DR. SMITH:—Mr. President, the essayist this evening has presented
a paper which is a resume of the methods of practice of many
practitioners throughout the country, but although they have given
their methods of capping exposed pulps, I do not see that they give
their results, and he cites but one case and pronounces that a failure.
The most important thing to avoid in the treatment of exposed pulps,
as held by the authorities, is pressure, and I endorse that opinion
most thoroughly. I believe a large proportion of failures in the
capping of exposed pulps is due to the lack of skill on the part of the
manipulator. We speak of accidental exposures in excavating; I believe
that that exposure is almost inexcusable. I don't believe any graduate
of the dental school of Harvard College has any right to punch an
excavator into a pulp unless he intends to do it when he starts. It may
be a little personal to say that my experience in accidental exposures
is very small, but such is the fact. I have had cases where perhaps
the exposure was excusable. In cases of a malformation of the pulp
or tooth, but under ordinary circumstances, in cases that we usually
meet, such exposure of the pulp I believe to be wholly inexcusable. The
practitioner of to-day in opening into a cavity knows, or should know,
that he is liable to come into contact with the pulp, and he therefore
ought to excavate with the greatest possible care, and with the careful
instructions given in the schools to-day there is no excuse for his
exposing that pulp.
The method cited of using gutta-percha, I do not believe in, and the
placing of gutta-percha directly on the pulp, I condemn, not from my
own experience, but from my observations of cases treated by other
practitioners, the patients have come into my hands afterwards. Trouble
has resulted in every case that I have seen, but they may have been
cases which should not have been capped, and perhaps it is hardly just
to deny that some were successes.
The pulp, while it is an organ of great sensitiveness and extreme
delicacy of structure, I believe to be most persistent in its vitality.
The capillary circulation of the pulp, as you all know, arising from
the vertical vessels forming loops, prevents a combination near the
surface, and the absence of lymphatics in the pulp prevents medicaments
from doing much good, as would be the case upon serous membrane. Where
the trouble is diffused through the entire membrane, in many cases the
application of arsenious acid will only destroy a part of the pulp, and
has to be re-applied again and again.
If a tooth has been aching, and there is congestion about the pulp,
or an exuding of pus, I invariably destroy it. I don't believe a
pulp can be brought to a healthy condition to stand capping after it
has reached that stage. But there are many cases where patients have
neglected their teeth and had a little pain, or after taking sweets,
they have a severe toothache that soon passes off, so that at the time
of examination there is no soreness nor inflammation; or if we have a
strong, robust, healthy patient, and in excavating carefully around the
pulp we remove a layer of decalcified dentine and find just a point
of the pulp exposed; in such cases I do not hesitate to cap, and my
mixture is as follows:
I take oxide of zinc, and mixing it with oil of clove or creasote,
flow it carefully over the pulp, then fill out the cavity with either
oxychloride, or oxyphosphate of zinc.
It is true, Mr. President, that I have kept a record of the pulp
exposures and my method of treating them, and the condition that they
were in, but in looking over my records I found that when I wanted to
get at the results, it was not a very easy matter, and it has taught
me in the future to keep a little book and enter the cases of pulp
exposure and treatment of dead teeth, so I can turn to a person's
name and find the result at once, but, you come to look through your
record-book for a case which was treated twelve or fifteen years ago
and follow out the record of the patient to find whether the pulp has
since died, you will have an endless job. I have one case where I had
five exposures of pulp in one mouth, of a right superior molar, mesial
cavity, and of the bicuspids on the same side, and the bicuspids of
the left superior. They were capped eight years ago, and last year—I
have not seen the patient this season—they were all tested with warm
instruments or ice, and every one of them was alive. How soon they
will die, of course, I cannot tell, but they were apparently in good
condition when I last saw them. Another case of which I have a record,
was an exposure on the mesial surface of an upper right molar, which
was exposed in such a manner that with a magnifying-glass you could
look into the cavity and see distinctly the pulsations in the pulp. At
that time I was with Dr. Shepard, and I called him to see the case. It
was extremely interesting, more so perhaps to us than to the patient.
As the patient was strong and healthy, the pulp was capped in the
manner I have just described, and that pulp is alive to-day.
That is all the data that I can give you, Mr. President, excepting that
I know, in my own practice that a majority of the pulps that I have
treated and capped in that way are still alive, and I am a believer
in capping certain exposed pulps. This is an exception: A patient
came to my office something over two years ago. On a lower right
second bicuspid was an exposure near the margin of the gum, which was
capped, and that patient had not been in to see me since that day until
yesterday, and would not have come then had there not been a pain in
that locality. In examination I found that decay had started below
the gutta-percha, upon the cervical wall, which I had placed there
for protection, after the first capping, and had again exposed the
pulp. The patient had suffered for two or three weeks with neuralgia
before coming in. I thought it was useless to try to preserve any
exposed pulps for that patient, so a new opening was made and the pulp
devitalized.
I do not hesitate, however, in destroying a pulp to-day so much
as I did some years ago, when we were taught to believe that the
devitalizing of an exposed pulp was almost a certain forerunner to the
total destruction of the tooth. There has been a radical change in that
theory, Dr. Atkinson, of New York, has written a paper in which he
speaks of the amputation of a pulp. If I remember rightly, he claims
that you may amputate a pulp up to the bifurcation of the roots, that
it is good surgery and it will live. I do not agree with him; and
yet when I have been trying to destroy pulps up in the canals, I have
sometimes thought they would live, no matter what you did to them.
I do not hesitate to destroy pulps to-day, because we have such an
excellent knowledge of the structure of the tooth, and we now know that
simply because the pulp is lost we must not suppose the tooth to be
entirely dead, but there is still life from the membranes of the root.
So I am now inclined to cap only those pulps which present the best
conditions for capping. If a pulp presents any symptoms of congestion
or inflammation, I believe you had better dispatch it at once, in order
to give the best results to the patient, but I am not a believer in the
wholesale destroying of pulps. I believe, gentlemen, in conservative
treatment.
DR. EDDY:—Mr. President and Gentlemen: I am a firm believer in
treating exposed pulps, with arsenious acid. I have tried almost
everything else during the last fifteen years and have found nothing
that will especially preserve the life of a pulp. I have had cases
apparently benefited by some kinds of treatment; but I think it has
been due fully as much to the temperament of the patient and general
condition of health. I believe that oxyphosphate will destroy a pulp
just as surely as arsenic, only not as soon. I believe this because
I used it nearly eight years, and have seen some of the results. I
have also had cases where I have used oxyphosphate of zinc underneath
amalgam fillings, as a cement, a non-conductor, but not in direct
contact with the pulp, and the pulps have died, and I laid it to the
oxyphosphate of zinc. Of course, I have had my experience with fresh
exposure, which I suppose was due to my being a graduate, and in those
cases I think I have had good results by doing nothing more than
touching the exposed pulp with carbolic acid and packing gold directly
over that, and it seemed to work very well. I have tried almost
everything that has come before us; and in those cases of exposure
resulting from decay, or even in cases where there is no exposure, but
a zone of softened tissue remains, which is liable to break down, I
think it will give the patient the most satisfaction to devitalize the
pulp. It may be a little more painful at first, but it is better than
having the neuralgia every now and then for from one to five years and
then destroy the pulp.
Another thing, Mr. President, when a pulp is destroyed by an
oxyphosphate filling it makes one of the dirtiest heaps of debris that
I have met. It goes all to pieces and makes a very bad mess. I have
used oxychloride for capping and had better results than with the
oxyphosphate.
DR. BLAISDELL:—I would like to ask if Dr. Eddy has ever used
oxysulphate?
DR. EDDY:—I have not.
DR. GILLETT:—I would like to hear more about this idea of oxyphosphate
destroying the pulp. As I understand the gentleman, he makes the
statement that he has ascribed the death of certain pulps to
oxyphosphate used either as a lining, or as a filling in cases where
there has been no exposure. Am I right?
DR. EDDY:—Yes, sir. I had one to-day, Mr. President, that I can
attribute to nothing but oxyphosphate. There was no exposure.
DR. NILES:—Mr. President, I used to cap pulps, but I seldom perform
that operation now. When I do, I feel that death will occur sooner or
later. I never cap with oxyphosphate unless I wish death to take place.
It has been said by one of the speakers to-night that the nerve has no
means of absorbing dead matter, as the pulp has no absorbents. Even if
it had, I should not want it to come in contact with the oxyphosphate.
Phosphoric acid is an escharotic, and I don't know why a creamy mixture
of it and the oxide should be flown over an exposed pulp, unless to
destroy it. If a pulp stands this treatment and lives, it is tough.
An acid that will etch glass, or dissolve silver, will destroy soft
tissue. It seems to me out of reason to use such things on exposed
pulps. Phosphates or chlorides mixed to the consistency of cream make
an unstable, strongly acid compound, that when hard very soon dissolves
in water, or to a large extent will become deteriorated in water or
moisture. In my opinion, the best treatment to save a pulp, provided
the patient is strong and robust enough to help out any treatment, is
to relieve it from all irritation, disinfect it, and let nature take
care of it. Any non-irritating mechanical means you can use to that end
will be more beneficial than stimulating, bleeding, etc. I would not
use strong carbolic acid or creosote to disinfect an exposed pulp, for
they also destroy its surface, and the dead matter remaining decomposes
and irritates the adjoining tissue. Sooner or later that pulp dies.
The most of the patients who come to us with exposed pulps have a
debilitated state of the system. It is not the best vitalized class
of people, but those who are sickly and delicate, and who have not
much reserve force for the body, to say nothing about the teeth. The
question of conservative treatment, in a large majority of cases, with
the hope of any lasting results, I shrink from. If I can painlessly
treat my patient and take him past the trouble by destroying the pulp
and filling the cavity and canal, I feel that I have done the best that
can be done for him.
DR. TAFT:—In my own practice I think I have been reasonably fortunate
in saving what exposed pulps I have had to deal with. I suppose I
have my proportionate share of them, and my practice has been almost
invariably to cap them. I think I am safe in saying that I have not
used arsenious acid half a dozen times for the purpose of destroying
pulps in the four years that I have been out of the school—I do not
think I have used it _four_ times. In those cases where I have used it,
the pulps have come to me in a highly inflamed condition, have been
aching a long time, and trying to save them by capping has seemed at
once to be out of the question, and in those cases—and in those cases
only—have I devitalized them at once. I do not believe in flowing
oxyphosphate directly over the pulp; neither do I believe it a good
plan to put carbolic acid over it. My method is either to mix oxide
of zinc with oil of cloves and apply it carefully, or to apply the
oil of cloves directly to the exposed portion, then dust the oxide of
zinc on that; afterwards flowing oxyphosphate in a creamy condition,
and waiting until it hardened, then fill the rest of the cavity with
oxyphosphate or amalgam.
I keep a record of all the pulps that come to me exposed, or that
I expose myself, and some I treat differently from others, but the
majority of them, when seen subsequently, are alive. Occasionally I
find one that comes back after a time, showing signs that the tooth
is dead, and of course the tooth is then opened and treated; but the
proportion of them is so very small that I believe in a conservative
treatment of them, and think the first thing to be done is to get rid
of whatever congestion there may be, if any, and I do not see why a
pulp should not then live as well under a careful and skillful capping
as it should against the hard, bony wall of the pulp cavity. I have had
such good success in the treatment of them that I do not believe in
destroying them at once.
DR. GILLETT:—Will Dr. Taft please to outline his treatment of
congested pulp, by which he brings it back to normal condition?
DR. TAFT:—I must say that I do not have a great many cases of
congested pulp, but where I do have one which has been exposed for some
length of time, and has given pain, I first apply local treatment,
using something of the nature of oil of cloves, then fill the cavity
with cotton and let it go for a few days. I had a case about three
weeks ago of a tooth that I had filled, a year ago, with gutta-percha.
At the time the tooth was filled I was unable to decide whether there
was an exposure or not. The tooth had been previously filled by a
well-known Boston dentist with gutta-percha, and was very sensitive to
excavating. The cavity extended far up under the gum, and I refilled
it with gutta-percha and it kept quiet for about a year. Three weeks
ago the lady came to me, complaining of great pain. I took the
gutta-percha out, and upon re-excavating I exposed the pulp and found
it alive. It had been troubling her then for about a week. I thought
at first I would try to save it, and began treatment by putting a
pledget of cotton, dipped in oil of cloves, into the cavity, sealing
it up temporarily with gutta-percha, and applying the little capsicum
plasters to the gum, hoping to reduce the inflammation in that way, but
after working over it a week I destroyed it. I think congestion of the
pulp can be reduced by internal treatment much better than by any local
treatment, and if we were physicians and had the knowledge of materia
medica that we should have under those conditions, I think we would
find it possible to easily and quickly get rid of the inflammation and
bring the pulp around to a healthy condition, so that it could then be
successfully capped, provided there had been no suppuration. When it
has reached that stage, the only thing to be done, in my opinion, is to
apply arsenious acid and destroy it.
DR. WERNER:—I look upon the treatment of a pulp principally from the
standpoint of whether such pulp is absolutely necessary for the welfare
of the tooth. The pulp is a formative organ. Its function decreases
as the tooth develops. In young persons it is largest; grows smaller
and smaller, and in old age it is nearly ossified or obliterated; that
is, its retrogressive stage begins materially after the crown of the
tooth erupts through the gum. I have seen three different times what
Dr. Smith spoke of—the actual pulsation of the pulp—which in a large
exposure, in a favorable light, is easily seen. All of those three
pulps were capped and they seemingly are alive to-day, but I think
the teeth would be quite as serviceable had the pulp been destroyed.
From a surgical standpoint the amputation of part of the pulp may at
times be successful, for we know how resistive they often are to any
kind of arsenious acid treatment, yet I should never do it unless
it were in a partially developed tooth, where the life of the pulp
is essential. What the surgeon does after trepanning the skull, we
should do in capping or bridging over the pulp cavity. He does not
flow escharotics like oxychloride or oxyphosphate of zinc over the
brain. He mechanically covers and takes good care not to press on the
contents of the cavity. The tooth pulp must be treated in the same
way; a simple mechanical covering over it being all that is necessary.
Whether you put a metallic cap, or whether you put court plaster, or
one of gutta-percha (though I should hesitate about using the latter),
makes little difference, only be sure that you do not press upon the
pulp. With the knowledge we have to-day in treating devitalized teeth,
there seems little reason for a young man to risk trying to save bad
cases of exposed pulps. It is in extreme practice successful only for
the time being—sooner or later ending in failure. To me many so-called
successful records are only apparent successes, the operations
only hastening the pulps to degeneration. The flowing over of all
escharotics, I think, is highly unscientific.
DR. CLAPP:—The last speaker has made the statement that after the
tooth is formed it no longer requires the presence of a pulp. I would
like to ask him when he considers a tooth formed?
DR. WERNER:—In many cases the pulps of teeth are very large at
twenty-five years. A tooth, however, is usually formed and the apical
foramen closed up at from three to five, or, at the latest, ten years
after the eruption.
DR. CLAPP:—I had occasion yesterday to cut off two central incisors
for a lady eighteen years of age. The pulp chamber was entirely
obliterated, entirely filled. I imagine that the pulps near the apex
of the root are still alive, and it seems to me that the presence of
the pulp is a great advantage to the teeth as long as they are in a
healthy condition, and I must say that I hesitate to destroy pulps. As
Dr. Taft says he has not destroyed the pulps in half a dozen teeth in
four years, I do not believe that my proportion is greater than that in
eighteen years.
I would like to inquire of the Society its opinion of the advisability
of removing softened dentine over the pulps that would be undoubtedly
exposed by the removal of such softened dentine.
DR. BIGELOW:—I do not rise to relate any experiences in capping pulps,
but there is one question that has come up in my mind many times that
I would like to have answered, if possible, by some of these gentlemen
that believe in capping, and practice it regularly. We were taught in
the school that in an inflammatory condition we might expect to find
heat, pain, redness, swelling—we might expect to find one or all of
these symptoms in an inflammatory condition of the tissue. It is said
of the bones, that an inflammatory condition might exist and yet have
neither swelling, redness, nor pain, but there might be heat. Now the
question that comes up in my mind is, how are we to know, really, when
the pulp is in an inflamed condition, and what treatment to give it
before capping? Very often patients come to us with teeth that have
been aching, and there is perhaps a swelling of the pulp and a certain
redness; I say swelling—the throbbing generally indicates a swollen
condition, in which cases the pulps are evidently inflamed; but what I
would like to know is, how are we going to tell whether these pulps
are in an inflamed condition or not? I would like to know the proper
treatment for an inflamed pulp. In cases where I have attempted to
subdue the inflammation, I have not had great success.
DR. SMITH:—In the absence of all symptoms, I should conclude that
there was no inflammation.
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.