Page images

roots, and the distal root was filled solid to its end with gold wire, using ehlor-percha to fill the interstices between the wire and the root walls. Then the nodule was rolled back and the mesial root was filled in the same manner.

In all operations Dr. Morrison stated it was his endeavor to accommodate the instrument to the case. In lateral incisors, for instance, where a dead pulp is diagnosed, an opening is drilled exactly on a line with the pulp-canal that will just admit the size of wire that is used for such canals, and no larger.

Dr. James & Knapp, New Orleans. All will agree that a large amount of valuable tooth-structure is very frequently cut out in these cases; but he thought Dr. Morrison carried his views on the subject to the extreme. The opening of which he speaks is too small to permit effective work.

Dr. W. H. Morgan, Nashville, approved the idea of preserving as much as possible of the tooth-structure in the crowns of pulpless teeth, for just in the proportion that you cut it away do you lessen the probable length of the usefulness of the tooth; when much weakened it will become so friable "as to break down in mastication. He inferred from Dr. Morrison's description that he proposed to make the opening of which he speaks round. It is much more difficult to fill properly a round cavity than one which is oblong or irregular in shape; and another objection to the round opening is the difficulty of seeing the work. He thought it would be better for this purpose if made slot-shaped. Dr. Morrison's next move—filling the canal immediately after destroying and removing the pulp— is, in the opinion of the speaker, radically wrong. This is the worst time to fill, because the fluids in the dentinal tubuli will necessarily decompose very rapidly. The contents of the tubuli should first be gotten into condition to prevent putrefaction, both in root and crown, by antiseptic treatment.. While we ought to save as much as possible of the crown we should cut out the root portion freely to get rid, as far as we can, of the material liable to putrefying processes. He approved of the method of filling which Dr. Morrison advocates, though he would prefer a wire with a screw on it, tamping with a permanent material like oxychloride. The only difficulty with this is that oxychloride is sometimes passed out through the foramen, if the foramen is not previously stopped. He indorsed heartily the suggestion as to the evil of cutting away so much of the dentine as we frequently find in living teeth. He had seen cases where the living dentine had been slaughtered in a manner that seemed like malpractice to him.

Dr. E. Parmly Brown, Flushing, L. I., disagreed with the essayist on one point,—his method of filling the canals,—and would not reVol. xxvn.—23.

commend that plan to students. He disagreed with Dr. Morgan as to the use of oxychloride, preferring gutta-percha instead. The least skillful can use this, and as soon as any of it passes through the foramen it will immediately notify you. Years ago he was in the habit of cutting away more good dentine and less weak enamel than now. Whether to fill canals at once after removing the pulps, is a question of care and correct diagnosis. He recalled the case of a lady who came under his care some years since. She said a German dentist had killed the pulps of ten teeth six months previous with arsenic. Most of the fillings were loose, and some of the pulps were suppurating. He took out all the dead pulps and filled the canals with gutta-percha the same morning, mummifying the pulps with oil of cloves and carbolic acid, equal parts. She had no inflamed face, and ten years afterwards her gums were as healthy as a baby's. Dr. Morrison is right in advocating the idea of making the opening as small as possible when cutting into teeth to remove dead pulps, and Dr. Knapp is wrong. Dr. Morrison looks ahead to see if he will have to remove the filling in case the pulp dies; if he decides that it will die, he puts in only a temporary filling.

Dr. Morgan replied that he proposed to do just what Dr. Brown advocated,—mummify the remains in the dentinal tubuli. In the case related by Dr. Brown very little antiseptic treatment was needed; but when the pulp has just been removed, the material is in the tubuli to putrefy, and it is against this contingency that we should provide. Where a pulp has been destroyed and suppuration has occurred we have only the debris to get rid of. Where the pulp has been freshly killed and extracted the fluids are certain to decompose, producing mephitic gases to give trouble, frequently causing abscess. There is no abscess except where there is decomposition. If you remove the material liable to be decomposed, you are safe from abscess.

Dr. Brown rejoined that he particularly objected to long treatment of roots. There are cases, of course, where, on the removal of a dead pulp, the roots should not be filled, but this can be determined by the character of the discharges.

Dr. Morgan could not see how you are going to have discharges to treat if you take the pulp out. If Dr. Brown has not had abscessed teeth to treat he is more fortunate than any one else who has practiced as long as he has. The abscess will come after awhile, in cases where the teeth are filled at once, if the patient lives long enough.

Dr. Spalding. We have heard various views expressed here, and both sides are right to some extent. It depends very much on the condition of the tooth. There are teeth which it does not do to fill at once. The speaker had removed fillings which had been put in at once on the removal of the pulp from the teeth of young patients, and found them in the condition named by Dr. Morgan. As a rule he fills at once, but he ascertains that the canals are pure before he does so. It takes but a short time to do this. He uses bichloride of mercury for antiseptic treatment; a solution of 1 part to 1000 distilled water. You must be sure that j^our menstruum is pure, or it will antidote or decompose your medicament. If the canal is treated antiseptically you may safely fill at once. If the tooth is not in condition to make operating painful you may disregard wholly the state of the canal or the pericementum. A tooth which is filled after the extirpation of the pulp only becomes sore because gases get in; if you purify the canal you can go ahead and fill with safety, because no gases will be generated. In regard to filling root-canals, he thinks we must have a positive operation. If you use oxychloride or gutta-percha, and pump it in, you don't know that you have got it to the foramen, and, unless the interior is perfectly dry, you fail to get the chemical action to consolidate the agent. He u^ed gold wires for filling root-canals thirty years ago, and had tried -every method that had been brought forward, except the use of cotton, of which he had never been guilty. He pursues the method described by Dr. Morrison in shaping and adapting the wire. He estimates the length of the root and the depth of the canal, and gauges the length of the wire accordingly. That is shaped and adapted as nearly as it can be, and, instead of cutting off one-eighth of an inch, it is made just the length to the entrance of the canal. He prefers a gutta-percha solution for tamping it in, pumping it in as best he can, and breaking off the wire at the point indicated. This method is eminently satisfactory.

Dr. A. W. Harlan, Chicago, had noticed a lack of definiteness in the instruction which is offered. If we wish to be successful in these cases, in order to prevent decomposition of the contents of the tubules, to prevent abscess, we must be governed by some welldefined scientific practice. If a pulp is destroyed to-day and removed to-morrow, how soon will nature remove the eschar? Will it be to-morrow? No; it will require at least eight days. Now, does it not follow that that is the proper period to wait before filling? How should we remove it?—when the mouth is wet, or should we adjust the dam and keep the tooth perfectly dry? If we allow anything to get into the canal that we do not ourselves introduce, we will supply the proper conditions to cause future trouble. The proper treatment is to use something to abstract the water from the dentine. We will not have decomposition if we do that, and then hermetically seal the canal. If you don't fill such cases thoroughly well, so as to exclude air and moisture, you will have badly-smelling dentine, that you will cut out even in young patients. There is no necessity for treating if you have removed the pulp. It is only necessary to abstract the water, for which purpose absolute alcohol is the readiest means.

With reference to the treatment of pulpless teeth, he would not permit an inflamed pulpless and suppurating tooth to be filled for him if there were not a fistulous opening. It would be too painful. When an abscessed tooth has a fistulous opening the necessity of treatment is not apparent. Any medicament will be sufficient, and he should fill the root at once.

With reference to cutting out the interior of a tooth, what is the necessity for weakening it, after you have gained access to the pulp-canal. He does not care what is used for filling the canal, except cotton, so that it is sealed perfectly. We talk about fitting gold wire and lead wire perfectly to the canal, but we depend on the plastic substance in which the wire is imbedded to fill up the irregularities. The average practitioner is utterly incapable of filling a canal with wire so as to be uniformly successful. A great many do not know how to use a plastic material; it hardens before they get it half way to the apex. In using gutta-percha the little cones should not be heated, but must be teased out to the smallest size that will permit them to retain their rigidity.

Dr. M. W. Williams, Hopkinsville, Ky., thought it was all wrong to treat these cases for two or three weeks, as is so frequently done. We should seal the apex (for which purpose he uses a lead point not more than one-sixteenth of an inch in length), and thus, as it were, close the door against deleterious influences; remove all surplus material in the root, thoroughly disinfect it, and, in a few days, we can fill with any material.

Dr. W. H. Eichards, Knoxville, Tenn., thought the day was not far distant when the capping of pulps will be left entirely to those who don't attend the meetings of societies, or keep within gun-shot of proper practice. It is one of the greatest impositions ever devisedThe results of this method of treatment are seen in dead teeth, in discolored teeth, in neuralgia and abscess, and even in general debility from foreign matters which find their way into the stomach. The worst feature of such troubles is that the patient, in his ignorance of the proper course, does not go to the dentist, but to the physician. The speaker is, therefore, opposed to capping the pulp, and prefers to take it out surgically. After extirpation he carefully excludes all foreign matters from the cavity, fills with cotton medicated antiseptically with carbolic acid for a few days, and in, say, a week it is ready for the permanent filling. G-utta-percha for this purpose, in his hands, is difficult to get satisfactory results from; oxychloride clogs; wires are apt to get through the foramen. He uses Eobinson's fibrous material, which he dissects, and finds it composed of very fine threads. With a Donaldson nerve-bristle he carries up a little thread of the material and then another. In this way he can pack around a curve more successfully than by any other means within his knowledge.

Dr. Walker. There are many cases where you cannot use gold or lead wires, and in these cases especially gutta-percha gives the best results. He uses the material and the method which seems to be demanded by the case. He favors saving the nutrient function of the pulp as long as possible.

Dr. O. Salomon, New Orleans, believes in saving the pulp as long as you can. His practice is to cap exposed nerves and keep them under observation for a few days, but he does not use metal caps. Crude gutta-percha—not the prepared—is the best for the purpose, or you can make a pellet of artificial dentine and put to place. If there is no pain for three or four days you can go ahead and fill permanently, with hope of a good result.

Dr. J. A. Eobinson, Jackson, Mich., would suggest the use of a spring broach to carry the material to the apex. If you take one of these and draw it over a stone to sharpen it it will carry the material perfectly. He believes it is impossible to fill successfully until the canal is thoroughly disinfected. If there is any odor, the presence of which is the best test of the need of disinfection, it must be removed, or the tooth may have to be extracted. We should use -every means in our power to prevent the loss of the teeth. For thirty years he has insisted that no tooth should be removed that cannot be lifted out with the fingers. He caps pulps when that seems to be the best course to pursue. We sometimes deceive ourselves about this capping and are timid about it.

Dr. E. S. Chisholm, Tuscaloosa, Ala., has used, for capping pulps? creasote with oxide of zinc, first proposed by Dr. King in the Tennessee Dental Association. With these he uses oil of cloves. He has had thousands of cases, and is satisfied that there are many where the pulps have been living for ten years under that treatment. We should be conservative and eclectic with reference to the treatment of roots. There are instances where, when the pulp has been lost through devitalization or disease, quick treatment is the thing. The great point is correct diagnosis of the trouble we are dealing with, for there are other cases where slow treatment is beneficial. It does not matter what the canal is filled with so that it be thoroughly done. Not long since he accidentally cut his hand, and applied to it spirit of turpentine. The cut healed so kindly that he determined to test the efficacy of the remedy when applied to a bleeding pulp. The first trial was in the mouth of a young lady. An

« PreviousContinue »