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PIEST DISTEICJT DENTAL SOCIETY, STATE OF FEW YOEK.
The First District Dental Society of the State of New York held a special meeting, Tuesday evening, September 22, 1885, in the rooms of The S. S. White Dental Mfg. Co., Broadway and Thirtysecond street.
The president, Dr. William Carr. in the chair.
Incidents Of Office Practice.
Dr. B. C. Nash. I have here a cast of the mouth of a patient, a young lady fourteen years of age, showing an unusual retention of temporary teeth and backwardness in the development of the permanent ones. In the upper arch are the permanent central incisors, bicuspids, and first molars; the lateral incisors and cuspids of the temporary set are retained, and the second permanent molars are still undeveloped. In the lower arch the six permanent front teeth are in position and also the first permanent molars, and on one side a second molar, but there is no indication of the appearance of the bicuspids, though the temporary molars on one side became loosened and were extracted about a year ago. The permanent teeth are generally of excellent quality, but much smaller than usual. I would like advice in this case, as I have heard of gentlemen who invariably extract temporary teeth when the time for their shedding comes. I have not extracted any of these teeth, and am inclined to await developments before doing anything in the matter.
(The opinions given were in confirmation of this view, and the matter was passed.)
Dr. W. H. Atkinson. Mr. President and gentlemen, I am about to present to you a paper which deals with a disputed point. I wish to invite your close attention, and I put you at liberty to stop me at a comma, semicolon, colon, period, or paragraph; and if I use a term that does not strike you as being relevant, stop me right there.
Dr. Atkinson then read the paper entitled
"Flow of pus from the tooth-sockets" has long been recognized as a disease which it was impossible or difficult to successfully treat. Those who have dealt with it are divided as to the character of the departure from health, and as to the manner of treatment. Dr. Biggs regards it as a local disease, and amenable to local surgical cure; while many others, mostly homeopathists, attribute it to constitutional cachexy; and still others regard it as localization of a systemic debility. My own view is coincident with the latter. Vol. xxvii.—48.
The great merit of Dr. Kiggs's practice is in his insistence upon the necessity for thoroughly removing all the altered tissue well down into the healthy structure, thus favoring reproduction by 11 first intention." His demerit is his persistent denial of any utility in constitutional or local medication.
All diversity of opinion respecting the diagnosis and treatment of this disease, and in fact of all diseases, lies in our tarrying in mere opinions, and acting as if they were well-established knowledge of nutrition and its aberrations. The various tissues of which the organs of the body are composed have characteristic degrees of form, density, toughness, pliability, and extensibility, by which we are able to distinguish and describe them. All the tissues are supported by the process known as nutrition. Hard tissues feed slowly; soft tissues are more rapid feeders. Hence nutrient changes differ in facility and rapidity in the various tissues in health, as well as in difficulty and slowness in the ratio of departure from the protoplasmic state, in which the most rapid nutrient changes occur.
The bottom facts of nutritional changes are so occult, in consequence of the smallness of the bodies in which they take place, that few have the patience and earnestness to study them for themselves; and therefore nearly all the recorded information on this subject is a repetition of the crude mass-observations of beginners in this field of research which have found their way into text-books and journals, so lacking in coherence of statement as to make it difficult for any pupil to master them so as to give to them a hearty assent by comprehending the changes described, or to reject them as nonunderstandable.
Nutritional changes consist of play of affinities so fine and evanescent as to defy formulation in such coarse terms as abound in the books recording the apprehensions of those who have made them a study. Hence the prevalence of adverse estimates pronounced in such cases on the one hand, and of enthusiastic assertions of easy and simple cure resulting in " all" cases with only " one application" of the "remedy" on the other hand. I have seen so many cases of the latter class, which had been pronounced cured with " one thorough treatment,"—in which, by the way, there were teeth which were not only loose in the sockets, but which had fistulse which were discharging more or less of the broken-down tissue,—that I feel bound to raise a warning voice against unwise confidence in the short, sharp, and quick method of treatment. Not that there are no cases so cured, but that so many supposed to be cured have proved to be only palliated and set back, to break out again when they were lost sight of by the operator who had pronounced them cured, to fall into, sometimes, less competent hands.
Under these experiences we are led to suppose that different conditions have been grouped together as being the same form of disease, or that differing degrees of degeneracy have been deemed to be alike amenable to one single remedy applied in one way, and that "my way."
I am convinced that we will not see eye to eye until these cases shall have been made subject to clinical investigation and demonstration such as has had marked success in the other branches of our art, viz., filling teeth and fitting regulating and restorative fixtures, now so far advanced toward perfection.
One of the greatest obstacles in the way of understanding the various modes of nutritional change is the classification by which those which belong together are named as if apart and distinct. All nutritional metamorphosis occurs in protoplasmic bodies, which are the elements of every form of nutrifying body which converts pabulum into tissue. Where protoplasm is not formed into tissual limitations of neural, osseous, muscular, connective, or epithelial differentiations, the ameboid form of feeding holds the dominion of the field of nutrient activity, which in reality is the only condition in which these changes can take place. Therefore all foods must be reduced to the fluid state before appropriation is possible.
Atrophic dyspepsia of connective-tissue is the most difficult of detection, and is the first step in every case of pyorrhea alveolaris.
The bond of union between the tooth and its socket consists of a connective-tissue layer attaching it on its inner border with the cement corpuscles, and on its outer border with the myxomatous tissue of the gum, which in turn is covered with an epithelial coat consisting of several layers of epithelial bodies of globular, cuboidal, cylindrical, and squamous conformations. The cement-substance connecting these elements of the tissues is nitrogenized hyper-oxidized hydrate of carbon. In other words, the ameboid ectosarc is of such plasticity as readily to hold to or let go of its fellows composing protoplasm, mucus, blood, muscle, nerve, or epithelium.
To this fineness of interpretation, then, do we come at last to enable us to catch a glimpse of the territory in which the first divergence of health is displayed in every case of "pyorrhea alveolaris."
Wasting of the cement releases the hold of the connection, which by the resilience of gum-tissue opens a gap at the point of death of ectoblastic structure. In this chasm various deposits may occur. Where inflammation is induced, it may resolve or proceed to suppuration or sphacelus, caries or necrosis, according to the constitution and status of health of the body at the time. As a rule, the earlier and more manageable stages of this disease are not noticed by either the patient or the practitioner, and hence well-pronounced cases are those which generally apply for relief.
When a ripened germ is separated from the bed in which it was generated, the act may well be named "parturition." If, then, protoplasm be the first form in which the feeding process can be proved to occur, are we not justified in the assertion that rejection of excess of food and incompatible material is the first example of increment and decrement, of coming together and going apart, or impregnation and parturition of elemental bodies?
All the functioning bodies of which we have any knowledge are composed of elemental bodies too small to be seen. When any department is denied its normal demand for nutrition, the harmony of function is lost, and career of body thus minified is cut short or destroyed. When enough destruction has been effected to be detected, the case is ready for investigation, diagnosis, prognosis, and treatment, or abandonment.
Concretions of lime are never causal of disease; only concomitant or sequential. No two specimens of calcareous deposit have yielded an identical analysis. They are the result of a breaking down of tissue-elements under stress of disease in which the acids requisite to holding the lime in solution are deficient in supply, or brought into contact with bases for which they hold higher affinity. The attempts to classify these deposits have resulted in a somewhat ambiguous nomenclature, viz., salivary calculus, serumal calculus, and sanguinary calculus.
The general term in common use to designate these deposits is "tartar," originating in a loose resemblance to the crust on winecasks called by this term.
Whenever a deposit is formed it takes the shape of the pocket in which it is precipitated from the fluid holding it in suspension. Take the example of the pocket produced by the recession of gum about the neck of the tooth from solution of the dental ligament, and we find the deposit to conform to the shape and size of the pocket, from a mere nodule to the segment of a circle, or to an entire ring about the neck of the tooth. Take a case of the so-called serumal or sanguineous deposit at the end, or near the end, of the root, where the solution of the connective-tissue corpuscles forming the pericemental tract has broken down the cement-substance which fuses the corpuscles into a sheet or membrane, and we find the nodules to correspond to the chasm formed by the retrogressive nutrient act in form and extent of the separated tissue. All calcareous deposits in an inclosed chamber necessarily arise from the precipitation of the lime in the locality, and must be from the circulation direct, or the broken down molecules and corpuscles of the tissues in the neighborhood. Deposits in open chambers may be from mucus, saliva, or free solutions of lime-salts, and may be properly named when we are able to determine their place of formation. The irregular composite calcareous bodies found in the respiratory, genito-urinal, and other circulatory tracts are easily understood so soon as their habitat is determined. The great masses of lime found ih the lungs, the kidneys, the liver, the joints, and the mouth are all very interesting subjects of study, and are developed under the general laws of nutrition by organic, tissual, corpuscular, and molecular chemistry, and are amenable to classification when their origin is ascertained.
If a calculus contain cholesterine, we refer it to the liver for origin ; if carbonate of lime predominates, we refer it to the respiratory tract; if phosphates and urates are present, to the urinal apparatus; if the carbonates and phosphates be mixed with epithelia and hete" rogenous foreign bodies, it is referred to the mucous and salivary tracts for origin. Wharton's duct, Steno's duct, and the necks of the teeth are the places where we may find concretions of this last character, as instance the large masses so often found about teeth which are not vigorously used.
If what has been said be comprehended, there remains only a very short statement to complete this paper upon pyorrhea alveolaris.
The three degrees or stages of this affection must be met by three degrees of extirpative energy: 1st, physiological; 2d, mechanical; 3d, chemical.
The first includes good feeding and hygienic cleanliness; the second, removal of foreign material by mechanical means; and the third, the destruction of ferments and their results by such means as kill the spores and their products and the debilitated tissue-elements, so that the physiological activities may throw off the offensive and effete matters and reproduce the tissues normal to the location.
To speak of the details of these methods of cure, and set forth their claims to attention, would involve the presentment of cases in the various stages and the special remedy to be resorted to in each. To give a mere hint of this labor, the best I can do is to give a former classification of application and remedy.
Where slight loss of the border of the gum is present, elixir of vitriol is the proper application to effect the purpose of inciting a return of physiological activity. Where greater loss of connection between tooth and socket is present, with some lime deposit, use a solution of aqua regia, one part to seven of water. In cases of greater loss of attachment and loss of considerable portions of the