which occasion swellings about the jaws, as enchrondromata, sarcomata,
and myxomata, abscesses, and the collections of fluids in the antrum.
Dental alveolar abscess may be distinguished by its acute course, and
when in a chronic, condition by the discharge of its contents through
the fistula, either upon the gum, or within the oral cavity. The tumor
formed by an abscess is never so sharply definite as is the case with
cysts; with dropsy of the antral cavity the distention of the facial
wall of the jaw is more uniform than it is with cysts.
In some cases of cystic tumors, they present so formidable an
appearance at first sight, that they may be taken for solid tumors;
especially is this so when their walls are compact and well organized,
nearly if not altogether obliterating the sense of fluctuation when
pressure is made upon them.
Cases have come under the observation of the writer where it required
the most delicate touch to detect any fluctuation when pressure was
made upon the apex of the tumor.
In some cases the diagnosis cannot be determined accurately until
after one or more teeth are removed that are involved with the tumor.
After such operation, a probe carried through the alveolus will
usually reveal the true condition of the lesion. One or more dead
teeth are found involved--one, however, being the rule in most cases
which have come to the notice of the writer, while two, and sometimes
three, are implicated with the tumor. The dead tooth may be easily
distinguished from the living ones by its opaque appearance. Such tooth
may be carious, and it may not.
Primarily the dentritic cyst originates from what pathologists
call a "cold abscess," that is, an abscess which has never opened;
subsequently, having developed into a tumor. The interior of the cyst
has a fibrous lining, and being compact in structure, is the seat of
an inflammatory process. The cyst contains a pyriform fluid; it may
attain such magnitude as to invest several teeth and extend beyond the
alveolar process. The tumor is usually oval in shape, with its apex
on a line with the diseased tooth directly involved. The size of the
tumor may be as large as a hulled walnut or as small as hazel-nut;
crepitates under pressure, and feels like parchment. In cases of long
standing, considerable resorption of the alveolar process takes place,
and the teeth immediately connected will be loose; especially will this
be the case if the alveolar borders are broken; these teeth should be
removed. These tumors are found painless, as a rule. I have met with
cases, however, where an acute inflammatory condition was present, with
all the symptoms of acute periodontitis manifested. So that it could
have been readily mistaken for the pointing of an alveolar abscess.
_Pathology._--Cysts of the jaw may be either simple or compound;
whether they be cysts of retention, exudation cysts, or extravasation
cysts belonging to the jaws, is a matter not as yet fully established.
The exudation cyst is a secretory cyst; in a generic relation, however,
it is just the opposite of the retention cyst. Serous sacs form the
foundations of the exudation cysts. "The mode of development of cysts
of the jaws," says Wedl, "has not yet been determined; it therefore
becomes necessary, in order to throw more light on the subject, to
pursue further anatomical investigations in that direction."
Rindfleisch says: "The accumulation of the fluid is not produced
by the continuance of the normal secretion, but by an exudation
surpassing the normal measure of the serum of the blood with salts,
albumen, fibrinogenous substance, and extractives, in the most varying
proportions. The exudation cysts have little to do with pathological
new formation. Of extravasation cysts," he says, "a parenchymatous
bleeding can very well be the point of departure for the formation of
a cyst. The hemorrhagic depot can present itself primarily as a cyst,
namely, when the blood is poured out between two surfaces in themselves
smooth; for example, bone and periosteum, cartilage and perichondrium,
and thereafter remains fluid. As a cyst may also be formed when upon
the one hand the limitary parenchyma furnishes a connective tissue
membrane, upon the other hand, the blood itself is resorbed through a
series of metamorphoses up to a small remainder, and is replaced by a
clear fluid."
The above-mentioned condition is liable to manifest itself within the
body of the jaw, the bone and periosteum, after severe mechanical
injuries to the bone, and the rupture of blood-vessels within the
parenchyma. There can be little doubt that many of the so-called
dentritic cysts of the jaws have their origin primarily from causes
brought about by falls, strokes and mechanical violence, causing
rupture of blood-vessels. It is quite true, history of cases fully
confirms such facts.
Clinical observations leads us to believe, however, that only in cases
where the abscess does not open, we find the pathological new formation
taking place within the jaws. Pulpitis, and as has been observed,
followed by pericementitis and periodontitis, is a prolific cause of
the development of the dentritic cystic tumor.
_Treatment._--The removal of all dead teeth involved. Other teeth
whose pulps are living may be loose, and to a casual observer appear
to be complicated, but a careful examination will reveal the fact
that they should not be disturbed but retained in their places; only
one tooth may be the offender, being a dead one which has caused the
trouble. After the removal of the cause, let it be either one or more
dead teeth or fangs of teeth, cyst walls may be punctured with a sharp
instrument, and the contents of the sac released, this being done
by carrying the instrument through the alveoli, and not through the
bony parietes of the jaw. After the contents of the sac is let out,
and the sharp spicula of bone trimmed, with engine burs, tincture of
iodine full strength may be forced into the cyst sac, by saturating
tufts of cotton-wool and allowing them to remain, again repeating
the treatment at intervals of a day. If necrosis of bone be present,
it is good practice to alternate the iodine treatment with aromatic
sulphuric acid. Cases generally yield to this treatment in from six
week to three months. I have seen cases not yielding to treatment for
nine months. There are other and shorter methods in the treatment
which perhaps some would prefer--the cutting down through the body of
the tumor, by making a crucial incision and scraping out the contents
of the sac, afterwards allowing nature to do the rest--but I do not
believe it is the best or safest way. There is surely a much greater
loss of structure, which is never restored as in the former method by
granulation, after the secreting cells have been destroyed by medicinal
applications of iodine and sulphuric acid treatment.--_Medical and
Surgical Reporter._
ARTICLE V.
THOROUGHNESS.
BY L. P. DOTTERER, D. D. S.
[Read before the South Carolina Dental Association.]
Though scarcely more than a novice in the vast field of Operative
Dentistry, I have gleaned sufficient experience from observation and
practice to know that THOROUGHNESS is the surest means of success.
Just as the tillers of the soil sow their seeds, watch their crops,
and reap their harvests, so must we do our duty, advise our patients
as to the best means of preservation, and would that I could say, reap
our harvest. There has been so much written upon this subject that I
have nothing _new_ to say, but will touch upon several points, and in
giving my idea of thoroughness, as there applied, I may draw out some
discussion.
The first step towards the preparation of the mouth for dental
operations is the removal of calculus and decayed fangs. Let this be
done in a manner that will _insure future cleanliness_, where the
proper after attention is given on the part of the patient.
As regards the preparation and filling of cavities, there are so many
conflicting conditions, that we must be governed entirely by the case
before us; but to be thorough in our preparation, we must so shape the
cavity as to have the walls nearly plumb, uniform margin, slightly
undercut. In proximal cavities there may be a groove or pit at cervical
wall, but do not have it too near the margin, on account of its
liability to produce fracture, and consequent failure at that point.
On grinding surfaces, cut out all fissures leading into cavity, and be
careful to have no angles.
The margin, after all, is the most important point; for just here
failure begins, especially at the cervical wall, and care should be
taken to thoroughly remove all softened structure, and aim to reach
a solid foundation. These margins should be carefully trimmed and
burnished, and thus our cavity is ready for the filling.
We often hear practitioners decry the rubber-dam, and boast of their
skillful use of the napkin; but, gentlemen, many are the failures
consequent! For in deep proximal cavities, the dam is invaluable in
keeping guard against oozing moisture from the gums, which, without
this precaution, will flow upon the filling without our knowledge.
The dam adjusted, we proceed to form a mass of non-cohesive gold, and
where the walls are strong enough, we can continue with this material
throughout. But where cohesive gold is necessary, we should cover our
borders, as far as possible, with soft foil; for this is more adaptable
to the walls. Another advantage to be found in non-cohesive gold, is
its pliability, ease of starting, and rapidity in finishing. We should
thoroughly condense from beginning to end, whatever may be the kind of
foil used.
Filing and finishing is too often hurried through, leaving a surplus
of material at the cervical wall, or lapping the edges--another sure
cause of failure; and every care should be directed to finish in such
way that an instrument passing over the line of demarkation cannot
detect it. After filing, we would use pumice, either on a strip of
orange-wood, or by some other convenient means, and then polish. The
same general rule holds good in amalgam work, and the main cause of
failure in these cases is that lack of thoroughness in finishing.
In grinding surface cavities, where the enamel leading thereto is
funnel-shaped, we often introduce too much amalgam, extending it
beyond the margins of the cavity, and finishing to a fine edge. This
material, when hard and bit upon, will fracture perpendicularly around
the margins, giving the finishing a bulged appearance, and exposing a
V-shaped crack, which will invite decay. Consequently, we should remove
all surplus material, and finish at the very margin of the cavity. When
gold is used, this precaution is not so necessary, as the edges of a
gold filling will not fracture. Since we do not have to mallet amalgam,
it is natural to suppose we don't require firm margins, but this is
a mistake; and as much, or even more care should be exercised in the
preparation of a cavity for amalgam than gold, as tooth-structure seems
to waste away more rapidly from the former.
Let our motto be, "Whatever is worth doing at all is worth doing well."
If applying arsenic or a disinfectant, cover it with gutta-percha,
for the patient may be delayed a few days longer than we anticipate;
and what is worse than removing a foul piece of cotton, and finding
the tooth in a poorer condition than we left it? If we introduce a
temporary stopping on account of exposure or frailty, let it be done
thoroughly; and after relating its importance to the patient, caution
her to return at a certain time for its removal and permanent filling.
We must be teachers at our chairs, if we wish the public to appreciate
us, and we should instruct patients in the proper care of their teeth
by an intelligent and thorough use of the brush, pick, etc.
Such is the importance of thoroughness in dental operations. This paper
does not half express it, but for fear of trespassing too much on your
valuable time, I commend these ideas to your criticism.--_Southern
Dental Journal._
ARTICLE VI.
WHAT FILLINGS SHOULD WE USE?
DR. W. G. A. BONWILL, PHILADELPHIA.
When I look back at my commencement and reflect that my early practice
was founded on what the older men in authority had published and
taught, and how I feared to do other than they demanded, I shudder at
the many teeth I extracted I now know might have been saved, with even
the amalgam of that day. And I tremble at the advice _now_ given by the
authorities that _gold_ only should be used as a permanent filling.
Young men knew no better, but the older do. God forgive them, I cannot.
While I do not belong to the disciples of the new departure, _so far as
their theory is concerned_, I stand side by side with any person _who
can save teeth by plastic materials_, where gold cannot be used. Better
do this than persist with gold indiscriminately, and lose teeth, rather
than stoop to conquer with _any article_ that is _not gold_. The public
are demoralized on the subject of _gold_. "Are you not going to fill my
teeth with gold?" says nearly every new customer; "Dr. ---- would not
think of using anything else." A city operator must have more than the
usual quota of courage to stand before the societies and state "he has
been using _amalgam_ more freely of late." For the first eight years of
my practice I would not touch it, because Doctors Elisha Townsend and
J. D. White passed their anathemas on everything but gold and tin. I
worked myself nearly to death with tin to find it preserves from caries
but not from attrition. Since 1862, I have been feeling my way, and
while I think I have reared many beautiful and substantial monuments of
gold, and have perfected machinery with which to do it, yet I consume
more amalgam than ever before.
A gold filling _properly_ impacted, with cavity judiciously prepared,
and the walls shaped as to forbid future decay, _will save_,
irrespective of the frailty of their bony structure? But as thousands
of teeth _cannot be so prepared_, both of strong and of frail
organizations, and the circumstances _cannot_ be controlled, we should
resort to something that will enable us the more surely to meet the
issue.
To enumerate the many cases of peculiar character that forbid the use
of gold, would be too great a task. Physical impossibilities lie in the
way of every undertaking; and it is for the successful engineer, who
is well acquainted with his material, and their relative strength and
_adaptability_ for his purposes, to so use each, that his design will
be consummated, and which shall not by future wear, prove a failure.
There is a fitness in every material that experience has proven to
be specially adapted for a given work, and when this general law is
recognized and we become first-class engineers, we shall the better
see where we can adapt our materials to the work to be done, and we
can be the more certain of success, for it is founded on the logic of
mechanics and physical law.
Where is the dentist that first lays out his design and orders
materials best adapted for specific portions of it?
As well say everything should be made only of iron, or steel, or
wood, as that every tooth should be filled with gold; or, as _equally
ridiculous_, that the amalgam or some one of the plastic fillings
should be the only material used.
It is not _necessary_ to found a _creed or departure_ on a law of
_incompatibility_ to tooth substance. We need not look so far into the
unknown and unknowable. We poor, short-sighted creatures must have
the tangible; not a hypothesis on a _supposed theory_. Any one with
half an eye can see just where the incompatibility is; not between gold
and dentos, but between dentos and untutored and unskilled brain and
hands to _carry out the law of adaptibility_--the correlation of forces
involved.
One skilled in the use of the mallet, with the rubber-dam and a
substantial starting point, with walls ever so frail, can perfectly
impact and complete the work in gold filling, _provided the
surroundings are there_. But allow _one little vacuum_ between the
tooth substance and the filling, and a _capillary tube_ will be formed
to suck up _fermentable material_; and the _acid generated_ will act
on the tooth whether it be filled with gold, amalgam, oxyphosphate, or
gutta-percha. A thousand capillary tubes making porosity in the gold
or the amalgam, will not do it; but if there is one, however small,
between dentos and filling, destruction is sure.--_Transactions of the
Odontological Society of Pennsylvania._
ARTICLE VII.
SOME METHODS OF SEPARATING TEETH WITH WEDGES.
BY DR. DWIGHT M. CLAPP, OF BOSTON.
[Read at the joint meeting of the Massachusetts and Connecticut Valley
Dental Societies, held at Worcester, Mass., June, 1885.]
Among the many disagreeable and annoying, not to say painful, things
that patients have to suffer at the hands of dentists, nothing,
perhaps, is received with greater dread and disgust than the
announcement that the teeth must be "wedged" before filling. Some,
a small minority among us, I think, always fill without previous
separation. In regard to the necessity for it, I will enter no argument
here, but only say that personally I am a firm believer in wide
spaces between the teeth at their necks, and labor to the best of my
ability to obtain this result. It is most likely that many of you are
using the same means that I am to get the desired room for filling,
but by presenting and discussing the subject, it is possible we may
obtain some help in doing what I fear the most of us find, at times,
difficult and perplexing. For a long time rubber was about the only
thing used for separating. It has some good qualities and many bad
ones. It probably causes more pain and annoyance to the patient than
any other wedge. Its liability to slide into contact with the gum,
causing great pain and soreness, and even suppuration, has caused me
to entirely abandon its use, I am willing to admit that it may be used
successfully sometimes. The best rubber to use, if it must be used
at all, is that of which the most inelastic tubing is made, or the
erasers sold by stationers, cut into suitable shape. Wedges of wood
are well adapted to cases where the sides of teeth to be wedged are
nearly parallel, or where there is less space at the gum than at the
points of the teeth. The wedge should be about as wide as the length
of the crown, that is, it should extend from the cutting edge to the
gum, nearly. It should be so shaped and trimmed as to not irritate the
tongue or cheek. One advantage of the wooden wedge is that it is more
cleanly than tape, cotton, or silk. This same class of teeth, those
with nearly parallel sides, can be separated as successfully, and I
think with less pain, with tape. Linen tape of various widths and well
waxed is the best. It should be folded so as to be of proper width and
thickness, and then drawn into place. A sharp knife is preferable to
scissors for cutting off the ends. The tape should be thoroughly waxed,
which assists materially in getting it between the teeth, and renders
it more cleanly when left in the mouth for several days. In teeth with
cavities so situated that cotton can be crowded in with sufficient
force, this is one of the best wedges that can be used, as regards both
effectiveness and comfort. It is necessary to so place the cotton that
the force of expansion will be exerted against adjoining teeth and not
expanded within the cavity. By once changing the cotton, space enough
can generally be obtained. It is difficult to adjust and keep wedges in
place between teeth having more or less space at the gum, and touching
only at a small point near the cutting ends. It is in these cases
that ligatures of various kinds serve an admirable purpose. Take for
instance, the superior central incisors. These usually have but a small
point of contact, with considerable space between them at the gum, and
it is very difficult to put in a wedge of rubber, wood, or tape, that
will not slip up against the gum, or come out altogether. If a ligature
is used, the knots can be so tied that the string will clasp the point
of contact in such a manner as to hold it quite firmly in place. There
are many ways of making the knots; one is to pass the silk once between
the teeth, then tie a surgeon's knot; but, before drawing it up, pass
one of the ends again between the teeth, and then draw the knot so it
will wedge from the gum towards the cutting ends; draw it closely, then
finish by tying so that the last knot will be at the labial, or palatal
side of the teeth. Another way is to make a series of knots like a
chain stitch in crochet work, thus enlarging the silk for a suitable
length; draw this between the teeth and tie as before, omitting the
first knot that is drawn between the teeth. Another, and a very good
way of enlarging the ligature, is, after well waxing it, to roll a
little cotton around the silk as you would around a broach for wiping
out a root canal, and draw this between the teeth and tie the same as
when the silk is knotted. Still another method, easy of application and
very effective in almost all cases where there is a cavity in one or
both of the teeth, is to secure a pellet of cotton with the ligature.
The silk is placed between the teeth in some of the before-mentioned
ways; a pellet of cotton is forced into the cavity, projecting against
the adjoining tooth, then the silk is tied firmly around the cotton.
The swelling of the cotton and silk will make all the space necessary
between any of the front teeth with but one application. The bulging
of the cotton into the cavity or cavities, caused by tying the silk
around it will hold it securely in place. This makes by far the most
satisfactory wedge I have ever used, and, so far as I am aware, is
original with me. It is sometimes well to open the cavity slightly with
an excavator or chisel before wedging, so that the cotton will be more
readily retained. For bicuspids and molars more than one application
may be needed if much space is required. Quick wedging is sometimes
possible, and when it can be done readily is usually desirable. Teeth
that move easily may be separated sufficiently for operations by
placing a wedge at the point of contact, and another near the gum,
applying force gently with the hand, or light blows with a mallet,
first on one, and then on the other, until wedged enough. Then remove
the wedge that interferes most with the operation, leaving the other in
place. Another way that often works well with children and with teeth
that move readily, is to insert a large piece of rubber and let it
remain from fifteen to twenty minutes, when the rubber will have opened
a considerable space. A wooden wedge will keep the teeth from springing
together while the work is being done. The appliances designed by Drs.
Perry, Bogue and others, for making rapid separations, I have not
used, but hear favorable reports in regard to them. Having spoken of
rapid and semi-rapid separations, it is left only to speak of a method
which works very slowly. It applies, as a rule, to the biscuspids and
molars only. In many cases where there are large cavities between these
teeth, and often, when it is desirable that they should be filled with
what I think is very properly called a "treatment filling," it is
well to fill the entire space between the teeth with gutta-percha. In
the course of a few months the process of mastication will force the
gutta-percha toward the gum, and on removing what has not worn away the
teeth will be found well separated, the cervical margins well in view,
and the cavities in good condition for a metal filling.--_Archives of
Dentistry._
ARTICLE VIII.
COCAINE.
WALTER W. ALLPORT, M. D., D. D. S., OF CHICAGO, ILL.
The introduction of cocaine as a local anæsthetic, and the more general
use of peroxide of hydrogen (H_{2}O_{2}) in the treatment of dental and
oral diseases, are the principal advance made in the medical department
of this practice during the year for which this report is made.
The two forms of cocaine which have been most generally used in surgery
are the hydrochlorate and the oleate.