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.