Part 1

Transcriber's Note.

Italic text is denoted by _underscores_.

SUCCESSOR TO _Missouri Dental Journal, also Consolidated with New England Journal of Dentistry_.

VOL. VII., NO. 4.] APRIL, 1890. [NEW SERIES.

Societies.

BLEACHING TEETH.

BY DR. K. M. FULLERTON, CEDAR FALLS, IOWA.

The bleaching of teeth has, from the first introduction of a positive method, been met with remarkable indifference and, at times, positive prejudice. Why this should be will remain a problem. The teeth that require bleaching belong mostly to a class condemned for all purposes except that of mastication. The process is generally only applicable to the six anterior teeth, while possibly an occasional bicuspid may be treated with advantage. When these anterior teeth, especially the incisors, are discolored, they are such a positive disfigurement that the operator has only the choice of evils—to bleach or to excise them, and insert an artificial crown. It would seem no difficult matter to come to a decision, or at least to determine to give the natural tooth a chance for future usefulness.

The fear of re-discoloration, or annoying labor, should not be taken into consideration. All operators are liable to meet with sudden discoloration in the regulating of teeth by the strangulation of the pulp at the apical foramen. When this occurs, it is one of the most humiliating of accidents, as it is one of the most annoying to patients. Discoloration is caused by decomposition, through a slow disintegration of the organic material and the deposit of carbonaceous matter. It therefore follows that the products producing color are not _necessarily_ taken into the tubes by imbibition, though doubtless, to a limited extent, this is the case, but are produced by local degeneration through putrefactive processes. This change, though very slow in producing results, eventually gives to the tooth the bluish tinge, or to a tooth long affected by decomposed matter, the dirty, bluish-yellow. It is unnecessary to enter minutely into the more remote causes of discoloration, but we may summarize them as follows:

1st. When death of a tooth is caused by a blow, attacks of caries, too rapid pressure in regulating teeth, etc., the death and devitalization are followed by imbibition of coloring matter through the largest diameter of the tubules and local discoloration of the tube contents in the minuter anastomosing conduits. These changes may occur in teeth affected by caries, or without any external evidence of disease.

2d. The more aggravated cases, when this color has changed to a bluish-yellow, involving the entire structure of the dentine.

3d. Of the latter class, there may be a further subdivision, in which these are complicated with periosteal lesions which more or less interfere with efforts at restoration to original color.

The necessity of making some effort to restore the color of teeth changed by devitalization was apparent to dentists very early in the present century. The constant destruction of pulps with the imperfect methods of practice then prevailing, necessarily increased this unpleasant complication to such a degree that treatment of the anterior teeth became, so far as appearances were concerned, of no value whatever. Under the defective modes of treating pulp canals then prevailing, discoloration was sure to follow the filling of teeth. Any attempt to change color is necessarily dependent for success upon preliminary measures. Without thoroughness _here_, all subsequent efforts will fail. The early attempts at bleaching, before the settled practice of filling root canals was established, was not a success, and it must ever remain a failure unless the minuter structure of dentine be carefully considered.

It has been demonstrated by artificial injection, and still better by sudden congestions of the pulp, that coloring matter may be carried nearly to the final distribution of the minute ramifications of the tubuli. This is an important point, for, without this vascularity, bleaching would be impossible. With it, the possibility exists of extending the whitening process to the peripheral border of the dentine; or, in other words, to its union with the enamel on the crown, or the cementum on the roots.

The diameter of the tubuli is so minute, always decreasing in size until lost in final distribution, that any agent used must necessarily require considerable time before it can penetrate to the minute tubes, therefore you must not expect to bleach rapidly and meet with good success. The change, if any change be made at all, is simply on the walls of the canal, and cannot penetrate to any depth of tissue. If the discoloration is superficial, this mode will be effected, but not otherwise.

Color can be changed by several of the acids: notably, oxalic and nitric. The former destroys the color, and the latter changes dark-blue to a yellowish tinge; but as both of these are very destructive, they should never be used except in connection with an ant-acid. The first named will be found to give better results when used in connection with chlorinated lime.

_Chlorine_, free, or in some of its combinations, has been and is to-day the main reliance for bleaching, and that it is the most effectual has been demonstrated.

Failures have _usually_ been the result of defective manipulation. It has great penetrating power, is a thorough bleacher, is readily applied, and if handled with care, will prove harmless.

The possibilities of chlorine were early understood in connection with the bleaching of teeth, but the result was not satisfactory for the reason named, and also from the fact that no practical mode had been devised for its use. To present free chlorine to a tooth was an impossibility, owing to its irritating character and necessarily superficial action; and no plan had been originated to free it from its compounds, hence, all teeth suitable for bleaching were condemned to remain a perpetual disfigurement. The first attempt to present chlorine free to a tooth was made by Dr. James Truman, in 1862.

Chlorine is liberated from chlorinated lime by all the acids, but more rapidly by some than by others.

It was found that, as rapid action was not desirable, those acids that affected this were not satisfactory. Tartaric acid was one of these. The conclusion arrived at was that a 50 per cent. acetic acid was the best, although later investigation seems to indicate to the contrary. The difficulty attending the use of chlorinated lime is due to the fact that a good article is rarely to be found.

Good chlorinated lime is in the form of a dry powder; when moist, it is worthless. It should have a strong odor of chlorine. A rough test can be made by adding to a solution of indigo, in a test tube, a small quantity of chlorinated lime; to this, add strong acid, and note the rapidity of change in color. If this is very slow, or not accomplished at all, the chlorinated lime is unfit for use, and should be discarded.

INSTRUMENTS.—These, though very simple, require special notice, for neglect in this particular will involve total failure. _No iron or steel instruments should be used in any connection with the agent employed in bleaching._ This must be impressed on the mind of every operator. The reason for this is, that the salts of iron formed discolor the teeth very rapidly. It would be preferable not to use any steel instruments at any stage of the operation, but this is difficult to avoid in the excavation of the cavity. Instruments can be made of hard wood that will serve the purpose, but ivory, platinum or gold can be used in place of this—either of the latter materials making efficient instruments.

Extreme care must be used not to produce any unnecessary irritation. The removal of all remains of decomposed pulp from the canal is of vital importance, but this must not be done in a rough, rapid, careless manner. It is of great importance that no inflammation of the periosteum should supervene, as that not only complicates the operation, but renders it more doubtful of success. The removal of the pulp should be followed by the usual treatment given to a tooth, and no attempt should be made to change the color of the tooth until all evidences of putrefaction have been removed, which will be manifested in the absence of the odor of decomposition.

If this preliminary process has been satisfactorily conducted, the next step will be that of filling the canal at its upper third. Gold is claimed to be the best material for this. The question may be asked, why fill the upper third? Because it is absolutely necessary for success that the root should be bleached as well as the crown. It must be remembered that the pulp chamber requires the same careful treatment as that given to the canal. It must be thoroughly cleansed of all debris to its fullest extent, and that, in the incisors and cuspid teeth, is almost to the enamel line of the cutting edge. Having proceeded thus far, the case is now prepared for the further process of bleaching.

The next point to be considered is the insertion of the material. Before this is attempted the canals and crown should be well washed with a solution of ether, borax, sodium bicarbonate, or ammonia, to remove fatty matter. It should then be well washed with distilled aqua. The tooth is then dried, the rubber dam having been applied at the beginning of the operation. There are several methods of bringing the acid used in connection with the lime. This apparently simple matter is really quite difficult. One process is, to saturate the entire canal and pulp chamber with the acid before inserting the chlorinated lime. Another is, to dip the instrument into the weak acid solution and then into the lime, and pack rapidly into the cavity; and still another is, to make a paste by the use of distilled aqua and pack this in the tooth, and then apply a stronger acid by means of cotton wrapped around the point used. There are difficulties attending all these modes. The point desired must be kept constantly in view—that of having acid sufficient and of proper strength to break up the compound and set free the chlorine used, and to preserve as much as possible of the latter for bleaching. Before commencing the packing, everything should be ready, so the cavity can be sealed at once.

Convenience of adaptation must govern the choice of the material used for closing the cavity. Gutta-percha, oxyphosphate or oxychloride of zinc may be used with good results, but the zinc preparations are harder to remove than the gutta-percha. After sealing the cavity, the tooth must be left for a day or two. On the return of the patient, remove all of the application, avoiding the use of steel instruments. Syringe out the canal with distilled aqua. If the bleaching has not gone far enough, a second application must be made, and this be repeated until a satisfactory result is obtained. The importance of using distilled water must be insisted upon. The reason for this must be apparent, for in many waters the minerals held in solution, especially those impregnated with iron, will defeat the desired object.

The immediate bleaching effect will be observed on the lower third of the tooth where the dentine is the thinnest. In the majority of cases this will be effected by one application. The greatest trouble will be found at the gingival border. Here the dentine is very thick, and it will be slow work, and in some cases end in failure, to restore normal color. The great objection made to this operation is, that the tooth will re-discolor, but if the subsequent operations are properly performed, this danger will be reduced to a minimum. The fact that dentine is permeated by pulp prolongations throughout the tissue, increases the difficulty of bleaching, and also increases the liability of a return of discoloration; but if the oxidation of the soft contents of the tubes has been properly effected, and then an agent used to fill the canal, and also act directly upon this microscopic tissue, there is but little reason to fear a return of discoloration. The operation, simple as it is, requires close attention to details and a clear comprehension of possible results.

The tooth having been restored to a good color, the next consideration is the proper filling to place in it. In this connection the before mentioned fact still remains an important factor, that the tubuli are still filled with decomposable matter. To allow this to remain without attention to future contingencies, must result in eventual failure. To effect any good results the antiseptic must not only operate in the main canal, but penetrate deeply into the minuter conduits. This quality is possessed in a remarkable degree by chloride of zinc, and maintains the same effect when combined with the oxide of zinc, forming the oxychloride of zinc. The canal and pulp chamber should be thoroughly filled with this paste, or, it is better to line the whole cavity with it, and then finish with the oxyphosphate, using gutta-percha at the cervical margin.

Chlorine acts as a bleaching agent by reason of its strong affinity for hydrogen. Vegetable and animal colors when brought in contact with chlorine in the presence of water, is seized upon by the chlorine, and the oxygen set free, oxidizes the color and destroys it. Chlorine in this case acting indirectly as an oxidizing agent.

If you wish to try to bleach more rapidly, a solution of oxalic acid is used to liberate the chlorine. Oxalic acid is more rapid than either tartaric or acetic.

Sulphurous acid is said to be a good bleaching agent, and acts by an entirely different method from chlorine. It is therefore of great interest from a chemical point of view.

As before mentioned, chlorine acts as a bleaching agent by reason of its strong affinity for hydrogen. Sulphurous acid, on the contrary, is a reducing agent by reason of its affinity for oxygen, in combining with which it becomes _sulphuric_ acid.

On the chemical character, therefore, of the coloring matter depends the choice of the agent to be used.

Chlorine should be used when the color is an oxidizable compound, or rich in hydrogen; while sulphurous acid should be used more particularly in substances highly oxidized and capable of being reduced.

There are a great many different agents used for the bleaching of the teeth, but I will not consume any more of your valuable time, as I find that my paper is already quite lengthy.

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DR. W. N. MORRISON is very proud of his son, who carried off the gold medal at the Missouri Dental College.

INCIDENTS AND ACCIDENTS OF OFFICE PRACTICE.[1]

BY H. H. KEITH, D.D.S., ST. LOUIS.

There are no more useful lessons than those contained in the incidents and accidents of office practice. If we do not communicate the knowledge gained, the event is limited to the individual. Not alone should we record our successes and apparent achievements, that we may stimulate the energy of the younger members of our profession, but as faithfully read the story of our failures.

In 1877, “S. A.,” a boy of ten years of age was presented with a mesial corner of the right superior central incisor broken in such a manner that the pulp, though not exposed, had died. The tooth was much discolored, abscessed, and very loose. A few days treatment sufficed to bring the tooth into a comfortable condition, when the boy's visits ceased. Some time elapsed: when he next came the tooth was elongated fully one-half the length of crown. The gums presented a most unfavorable appearance, and extraction was at once pronounced as the only proper treatment. At the earnest solicitation of the boy's mother this was deferred until the next day, and such treatment applied as the case seemed to indicate. Just here it may be well to say that exploration showed the root was not fully developed, the canal being quite large and funnel-shaped. So marked was the improvement the next day, that all idea of extraction was dismissed, and the root was finally filled with gutta-percha. A temporary filling of oxyphosphate was then introduced, and allowed to remain for two years. Then the contour was restored with gold. This filling was again replaced six years later with another of gold, which remained to within a short time ago, when a porcelain faced crown took its place. Deferring extraction to the next day has saved this tooth for thirteen years so far, with prospects of many years valuable service yet.

The second case is that of a right inferior second molar, a root filled with gutta-percha being allowed to fill pulp chamber, on which was placed a gold filling, February 20, 1878. In 1887 the gentleman complained of discomfort, but it was sometime before the cause was ascertained. The tooth had been split through its antero-posterior length, the fracture terminating nine-sixteenths of an inch below the point of the crown, on the lingual side. The fractured piece was removed, and the gum pressed out by means of gutta-percha, to give a better view of the remaining root. It was finally decided to attempt to restore the tooth by means of a band and crown. The fragment removed was used as a model from which dies were made, on which was struck a piece representing the lost part, having extensions sufficiently long to encircle the remains of the crown. This, when adjusted in position, was partly filled up on the inside with gutta-percha. A porcelain cusp crown was then arranged to antagonize the superior teeth. For a time everything seemed to go well. A little inflammation about the margin of the gum upon the lingual side instead of decreasing, suddenly grew worse, and pus was formed at the point of division of the roots. This finally yielded to treatment, and now the tooth is apparently in perfect health. The cause of this fracture appears to have been elasticity of the gutta-percha, under the pressure of the gold filling.

Case 3:—E. W., a boy of nineteen years of age, had broken a point off the right superior central incisor, not quite exposing the nerve, which subsequently died. The accident occurred some five years previous to his visit to me. The canal was found large and funnel-shaped, and was treated in the following manner: The lower portion was enlarged a trifle more than the diameter at the apex. A piece of lead was then introduced, and found to extend to the top by accurate measurement. In order to produce an accurate adaptation of the lead to the surrounding walls at the apex, the lead was reduced with fine sandpaper, the scratches of the sand being parallel to the long axis of the tooth. When the lead was forced into place, these fine ridges could be seen to be flattened when examined with a magnifying glass, and an adjustment continued in this manner, until the lead was found to close the apical foramen completely. The filling was completed with gutta-percha, and a porcelain crown was mounted upon the root. This has remained in a favorable condition up to the present time, about a year and a half.

Case 4, is that of a central incisor, pulp destroyed, canal filled, in which a Howe screw-post was used as an anchor to secure a large contour filling. Some time after, the tooth began to show a decidedly green discoloration, near the neck, which gradually extended throughout the crown. The filling was removed and replaced, however, using a screw of silver and platinum instead. I have here two specimens of roots in which the Howe post has been used, and have seen two other cases in the mouth, the same green stain appearing in all.

When the Howe post was put upon the market by the White Manufacturing Company, their agents refused to tell of what metal they were made, but gave the impression that they were some form of platinum and iridium alloy. They proved, however, to have been made of chrome steel. Besides the disagreeable discoloration of all these roots, I am inclined to the believe that the chrome salt formed, acts as a constant irritant to the peridental or dental membrane, and will result ultimately in the loss of the tooth.

Case 5:—In this case the left superior second bicuspid was devitalized and became discolored. The gentleman who was the lady's dentist at the time, desiring to improve the appearance of the tooth, removed the dentine extensively on the labial surface, and proceeded to fill with gold. When the tooth came into my hands for treatment, I found the part of the filling against the lingual wall well condensed, but that against the frail labial wall quite soft, and this portion of the filling had leaked, and the tooth was again discolored, showing that in order to avoid undue pressure on the thin enamel wall, insufficient force had been applied to condense the gold. Would it not have been better in this case, and in fact in all similar cases, to have sacrificed somewhat the appearance of the tooth and made a more permanent filling by the removal of all that portion of the enamel which was liable to fracture.

Case 6, is one of those mistakes in diagnosis which are liable to occur in almost any practice. Miss E. presented herself with every appearance of an abscessed right superior second molar, a large sac protruding into the mouth, opposite the palatine root. The tooth was so extremely loose and so sore that the patient would not allow it to be opened. The abscess sac was opened and syringed out, and two days later the soreness of the tooth had sufficiently subsided to permit the removal of the filling. Drilling toward the pulp chamber, a short distance, developed the fact that the tooth contained a living nerve. The result of this case showed that the abscess was caused by the lodgement of a fragment of a wooden toothpick between the first and second molar.

Another case, in my own mouth. The second left superior molar had for years stood alone, which facilitated a thorough cleansing upon all sides: I was therefore somewhat surprised at what appeared to be the development of a case of pyorrhoea alveolaris. The tooth continued sore, becoming looser, until its removal was a necessity. Neuralgia, and all the symptoms of a dying pulp had been present for three months. On extracting the tooth the nerve was found to be alive, and not much congested. The three roots were absorbed upon their inner surfaces. Exploration of the socket revealed the fact that a portion of the process enclosed by the three roots had been entirely absorbed. As the socket did not close in the usual time, I made an examination, and the probe revealed the presence of the missing wisdom tooth. The tooth has still continued to come down, but has not yet reached the gum line.

Another case in my own mouth is of interest: the result of wearing a wedge for three weeks between the first molar and the second bicuspid, on the right side. Some time after the tooth was filled, the first bicuspid became sensitive to heat and cold, and showed symptoms of peridental inflammation. Had a patient come to me describing the conditions of this tooth, I think I should have at once drilled into it, and applied the arsenic, but as it was in my own mouth I did nothing; and for fifteen months this tooth gave more or less trouble, but finally these disagreeable symptoms subsided, and the tooth is now apparently perfectly well.

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DR. G. L. CURTIS, of Syracuse, has been acting as Dr. Garrettson's assistant in oral surgery this winter, in Philadelphia.

CAMPHO-PHENIQUE.[2]

BY J. W. DOWNEY, M.D., STATE CENTRE, IOWA.

_Mr. President and Gentleman_:

Campho-phenique is a germicide and antiseptic or nothing, therapeutically considered; and discussing its properties necessarily opens the entire subject of germicides and antiseptics, a subject fraught with peril to the writer or speaker, especially if he is not a practical chemist, pathologist, and microscopist.