: The Archives of Dentistry Vol. VII No. 4 April 1890 by Various Eames W H William Henry Editor Stockton C S Editor - Dentistry Periodicals

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Editor: W. H. Eames C. S. Stockton

Transcriber's Note.

BY H. H. KEITH, D.D.S., ST. LOUIS.

There are no more useful lessons than those contained in the incidents and accidents of office practice. If we do not communicate the knowledge gained, the event is limited to the individual. Not alone should we record our successes and apparent achievements, that we may stimulate the energy of the younger members of our profession, but as faithfully read the story of our failures.

In 1877, "S. A.," a boy of ten years of age was presented with a mesial corner of the right superior central incisor broken in such a manner that the pulp, though not exposed, had died. The tooth was much discolored, abscessed, and very loose. A few days treatment sufficed to bring the tooth into a comfortable condition, when the boy's visits ceased. Some time elapsed: when he next came the tooth was elongated fully one-half the length of crown. The gums presented a most unfavorable appearance, and extraction was at once pronounced as the only proper treatment. At the earnest solicitation of the boy's mother this was deferred until the next day, and such treatment applied as the case seemed to indicate. Just here it may be well to say that exploration showed the root was not fully developed, the canal being quite large and funnel-shaped. So marked was the improvement the next day, that all idea of extraction was dismissed, and the root was finally filled with gutta-percha. A temporary filling of oxyphosphate was then introduced, and allowed to remain for two years. Then the contour was restored with gold. This filling was again replaced six years later with another of gold, which remained to within a short time ago, when a porcelain faced crown took its place. Deferring extraction to the next day has saved this tooth for thirteen years so far, with prospects of many years valuable service yet.

The second case is that of a right inferior second molar, a root filled with gutta-percha being allowed to fill pulp chamber, on which was placed a gold filling, February 20, 1878. In 1887 the gentleman complained of discomfort, but it was sometime before the cause was ascertained. The tooth had been split through its antero-posterior length, the fracture terminating nine-sixteenths of an inch below the point of the crown, on the lingual side. The fractured piece was removed, and the gum pressed out by means of gutta-percha, to give a better view of the remaining root. It was finally decided to attempt to restore the tooth by means of a band and crown. The fragment removed was used as a model from which dies were made, on which was struck a piece representing the lost part, having extensions sufficiently long to encircle the remains of the crown. This, when adjusted in position, was partly filled up on the inside with gutta-percha. A porcelain cusp crown was then arranged to antagonize the superior teeth. For a time everything seemed to go well. A little inflammation about the margin of the gum upon the lingual side instead of decreasing, suddenly grew worse, and pus was formed at the point of division of the roots. This finally yielded to treatment, and now the tooth is apparently in perfect health. The cause of this fracture appears to have been elasticity of the gutta-percha, under the pressure of the gold filling.

Case 3:--E. W., a boy of nineteen years of age, had broken a point off the right superior central incisor, not quite exposing the nerve, which subsequently died. The accident occurred some five years previous to his visit to me. The canal was found large and funnel-shaped, and was treated in the following manner: The lower portion was enlarged a trifle more than the diameter at the apex. A piece of lead was then introduced, and found to extend to the top by accurate measurement. In order to produce an accurate adaptation of the lead to the surrounding walls at the apex, the lead was reduced with fine sandpaper, the scratches of the sand being parallel to the long axis of the tooth. When the lead was forced into place, these fine ridges could be seen to be flattened when examined with a magnifying glass, and an adjustment continued in this manner, until the lead was found to close the apical foramen completely. The filling was completed with gutta-percha, and a porcelain crown was mounted upon the root. This has remained in a favorable condition up to the present time, about a year and a half.

Case 4, is that of a central incisor, pulp destroyed, canal filled, in which a Howe screw-post was used as an anchor to secure a large contour filling. Some time after, the tooth began to show a decidedly green discoloration, near the neck, which gradually extended throughout the crown. The filling was removed and replaced, however, using a screw of silver and platinum instead. I have here two specimens of roots in which the Howe post has been used, and have seen two other cases in the mouth, the same green stain appearing in all.

When the Howe post was put upon the market by the White Manufacturing Company, their agents refused to tell of what metal they were made, but gave the impression that they were some form of platinum and iridium alloy. They proved, however, to have been made of chrome steel. Besides the disagreeable discoloration of all these roots, I am inclined to the believe that the chrome salt formed, acts as a constant irritant to the peridental or dental membrane, and will result ultimately in the loss of the tooth.

Case 5:--In this case the left superior second bicuspid was devitalized and became discolored. The gentleman who was the lady's dentist at the time, desiring to improve the appearance of the tooth, removed the dentine extensively on the labial surface, and proceeded to fill with gold. When the tooth came into my hands for treatment, I found the part of the filling against the lingual wall well condensed, but that against the frail labial wall quite soft, and this portion of the filling had leaked, and the tooth was again discolored, showing that in order to avoid undue pressure on the thin enamel wall, insufficient force had been applied to condense the gold. Would it not have been better in this case, and in fact in all similar cases, to have sacrificed somewhat the appearance of the tooth and made a more permanent filling by the removal of all that portion of the enamel which was liable to fracture.

Case 6, is one of those mistakes in diagnosis which are liable to occur in almost any practice. Miss E. presented herself with every appearance of an abscessed right superior second molar, a large sac protruding into the mouth, opposite the palatine root. The tooth was so extremely loose and so sore that the patient would not allow it to be opened. The abscess sac was opened and syringed out, and two days later the soreness of the tooth had sufficiently subsided to permit the removal of the filling. Drilling toward the pulp chamber, a short distance, developed the fact that the tooth contained a living nerve. The result of this case showed that the abscess was caused by the lodgement of a fragment of a wooden toothpick between the first and second molar.

Another case, in my own mouth. The second left superior molar had for years stood alone, which facilitated a thorough cleansing upon all sides: I was therefore somewhat surprised at what appeared to be the development of a case of pyorrhoea alveolaris. The tooth continued sore, becoming looser, until its removal was a necessity. Neuralgia, and all the symptoms of a dying pulp had been present for three months. On extracting the tooth the nerve was found to be alive, and not much congested. The three roots were absorbed upon their inner surfaces. Exploration of the socket revealed the fact that a portion of the process enclosed by the three roots had been entirely absorbed. As the socket did not close in the usual time, I made an examination, and the probe revealed the presence of the missing wisdom tooth. The tooth has still continued to come down, but has not yet reached the gum line.

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