance of the functions of the organ occurs."

From my own experience and observation, and with all due regard for the experiences and opinion of others, I will say, when there has been an exposure of the pulp, with any considerable pain as a consequence, I would in all cases destroy and remove. In cases where from the location of the cavity, or where the surroundings would not admit of a satisfactory operation otherwise, I would devitalize. With the remedies at our command, the increased facilities for destroying and removing the pulp, cleansing the canals, and the various means for hermetically filling them, thereby rendering the tooth absolutely free from painful impressions, just as serviceable, just as beautiful, and in all respects as enduring. I fail to see how we can justify ourselves, or do justice to the patient by subjecting them to a painful and, possibly, an imperfect operation, with the probabilities that they will again be obliged to seek for relief from the same offending member.

In conclusion, I would add, that accepting the reasoning of Dr. Black as the correct explanation of the conditions presented, I believe there are, comparatively, a small number of cases where we are able to so protect the exposed pulp as to leave it in a normal condition; and while we should endeavor to save the patient time and expense, we should also endeavor to secure them relief from pain and future suffering, and also protect ourselves and the profession from the criticisms following operations that are worse than failures. Since my experience has enabled me to distinguish, to a certain extent, between facts and fables, between the teachings of reasoning intelligence and egotistical statements, my practice has been most satisfactory, my ways have been those of pleasantness, and my paths those of comparative peace.

* * * * *

DRS. J. A. PRICE, Weston, Mo., J. C. Goodrich, Wentzville, Mo., J. H. Kennerly, Lebanon, Ill., P. H. Helmuth, Highland, Ill., Geo. Cameron, Carrollton, Ill., F. A. Green, New Albany, Ind., F. H. Caughell, Morrison, Mo., J. O. Eppright, Odessa, Mo., R. R. Vaughan, Fulton, Mo., visited St. Louis during the past month.

OBITUARY.

At the annual meeting of the Southern Illinois Dental Society, held in Chester, October 21st, 1890, the following resolutions, expressive of the sense of the Society, relative to the death of Dr. Homer Judd, and Dr. M. D. LaCroix were adopted.

WHEREAS, The Southern Illinois Dental Society having learned with profound regret of the death of Dr. Homer Judd since the last annual meeting, the members in convention assembled desire at this time, both individually and collectively, to testify to their high esteem and great love for the life and character of the deceased. Much of the success of the Society is due to his kind helping hand as one of the founders, and the admirable rules and by-laws governing it, were largely the work of his experience.

The members of the Southern Illinois Dental Society will ever hold in reverent regard the memory of Dr. Homer Judd, and extend to his family their respectful sympathy; and the Secretary is hereby requested to advise the family of this action.

C. B. ROHLAND, } T. W. PRICHITT, } _Committee_. L. BETTS, }

WHEREAS, We have learned with deep regret and sorrow of the death of our friend and professional brother, Dr. M. D. LaCroix of Lebanon, Illinois, in the prime of his young manhood and usefulness in the dental profession; it is hereby

_Resolved_, That in the death of this estimable young man, the Southern Illinois Dental Society has lost one of its most earnest and enthusiastic members, the world a useful and honorable citizen, and the social circle a faithful and beloved companion;

_Resolved_, That our heartfelt sympathies are hereby tendered to the family of our deceased brother, in the hour of their sad bereavement;

_Resolved_, That these resolutions be entered upon the records of this Society, that copies be sent to the family of the deceased, and to the dental journals for publication.

J. J. JENNELLE, } C. C. CORBETT, } _Committee_. R. H. CANINE. }

NORTHERN OHIO DENTAL ASSOCIATION.

The thirty-second annual meeting will be held in Oberlin, Ohio, Tuesday, May 12th, 1891, at ten o'clock A.M., and continue its sessions three days.

SUBJECTS FOR DISCUSSION.—"Development of the Teeth." Paper by Dr. W. H. Whitslar, Youngstown. Discussion opened by Dr. A. J. Dowds, Canton.

"The Recurrence of Decay in Teeth." Paper by Dr. J. G. Templeton, Pittsburgh, Pa., and "Hind Sight." Paper by Dr. W. H. Atkinson, New York. Discussion opened by Dr. C. R. Butler, Cleveland, and Dr. E. J. Waye, Sandusky.

"The Sanitary Condition of the Mouth, and How Best to Maintain It." Paper by Dr. J. F. Dougherty, Canton. Discussion opened by Dr. W. T. Jackman, Cleveland and Dr. J. H. Wible, Canton.

Correspondence.

DEPOSIT PLATES.

EDITOR ARCHIVES:—Please allow me a word in regard to the electric deposit plate. Mr. E. E. Clark, the owner and manager, has been absent in the West in its interest most of the year, and I have, in his absence, undertaken to look after the making of the plates. For a considerable time past, the plates have been sadly deficient in gold, sometimes not enough being put on to properly vulcanize over.

I was unable to account for it, knowing that full quantity of gold was supplied. The secret has been discovered, and the thief lined his pockets instead of coating the plates with gold, and is now in jail awaiting trial for larceny.

The plates as now made are all right in every respect, and it is hoped that all its former friends will again come back to its use.

Yours, etc., C. S. STOCKTON.

Newark, Nov. 17th, '90.

Selection.

PEROXIDE OF HYDROGEN AND OZONE. THEIR ANTISEPTIC PROPERTIES.[4]

BY DR. PAUL GIBIER,

_Director of the Pasteur Institute of New York_.

GENTLEMEN:—Since the discovery of the peroxide of hydrogen by Thenard, in 1818, the therapeutical applications of this oxygenated compound seem to have been neglected both by the medical and surgical professions; and it is only in the last twenty years that a few bacteriologists have demonstrated the germicidal potency of this chemical.

Among the most elaborate reports on the use of this compound may be mentioned those of Paul Bert and Regnard, Baldy, Péan and Larrivé.

Dr. Miguel places peroxide of hydrogen at the head of a long list of antiseptics, and close to the silver salts.

Dr. Bouchut has demonstrated the antiseptic action of peroxide of hydrogen, when applied to diphtheritic exudations.

Prof. Nocart, of Alfort, attenuates the virulence of the symptomatic microbe of carbuncle before he destroys it, by using the same antiseptic.

Dr. E. R. Squibb,[5] of Brooklyn, has also reported the satisfactory results which he obtained with peroxide of hydrogen in the treatment of infectious diseases.

Although the above-mentioned scientists have demonstrated by their experiments that peroxide of hydrogen is one of the most powerful destroyers of pathogenic microbes, its use in therapeutics has not been as extensive as it deserves to be.