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OPERATIVE DENTISTRY. 
 
LINDSAY & BLAKISTOFS DENTAL PUBLICATIONS. 
 
 1. 
 
 HARRIS'S DICTIONARY OF MEDICAL TERMINOLOGY, DENTAL 
 
 SURGERY, AND THE COLLATERAL SCIENCES. 
 
 Third Edition, carefully revised and enlarged. Royal octavo. 
 
 Cloth, $6 50. Sheep, $7 50. 
 
 HARRIS'S PRINCIPLES AND PRACTICE OF DENTAL SURGERY. 
 
 Ninth Edition, with 320 Illustrations. Royal octavo. 
 
 Cloth, $6 00. Sheep, $7 00. 
 
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 BOND'S PRACTICAL TREATISE ON DENTAL MEDICINE. 
 
 Being a Compendium of Medical Science, as Connected with the Study of Den- 
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 4. 
 ROBERTSON'S MANUAL ON EXTRACTING TEETH. 
 Founded on the Anatomy of the Parts involved in the Operation, &c, &c. 
 Second Edition. 12mo. $1 50. 
 
 5. 
 TAFT'S PRACTICAL TREATISE ON OPERATIVE DENTISTRY. 
 A new "edition, thoroughly revised, containing 86 Illustrations. 
 Octavo. Sheep, $3-45. UJ~o 
 
 6. 
 FOX AND HARRIS ON THE HUMAN TEETH. ' 
 Their Natural History, Structure, &c. With 250 Illustration. Octavo. $4 00. 
 
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 DENTISTRY. 
 With over 100 Illustrations. Octavo. Sheep, $3 50. , 
 
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 10. 
 
 TOMES' SYSTEM OF DENTAL SURGERY. 
 
 With 208 beautifully executed Illustrations. Octavo. Sheep, $4 50. 
 

 PRACTICAL TREATISE 
 
 OPERATIVE DENTISTRY, 
 
 By JR TAFT, 
 
 PROFESSOR OF OPERATIVE DENTISTRY AND DENTAL HYGIENE IN THE OHIO 
 COLLEGE OF DENTAL SUROERY. 
 
 $ttw& ®flitu>», 
 
 WITH 
 
 EIGHTY-SIX ILLUSTRATIONS. 
 
 PHILADELPHIA: 
 
 LINDSAY & BLAKISTON 
 
 1868. 
 
^ 
 
 
 Entered, according to Act of Congress, in the year 1868, 
 
 BY LINDSAY & BLAKISTON, 
 
 In the Clerk's Office of the District Court for the Eastern District of 
 Pennsylvania. 
 
 HENRY B. ASHMEAD, PRINTER, 
 
 Xos. 1102 and 1104 Sansom Street, Philadelphia. 
 
PREFACE. 
 
 SECOND EDITION. 
 
 The preparation of the present edition of this work, 
 has been attended with more labor and effort, than 
 the author had anticipated. 
 
 The first edition at the time of its writing was de- 
 signed to embody and present the principles and prac- 
 tice of the profession in the operative department, in 
 its highest attainment. 
 
 Since that time, however, so great have been the 
 changes in many points of practice and application of 
 principles, that those given as the best, nine years 
 ago, are superseded by others and out of use ; so that 
 in many particulars the labor has been almost equal 
 to the preparation of new matter. 
 
 The object in this, as in the former edition, has been 
 to bring the work up to the present status of the pro- 
 fession ; and though it has been accomplished with 
 many misgivings and consciousness of defects, the 
 author is not without hope that it may be of value to 
 those preparing to enter the profession, if not to those 
 already in it. 
 
 Cincinnati, April 1, 1868. 
 
PREFACE 
 
 The exigences of the Profession seemed to require, 
 for the department of Operative Dentistry, a work 
 that should contain all that is known in this branch 
 of the science. To answer that requirement, the 
 author of the present work has aimed to furnish, in 
 as compact a form as possible, the Principles of the 
 Science, properly digested, the Experiments Detailed, 
 the Manipulations Described, and the whole method- 
 ized and thus made available to the Student and the 
 Practitioner. In the accomplishment of this object, 
 he has, he believes, included everything meritorious 
 or important in this department of Dental Study. 
 
 To the dental writers whose labors have lightened, 
 in any degree, the toil of this undertaking, the intelli- 
 gent reader y T ,ill ascribe the credit due ; and to the 
 members of the profession, whose suggestions have 
 found place in various parts of the volume, the author 
 gratefully acknowledges his obligations. 
 
 J. TAFT. 
 
 Cincinnati, July 1, 1859. 
 
CONTENTS 
 
 ~~. 
 
 
 CHAPTER I. 
 
 
 
 PAffE 
 
 Introduction, . - 
 
 17 
 
 Deposits, ...... 
 
 18 
 
 Tartar, 
 
 18 
 
 Origin of, 
 
 19 
 
 Points of Deposit. 
 
 .20 
 
 Effects of, . 
 
 21 
 
 Method of Removing, . 
 
 22 
 
 Green Tartar, ..... 
 
 24 
 
 Origin of, ... . 
 
 25 
 
 Treatment of, ... 
 
 26 
 
 Irregularity, ..... 
 
 27 
 
 Effects of, . . . . 
 
 28 
 
 Atrophy, . , . . 
 
 29 
 
 Cause of, ..... 
 
 30 
 
 Effects of, ..... 
 
 . 32 
 
 Exostosis, . . . . . . 
 
 31 
 
 Effects of, ..... 
 
 34 
 
 Cause of, ..... 
 
 34 
 
 Denuding, ..... 
 
 35 
 
 Chemical Abrasion, ..... 
 
 
 Cause of, . 
 
 38 
 
 Necrosis of the Teeth, .... 
 
 39 
 
 Causes of, 
 
 41 
 
Xll CONTENTS. 
 
 CHAPTER II. 
 
 Caries of the Teeth, ...... 42 
 
 Causes of Caries, . . . . . .52 
 
 Predisposing causes of Caries, ... 52 
 
 Exciting causes of Caries, . . . .56 
 
 Comparative liability to Decay, ... 63 
 
 Consequences of Caries, . . . . .65 
 
 • Treatment of Caries, . '. . . 67 
 
 CHAPTER III. 
 
 General Remarks on Filling, . . . . .73 
 
 Materials for Filling — their properties, . . 77 
 
 Lead, ....... 81 
 
 Tin, ...... 81 
 
 Silver, ....... 83 
 
 Platinum, ...... 84 
 
 Gold, 85 
 
 Various Preparations of Gold, . . 87 
 
 Crystal Gold, ..... 88 
 
 Amalgam, ...... 90 
 
 Non-metallic Materials, . . . . .93 
 
 Hill's Stopping, ..... 94 
 
 Os Artificial, ...... 96 
 
 CHAPTER IV. 
 
 Instruments for Filling, ..... 97 
 
 Heavy Cutting Instruments, . . . .97 
 
 Drills, ....... 99 
 
 Bur Drills, . .' . . .99 
 
 Scranton's Drill, ..... 101 
 
 Common Drills, ..... 102 
 
 Drill Ring, 103 
 
 Drill Stocks, ...... 103 
 
CONTENTS. 
 
 Xlll 
 
 Broaches, 
 Excavators, 
 
 Manufacture of Excavators, 
 Plugging Instruments, 
 The File, 
 
 File Caries, . 
 
 Use of the File, . 
 
 Mode of using the File, 
 
 104 
 105 
 109 
 111 
 119 
 121 
 122 
 123 
 
 Separation of the Teeth, . 
 
 CHAPTER V. 
 
 CHAPTER VI. 
 
 Filling Teeth, 
 
 Examination, 
 Opening Cavities, 
 Removal of Decay, . 
 Forming Cavities, 
 Drying Cavities, 
 Introducing the Filling, . 
 Cylinder or Block Filling, 
 
 Forming Blocks, 
 
 Introducing the Blocks 
 
 Pellets, 
 
 Adhesive Foil, . 
 
 The Mallet, . 
 Crystal or Sponge Gold, 
 Finishing Fillings, 
 
 CHAPTER VII. 
 
 Classification of Decayed Cavities, 
 
 Filling by Classes and Modifications, 
 First Class, 
 
 Exclusion of Saliva, 
 
 127 
 
 134 
 135 
 136 
 138 
 142 
 150 
 154 
 159 
 160 
 163 
 166 
 167 
 171 
 174 
 179 
 
 183 
 185 
 185 
 188 
 
XIV 
 
 CONTENTS. 
 
 Filling with Foil, . 
 
 
 
 195 
 
 Adhesive Foil, . 
 
 
 . 
 
 196 
 
 Crystal Gold, 
 
 . 
 
 
 198 
 
 1st Modification, . 
 
 
 
 199 
 
 2d Modification, 
 
 . 
 
 
 201 
 
 Second Class, 
 
 
 . 
 
 201 
 
 1st Modification, i . 
 
 - 
 
 
 203 
 
 Third Class, 
 
 
 
 205 
 
 2d Modification, 
 
 . 
 
 
 209 
 
 Fourth Class, . 
 
 
 
 210 
 
 1st Modification, 
 
 . 
 
 
 215 
 
 2d Modification, . 
 
 
 
 217 
 
 3d Modification. 
 
 
 
 218 
 
 4th Modification, . 
 
 
 . 
 
 219 
 
 Fifth Class, 
 
 . 
 
 
 222 
 
 Special Cases, . 
 
 
 . 
 
 226 
 
 The Palatal portion of the Crown broken 
 
 away, 
 
 
 leaving the ou 
 
 ter portion standing- 
 
 -nerve 
 
 
 not exposed, 
 
 . 
 
 
 227 
 
 Filling large Cavities on the Labial Surfaces 
 
 
 of the Superior 
 
 Incisor, 
 
 . 
 
 231 
 
 CHAPTER VIII. 
 
 Pathological Conditions, . 
 Inflamed Dentine, 
 Treatment of Inflamed Dentine, 
 Tannin, or Tannic Acid, 
 Creosote, or Carbolic Acid, . 
 Nitrate of Silver, 
 Chlorid of Zinc, 
 Terchlorid of Gold, 
 Arsenious Acid, 
 Alkaline Caustics, 
 
 233 
 234 
 237 
 240 
 241 
 241 
 243 
 244 
 245 
 247 
 
CONTENTS. 
 
 XV 
 
 CHAPTER IX. 
 
 
 Exposed Pulps, . . 
 
 . 249 
 
 Treatment of Exposed Pulps, . 
 
 251 
 
 Destruction of the Pulp, .... 
 
 . 260 
 
 , Actual Cautery, 
 
 265 
 
 Potential Cautery, .... 
 
 . 266 
 
 Arsenious Acid, . , . . 
 
 266 
 
 Application of, 
 
 . 268 
 
 Filling Pulp-Cavities and Canals, 
 
 273 
 
 Preparing the Teeth and Roots for Filling, 
 
 . 281 
 
 Dental Periostitis, .... 
 
 290 
 
 Treatment of, . . . ... 
 
 . 293 
 
 . Alveolar Abscess, .... 
 
 297 
 
 Treatment of, . 
 
 . 299 
 
 CHAPTER X. 
 
 
 Pivot Teeth, 
 
 307 
 
 Fitting the Crown, . ... 
 
 . 311 
 
 Attachment of the Crown, 
 
 314 
 
 Wood Pivots, ..... 
 
 . 314 
 
 Metallic Pivots, .... 
 
 319 
 
 CHAPTER XI. 
 
 
 Extraction of Teeth, . . . . 
 
 . 325 
 
 General Remarks, .... 
 
 325 
 
 Indications for Extraction, .... 
 
 . 332 
 
 Extracting Instruments, 
 
 334 
 
 The Key, . 
 
 . 336 
 
 Modus Operandi of, . 
 
 336 
 
 The Forceps, ..... 
 
 . 340 
 
 Elevators, ..... 
 
 351 
 
 Hooks, ...... 
 
 . 352 
 
 The Screw, ..... 
 
 353 
 
 The Gum-Lancet, .... 
 
 . 354 
 
 Method of Lancing the Gums, . 
 
 357 
 
XVI 
 
 CONTENTS. 
 
 Extraction of the Teeth, ..... 
 
 358 
 
 Superior Incisors, ..... 
 
 358 
 
 Superior Cuspids, ..... 
 
 361 
 
 Superior Bicuspids, .... 
 
 362 
 
 Superior Molars, ..... 
 
 365 
 
 Extraction of Roots, .... 
 
 367 
 
 Removal of the Dentes Sapientias, 
 
 368 
 
 Extraction of the Inferior Incisors, 
 
 371 
 
 Roots, . 
 
 372 
 
 Inferior Cuspids, ..... 
 
 372 
 
 Inferior Bicuspids, ..... 
 
 374 
 
 Inferior Molars, . . . . 
 
 375 
 
 Inferior Dentes Sapientiae, . ... 
 
 379 
 
 Extraction preparatory to the Insertion of Artificial 
 
 
 Dentures, ..... 
 
 380 
 
 Conditions to be observed in the Extraction, . 
 
 382 
 
 CHAPTER XII. 
 
 
 Accidents in the Extraction of Teeth, 
 
 388 
 
 Hemorrhage, ...... 
 
 389 
 
 Treatment, ...... 
 
 391 
 
 Fracture of the Alveolus, ..... 
 
 400 
 
 Laceration of the Gums, .... 
 
 402 
 
 Breaking the Teeth, ..... 
 
 402 
 
 Removal of a Wrong Tooth, .... 
 
 403 
 
 Dislocation of the Inferior Maxillary, 
 
 406 
 
 Syncope, ...... 
 
 408 
 
 CHAPTER XIII. 
 
 
 Anaesthetics, . . . . . . . 
 
 410 
 
 Ether — Chloroform, ..... 
 
 410 
 
 Nitrous Oxide, ...... 
 
 415 
 
 Local Anaesthesia, ..... 
 
 416 
 
 Congelation, ...... 
 
 416 
 
 Extraction by Electro-Magnetism, 
 
 420 
 
 Application, ...... 
 
 422 
 
OPERATIVE DENTISTRY. 
 
 CHAPTER I. 
 
 INTRODUCTION. 
 
 As introductory to the following treatise, a cursory 
 consideration of those conditions and diseases of the 
 teeth which require the aid of dental surgery, would 
 seem appropriate. To refer, however, to all of these, 
 or to remark extendedly upon any of them, would 
 not be consistent with the design of this work, or 
 necessary to a proper understanding of the subjects 
 proposed. Only those affections which pertain to the 
 teeth directly, and which for the most part, are con- 
 fined to the tooth-substance itself, will here be con- 
 sidered. Nor will the pathology of contiguous parts 
 be introduced ; for the treatment of these, being 
 mainly therapeutic rather than surgical, would involve 
 a discussion of questions not within the scope of the 
 present volume. Indeed, it is proposed merely to 
 speak of those affections of the teeth, which generally 
 
18 INTRODUCTION. 
 
 suggest surgical remedies, and which are implicated 
 more or less in the operations described in the follow- 
 ing pages ; and first, of 
 
 DEPOSITS. 
 
 In this term are included those calcareous forma- 
 tions commonly called tartar, a certain coloring mat- 
 ter denominated green or brown stain, and such other 
 impurities on the teeth as result from neglect, the use 
 of tobacco, and like causes. The word 
 
 TARTAR 
 
 Implies all calcareous desposits upon the teeth. Of 
 this substance there are several varieties, the more 
 obvious of which have respect to color, composition 
 and consistence. In color, there are all shades, from 
 a white as light as that of the tooth, or even lighter, 
 to a jet black ; and in consistence, all degrees, from a 
 thick, gummy mucus, to nearly the density of the den- 
 tine itself. The color will, in most cases, be indicative of 
 the density, the lightest shade corresponding with the 
 softest, and the darkest with the hardest consistence. 
 The tenacity to the teeth is also in proportion to the 
 density, the dense and dark adhering most firmly. 
 The density of the desposit, too, is generally indicative 
 
TARTAR. 1 9 
 
 of the rapidity of its formation, being in an inverse 
 ratio to this. 
 
 All the varieties of tartar are composed principally 
 of the same elements, — phosphate of lime, fibrin, fat, 
 and animal matter being contained in them all, though 
 in various proportions. The fact that some varieties 
 are soluble in acids, and others not, has been adduced 
 to prove that they are entirely different in their com- 
 position. This, however, is accounted for on another 
 hypothesis : in the softer varieties, the phosphate of 
 lime is so protected by the fat and the animal matter 
 that, under ordinary circumstances, acid can not come 
 in contact with it; but the dense varieties are very 
 soluble, because the acid readily comes in contact with 
 the calcareous material. 
 
 Its origin. — It is a precipitate of the saliva, — or at 
 least the phosphate of lime, and probably the fibrin, 
 comes into the mouth with the saliva ; while perhaps 
 the fat and other animal matter are deposited from 
 the mucus. In all cases in which this substance is 
 formed upon the teeth, the saliva has a definite alka- 
 line character, holding in solution the phosphate of 
 lime, which, by the action of the acid mucus upon the 
 saliva, is precipitated. 
 
 Persons of a lymphatic temperament, or a tendency 
 toward it, with muscles of a soft, flabby texture, hair 
 light, teeth of a rather inferior quality, and a free flow 
 
20 INTRODUCTION. 
 
 of saliva, are most subject to the deposition of tartar; 
 yet there are conditions of almost all constitutions, 
 in which it is freely eliminated. That it is precipi- 
 tated from the saliva, is a fact so easily demonstrated 
 and so generally admitted, that it need not here be 
 considered. 
 
 Points of Deposit. — The points at which salivary 
 calculus is deposited in the greatest quantities upon 
 the teeth, are in the vicinity of the orifices of the sali- 
 vary ducts ; and hence it is found most abundant on 
 the lingual surfaces of the inferior anterior teeth, and 
 on the buccal surfaces of the superior molars. Fre- 
 quently, also, it collects in considerable quantities 
 upon the external surfaces of the inferior front teeth. 
 The points upon the teeth to which it most readily 
 attaches, are at the necks, immediately beneath the 
 free margin of the gum, and at the termination of the 
 enamel where it is thickest. A nucleus once formed, 
 and it encroaches upon the crown of the tooth, if no 
 means are employed to prevent its lodgment, at a 
 rate determined by the condition of the saliva. 
 
 It is deposited first and most abundantly on the 
 necks of the teeth, because here the saliva first comes 
 in contact with these organs, and here remains for 
 the longest periods and in the largest quantities. 
 That it is precipitated very soon after the saliva 
 enters the mouth, is evident from the fact that it is 
 
TARTAR. 21 
 
 found collected upon the superior molars, just in the 
 vicinity of the orifices of the ducts-of-Steno, where 
 the saliva cannot be retained for any considerable 
 time, by reason of the position, but must very soon 
 pass along upon the surfaces of the contiguous teeth, 
 on which we generally find it deposited in much 
 smaller quantities. Indeed, this calcareous material 
 has been sometimes found in the salivary ducts them- 
 selves. > 
 
 Its Effects. — It exercises no directly injurious influ- 
 ence upon the substance of the teeth ; but it is highly 
 prejudicial to the parts immediately in connection 
 with them, upon which they depend for support. It 
 encroaches upon the gums and alveoli, and causes an 
 absorption of these important surroundings ; and as 
 they become absorbed, its encroachments are con- 
 tinued and accelerated. In some constitutions this 
 process goes on with little or no annoyance to the 
 patient; while in others, irritation, inflammation, and 
 even suppuration of the gums occur ; and thus their 
 destruction is effected in a twofold manner. This 
 irritation and inflammation may extend to the mucous 
 membrane, and involve all the adjacent parts. The 
 dental periosteum, will usually become implicated in 
 the difficulty ; periostitis will ensue, and often sup- 
 puration, thus' breaking up the attachments of the 
 teeth even before the surroundings are removed. 
 
22 INTKODUCTION. 
 
 The alveolus, too, becomes diseased, and in some in- 
 stances its death and exfoliation result. Salivary cal- 
 culus, however, never induces caries of the teeth, nor 
 even favors it; except by inducing disease in the 
 surrounding parts. On the contrary, we frequently 
 meet with instances of decay entirely arrested by a 
 deposit of tartar in the cavity. ' 
 
 Persons of all ages are subject to this affection ; 
 those past middle life being most so, and those 
 advanced in years sometimes having teeth nearly 
 covered with tartar. Occasionally to such an extent 
 
 Fig. 1. 
 
 do the roots become invested with it that the teeth 
 drop from the sockets. There are some constitutions 
 whose diathesis is favorable to a deposition of sali- 
 vary calculus through life. Others, again, will be 
 entirely exempt from it till some peculiar constitu- 
 tional change intervenes, when it will begin to be 
 rapidly eliminated. 
 
 Method of removing it.- — The removal of salivary 
 calculus is an operation that does not involve a great 
 
TARTAR. 
 
 23 
 
 amount of skill, but, with suitable appliances, is 
 easily performed. There are two methods of effect- 
 ing it; the one, that of scaling and scraping, and the 
 other, that of decomposing the deposit by the appli- 
 cation of an acid. The former is always to be pre- 
 ferred; for, in the latter, the chemical action of the 
 acid does not stop with a decomposition of the de- 
 posit, % but, by the same affinity, and nearly as readily 
 attacks the tooth itself. For the successful accom- 
 plishment of the operation, instruments of various 
 forms and curves will be necessary, adapted and ad- 
 justed to the various shapes and situations of the 
 surfaces to be operated upon. The most common 
 forms are represented in the following figure. The 
 blade of the instrument should be applied at a slightly 
 obtuse angle with the surface of the tooth, just beyond 
 
 Fiji. 2. 
 
 the edge of the deposit next the gum, and thus slid 
 under the tartar, scaling it off to the point, in such a 
 manner as not to roughen or abrade the enamel. De- 
 
24 INTRODUCTION. 
 
 posits of this substance on proximal surfaces of the 
 teeth are to be carefully observed, and removed with 
 instruments of attenuated blades. When the thick 
 incrustations have been thus removed, the surface 
 should then be gently scraped, so as entirely to clean 
 off all remaining portions, and afterward thoroughly 
 polished with fine pumice, or Arkansas or rotten-stone, 
 and finished by burnishing. During the operation, a 
 frequent employment of the toothbrush with water 
 will be required, to cleanse the mouth of the detached 
 deposits and the increased secretions; and, in general, 
 the completion of the process will occupy more than 
 one sitting. Since this deposit often extends beneath 
 the free margin of the gum, much care is necessary 
 to see that it all be removed. 
 
 GREEN TARTAR. 
 
 This deposit has been so referred to by writers, as 
 to convey the impression that it is of the same 
 generic character as salivary calculus. Such a mis- 
 apprehension is hardly pardonable. The teeth of 
 young persons only are subject to this affection, it 
 being often found on those of children three or four 
 years old ; appears on the labial surfaces of the su- 
 perior front teeth, and in largest quantity near the 
 margin of the gum. It is seldom seen on the inferior 
 
GREEN TARTAR. Zb 
 
 teeth, and only on the anterior surfaces of the super- 
 ior. The color of this deposit varies from a light 
 brown to very dark, inclining to green. Wherever 
 it attaches, the surfaces of the teeth are abraded, and 
 when it is of long standing, the entire enamel beneath 
 it is destroyed, and the dentine is gradually involved 
 in the dissolution. This effect upon the teeth is not 
 produced by the coloring matter observed upon them, 
 but by an acid in combination with this material 
 before it is deposited. The stain is a precipitate 
 from this compound, and the acid, leaving this, com- 
 bines with the calcareous ingredients of the teeth, to 
 their detriment as above; but the precipitate is en- 
 tirely innocent. 
 
 Its Origin. — Green tartar, or green stain, doubtless 
 has its origin in the mucus, when this is in a particular 
 acid condition. That it does not proceed from the 
 saliva is proved by the fact that it is never found 
 where there is a free flow of saliva, or where it has 
 free access; but the point of its deposit is where 
 the saliva is least frequently present, being most 
 abundant in cases in which there is a large relative 
 amount of mucus, and this in a very acid condition. 
 But the query might arise here, if the mucus of the 
 mouth were wholly in that condition, why would not 
 the teeth suffer from it elsewhere. Because, on the 
 masticating surfaces of the teeth, the friction of the 
 
26 INTRODUCTION. 
 
 food will prevent it, and on the inner surfaces, the 
 friction of the tongue; besides, wherever there is a 
 free flow of saliva, this will have a counteracting 
 effect. Decay goes on very rapidly, after it has once 
 commenced, upon teeth affected by this deposit. 
 
 There are points of dissimilarity between this green 
 tartar or stain and salivary calculus, that it may be 
 well to notice. The latter is from the saliva; the 
 former from the mucus; and hence the one exists 
 Avhere there is an abundant flow of saliva, and the 
 other where the relative quantity of this is small. The 
 calculus is deposited when the saliva is in an alkaline 
 condition; the stain, when the mucus is very acid. 
 The former is deposited in large quantities and thick 
 incrustations, and upon the surfaces of the teeth, and 
 is easily removed without detriment to their substance; 
 whereas the latter is a thin film, barely sufficient to 
 stain the surface, and yet it enters into the tooth- 
 substance itself, and cannot be removed without 
 detaching some portion of the tooth with it. The one 
 seems rather preventive of caries, which does not occur 
 beneath it; but the other is highly promotive of decay. 
 With these marked features of difference, it is sur- 
 prising that the two should ever have been confounded, 
 since it is so important that the distinctive character 
 of each be understood, in order to its correct treatment. 
 
 Treatment. — In order to a perfect and final remedy 
 
IRREGULARITY. 27 
 
 for green stain, therapeutic treatment must be com- 
 bined with the operative; but only the latter will be 
 here described, which has for its object the removal 
 of the deposit, and the rendering of the eroded sur- 
 face smooth and polished. There are two or three 
 methods of accomplishing this object. When the 
 erosion is but slight, it will be effected with Arkansas- 
 stone, or pulverized pumice and water applied with 
 a wooden polisher of the proper form till the stain 
 disappears, and with the subsequent use of the 
 burnisher with a solution of soap. But when the 
 erosion is too extensive to be thus reduced, it must be 
 cut down with a file, and then finished with stone and 
 burnisher, as before. And when the erosion is extreme, 
 a cutting-instrument must precede the file. 
 
 IRREGULARITY. 
 
 By this term we imply those variations from a 
 beautiful and natural position, in which the teeth are 
 so frequently found. The principal cause of irregu- 
 larity is a disproportion between the actual size of the 
 arch, and the size required for the accommodation of 
 the teeth. When this disproportion exists, the teeth 
 which are first erupted, occupy very nearly their 
 proper position; but those which come in afterward, 
 are more or less disarranged, in proportion to the pre- 
 
28 INTRODUCTION. 
 
 occupation of the space. There are cases in which 
 the roots of the temporary teeth are not absorbed, 
 and the permanent teeth are erupted out of their 
 true position, even when there is room enough for 
 them were the former removed. Irregularity is mainly 
 confined to the front teeth, and consists in either 
 an inward or an outward inclination, and, in some 
 instances, both. Sometimes the incisors are turned 
 round in the socket, so that the edge stands at a very 
 considerable angle with the proper position. 
 
 The upper teeth are oftener materially disarranged 
 than the lower, though the latter frequently exhibit 
 some irregularity in front, in consequence of a crowded 
 condition. The teeth most liable to be out of position 
 are the cuspidate. These, of the teeth of replacement, 
 are the last in their eruption; and it often occurs that 
 the arch is previously well-nigh occupied; in which 
 case they are thrown outward. When there is any 
 irregularity of the bicuspids, it is that of an inward 
 inclination. The first and second molars are very 
 seldom out of proper position. The third molars, 
 however, for want of room, are sometimes thrown out 
 toward the cheek, or even prevented from coming out 
 at all in any direction. 
 
 Effects. — In all cases, irregularity is favorable to 
 decay. It is even maintained by some that the organic 
 structure of irregular teeth is less perfect than that 
 
ATROPHY. 29 
 
 of regular, because the former are impeded in their 
 eruption, and thus impaired. But this, to say the 
 least, is questionable; for it will be remembered 
 that the crowns of the teeth are formed and ossified 
 before they can be much affected by a crowded state; 
 and it is hardly probable that they could be materially 
 modified in their structure after this period. The 
 crowns of the teeth are rarely if ever deformed by a 
 crowded condition. The principal cause of the liability 
 of irregular teeth to decay, is the facility they furnish 
 for the lodgment of foreign substances about them, 
 and the difficulty they present to its removal. And, 
 again, in irregular teeth, parts are approximated that 
 nature did not intend should be brought together. 
 Irregularity impairs the speech, impedes the mastica- 
 tion, and often distorts the countenance and deforms 
 the features. 
 
 ATROPHY. 
 
 This affection is characterized by defective spots in 
 the enamel, white, chalk-like — which scarcely ever 
 penetrate the dentine. In these spots there is little 
 or nothing of that organic structure exhibited by well 
 formed enamel. They are in all cases quite small, 
 but vary greatly in number. They are often found 
 arranged in transverse rows across the tooth affected. 
 
30 INTRODUCTION. 
 
 The superior incisors are most frequently found with 
 atrophy, though the biscuspids and molars sometimes 
 exhibit it. The front upper teeth are attacked by it 
 only on the anterior surfaces. 
 
 Instead of the spots we sometimes find pits, or 
 indentations, into or through the enamel, which occa- 
 sionally run together, so as ultimately to form trans- 
 verse grooves of considerable extent upon the teeth. 
 In many cases, where on the eruption of the teeth 
 the spots only are presented, the organs are not 
 injured, except in appearance, the spots retaining 
 the smooth, enamel-like surface during life. In other 
 cases, the spot is of such a soft, friable texture, that 
 it early crumbles out, leaving the little pits above 
 referred to. These indentations, however, sometimes 
 exist at the first appearance of the tooth, but more 
 frequently afterward, being formed by the disintegra- 
 tion of the defective portion. 
 
 Atrophy usually occurs on teeth of good structure, 
 short, thick crowns, and rather yellowish color. The 
 long, thin, white tooth, of imperfect organization and 
 insufficient density, seldom or never presents an atro- 
 phied condition. 
 
 The Cause. — It may be difficult to point out the 
 precise cause of this affection, but some facts in re- 
 gard to it are very obvious. There is, in every case, 
 an obstruction in the development of the enamel at 
 
ATROPHY. 31 
 
 the point of defect, and at the time of its origination. 
 In some cases, doubtless, there are a deficient amount 
 and an inferior quality of the material elaborated for 
 the upbuilding of the structure; and this is probably 
 the case when the pits exist at the eruption of the 
 teeth. In other cases, the requisite quantity of 
 material may be elaborated, and yet the vital energy 
 be insufficient to organize it, as in the case of the 
 spots referred to. The latter condition is more fre- 
 quent than the former, as is evidenced by the more 
 frequent appearance of the spots than of the pits. 
 We are led to infer, then, that the origin of this 
 affection is for the most part constitutional, and not 
 local. There are commonly found traces of it on all 
 the teeth whose enamel was in process of formation 
 at the time of the interruption. 
 
 Any general disturbance, such as to interrupt the 
 assimilative process, would be detrimental to the per- 
 fect formation of the tooth. Again, some affections 
 may materially affect the organizing power of the 
 system, without interfering with the assimilative 
 power. Any disease that should interrupt the func- 
 tions of the digestive apparatus, would be prejudicial 
 to the process of assimilation; whilst other diseases, 
 such, for instance, as those of a febrile character, 
 would diminish the vital power, and consequently 
 the ability to build up organic structures, without 
 
82 INTRODUCTION. 
 
 interrupting in any special manner the process of 
 assimilation. These things are referred to here for 
 the purpose of showing under what circumstances 
 atrophy of the teeth may occur. 
 
 Effects. — In the best formed teeth, there are no 
 unpleasant results from atrophy, other than its de- 
 traction from their beauty. The spots are unsightly, 
 and when the pits are present, they become dark, 
 and sometimes black, from deposit; which, by ordi- 
 nary means, is difficult of removal. In teeth of infe- 
 rior structure, decay often supervenes in these pits, 
 and, extending thence, involves the other parts ; and 
 anything that will affect the tooth-substance, will 
 affect the spots in a greater degree. 
 
 EXOSTOSIS. 
 
 This term, critically defined, implies outgrowth from 
 a hone; but, as applied to the bones generally, and 
 particularly to the teeth, it probably conveys the idea 
 of growth upon the lone. The affection thus denomi- 
 nated is common to all the bones; some, however, 
 being more frequently attacked by it than others. 
 It occurs upon the roots of the teeth, but is never 
 developed where there is no periosteum. The man- 
 ner of its deposit is not uniform ; but it is commonly 
 in an enlargement on the point of the root, or from 
 
EXOSTOSIS. 33 
 
 the point some distance toward, and occasionally all 
 the way to, the neck of the tooth. In some cases, it 
 extends entirely round the root, and in others, is con- 
 fined to one side. It sometimes results in such an 
 enlargement of the root, especially if it is near the 
 point, as to render the tooth very difficult of removal. 
 When it is bulb-form, the entire attachment of the 
 tooth may be broken up, so as to allow this to rotate 
 in the socket, and yet the tooth be very difficult to 
 remove; indeed, in some instances, impossible, with- 
 out cutting away a portion of the process. 
 
 The density of the deposit is usually greater than 
 that of the root on which it is found; though in this 
 respect there is considerable variation : in a few in- 
 stances we have found it softer than the root proper. 
 The surrounding parts are absorbed for its accommo- 
 dation. The color of the substance is slightly yellow, 
 not differing much from that of the root itself; and 
 frequently it exhibits a semitranslucent appearance. 
 The rate of its formation varies considerably, some- 
 times increasing so rapidly as to occasion much diffi- 
 culty, and at other times seeming to advance very 
 slowly ; and frequently it is arrested altogether. 
 Roots are often found affected with exostosis, that 
 have been dead and crownless for a number of years. 
 and yet have never, so far as known, given any trouble 
 
 c 
 
84 INTRODUCTION. 
 
 because of the affection; and teeth perfectly healthy 
 in other respects may be thus affected. 
 
 Its Effects. — It always increases the difficulty of 
 removing the tooth, either by enlargement of the point 
 of the fang, or by deposit upon one side of it, causing 
 it to curve; in which latter case the difficulty is all 
 the greater, from the impossibility of determining the 
 direction of the curve. It sometimes produces a 
 diseased condition of the surrounding parts — in some 
 instances chronic inflammation — that may continue as 
 long as the tooth remains. Nervous affections often 
 result from exostosis, either through irritation caused 
 by pressure on the nerve, or through the diseased 
 condition of the surrounding parts. The floor of the 
 antrum is sometimes absorbed away, in consequence 
 of the enlargement of the point of the fang; and then 
 disease of the lining membrane of that cavity may 
 occur. 
 
 The Cause. — The cause of this affection is not well 
 understood. Though much light has been thrown 
 upon it by the researches upon the reproduction of 
 bone, and especially so far as the function of the 
 periosteum is concerned. It is most probably deposited 
 by the periosteum when this is in an abnormal condition; 
 but what peculiar condition, it is not clearly ascer- 
 tained, though some have supposed it to be inflamma- 
 tion. It is patent, however, that something more than 
 
DENUDING. 35 
 
 a state of simple inflammation exists ; for there is in- 
 flammation in numerous instances without this deposit. 
 Again, in all cases where there is periostitis, that 
 state is definitely indicated by percussion upon the 
 affected tooth: indeed, in the occlusion of the jaws, 
 pain is usually experienced. Yet there are found 
 many teeth whose roots are subjects of this deposit, 
 that have never given any indications, either by pain 
 or otherwise, of a diseased condition. 
 
 This subject is one in which there is room, at least 
 so far as dentists are concerned, for extensive obser- 
 vation. 
 
 DENUDING. 
 
 This consists in a wasting away of the enamel of 
 the anterior teeth, from the points toward the necks. 
 The affection, however, is of too rare occurrence to 
 demand extended consideration. The color of the 
 enamel is not changed by this process, nor is its 
 natural polish impaired by any abrasion. The dentine, 
 on becoming exposed by this removal of its natural 
 protection or covering, is perfectly smooth, but of a 
 yellowish cast, in some cases inclining to brown. 
 When the enamel is removed, there seems to be a 
 cessation of the destructive process; for the crowns 
 of such teeth will, in many instances, endure for a 
 t 
 
36 INTRODUCTION. 
 
 long time — indeed, till they are worn down by the 
 friction in mastication. 
 
 This wasting process usually begins at the points 
 of the teeth, and proceeds toward the necks, on all 
 sides, till the enamel is entirely destroyed. Sometimes, 
 however, it commences on their labial surfaces; this 
 is particularly the case with the superior anterior, 
 but very seldom with the inferior teeth. The affection, 
 however, attacks the inferior more frequently than 
 the superior teeth; yet it is found assailing both with 
 about equal energy. 
 
 The cause of the disease is not well understood, 
 though it is generally conceded to be the operation 
 of an acid contained in the mucus. Doubtless, the 
 agent producing the affection is contained in the mucus; 
 for it usually occurs where there is a large relative 
 amount of this secretion ; but that it is an agent of a 
 very decided acid character, we are not prepared to 
 affirm. Decay of the teeth does not seem to progress 
 with greater rapidity while this affection exists, than 
 at other times; and again, the enamel does not present 
 the roughened, abraded appearance we find resulting 
 from the operation of any ordinary agent. With these 
 apparently incongruous facts, it is rather difficult to 
 arrive at a definite conclusion as to the precise manner 
 in which this condition is produced, or the exact 
 character of the agent instrumental in its production. 
 
CHEMICAL ABRASION. 37 
 
 CHEMICAL ABRASION. 
 
 This consists in a gradual destruction of the entire 
 substance of the crown of the tooth — the enamel and 
 the dentine. It is an affection of comparatively rare 
 occurrence. It assails the superior more often than 
 the inferior teeth, though both are subject to it. It 
 begins upon the points of the central incisors, wasting 
 them away most rapidly at the median line, from 
 which it progresses each way, involving the lateral 
 incisors, cuspids, and sometimes the bicuspids, so that 
 a curved line is presented by the edges of the teeth, 
 of greater or less inclination, according to the rapidity 
 of the process. When the superior teeth only are 
 affected, the opening between the ends of the upper 
 and of the lower front teeth, when closed, is a semi- 
 ellipsis. If the inferior teeth are affected, as is some- 
 times the case, then the opening will be an ellipsis. 
 
 In the case of Mr. Gr., the affection had been in 
 process about two years and a half; the wasting away 
 extended to the first bicuspids both above and below ; 
 and when the jaws were closed, the ends of the upper 
 and of the lower central teeth were about one third 
 of an inch asunder, and the opening was of the 
 elliptical form. It was a mystery to him. Two years 
 and a half before, his anterior teeth shut close together 
 
38 INTRODUCTION. 
 
 on the ends. He had not used them in the mastica- 
 tion of his food, for his molar teeth were all good, 
 and sufficient for this purpose; and moreover it had 
 been impossible for him to use them in mastication, 
 since he could not bring them together; and he had 
 not been in the habit of putting any hard substance 
 between them. 
 
 The Cause. — The cause of this affection, like that 
 of denuding, is not well understood. It is supposed, 
 however, to be induced by an acid contained in the 
 mucus. If this supposition is correct, it must be 
 some -acid with whose nature we are but little, if at 
 all, acquainted; or, if any ordinary acid, it certainly 
 must be modified by very peculiar circumstances, so 
 that it effects a solution of both the animal and earthy 
 constituents. The surface upon which it acts is always 
 perfectly smooth and polished, never presenting that 
 roughened and abraded appearance caused by the ac- 
 tion of any ordinary acid upon enamel or dentine. 
 And again, if this affection results from the operation 
 of an acid in the mucus, why does not this acid, to 
 some extent at least, affect the teeth at other points? 
 Such is not the fact; and caries that has previously 
 commenced at other points on the teeth, does not 
 progress more rapidly during the existence of this 
 disease, than before ; but it certainly would, if there 
 were a large quantity of acid in the mucus. 
 
NECROSIS OF THE TEETH. 39 
 
 It has been supposed that the mucous follicles of 
 that part of the tongue which comes in contact with 
 the teeth at the affected part, are the agents that 
 produce the disease. Of this, however, there is not 
 evidence sufficient to warrant an adoption of the 
 theory. The cupping of the molars and bicuspids 
 bears strong indications of being an analogous pro- 
 cess, and yet no such influence can exist for its ac- 
 complishment. We have no theory on this subject 
 to present, regarding it as still an open field for in- 
 vestigation. There can be little doubt, however, that 
 the cause of denuding, of chemical abrasion, and of 
 cupping, has its origin in the constitution, is not 
 merely local, and may be removed, and the affection 
 arrested by constitutional treatment. 
 
 NECROSIS OF THE TEETH. 
 
 By this term is understood the death of the part 
 affected. It has been remarked that the condition is 
 similar to mortification in the soft parts of the sys- 
 tem. But in the latter there occurs a change of 
 structure; whereas, in the bones, and particularly in 
 the teeth, there is not necessarily any structural 
 change consequent on the loss of vitality. The teeth 
 have their organic connection with the surrounding 
 parts by the external and the internal periosteum 
 
40 INTRODUCTION. 
 
 and the pulp ; their crowns depend chiefly for vitality 
 upon the internal organism, as is evident from the 
 total loss .of sensibility in them immediately after the 
 destruction of the pulp. 
 
 Necrosis of the teeth differs from that of the other 
 bones in some particulars, one of the most obvious of 
 which is, that in the former there is no exfoliation, 
 the living structure not having the power to throw 
 off the dead or necrosed portion. Again, a dead part 
 in contact with the living, does not materially affect 
 it. The roots of the teeth depending for their vi- 
 tality upon both their internal and their external 
 connections, the former of these connections may 
 be destroyed, without materially affecting the latter. 
 Thus, a tooth may be partially necrosed, — that is, 
 vital in one part and dead in another, — without im- 
 mediate injury to the living portion, and without 
 separation of the living from the dead. It is a happy 
 provision that the analogy between the teeth and 
 the other bones does not, in this respect, obtain ; for 
 if it did, we should find the crowns of the teeth sepa- 
 rated from the roots in all cases, immediately after 
 the death of the pulp. 
 
 There results but little change of color to the teeth 
 from necrosis, unless coloring matter is absorbed by 
 the dentine from the decomposed pulp; though of 
 course the lifelike lustre and appearance of the 
 
NECROSIS OF THE TEETH. 41 
 
 living teeth are not present. Total necrosis destroys 
 the entire organic connection of the teeth with the 
 surrounding parts; in which case they are immedi- 
 ately expelled from their sockets as useless. 
 
 Causes. — Caries is a very common cause of ne- 
 crosis, especially the partial form of it to which 
 reference is made above. Protracted fever, or dis- 
 eases of any kind that diminish the vitality of the 
 constitution, will in a corresponding degree diminish 
 that of the teeth, and sometimes destroy it entirely. 
 Excessive medication, especially with mercurials, will 
 sometimes produce partial, and occasionally total ne- 
 crosis, as will also sometimes blows or violent shocks, 
 when these are not sufficient to displace the teeth. 
 Great and sudden changes of temperature have been 
 reckoned causes of this affection ; but it may well be 
 doubted whether they are adequate, without the con- 
 currence of other influences. 
 
CHAPTER II. 
 
 CARIES OF THE TEETH. 
 
 Notwithstanding the teeth are so important in 
 the human economy, having functions so various and 
 so extensive to perform, they are greatly neglected 
 in most instances, and, in many subjected to positive 
 violence; as, for example, in crushing or biting hard 
 substances, sustaining weights, and suffering severe 
 percussion, sudden extremes of temperature, bungling 
 dental operations, etc. Very few give that attention 
 to these organs, which is requisite to preserve them 
 from injurious influences ; and, owing to artificial 
 modes of life, and consequent impairment of health, 
 this is often difficult to do. Indeed, these influences 
 are frequently not known, and the causes of disease 
 in the teeth not explored. 
 
 Such is the truth, to some extent, in regard to 
 caries ; though this affection is more generally a re- 
 sult of conditions well understood. The dentine is 
 affected more frequently by caries than by any other 
 form of disease. It is both frequent in occurrence 
 and fatal in tendency. Scarcely any that have at- 
 
CARIES OF THE TEETH. 43 
 
 tained maturity, are exempt from its ravages. It is 
 a disease which the vital forces, owing to the nature 
 of the tissue, can but feebly withstand, at least with 
 far less efficiency than in more highly organized 
 structures ; and the restorative process is wholly in- 
 operative here. Some maintain that softened dentine 
 does in many cases regain its normal density ; but 
 this cannot be, unless it retains its vitality. But 
 any agent possessed of sufficient energy to decompose 
 the dentine, will destroy its vitality. What is that 
 decomposition ? Either a lack of vital power to 
 maintain the integrity of the organic structure, or 
 the action of some agent having an affinity for a cer- 
 tain part of the dentine more potent than that vital 
 power. In either case, the vitality is destroyed. In 
 an organized structure, removal of one of its essential 
 constituents occasions a loss of vitality. 
 
 Caries usually makes its first attack upon the den- 
 tine, and progresses most rapidly in the direction of 
 the tubuli. There are variations from this course; 
 as, for example, in the large superficial caries on the 
 labial surfaces of the superior incisors. In many 
 cases, too, it advances immediately beneath the en- 
 amel. Portions of the dentine imperfectly protected 
 by the enamel, on account either of an injured con- 
 dition or of an imperfect formation of the latter, are 
 liable to be attacked by this disease ; and points that. 
 
44 CARIES OF THE TEETH. 
 
 by their location or any other unfavorable circum- 
 stance, retain injurious agents in contact with the 
 tooth, are very subject to decay. 
 
 The attack and progress of caries are modified by 
 the constitution of the teeth. These may be defec- 
 tive either originally or accidentally. Original de- 
 fectiveness would extend to all the teeth of the same 
 individual, whilst accidental might exist only as to 
 some of the teeth in the same mouth, and these only 
 at particular points. Such conditions are peculiarly 
 favorable for the attack of caries. When the whole 
 crown of the tooth is imperfectly organized, the decay 
 will advance with uniform rapidity, till the whole is 
 destroyed. But when it is only portions of the tooth, 
 the caries, after a time, becomes retarded in its pro- 
 gress, and in some cases checked altogether. 
 
 Among the circumstances which modify the pro- 
 gress of this disease, are, a change of the condition 
 or character of the agencies producing it, and an 
 increase or a diminution of the amount of such agen- 
 cies. The progress of caries will also be governed 
 somewhat by the age of the person whose teeth it 
 attacks, and by the peculiar constitution of the 
 organs themselves ; for, in regard to constitution, 
 these present an almost infinite variety, the relative 
 proportions of their constituents being exceedingly 
 various, even in persons of the same age, and con- 
 
CARIES OF THE TEETII. 45 
 
 tiimally varying in the same person at different ages. 
 There is a constant change going on, the calcareous 
 elements increasing, and the animal decreasing. But 
 a proper relative amount of elements may be elabo- 
 rated, and yet a defective organization exist. This 
 condition arises from defective organizing power, or 
 from a failure in arrangement and combination of the 
 materials; and is dependent entirely on accidental 
 causes. In vital energy, indeed, the teeth exhibit 
 great diversity; and this corresponds with, and to 
 some extent depends upon, the vital energy of the 
 general constitution. Dead dentine is decomposed 
 more readily than living ; and hence the conclusion 
 that vitality resists caries, and that this resistance 
 corresponds with the vigor of the vitality. 
 
 The points most frequently attacked by caries, are 
 the proximal surfaces of the teeth, the indentations 
 and fissures on the masticating surfaces of the molars 
 and bicuspids, the longitudinal depressions on the 
 buccal and palatal walls of the molars, and the necks 
 of the teeth at the termination of the enamel. On the 
 proximal surfaces, the enamel is thinner than else- 
 where ; and the situation is peculiarly favorable for 
 the accumulation and retention of injurious agents. 
 The union of the enamel in the fissures and indenta- 
 tions of the crowns of the molars, is often imperfect ; 
 and thus there is a way of entrance for vitiated fluids 
 
46 CARIES OF THE TEETH. 
 
 to the dentine. Decay is found at the terminations 
 or intersections of these fissures earlier than at any 
 intermediate points. The indentations, or grooves. 
 on the sides of the teeth, are usually attacked by ca- 
 ries at that point next to the neck. Less frequently. 
 the disorder is exhibited at the neck, just beneath the 
 border of the enamel, under which it barrows with a 
 transverse extension. 
 
 The order in which the elements are removed, is 
 governed by the nature of the agent which effects the 
 decomposition ; and this is usually one having an 
 affinity for the calcareous elements strong enough to 
 destroy the texture of the dentine, and remove the 
 earthy portion. Those acids which have an affinity 
 for the lime of the dentine, produce its decomposition 
 in this manner. When the decay is thus caused, the 
 portion remaining in the cavity is soft, and approximates 
 the gelatinous condition as the calcareous material is 
 abstracted. Agents of a different character, too. often 
 produce decay. Alkalies will act upon the animal 
 portion of the dentine, and remove it; and in caries 
 thus produced, the residue is friable and chalk-like. 
 
 In other cases the constituents are simultaneously 
 removed. Nitric acid will cause an entire breaking- 
 up of both the earthy and the animal constituents. 
 
 The dentine outside of the decay may be in an in- 
 flamed and irritable condition, so that contact with the 
 
CARIES OF THE TEETH. 47 
 
 decayed portion will produce pain : and thus we may 
 he led falsely to conclude that the softened dentine is 
 sensitive; and, indeed, it is maintained that in some 
 cases the partially decomposed dentine is so, on the 
 supposition that a small portion of the calcareous 
 elements may be removed, and yet the vitality of the 
 part, not be destroyed. 
 
 The progress of caries is far more rapid in the crowns 
 of the teeth than in the roots, for the reason that the 
 former are more exposed to the influences of external 
 injuries . It is true that the crowns are covered by 
 enamel, which is designed to shield the dentine from 
 injury, but which is often defective, and on which are 
 accumulated agents that it can not resist, even when 
 it is perfect ; so that the enamel itself is sometimes 
 decomposed. The roots, too, possess a higher degree 
 of vitality than the crowns, and their ability to resist 
 the encroachments of decay is correspondingly greater ; 
 and hence we often find the roots of teeth solid and 
 free from decay, the crowns of which have been 
 removed by rapid decomposition. Injurious substances 
 are sometimes pressed into contact with the dentine, 
 through defects in the enamel, or under its projections, 
 and there retained till their mischievous effect is pro- 
 duced. 
 
 It is maintained by some writers that caries is con- 
 tagious. Dr. Koecker was of this opinion. The 
 
48 CARIES OF THE TEETH. 
 
 question, then, is, whether there is any property i n 
 the decayed dentine of one tooth, capable of producing 
 the same condition in the healthy dentine of another. 
 The residue of abnormal dentine in the soft decay, 
 consists of the animal elements and a small portion of 
 earthy material; and in decay in which the gelatinous 
 constituent is abstracted, the remainder is chalk-like, 
 consisting mainly of phosphate of lime. In neither of 
 these is there anything that can possibly operate on 
 the healthy dentine. There is one thing here, how- 
 ever, that is worthy of remark, and that has perhaps 
 led to the mistaken notion that caries is contagious: 
 decayed dentine will absorb and retain fluids that 
 injuriously affect sound dentine; and when the decay 
 is on the proximal portion, two teeth are subject to 
 the same exciting cause. But it is seldom that two 
 teeth thus situated are both in the same stage of decay; 
 a fact principally attributable to the difference in their 
 constitution. The decay of the teeth in pairs has also 
 been adduced as evidence of the contagious character 
 of the disease. This, however, results from the fact 
 that the pairs are formed at the same time; are subject 
 to the same influences in their formation, and hence 
 are constituted alike ; and if one of the pair is defec- 
 tive, the other will be in a like condition. When there 
 is a vitiation of the saliva or mucus, they will be 
 similarly affected. In no common acceptation of the 
 
CARIES OF THE TEETH. 49 
 
 term contagious, can it be applied to caries of the 
 teeth. 
 
 The color of caries is exceedingly various, from that 
 of healthy dentine, through every intermediate shade, 
 to jet black. The rate of the progress is indicated by 
 the color of the decay, being slower as this is darker, 
 so that when the decay becomes almost stationary, 
 the affected portion is usually black. The degrees of 
 color are differently enumerated by different writers; 
 as, by Koecker five, by others seven, and so on. Three, 
 however, are sufficient for our purpose : white, brown, 
 and black. The sensitiveness of the dentine is greatest 
 in teeth affected by the white decay, and usually 
 decreases as the color darkens; though there are 
 exceptions to this rule ; for occasionally we find teeth 
 affected by dark decay, that are quite sensitive. The 
 light-colored decay is more difficult to arrest than the 
 dark. In many cases of the former, filling seems 
 hardly to retard its progress ; whereas, in the latter, 
 by proper filling, the advance of the decay may be 
 checked altogether. The cause of the dark color of 
 caries is not perfectly understood ; but is probably 
 owing to the carbonization of the animal portion. 
 
 The opinion is entertained by some, that this dark 
 material protects the dentine from the influence of 
 injurious agents. But this is most probably not 
 correct, at least to any perceivable extent. If the 
 
50 CARIES OF THE TEETH. 
 
 deposit does thus serve as a protection, the removal 
 of the discolored portion would subject the dentine to 
 a renewed attack of caries, which experience assures 
 us it does not do, hut that after some time it assumes 
 the dark hue again. Those who maintain this opinion, 
 refer, in support of it, to the fact that a deposit of 
 oxyd of silver being made upon a decay of light color, 
 )Sy the use of nitrate of silver, the progress of the 
 decay is thereby retarded. This retardal, however, 
 is effected more probably by a change in the character 
 of the decay, than by any protection afforded by the 
 coating of oxyd of silver. 
 
 Some sensitiveness commonly accompanies caries. 
 It does not often amount to pain, but is rather a sense 
 of uneasiness; yet from change of temperature or 
 contact of acids or hard substances, intense pain may 
 be produced. Dr. Koecker remarks that caries is 
 most tender in its first stages; and Dr. Cone, that 
 when a tooth is attacked by it, the sensitiveness is 
 increased. The surface of the dentine, or that part 
 united to the enamel, is susceptible of the most 
 acute sensitiveness, this being on the periphery of 
 the vital force. When there is inflammation of 
 the dentine, intense pain may be produced by the 
 contact of an instrument, in a cavity of decay, at the 
 line of union of the dentine with the enamel, and very 
 little sensitiveness be present elsewhere in the cavity. 
 
CARIES OF THE TEETH. 51 
 
 Sensitiveness of a uniform character sometimes 
 pervades all parts of the cavity, while at other times 
 it may be very intense at one point, and very slight 
 or entirely absent at any other. A thin lamina of the 
 dentine lining the whole cavity, may be uniformly 
 sensitive, and in some cases this sensitiveness may 
 involve the entire body of the dentine. 
 
 By means of this sensitiveness, warning is trans- 
 mitted to the pulp, which emits osseous material with 
 increased energy; and thus a process of rilling up the 
 natural cavity of the tooth is instituted, that the decay 
 may not encroach upon the pulp. But this warning 
 may, in some degree, be transmitted to the pulp, 
 though there be no increase of sensitiveness. 
 
 This sensitiveness is modified by the character of 
 the teeth, the nature of the decay, and the state of 
 the patient's constitution. The teeth of the same 
 person will be more sensitive at one time than at 
 another, because of a greater irritability of the nervous 
 system. Those teeth which decay most rapidly, are 
 usually most sensitive; though in teeth whose vitality 
 is lost considerably in advance of their decay, there 
 is no sensitiveness at all. Except in such cases as 
 last mentioned, the whitest and most rapid decay has 
 most sensitiveness, the brown much less and the black 
 scarcely any. 
 
52 CARIES 0E THE TEETH. 
 
 CAUSES OF CARIES. 
 
 The causes of caries of the teeth may be considered 
 under two general divisions — predisposing and ex- 
 citing. Of the former some are original, others 
 accidental. The original development of the consti- 
 tution may be defective, either from original or from 
 accidental defect in the parent; but more certainly 
 from the former. Constitutional characteristics are 
 transmissible, and a defect is as surely hereditary as 
 anything else. In the fetus, during gestation, there 
 may have originated germs from which perfect organs 
 can never be developed, and these germs may be 
 more or less defective according to the constitutional 
 condition of the mother, or according to accidental 
 conditions to which she may be subject, and which 
 may seriously affect the fetus. After birth, too, the 
 child is exposed to injurious impressions, which will, 
 to a greater or less degree, render the development 
 defective ; as imperfect nourishment and the diseases 
 and functional derangements peculiar to childhood. 
 A diseased condition, or functional derangement, will 
 interrupt the proper elimination and perfect upbuild- 
 ing of the materials necessary for the perfect struct- 
 ure; and indeed anything that will disturb the 
 equilibrium of action in the system, may be detri- 
 mental to the teeth. 
 
CAUSES OF CAIIIES. 53 
 
 In some instances the teeth will exhibit :he pecu- 
 liarities of the mother, and in others, those of the 
 father ; while sometimes they similate those of both 
 parents ; and when the parental imprint is thus found 
 stamped on the teeth, it will also be found that those 
 of the same class decay at the same points and at 
 about the same age as in the parent. In such cases 
 the defect is manifestly hereditary ; it cannot be acci- 
 dental : the coincidences thus constantly occurring 
 preclude any other conclusion. Hereditary taint, then, 
 may be regarded as a predisposing cause of caries. 
 
 Impaired vitality is another predisposing cause ; 
 and not only impaired vitality of the teeth and con- 
 tiguous parts, but also that of the general system. 
 Indeed, the vital vigor of the teeth depends upon 
 that of the general system, and, when there is no 
 local adverse influence at work, corresponds with it ; 
 so that when the general system is in the most healthy 
 condition, the teeth possess the greatest power of re- 
 sistance to deleterious agencies. This resisting power 
 is, at best, comparatively feeble ; but its feebleness is, 
 to some extent, compensated by the peculiar structure 
 of the teeth, which are less liable to decomposition 
 than any other part of the human body. Yet the 
 integrity of these organs depends much on the main- 
 tenance of a healthy vitality, and this on that of the 
 general system. A dead tooth will decay far more 
 
54 CARIES OF THE TEETH. 
 
 rapidly than a living one in similar circumstances ; 
 and hence the conclusion that vitality resists inju- 
 rious agents, and that the resistance will be in pro- 
 portion to the vitality. 
 
 All febrile conditions promote and facilitate decay, 
 and frequently in two ways : by diminishing the 
 general vitality, and by changing the secretions of 
 the mouth so that these act injuriously upon the 
 teeth. Accompanying such conditions, there is gene- 
 rally inflammation of the dentine ; and in such cases, 
 this always partakes of the general disorder so as to 
 become very susceptible to injury. All diseases, 
 indeed, that impair the vitality and change the secre- 
 tions, may be considered predisposing causes of decay, 
 and some even more ; dyspepsia, for instance, being 
 not only predisposing, but also exciting, since it pre- 
 pares in the stomach an acid that is almost continu- 
 ally thrown upon the teeth, and that acts upon them 
 with great energy. Residence in miasmatic regions, 
 is also a predisposing cause, inducing unfavorable 
 conditions. 
 
 Diminished vitality may result either from consti- 
 tutional or from local causes. These latter are such 
 as produce an irritable or diseased condition of the 
 contiguous parts, or an abnormal condition of the den- 
 tine, without the power to effect its decomposition. 
 Local causes of a diminution of vitality are not in 
 
CAUSES OF CARIES. 55 
 
 their character so formidable, and not so difficult to 
 control, as those which are constitutional. 
 
 Many medicinal agents are regarded as predis- 
 posing causes of caries ; and among these, mercurials 
 occupy a prominent place. They operate by vitiating 
 the secretions of the mouth, and producing an abnor- 
 mal condition of the periosteum about the fangs of 
 teeth, the mucous follicles, and the salivary glands. 
 Some entertain the opinion that the abnormal action 
 of the absorbents, induced by mercurials, predisposes 
 to decay. 
 
 Dental operations performed at an improper time 
 and in an improper manner, may be reckoned among 
 the predisposing causes of caries. The vitality of tho 
 teeth may be thus impaired, or a diseased condition 
 established, or the part operated upon may be per- 
 mitted to remain rough, so that foreign substances 
 will be retained, and, becoming vitiated, produce a 
 deleterious effect. Often, from an improper use of 
 the file, extensive inflammation of the dentine super- 
 venes, which is sometimes followed by death of the 
 tooth, and by disease of the contiguous parts. Arti- 
 ficial substitutes imperfectly adapted, are, in many 
 instances, the occasion of caries ; not that clasps or 
 the edges of the plate tend directly to injure the 
 tooth, but the agencies superinduced by them do, 
 
56 CARIES OF THE TEETH. 
 
 and especially when the material used is not of the 
 right quality. 
 
 Lack of proper exercise in mastication induces a 
 condition favorable to decay, both by favoring the 
 action of injurious agents upon the teeth and by with- 
 holding the stimulus of normal exercise. Tartar and 
 other deleterious substances are much more rapidly 
 deposited when the teeth are idle. 
 
 The teeth cannot, with impunity, undergo great and 
 sudden transitions of temperature, or even such vari- 
 ations as may be endured by the surrounding parts. 
 By these, inflammation of the dentine may be induced, 
 and the vitality of the teeth diminished. And in 
 friable teeth, checking of the enamel may occur, and 
 thus a condition arise that will facilitate decay. 
 
 EXCITING CAUSES OF CARIES. 
 
 When there is a predisposition to caries, any of the 
 exciting causes act with more effect. Well organized 
 teeth of unimpaired health and vitality, withstand 
 influences that, in less favorable circumstances, des- 
 troy them in a very short time. The immediate 
 cause of decay is the action of agents chemically upon 
 the teeth. It is not here proposed to enter upon an 
 investigation of the manner in which these various 
 agents operate ; for that would open up a vast field 
 
EXCITING CAUSES OF CARIES. 57 
 
 for exploration — a field outside of the province of 
 this work. The sources of these, however, are sev- 
 eral : as, vitiated secretions of the mouth ; the saliva, 
 and the mucus ; abnormal secretion from the stomach ; 
 decomposition of animal and vegetable substances in 
 the mouth ; acids taken with food, or administered as 
 medicines ; and galvanic action. 
 
 The natural state of the mucus is acid, but that of 
 the saliva alkaline ; so that these secretions counter- 
 act each other ; but when the saliva and the mucus 
 are both acid, the teeth must suffer. These secre- 
 tions may become vitiated, through inability of the 
 glands, from disease or an enfeebled condition, per- 
 fectly to perform their functions ; or the blood may 
 be in an abnormal state, and the glands unable, on 
 that account, though they were healthy, as they 
 seldom are in such case, to elaborate healthy saliva : 
 when the fountain is corrupt, the stream cannot be 
 pure. Thus, anything that produces a diseased con- 
 dition of the blood, tends to the decay of the teeth ; 
 and such diseased condition often has a direct injurious 
 effect on the secretive apparatus, and so works a 
 double harm. 
 
 But to the theory of the pernicious influence of the 
 saliva, it may be objected, that, if it were true, all 
 parts of the teeth would be alike affected. This 
 objection, however, will loose its force when it is con- 
 
58 CARIES OF THE TEETH. 
 
 sidered that the teeth, in many cases, are not equally 
 well organized in all their parts ; that some parts are 
 not so well protected as others ; and that between the 
 teeth there is room for the retention of saliva and 
 foreign substances, which there combine their influ- 
 ence upon them. In cases in which there is a great 
 quantity of viscid saliva constantly flowing, the teeth 
 decay very rapidly. The decay is of a light color ; 
 so light, indeed, that, in many instances, it is difficult 
 to distinguish it, by this, from undecomposed dentine. 
 The gastric fluid often becomes deranged by irrita- 
 tion or disease of the stomach, so that the function 
 of the latter is very imperfectly performed, and fer- 
 mentation of the food occurs, evolving agents that 
 injuriously affect the teeth. In dyspepsia, such agents 
 are often brought in contact with the teeth by eructa- 
 tion and vomiting; and the diseased gastric fluid, 
 which contains a large proportion of hydrochloric acid, 
 is also thus brought in contact with them, acting upon 
 them with great violence. After food commingled 
 with this secretion is ejected from the stomach, the 
 teeth will be found eroded over all their surfaces. 
 Dyspeptics will appreciate this remark. In such 
 cases, if the teeth are not of superior organization, 
 they are destroyed in a short time. Their surfaces 
 thus roughened, afford a lodgment for foreign sub- 
 stances on all parts. 
 
EXCITING CAUSES OF CARIES. 59 
 
 The most common agents, however, that injure the 
 teeth, are originated in the mouth, by the decompo- 
 sition of animal and vegetable matter. By this pro- 
 cess, elements are eliminated, that form new combi- 
 nations and these operate with energy in the 
 destruction of the teeth. Favorable conditions exist 
 in the mouth for such decomposition, and also for 
 such new combinations ; for there is a sufficient amount 
 of heat and moisture; for both of these, especially 
 the former, facilitate the action of any acid upon the 
 dentine. The character of the saliva and mucus will 
 very much modify the decomposition of foreign sub- 
 stances in the mouth. If these secretions are both 
 acid, the decomposition will be much more rapid, and 
 more potent in its effect. 
 
 Again, it is sometimes the case that the salivary 
 glands are comparatively inactive, except when spe- 
 cially excited, and yet the mucous glands still effi- 
 cient, eliminating their secretion; so that the mouth 
 assumes an acid condition, because there is not saliva 
 sufficient to neutralize the mucus; in which condition 
 decomposition of foreign substances would be greatly 
 accelerated. There are many cases, however, in which 
 the flow of saliva is copious, and yet the decay very 
 rapid; which is in consequence of an acid condition of 
 both secretions, or of a rapid decomposition of foreign 
 substances in the mouth. 
 
60 CARIES OF THE TEETH. 
 
 There are acids taken with the food that act di- 
 rectly upon the teeth; as acetic acid, or vinegar. 
 Professor Westcot says: " Acetic and citric acids so 
 corroded the enamel in forty-eight hours, that much 
 of it was easily removed with the finger-nail." And 
 "Malic acid, or the acid of apples, in its concentrated 
 state, also acts promptly upon the teeth." Now, these 
 acids, in the use of many kinds of food, are brought 
 into frequent contact with the teeth. In the manufac- 
 ture of vinegar, sulphuric acid is often employed; so 
 that in this article of food we have that acid either 
 alone or combined with the acetic, the former acting 
 with greater energy upon the teeth than the latter. 
 Acetic acid also facilitates the fermentation of food 
 retained in the mouth, and thus reproduces itself in 
 abundance. 
 
 After eating apples that contain a great amount of 
 malic acid, the teeth will be found corroded over all 
 their surfaces. This acid, as well as the others, affects 
 the enamel somewhat, and when the latter is very thin, 
 though it may not be all removed from any particular 
 point, yet its integrity will be destroyed, so as to be 
 readily fractured, thus admitting injurious agents to 
 contact with the dentine, which is much more suscepti- 
 ble of injury from acids than the enamel: points 
 imperfectly protected by this are violently attacked 
 by acetic, malic, and sulphuric acids. In decayed 
 
EXCITING CAUSES OF CARIES. 61 
 
 cavities these agents produce rapid results. They 
 should be as much as possible avoided, and, when 
 necessarily used, should be removed from the teeth 
 by cleaning with great care. It would be safest to 
 employ some neutralizing agent after the use of any 
 acids with food. During mastication, there is an 
 increased secretion of saliva, which, if in a healthy 
 state, w T ill tend to neutralize any acid that may at the 
 time be present, and also, by its flow, to remove 
 foreign substances from the mouth. 
 
 Salts may be decomposed in the mouth, and their 
 acids act upon the teeth; as when the acid of the 
 salt has a stronger affinity for any element of the tooth- 
 bone than for the base with which it is combined. 
 Many medical preparations contain agents peculiarly 
 deleterious to the teeth; acids being especially in 
 requisition for these, and oftentimes in considerable 
 quantities. The acids most commonly thus adminis- 
 tered are the hydrochloric, the nitric, the sulphuric, 
 the acetic, the tartaric, and the citric, any one of 
 which will produce direct and rapid decomposition of 
 the dentine, even when unaided by the temperature of 
 the mouth. These acids are often administered by 
 physicians, without any regard to their nature or 
 their influence upon the teeth. Sometimes, however, 
 they are given through a tube; though this method 
 generally does not amount to much as a precautionary 
 
62 CARIES OF THE TEETH. 
 
 measure ; for in most instances the fluid comes in 
 contact with all parts of the mouth. A subsequent 
 rinsing of the mouth with water effects only a dilution, 
 not an entire removal of the acid. In order wholly 
 to counteract their injurious influence upon the teeth, 
 an alkaline solution should be used after the adminis- 
 tration of such medicines. 
 
 Galvanic action is a cause of decay of the teeth, 
 only so far as it is a means of decomposing com- 
 pounds in the mouth, and the elements of which, 
 according to the laws of affinity, form other com- 
 pounds, prejudicial to the teeth. The elements hy- 
 drogen, nitrogen, and oxygen, may thus be set free 
 from animal and vegetable substances, when they will 
 at once seek other elements with which to combine ; 
 and the character of the combinations will be deter- 
 mined by the nature of the elements, and by the 
 attendant circumstances. These compounds will fre- 
 quently be of an acid character. 
 
 Such an arrangement may exist as will maintain a 
 constant galvanic action, whose legitimate effects will 
 be as constant upon the teeth ; and this ceaseless 
 process cannot but make its mark. It is a favorable 
 arrangement for galvanic action when there are two 
 or three kinds of metals in the mouth at once, par- 
 ticularly if these are such as differ in their affinities 
 for oxygen, and in their electric conditions. In some 
 
COMPARATIVE LIABILITY TO HECAY. 63 
 
 cases three, or four kinds of metals are employed in 
 filling teeth of the same mouth ; in some, fillings of 
 one metal and a plate of another ; and in others, plates 
 of so low a carat are used that they oxydize rapidly 
 in the mouth, without the aid of any other metal. 
 
 COMPARATIVE LIABILITY TO DECAY. 
 
 All classes of teeth are not alike liable to decay. 
 Their difference in this respect may arise from a dis- 
 similarity in their organic structure, the best organized 
 being the most capable of resisting disease ; or from a 
 concentration of the destructive agency upon the 
 tooth first affected. The first molars are much more 
 liable to decay than any other teeth, since they are 
 less perfectly developed than those formed at a later 
 period of life. They are the first permanent teeth 
 erupted, and are subjected to all the irritating condi- 
 tions consequent on the removal of the temporary, and 
 the development and eruption of the permanent teeth. 
 But these conditions, in many cases, produce no ap- 
 parent injury upon them, they maintaining their integ- 
 rity till all the other permanent teeth appear, and then 
 decaying earlier than any others. In such cases, 
 the decay is a result of influences more potent than 
 those occurring on the eruption of the other teeth. 
 
 After the first, the second molars are most subject 
 
64 .CARIES OF THE TEETH. 
 
 to caries; and after these the second bicuspids. The 
 latter two classes doubtless are so subject, more from 
 the facility they afford to the lodgment of deleterious 
 substances, than from a relatively imperfect organiza- 
 tion. Besides, from six to fifteen years of age, the 
 teeth are less appreciated and less cared for than at 
 a later period of life. The next most liable to decay 
 are the third molars. Then follow in order the first 
 bicuspids, the lateral incisors, the central incisors, and 
 the cuspids. Below are appended, in tabular form, 
 one thousand cases of decayed teeth, as observed 
 under ordinary circumstances, exhibiting the number 
 and per cent, of these in each class : — 
 
 26, or 2J per cent., in central incisors. 
 
 38, or 3| 
 
 a 
 
 in lateral incisors. 
 
 24, or 21 
 
 (< 
 
 in canines. 
 
 87, or 8f 
 
 " 
 
 in first bicuspids. 
 
 134, or 13i 
 
 a 
 
 in second bicuspids. 
 
 370, or 37 
 
 a 
 
 in first molars. 
 
 218, or 22f 
 
 a 
 
 in second molars. 
 
 102, or 10i 
 
 " 
 
 in third molars. 
 
 Of these, a large proportion were removed for relief 
 from disease originating in caries of the dental tissue. 
 In general, the superior teeth are liable to decay 
 earlier and more rapidly than the inferior. 
 
CONSEQUENCES OF CARIES. 65 
 
 CONSEQUENCES OF CARIES. 
 
 It is here proposed to refer only to some of the 
 more common results of this affection, one of the 
 most obvious of which is the exposure of the pulp of 
 the tooth; on which exposure, disease ensues, and 
 finally death. During this diseased condition of the 
 pulp, there occurs that very peculiar sensation com- 
 monally denominated toothache. As well as the 
 destruction of the pulp, the entire destruction of the 
 crown of the tooth is the inevitable consequence of 
 caries, unless arrested in its progress. After the 
 destruction of the pulp and the lining membrane, 
 the external periosteum in many cases becomes 
 involved, the affection being but an extension of 
 that which destroyed the internal periosteum. In- 
 flammation and suppuration are of common occur- 
 rence, by which a discharge is established from be- 
 tween the margin of the gum and the neck of the 
 tooth, or through a fistulous opening in the process 
 and the gum, as is the case when an abscess is formed 
 at the point of a root. 
 
 A diseased condition of the alveolar process is, in 
 many instances, produced by diseased and dead teeth ; 
 necrosis and exfoliation of considerable portions being 
 sometimes the result. Indeed extensive caries o^ 
 
66 CARIES OF THE TEETH. 
 
 the jaw is occasionally thus produced. Disease of 
 the antrum, too, is very generally induced or greatly 
 aggravated by the same cause. Tumors, sometimes of 
 a malignant character, connected either with the bony 
 or with the soft parts, not unfrequently spring from 
 this source, particularly in constitutions of a cancerous 
 diathesis. Great nervous derangement may result, 
 either in whole or in part, from decayed teeth, as does 
 very frequently facial neuralgia, which is sometimes 
 confined to a single nerve-branch in the immediate 
 vicinity of the irritating cause, sometimes ramified 
 over the whole side of the face and head,, and occa- 
 sionally spread much farther, so as even to implicate 
 the shoulder and the arm. Neuralgia of these, ex- 
 tending down to the hand, is often found to be in- 
 stantly relieved by extraction of a diseased tooth ; 
 and any operator of much observation can call to 
 mind numerous instances in which facial neuralgia 
 has been thus relieved or wholly cured. This affec- 
 tion of the face, however, does not always originate 
 in diseased teeth ; though there is little doubt that, 
 in a majority of cases, it rises wholly or partially from 
 this cause. 
 
 Inflammation of the mucous membrane of the mouth, 
 is a common result of diseased teeth ; and it is liable 
 to extend to distant parts of this membrane, and 
 occasion greater difficulty than in the mouth, as 
 
TREATMENT OF CARIES. 67 
 
 would especially be the case when there is an irri- 
 table condition of the throat and bronchia ; and the 
 esophagus and stomach are not exempt. In what 
 degree such an implication of the respiratory and the 
 digestive apparatus is referable to diseased teeth, it 
 may not be easy to determine ; but it is impossible 
 that a number of such teeth, involving in their disease 
 all the ramifications of the facial nerves and the 
 whole mucous membrane of the mouth, could remain 
 there with impunity. And besides this direct influ- 
 ence on the lungs and stomach, diseased teeth are 
 constantly emitting offensive odors, which are taken 
 in by inhalation, and offensive matter, which is swal- 
 lowed with the food. 
 
 TREATMENT OF CARIES. 
 
 In the rational treatment of caries, the first con- 
 siderations are the nature and peculiarities of the 
 obvious predisposing causes ; whether these are con- 
 stitutional or local ) and if constitutional, whether 
 they are such as can be modified by therapeutic 
 treatment of the general system. If the latter, such 
 treatment should be adopted as will bring about the 
 most perfect state of health, so as to obviate as far as 
 possible all conditions favorable to decay, by securing 
 a healthy condition of the mouth in all its parts — as 
 
68 CARIES OF THE TEETH. 
 
 the gums, the mucous membrane, and the salivary 
 glands. The teeth should be kept free from all de- 
 posits and accumulations of whatever character ; for, 
 though some of these may not affect the teeth directly, 
 yet they induce disease of the surrounding parts, and 
 thus indirectly exert a pernicious influence upon 
 them. 
 
 The foregoing remarks, however, refer rather to 
 the prevention of decay than to its treatment after it 
 actually exists. Yet they are, on that account, none 
 the less important, since here, as elsewhere, preven- 
 tion is better than remedy. But they apply to such 
 prevention as well after decay has commenced as 
 before, if the ultimate object is preservation of the 
 teeth. After the first attack, the teeth are more 
 vulnerable, and less capable of resistance. 
 
 When decay has attacked a tooth, the treatment 
 depends upon the nature and extent of the disease. 
 Rapid decay requires more prompt and energetic 
 treatment than that of slow progress. Remedies 
 that would be appropriate and efficient in the one, 
 would be quite inapplicable to the other. The per- 
 sistence of caries is not always in proportion to its 
 rate of progress. We sometimes find teeth in which 
 the decay is not advancing rapidly, and thence are 
 led to conclude that it may be easily arrested ; the 
 affected part, if superficial, is removed, and the den- 
 
TREATMENT OF CARIES. 69 
 
 tine thoroughly polished ; and yet after a time, decay 
 again attacks the tooth at the same point. Or, where 
 the caries has penetrated the tooth, so that it re- 
 quires filling, though it is skillfully filled, and the 
 plug and tooth carefully polished, yet in many in- 
 stances the dentine soon softens about the border of 
 the plug. 
 
 The extent and nature of the decay will suggest the 
 mode of treatment. Superficial caries on some parts 
 of the teeth may be remedied and removed by cutting 
 away the portion implicated in the disease, dressing 
 with a fine file, polishing with Arkansas, Scotch, or rot- 
 ten stone till the file marks disappear, and then apply- 
 ing the burnisher very thoroughly to the entire surface 
 operated upon. Afterward, the most careful atten- 
 tion to cleanliness is requisite, to prevent a recur- 
 rence of the attack. This treatment is applicable to 
 decay upon proximal surfaces; but in the depressions 
 of the masticatory and buccal surfaces of the molars, 
 it is not practicable. 
 
 Sometimes the dentine, at points where it is ex- 
 posed, gives warning, by acute sensitiveness, of 
 threatened decomposition, before there are any other 
 indications of it, thus evidencing the presence of 
 some very irritating agency promotive of decay. 
 Such points should receive prompt and strict atten- 
 tion, and the increased sensitiveness be immediately 
 
TO CARIES OF THE TEETH. 
 
 subdued ; as it may be, by the use of some prepara- 
 tion that will counteract the exciting influence — some 
 dentifrice or lotion containing an alkali ; or a rubbing 
 of the sensitive surface with a smooth steel burnisher, 
 will in many cases effect this object, and prevent the 
 development of decay. 
 
 It has been suggested that the character of the 
 caries may be modified by the local application of 
 therapeutic agents — that the rapid decay may be 
 changed to the slow — and this, too, without regard 
 to the attendant circumstances,, such as the condition 
 of the secretions of the mouth, the causes producing 
 the disease, etc. ; for this purpose various agents have 
 been proposed. It is held that by an application of 
 the nitrate of silver, the white, rapid decay being 
 changed to that of a dark color, is arrested in its pro- 
 gress. But there is no very palpable principle on which 
 this agent can be supposed to operate to arrest caries. 
 It is generally conceded to be injurious to a healthy 
 tooth ; how, then, it becomes beneficial to one de- 
 cayed, it is not easy to perceive. The notion may 
 have originated in the fact that, after the application 
 of nitrate of silver, the cavity turns dark, or black ; 
 and this color being naturally associated with the 
 slow form of decay, it may have been concluded that 
 it might be thus associated by artificial means. This 
 conclusion, however, is fallacious; for the coloring 
 
TREATMENT OF CARIES. 71 
 
 matter being the oxyd of silver deposited on the 
 walls of the cavity, is wholly foreign, and holds no 
 necessary relation to the kind of decay, or to the 
 agency producing it. The deposit may possibly serve 
 as a temporary shield to the dentine beneath, but 
 only temporary ; whereas, on the other hand, it will 
 be remembered that nitric acid is liberated by the 
 decomposition of the nitrate, and operates destruc- 
 tively upon the tooth-bone. An ethereal solution of 
 the terchloride of gold has also been suggested as a 
 preventive application. Its operation would be much 
 the same as that of the nitrate of silver, and equally 
 inefficient. Preparations to neutralize and counteract 
 the effects of deleterious agents upon the teeth have 
 been recommended as topical applications. These 
 are such as possess alkaline properties. But anything 
 of this kind would require frequent application ; in- 
 deed, it would be necessary to keep the affected part 
 constantly under its influence, as long as the sur- 
 rounding conditions continued to favor decay. 
 
 Though nothing of this kind can be relied upon 
 permanently to arrest caries, yet, in many instances, 
 much benefit is to be derived from local treatment. 
 Alkaline topical applications will, in many cases, 
 alleviate the most acute sensitiveness of the dentine ; 
 accomplishing this, no doubt, by their neutralizing 
 influence upon the irritating agents. Many opera- 
 
72 CARIES OF THE TEETH. 
 
 tors employ simply the bicarbonate of soda for this 
 purpose, with the happiest results. As another class 
 of topical applications to check or modify caries, 
 those have been suggested, which will form an insol- 
 uble compound with the gelatinous or animal portion 
 of the tooth ; such as tannin, creosote and some of the 
 essential oils. The only effect of these, however, is, 
 to form a shield or protection over the structure be- 
 neath : there is, of course, no change effected in the 
 conditions or agencies which produce the decay. 
 
CHAPTER III. 
 
 GENERAL REMARKS ON FILLING. 
 
 The importance and value of the operation of fill- 
 ing are obvious, from various considerations. It is 
 one that is in frequent requisition. It is the only 
 treatment for deep-seated caries : by it, the disease is 
 arrested and the lost part restored, so far, at least, as 
 it can be by a foreign substance. There is no mate- 
 rial similar to that destroyed — no substance possess- 
 ing the characteristics of the lost portion of the tooth 
 — with which to effect the restoration. Under favor- 
 able circumstances the operation of filling is efficient 
 in arresting caries and restoring the lost portion of 
 the tooth. In order, however, that it be permanent 
 in its character, the case needs to be attended with 
 favorable conditions, and the work to be thoroughly 
 done. But, two similar operations, both equally well 
 performed, may result very differently as to ultimate 
 success in preserving the teeth to which they may 
 have been applied ; the one effectually preventing 
 further decay, and the other seeming to interpose to 
 it but little obstacle. Indeed, the probabilities of 
 
74 GENERAL REMARKS ON FILLING. 
 
 such success in different operations, equally well ac- 
 complished, cannot be calculated, without consider- 
 ing a variety of circumstances, such as differences in 
 constitutions, in states of health, in previous and sub- 
 sequent habits. 
 
 The rilling of the teeth is predicated upon the na- 
 ture of decay, upon the fact that the lost portion will 
 not be restored by nature, and upon the fact that 
 caries is an effect of external causes, and not of any 
 cause within the tooth itself. If the cause of caries 
 were alone within the tooth, then rilling would not 
 be its rational treatment. The organic structure of 
 the teeth is of such nature that no change to the ex- 
 tent of decomposition will take place in it, indepen- 
 dently of external influences. Any organ possessing 
 sufficient vitality and circulation to be susceptible of 
 disease and decomposition, independently of external 
 influences, possesses recuperative power enough to 
 restore to itself a lost part ; and if dentine could be 
 decomposed without external agents, the introduction 
 of any foreign substance whatever into the cavity, 
 would certainly not arrest the decay, but most pro- 
 bably accelerate it. If it is true that the decay of 
 the teeth ever originates in constitutional causes, 
 then the treatment should be constitutional, and not 
 local. 
 
 The filling of teeth, then, is based upon the ina- 
 
GENERAL REMARKS ON FILLING. 75 
 
 bility even of healthy dentine to resist the encroach- 
 ment of decay. As preliminary to the operation, all 
 the circumstances, both direct and collateral, should 
 be carefully noted in every case, and the course of 
 treatment should conform to the indications thus ob- 
 served. The constitution, temperament, and health 
 of the patient; the peculiarities of the teeth; their 
 susceptibility of decay ; their present condition, and 
 that of the parts about them; the periosteum, the 
 gums, the mucous membrane, the secretions of the 
 mouth, the saliva, and the mucus, should all be 
 closely considered; for only on a correct diagnosis 
 can a proper treatment be based. Every operation 
 should be performed as completely as, under the cir- 
 cumstances, is possible. Indeed, every step in the 
 operation should be perfect, before a successive one 
 is attempted. All the instruments employed should 
 be unexceptionable in material, form, and condition ; 
 inferior instruments should find no place in the case 
 of the dental operator. The material for filling 
 should be of the best quality and prepared in the best 
 possible manner. Not that material for filling should 
 be prepared in only one way; for some materials, 
 gold for instance, may be prepared in three or four 
 different forms^ each perfect in its kind, and efficient 
 in the hands of the expert manipulator. While with 
 instruments and material all in the most perfect con- 
 
76 GENERAL REMARKS ON FILLING. 
 
 dition, and with a thorough cognizance and apprecia- 
 tion of all the attendant circumstances, our most skill- 
 ful operators barely attain success, need we be aston- 
 ished that the man ignorant of all these circumstances, 
 and possessed of only a few crude, ill-conditioned 
 instruments and materials, the nature of which he does 
 not understand, fails in almost every essay ? 
 
 Much depends on therapeutic treatment ; not, in- 
 deed, to restore parts already lost, or to restore to 
 health parts much diseased, but to avert a tendency 
 to disease in parts but feebly organized. This treat- 
 ment may be either constitutional or local, or both ; 
 but constitutional when there is indicated any idio- 
 syncrasy favorable to decay. If, however, the whole 
 difficulty is local, topical treatment only is required. 
 What the special treatment should be in either case 
 will be more fully considered hereafter. Compara- 
 tively little can be accomplished by local application 
 to the substance of the tooth ; but the parts contigu- 
 ous, as the gums and the mucous membrane, may be 
 thus treated, with an assurance of more signal results. 
 
 Though in the teeth nature does not assist to re- 
 store a lost portion, as in those parts more highly 
 organized, yet, to compensate in some degree, the de- 
 structive process is far less rapid in the former than 
 in the latter. The general surgeon depends much 
 upon nature for the success of his operations ; for, 
 
 \ 
 
MATERIALS FOR FILLING. 77 
 
 though he perform them unskillfully, yet the kind 
 energy of nature is always present to assist him ; but 
 in this specialty the practitioner must necessarily. de- 
 pend more upon his skill, and less upon the curative 
 efforts of nature ; though much more reliance is placed 
 upon it now than formerly. 
 
 MATERIALS FOR FILLING. 
 
 In the selection of materials for rilling teeth, there 
 are some important considerations that should be 
 kept constantly in view; the first and principal of 
 which is to choose that kind which will protect the 
 tooth from further decay — protect the affected part 
 against the influence of those agencies on which the 
 disease depends. A material or class of materials 
 should be selected that would not, under any circum- 
 stances, operate either as a local or a constitutional 
 injury. There are several properties that materials 
 for filling teeth should possess, one of the most impor- 
 tant of which is indestructibility. Any substance, 
 whether simple or compound, that will not maintain 
 its identity and integrity when subjected to any con- 
 ditions of the mouth, is wholly unfit to be used as a 
 material for filling. If compounds are employed, they 
 should be such as would not be affected by the secre- 
 tions of the mouth, or by any attendant conditions. 
 
78 GENERAL REMARKS ON FILLING. 
 
 A mere mechanical mixture would not be an appropri- 
 ate material for permanent rilling ; and all compounds 
 of the metals, so far as we are familiar with them, are 
 unfit for this purpose, by reason of the facility with 
 which they are destroyed in the mouth. 
 
 The next most important property of a material 
 for filling is adaptability ; by which is meant a capa- 
 bility of being wrought into suitable shapes for the 
 purpose, — a facility of being applied and conformed 
 to the parts upon which it is to be placed. There 
 are substances that would be entirely indestructible 
 in the mouth and that would be very desirable in 
 other respects as materials for filling, yet that are 
 altogether worthless for this purpose, from lack of 
 adaptability. Quartz, if it possessed this property, 
 would be valuable as a material ; but as yet there has 
 been discovered no method of preparing it in an avail- 
 able form. On the other hand, many things possess 
 the property of adaptability, that are lacking in some 
 other important particulars. 
 
 The next important property is, hardness. A ma- 
 terial may possess all the other suitable qualities, and 
 yet be too soft. A material should be hard enough 
 not to be broken or w T orn away by any pressure or 
 friction liable to be applied. This property is espe- 
 cially desirable for fillings in the masticatory surfaces 
 of the molars and bicuspids. It would, however, be 
 
MATERIALS FOR FILLING. 79 
 
 admissible to employ a softer material for filling cavi- 
 ties in the proximal surfaces of the teeth, provided 
 it perfectly excluded all foreign substances. 
 
 Again, a material should be as nearly as possible a 
 non-conductor of heat, particularly for filling sensitive 
 teeth, or those liable to become so under the influence 
 of slight causes. Great variations of temperature will, 
 in most instances, aggravate sensitiveness, and, in 
 susceptible cases, produce it; and, if the irritation is 
 continued, the result may be necrosis. Gold, which 
 possesses the largest number of desirable qualities as 
 a material for filling, is in this respect very defective, 
 being one of the best conductors of heat. To obvi- 
 ate this defect, some non-conducting material is em- 
 ployed between the gold and the sensitive portion of 
 the tooth. The nerve is liable to. be affected by sud- 
 den and great changes of temperature, transmitted to 
 it through a gold plug. 
 
 In the next place, a material should be susceptible 
 of being welded, or united into a solid mass. The 
 permanency of an operation depends very much upon 
 this quality. A filling having the different pieces 
 which compose it perfectly united, will be much more 
 durable than if effected with a material in which this 
 cohesive property is lacking, it can be made with 
 greater facility, and will be better and longer retained ; 
 and mainly because such a filling cannot be destroyed 
 
80 GENERAL REMARKS ON FILLING. 
 
 piecemeal. Non-adhesive material is retained by the 
 general form of the cavity, which is to be shaped so 
 as to bind all the pieces together, and thus hold them 
 in place ; but a substance that will weld, requires only 
 two or three good retaining points, angles, or pits, 
 properly situated, in order to be firmly and perma- 
 nently fixed in a cavity of any form. 
 
 Color. — Another desirable property of material for 
 filling, is, such a color as shall best harmonize with 
 that of the teeth, particularly if they are in front. In 
 this respect, all the metals are objectionable ; though 
 gold is probably less so than any of the others, the 
 objection to this being not so much in its color as in 
 its luster ; which objection, however, may be partially 
 obviated by the kind of finish given to the work. In 
 teeth of certain shades — semitransparent bluish white, 
 for instance — gold, for exposed fillings, is very objec- 
 tionable ; indeed, in some cases, almost as unsightly 
 as the absence of the tooth ; and, in such instances, the 
 darker metals would of course appear much worse. 
 For such teeth, some mineral substances, having more 
 nearly the color of the teeth, would be most desirable. 
 
 Most of the materials employed for filling are metal- 
 lic; only a few non-metallic substances have been 
 used, and these rather by way of experiment, and for 
 temporary purposes, than with any hope of permanent 
 results. Of the metals, gold possesses more of the 
 
MATERIALS FOR FILLING. 81 
 
 indispensable properties than any other; but the fol- 
 lowing have been used for filling; lead, tin, silver, 
 platinum, gold, and amalgam. In the preparation of the 
 latter, gold, silver, platinum, tin, bismuth, antimony, 
 cadium, zinc, and mercury, have been employed. 
 
 Lead. — This metal, in the early history of the pro- 
 fession, was used to some extent for filling teeth, though 
 it possesses but few of the requisites for that purpose. 
 The principal quality which recommended it, is its 
 adaptability ; but it is quite too soft for permanent 
 fillings in the masticating surfaces of the molars. It 
 is easily wrought into foil and welded into mass in 
 the cavity, but it is rapidly worn down by mastica- 
 tion, and its integrity readily impaired by the influ- 
 ence of peculiar conditions of the mouth ; much more 
 readily, indeed, than that of tin or silver. Acetic and 
 other acids act upon it with considerable energy in 
 the mouth. By exposure to air and moisture, it is 
 soon coated with carbonate or protoxyd of lead ; and 
 this change is effected much more readily in the 
 mouth. Lead is also objectionable in color — especially 
 for fillings in the anterior teeth — it being darker 
 than the other metals employed for the purpose. It 
 is, however, a less perfect conductor of heat than some 
 others that are in far more extensive use. 
 
 Tin. — This metal has been, and is even yet, much 
 employed as a material for filling. It is easily 
 
82 GENERAL REMARKS ON FILLING. 
 
 wrought into foil, and in that condition is readily 
 adapted to the purpose, by reason of its softness and 
 pliability. Fillings can be made with it in all cases 
 in which non-adhesive gold foil can be used, to much 
 of which, indeed, it can, by skillful manipulation, be 
 made superior in adhesive property. Its quality, 
 however, is greatly dependent on the manner of its 
 manufacture. It is harder than lead, and in many 
 cases hard enough for permanent fillings : we have 
 known it retained in crown cavities of the molars, 
 effectually preserving the teeth, for fifteen years. In 
 favorable conditions of the mouth, it is not materially 
 changed, not oxydizing easily, and not readily uniting 
 with any substances liable to be brought in contact 
 with it. But in an unhealthy mouth, with the secre- 
 tions in an abnormal condition, and the teeth neg- 
 lected, tin fillings are very rapidly destroyed, chiefly 
 by the action of the soluble chlorides. Such a 
 change may take place in the mouth, as will in a little 
 time destroy tin fillings that had long remained in. 
 good preservation ; and hence this material is not en- 
 tirely reliable in any case, since such change may at 
 any time occur. Some cases seemingly favorable to 
 its use, are found, on examination, to be otherwise ; 
 and in almost any mouth in which there is a large 
 proportion of mucus secreted, it cannot be depended 
 upon for permanency. Its color renders it unfit for 
 
MATERIALS FOR FILLING. 83 
 
 the anterior teeth. It is a less perfect conductor of 
 heat than gold ; on which account it is frequently em- 
 ployed where the latter metal can not be. It should 
 not be used in a tooth in which there is another metal ; 
 notwithstanding some economical dentists do some- 
 times use it to fill the interior of large cavities, placing 
 upon it a covering of gold. This method is objection- 
 able in two particulars : first, the tin is softer than 
 the gold, and under much pressure yields beneath it, 
 so as to destroy the integrity of the filling ; and second, 
 when the fluids of the mouth come in contact with 
 the two metals, a chemical action is induced, by which 
 the tin is rapidly corroded. It is for this reason that no 
 two metals should be applied to the same tooth ; as, for 
 instance, tin for filling a tooth round which there is 
 a gold clasp, or in contact with which is a gold plate. 
 Finally, the use of this material should be deter- 
 mined not only by all these circumstances, but also 
 by the constitutional predisposition of the patient, 
 and the character of the teeth, which should be dense 
 and well organized, in order to render it at all ad- 
 missible. 
 
 Silver. — This metal was formerly in more exten- 
 sive use as a material for filling, than it is at present. 
 It is not for this purpose superior to tin in any par- 
 ticular, except in being somewhat harder; and in 
 some particulars it is inferior, being quite as do- 
 
84 GENERAL REMARKS ON FILLING. 
 
 structible in the mouth ; more easily affected by cer- 
 tain agents, such as nitric acid, nascent chlorine, etc. ; 
 less pliable and less adaptable ; more difficult to work 
 into foil ; not so readily formed into fillings ; and pos- 
 sessed of much less cohesiveness, being almost un- 
 weldable by the ordinary method of manipulation. 
 Silver is a better conductor than tin, and would there- 
 fore in some cases be more objectionable. The saliva 
 is often in such a condition as to act upon it with 
 great energy and rapidity. Its color, too, is objec- 
 tionable. With these disadvantages, its use has very 
 properly been wholly abandoned. 
 
 Platinum. — This metal has been but little used for 
 the purpose of filling ; though it possesses some of 
 the requisite qualities in a. very high degree ; as, for 
 instance, indestructibility, in which property it is su- 
 perior to gold. In other respects, however, it is very 
 deficient ; it has not as yet been wrought into any 
 form in which it can be welded with facility ; it is 
 difficult to work into foil ; and when it is put into this 
 form, it possesses a stiffness and harshness that ren- 
 der its adaptation and condensation almost impracti- 
 cable. It is more on this account, perhaps, than on any 
 other, that it has been so little employed for the pur- 
 pose of filling. It has also less adhesiveness than 
 gold, and much sooner parts with this property. Slight 
 crumpling or bending serves to stiffen it so as to de- 
 
MATERIALS FOR FILLING. 85 
 
 stroy its applicability. Good fillings may be made 
 of well prepared platinum sponge, recently annealed. 
 It requires skillful manipulation, however; for the 
 least moisture destroys its cohesive property entirely. 
 It is a good conductor of heat, and on this account 
 objectionable. In the respect of color, too, it is undesi- 
 rable. Platinum should never be placed in close prox- 
 imity to tin fillings, or to gold plate or clasps of low 
 carat. It is not now, however, used in filling at all, 
 except experimentally. 
 
 Gold. — Of all the metals that have as yet been 
 used 'for filling teeth, gold possesses more of the 
 requisite properties than any other, except platinum, 
 and sufficiently so for all practical purposes. Twenty- 
 carat gold is very seldom affected by any agencies 
 with which it is brought in contact in the mouth ; 
 pure gold never. In the filling of teeth, there are 
 two objects to be aimed at : one, a sufficient hardness 
 to withstand the wear of mastication ; the other, a 
 thorough protection to the cavity against all foreign 
 substances. For the attainment of the first of these, 
 gold is not all that could be desired ; yet it is, per- 
 haps, as efficient in this respect as any other metal 
 that can be employed. But the second object, gold 
 when well manipulated, accomplishes very effectually ; 
 that is, so long as the filling maintains its integrity : 
 after it is partially worn out, it thus far fails, of course. 
 
86 GENERAL REMARKS ON FILLING. 
 
 In adaptability, too, gold is superior to any other 
 metal. It can be elaborated into a variety of forms, 
 with any of which very good fillings can be made. 
 It can be perfectly conformed to any shape of surface, 
 however irregular. A tooth that can be filled at all, 
 can be filled with gold. This assertion was made a 
 number of years ago ; and if it was true then, it is 
 much more true now ; for then the adhesive property 
 of gold was not employed at all, or even recognized as 
 available ; but now, this property has been rendered 
 efficient and practicable. Then, our best operators 
 did not aim to unite the different portions of gold of 
 which the fillings were composed. The idea that such 
 consolidation could be effected, seemed never to have 
 entered their minds. Indeed, with the instruments 
 and the method of manipulation then employed, this 
 adhesive property could not have been made available ; 
 but as it came to be recognized, the instruments and 
 the manipulation were adapted to the purpose. For- 
 merly, an ordinary gold plug when removed from a 
 cavity, could be readily separated into as many pieces 
 as originally composed it ; but now, when adhesive 
 gold is skillfully used, the mass composing a filling 
 can not be divided into its original parts, but may be 
 wrought into plate, wire, or foil. Non-adhesive gold 
 — the modification in which, till recently, it was 
 always employed — would not weld, even under great 
 
MATEEIALS FOR FILLING. 87 
 
 pressure ; but, in the mode in which it is now pre- 
 pared, it will weld readily and thoroughly. There 
 are certain requisites essential to this welding pro- 
 perty of gold: if it is in the form of foil, it should not 
 present a smooth, planished surface ; it must be an- 
 nealed after hammering, in order that its ultimate par- 
 ticles may be in the best condition for cohering : it 
 must be entirely free from all deposits of foreign sub- 
 stances ; and it must be kept from exposure to the 
 atmosphere. 
 
 Gold is a good conductor of heat ; and this is the 
 chief objection to it as a material for filling. As to 
 sensitive teeth, this is a very serious objection, in 
 some cases necessitating the employment of non- 
 conducting materials with it, and in others preclu- 
 ding its use altogether. The color of gold, however, 
 is seldom an objection to its use; though it some- 
 times renders it unsuitable for fillings in the front 
 teeth. But this objection has been already adverted 
 to. 
 
 Various preparations of Gold. — And first, of the 
 manufacture of gold foil. For this purpose, pure 
 gold is used; for procuring which, various methods 
 are employed. But the most common of these are 
 insufficient for the production of gold absolutely pure. 
 It is, however, deemed irrelevant here to detail the 
 process by which this end is attained : it is enough to 
 
85 GENERAL REMARKS ON FILLING. 
 
 premise that, for the manufacture of the best quality 
 of foil, perfectly pure gold is indispensable. The 
 gold is cast into an ingot about an inch wide, which 
 is placed between a pair of rollers, and rolled down 
 as thin as practicable, the piece, while rolling, being 
 frequently annealed. It is then cut into squares, 
 which are inserted with wooden pliers between vel- 
 lum leaves, a hundred and sixty or seventy in a 
 pack. Over this pack two pockets are drawn, in- 
 closing it completely. The pack then is hammered 
 on a marble block, with a hammer weighing twelve 
 or sixteen pounds, till the leaves are spread out to 
 the full extent of the pack. Much experience and 
 skill are requisite to the proper accomplishment of 
 this part of the work : by a single unskillful stroke of 
 the hammer, a whole pack might be spoiled. 
 
 Gold foil is numbered according to the grains con- 
 tained in each leaf, ranging from 2 to 30. The most 
 common numbers are, 2, 3, 4, 5, 6, 8, 10, 15, 20, and 
 30, the smaller, from 2 to 6, being in most frequent 
 use. It has heretofore been a desideratum to obtain 
 gold foil perfectly uniform; but some few manufac- 
 turers now seem to have attained this perfection. 
 
 Crystal Gold. — This form of gold was introduced to 
 the profession about fourteen years ago. Some ex- 
 periments in this direction, indeed, had been made as 
 early as 1825, by C. Ash, of London, and again in 
 
MATERIALS FOR FILLING. 89 
 
 1850, by Dr. S. A. Main, of New York. Their prep- 
 arations, however, were simply precipitates, and 
 nothing more. But in 1853, Dr. A. J. Watts, of 
 Utica, New York, obtained letters patent for his prep- 
 aration of gold for filling teeth. This preparation 
 was at first denominated sponge gold, but after some 
 modification, received its present name. There are 
 numerous formulas by which preparations of crystal 
 gold may be made ; but so far as we are acquainted 
 with them, they are all embraced in two general 
 methods : the one, to obtain simply a precipitate of 
 the metal, adaptable to the filling of teeth ; and the 
 other, to combine this precipitate with mercury, 
 and obtain a definite crystallization. For the prepa- 
 ration of the sponge or crystal gold, the absolutely 
 pure metal is required. This is dissolved in nitro- 
 muriatic acid, the gold being added till the solution 
 is saturated. Various materials may be used to pre- 
 cipitate it, the most common of which are sulphate of 
 iron and oxalic acid, the latter on some accounts 
 being preferable. The character of the precipitate 
 will be determined, in a great degree, by the manner 
 in which the precipitant is added : if slowly, the pre- 
 cipitate will be more fibrous, or structural. 
 
 A preparation may be made by introducing the 
 precipitant gradually, and then carefully washing the 
 precipitate, and heating almost to redness. For per- 
 
90 GENERAL REMARKS ON FILLING. 
 
 feet crystallization of the gold, combine the precipi- 
 tate with from six to twelve times its weight of pure 
 mercury, let it stand a short time, subject to a gentle 
 heat, and then remove the mercury with dilute nitric 
 acid. Afterward wash the nitrate of mercury from 
 the gold ; place the latter upon a slide, and bring it up 
 to a full red heat in a muffle, and the gold is then in 
 a condition to be used for filling. This is about the 
 formula on which a patent was granted to A. J. 
 Watts. The preparation possesses some advantages 
 over gold foil : it is as readily introduced ; it is more 
 capable of thorough consolidation ; it has, besides the 
 cohesiveness of foil, the additional property of inter- 
 lacing its crystals one with another, by which prop- 
 erty, even without cohesion, the pieces of a filling 
 can be firmly united ; and it takes a better hold upon 
 the walls of the cavity, to which it presents the 
 angles and ends of the crystals, so as to be more 
 thoroughly adapted and fastened. 
 
 Amalgam. — By this term are designated all those 
 preparations formed by a combination of mercury 
 with various other metals ; most frequently with sil- 
 ver and tin, but occasionally with gold, platinum, 
 bismuth, cadmium, zinc, and lead. The several form- 
 ulas for amalgam need not here be specified. The 
 kind most in use is prepared by melting together and 
 carefully mixing pure tin and silver, filing this mix- 
 
materials for filling. 91 
 
 ture, when cooled, into dust, combining the latter 
 with mercury in sufficient proportion to give the 
 requisite plasticity, and then thoroughly washing the 
 whole in alcohol or boiling water, to remove the 
 oxyds formed during the combination of the metals. 
 If there is a redundance of mercury, it may be re- 
 moved by pressing the paste in a piece of chamois skin. 
 This preparation may in some cases be used for 
 filling with considerable success ; but in no case can 
 it be relied upon as a durable material, its destructi- 
 bility being no less than that of tin or silver in any 
 circumstances, and being greater where all the mer- 
 cury is not removed from the surface of the filling, 
 and the surface not burnished down solid and 
 smooth. Mercury oxydates with considerable rapid- 
 ity when exposed to air and moisture, and with 
 increased energy, under the influence of heat, especially 
 when some acid is present. This facility of oxyda- 
 tion is still increased when other metals are com- 
 bined with mercury. Oxydation of such fillings will 
 in some cases be confined to the surface, wherever 
 there is contact of moisture ; in others, it will per- 
 vade the whole mass, rendering it black and spongy 
 throughout. 
 
 Amalgam fillings, in a short time after their inser- 
 tion, undergo a hardening process, occasioned by crys- 
 tallization of the mass, as well as by evaporation of the 
 
92 GENERAL REMARKS ON FILLING. 
 
 mercury. The consequence is, either that the mass 
 becomes porous, or that it contracts ; the former, 
 doubtless, in cases where the oxydation blackens 
 through, and the latter, where it is confined to the 
 surface. When a plug is in either of these conditions, 
 the preservation of the tooth is very uncertain. On 
 removing an ordinary amalgam plug that has been worn 
 for some time, its entire surface will generally be found 
 oxydized : and a tooth filled with this material gene- 
 rally becomes blackened, and its appearance ruined. 
 
 To such objections against this material, another is 
 to be added in cases in which there are fillings or plate 
 of platinum or gold : galvanic action will be estab- 
 lished, in a degree proportionate to the proximity and 
 extent of surface of the metals and the condition of 
 the secretions. This may occasion much mischief. 
 Some constitutions are very susceptible of the influ- 
 ence of mercury ; and a gradual decomposition of sev- 
 eral amalgam fillings in the mouth, may seriously 
 impair the general health. Therefore, before this 
 material is ever employed, the health, temperament 
 and habits of the patient, should be carefully noted ; 
 for these and other circumstances may often indicate 
 its inadmissibility. 
 
 So great and so numerous are the objections to this 
 material, that it is but little used by reliable opera- 
 tors. Its adaptability is the main property on which 
 
MATERIALS FOR FILLING. 93 
 
 are based the arguments in its favor : it is easily ap- 
 plied, and consolidates with considerable hardness. 
 It is affirmed, also, that teeth which can not be saved 
 with any thing else, may be filled with this, and made 
 valuable. This, however, is not true since the em- 
 ployment of the adhesive property of gold ; which 
 property renders this metal equal in adaptability to 
 amalgam. 
 
 Non-metallic Materials. — Of the non-metallic mate- 
 rials experimented with for filling, there are not many 
 worthy of any particular consideration. Indeed, gutta- 
 percha and its preparations constitute the chief of 
 these substances now used for this purpose, though 
 some others have been employed. Gutta-percha is 
 useful for temporary fillings, and, under ordinary cir- 
 cumstances, is sufficiently durable. It is valuable for 
 filling those teeth which it may be desirable to retain 
 only a short time, or those in which it may be neces- 
 sary temporarily to protect a sensitive part against the 
 influence of irritating agents, in order to restore it to 
 health. Gutta-percha is not readily decomposed by 
 the fluids of the mouth, when they are in a healthy 
 condition. In some instances we have known it worn 
 in the mouth for years, with but little change. But 
 in cavities on the grinding surfaces of the molars and 
 bicuspids, it will not withstand the wear of mastica- 
 tion a great while, though long enough in most cases 
 
94 GENERAL REMARKS ON FILLING. 
 
 to subserve the purposes of temporary fillings. It 
 possesses great adaptability : by simply being warmed 
 over a spirit-lamp or in boiling water, it becomes plas- 
 tic, and is with great facility introduced and con- 
 formed to the cavity. It may be applied also in solu- 
 tion, being dissolved in chloroform till it approaches a 
 pasty consistence, then absorbed in a pledget of cotton, 
 and introduced into the cavity ; where the chloroform, 
 evaporating, leaves the gutta-percha as a filling. The 
 only objection to this method is, the contraction con- 
 sequent on the evaporation of the chloroform. Another 
 property that renders this substance highly valuable, 
 is, its non-conduction of heat, it being in this respect 
 as nearly perfect as any other material employed. 
 
 A preparation of gutta-percha with mineral sub- 
 stances, known as Hill's stopping, has for some years, 
 been extensively used for temporary fillings ; indeed, 
 it has superseded simple gutta-percha almost entirely. 
 The aim of this preparation was to obviate two or 
 three objections to pure gutta-percha; as, its contrac- 
 tibility in the cavity, its softness, and its color. The 
 composition of Rill's stopping is as follows : With pure 
 gutta-percha in a plastic state, are mixed quicklime 
 two parts, and quartz and feldspar one part each, 
 which latter are reduced to an impalpable powder, and 
 kneaded into the mass as long as it will receive them 
 without becoming brittle. Such is the formula given 
 
MATERIALS FOR FILLING. 95 
 
 by the inventor of this preparation ; though it is pre- 
 sumed that one of these materials alone, namely, pul- 
 verized quartz, would be found entirely sufficient, 
 since it is capable, by itself, of quite as much as is 
 attained by all together. The addition of gold or 
 platinum filings has been recommended ; but no 
 advantage is thus gained. It was at first claimed for 
 this material that it would serve for permanent fill- 
 ings ; but it was soon demonstrated to be insufficient. 
 It was supposed, also, that it might be employed for 
 partial fillings in large cavities, which could be com- 
 pleted with gold; but for this, too, it was found 
 impracticable, since it did not make a sufficiently firm 
 foundation. 
 
 This preparation is applied in the same manner as 
 simple gutta-percha, being warmed on a porcelain or 
 metal slab over a spirit-lamp till sufficiently soft, and 
 then packed into the cavity. It cannot be employed 
 in the form of solution, nor should it be softened in 
 boiling water. It may be conveniently prepared by 
 dissolving the gutta-percha in chloroform to almost 
 a pasty consistence, then adding the mineral sub- 
 stances, and putting it into a vessel suitable for the 
 evaporation of the chloroform. It should be made so 
 thick, that the silex would not fall to the bottom. 
 When Hill's stopping or gutta-percha is used, as soon 
 as the cavity is filled, an instrument with the end 
 
96 GENERAL REMARKS ON FILLING. 
 
 nearly as large as the orifice of the cavity, should be 
 placed upon the filling, and retained there with con- 
 siderable pressure till the mass is cool. After cutting 
 and dressing the surface of the filling as perfectly as 
 can be with instruments, then by passing over the 
 surface a short camel's-hair brush, with chloroform, a 
 very smooth surface and perfect finish will be made. 
 In some respects, there is, perhaps, nothing better 
 for temporary fillings than this preparation of gutta- 
 percha. 
 
 Os Artificial. — This preparation is an oxy-chloride 
 of zinc, and has been used for several years for filling 
 teeth ; and when well prepared, and properly manip- 
 ulated, serves a very valuable purpose. In very many 
 cases it resists the secretions of the mouth quite effectu- 
 ally. For proximal fillings it resists the wear of masti- 
 cation well, but for crown fillings it is not sufficiently 
 resistant. It is one of the best materials for temporary 
 filling. A little experience renders its use easy. It 
 effectually excludes all foreign substances; is a good 
 non-conductor ; and is only displaced by wear. It is 
 a good protection to sensitive dentine, and in many 
 cases for exposed pulp, under gold filling. It more 
 nearly resembles the natural teeth in color than any 
 other material that has been used for filling. To Dr. 
 C. H. Roberts is due the credit of having brought this 
 material to its present state of perfection. 
 
CHAPTER IV. 
 
 INSTRUMENTS FOR FILLING. 
 
 In describing the instruments for filling teeth, it 
 will be convenient to take them somewhat in the 
 order in which they are employed in ordinary prac- 
 tice ; first referring to those which are used for cut- 
 ting away portions of the teeth, for the purpose of 
 separating them, and for dressing off the borders of 
 cavities ; then to those for removing decay and form- 
 ing the cavities ; and finally to those for introducing, 
 consolidating, and finishing fillings. The first, then, 
 that claim our attention, are the 
 
 HEAVY CUTTING-INSTRUMENTS. 
 
 These are of the thick chisel shape. They should 
 be of good steel, well wrought, and thoroughly tem- 
 pered. Every step in the process of their manufac- 
 ture should be most perfectly executed, so as to in- 
 sure an edge that will cut not only dentine, but also 
 enamel, which is the hardest animal substance. Va- 
 rious sizes of the straight chisel form are required. 
 
98 
 
 INSTRUMENTS FOR FILLING. 
 
 In all cases they should be as thick as possible, with- 
 out being thus impaired in their efficiency ; so firm 
 that there may be no springing or tremulous motion 
 under the pressure they are required to sustain. For 
 separating front teeth, however, they must be thin 
 enough to pass readily into the intended space, and 
 
 Fig. 3. 
 
 about one-fourth of an inch wide at the edge. But, 
 for separating bicuspids and molars the instruments 
 should be thicker and broader • as thick, indeed, 
 
 Fig. 4. 
 
 as the required space will admit. In some cases, 
 they should have the edge oblique, as in Fig. 5. 
 It is seldom that these instruments need any curve. 
 
 Fig. 5. 
 
 The straight form is the best, unless, as it rarely hap- 
 pens, the point to be operated upon cannot be reached 
 efficiently with it; as, for instance, in a small mouth, 
 a slight anterior curve will be required in the shaft 
 
DRILLS. 
 
 99 
 
 of the instrument, to facilitate its approach to the 
 front proximal surface of a second or a third molar. 
 (Fig. 6.) A heavy instrument, with a sharp point 
 
 Fig. 
 
 and a lateral curve, is often efficient in opening up 
 cavities and cutting down strong projections of ena- 
 mel. (Fig. 7.) We consider as a very valuable 
 
 rig. 7. 
 
 form. Every operator should have at hand a suffi- 
 cient variety to meet every demand — from three to 
 five sizes of each form. 
 
 DRILLS. 
 
 Bur Drills. — Of this indispensable class of instru- 
 ments there are various forms. They should be man- 
 ufactured of the best steel, and wrought with the 
 greatest care. After having been forged as near the 
 proper size as possible, the bulb is shaped by dressing 
 with a fine file, or which is better, by turning in a 
 lathe ; those made by the latter method being supe- 
 rior, and cutting much more smoothly ; they do not 
 catch and jar as do those of less regular form. After 
 
100 
 
 INSTRUMENTS FOE FILLING. 
 
 the bulb is formed, it is usually cut with a sharp- 
 edged file. 
 
 Fig. 8. 
 
 Of these drills, Fig. 8 represents a bur of a spher- 
 ical form. Fig. 9 is cone-shaped, which may have 
 
 Fig. 9. 
 
 various degrees of bevel, terminating in a sharp point. 
 Fig. 10 is of a cylindrical form, cut upon the sides 
 and end. Fig. 11. is in the form of a wheel, cut upon 
 
 Fig. 10. 
 
 the edge only, or upon both the edge and the end. 
 The cutting upon all of these should be very regular 
 and uniform. This should be made by machinery, 
 though it is usually done by hand. Of these instru- 
 
 Fig. 11. 
 
 ments, there should be a variety in size, the smallest 
 
DRILLS. 101 
 
 considerably less than the smallest cavity the dentist 
 ever attempts to fill — that is about one thirty-second 
 of an inch in diameter, and the largest about one-fifth 
 of an inch. Inclusive of these extremes, there should 
 be about ten sizes of each particular form. These 
 instruments are used for opening cavities. With them 
 a more regular and perfect orifice is made in small 
 and medium-sized cavities, than by any other method. 
 They are also used to some extent for forming the 
 cavities, and even sometimes, in large cavities, for 
 making retaining-points for a filling. 
 
 Within comparatively a recent period a new form 
 of drill has been introduced by Dr. Scranton ; and 
 hence denominated u Scranton s Drill." 
 
 Its form is spherical, and in the manufacture the 
 bulb is formed as for the ordinary bur drill ; but in- 
 stead of having cut upon it numerous serrations, thus 
 forming a series of sharp edges : a cutting is made 
 upon two opposite sides with a small round file. The 
 instrument then presents two concave and two convex 
 sides, with four sharp longitudinal edges ; these may 
 be so inclined as to cut, only when rotated in one 
 direction ; or to operate alike well when rotated either 
 to the right or the left. 
 
 This instrument has two or three advantages over 
 the ordinary bur ; it can be kept sharp with the oil 
 stone till it is almost entirely used up ; and will con- 
 
102 
 
 INSTRUMENTS FOR FILLING. 
 
 sequently last much longer ; and it will cut much 
 more rapidly than the serrated bur. It is a very 
 valuable instrument for operating upon firm strong 
 teeth. It is represented in Fig. 12. 
 
 Fie. 12. 
 
 Common Drills. — Of other drills, Fig. 13, repre- 
 sents one with a square point, beveled from both 
 
 Fie. 13. 
 
 sides, measuring from a half to a whole line in length, 
 and attached to a small round shaft. The edges of 
 the drills should be very hard, so that they may cut 
 with the greatest celerity. Of this kind, there should 
 be about ten sizes, ranging in width from No. 12 to 
 No. 25 of Stubb's gauge. These are used mainly for 
 forming retaining-points in cavities. 
 
 Fig. 14. 
 
 Fig. 14 is the spear-shaped drill, the edges of which 
 are formed by dressing from both sides ; or, it may be, 
 from only one, in which case it will cut only when 
 
DRILLS. 103 
 
 rotating one way. This shape is employed principally 
 for drilling out fangs for filling, or receiving pivot teeth. 
 The burs and drills may be made of pieces of wire 
 one and a half inches long, and fitted to a socket- 
 handle that will accommodate a large number ; or of a 
 continuous piece of large wire. The latter is the pre 
 ferable method, since much time is consumed in chang- 
 ing them in sockets. The handles should be made 
 with six or eight sides, and cut on each alternate side. 
 In the use of these instruments, the drill-ring is al- 
 most indispensable. This is an open ring for the 
 middle or the index finger, with a socket attached, 
 in which rests the end of the handle of the instru- 
 ment. (Fig. 15.) The drill is rotated commonly 
 with the thumb and fingers. 
 
 Fig. 15. 
 
 Brill-stocks of various forms have been invented 
 with the view of increasing the motion of the drill 
 
104 
 
 INSTRUMENTS FOR FILLING. 
 
 of augmenting its power, or, especially, of bringing it 
 to bear upon points inaccessible to the straight in- 
 strument. Some of these stocks are very compli- 
 cated ; as, for example, that denominated Chevaliers 
 
 Fig. 16. 
 
 drill-stock, than which there are none better adapted 
 for bringing the drill to bear in various directions. 
 (Fig. 16.) Another, more simple in construction, 
 called Merry s drill-stock, was some years ago intro- 
 duced to the notice of the profession. With this, 
 the drill can be applied at any desired angle, the 
 operator having almost as complete control of the in- 
 strument as of the common straight drill. (Fig. 17.) 
 
 Fig. 17. 
 
 Broaches. — The broaches of three or four sides are 
 made of the best steel, and are of various sizes.- 
 They are constructed both of a straight and of a ta- 
 pered form. They should in no case have more than 
 
EXCAVATORS. 105 
 
 a spring temper, in which the color, when drawn, 
 is a deep blue. These instruments are used for en- 
 larging the canals of fangs for the purpose of filling. 
 Six or eight sizes will probably meet all ordinary 
 cases. When the course into the canal is tortuous, 
 the temper of the instrument should be so low as to 
 spring readily. 
 
 EXCAVATORS. 
 
 Of the small cutting-instruments for opening and 
 forming cavities and removing decay from them, there 
 is a great variety, though a few general forms com- 
 prise the whole. Hitherto there has been no very 
 systematic arrangement of these instruments, such as 
 the convenience both of the profession and the man- 
 ufacturers of dental instruments would seem to dic- 
 tate, In a classification that we have adopted and 
 found very convenient, they are arranged by num- 
 bers, the most simple being placed under the first, and 
 under each successive number a more complicated 
 form. All the varieties are embraced in twelve 
 numbers, which are represented in Figs. 18 and 19. 
 These varieties are discriminated by the forms of the 
 points and their position on the shaft to which they 
 are attached, and not by any curve which the shaft 
 may have at any distance from the point. 
 
106 
 
 INSTRUMENTS FOR FILLING. 
 Fig. 18. 
 
 No. 1 has simply a flat point slightly curved, with 
 a round edge transverse to the shaft. Four sizes will 
 be sufficient for ordinary purposes. 
 
 No. 2 has a flat point with a short curve, bringing 
 the point to a right angle with the shaft ; the edge is 
 transverse. This differs from No. 1 in having the 
 curve more short and abrupt, and the edge more 
 nearly square. Of these there should be five sizes, 
 with some variety of form. 
 
 No. 3 has a flat point with a square transverse 
 edge, which rises at a right angle from the shaft ; the 
 blade being from one to two lines in length. Five sizes. 
 
 No. 4 has a flat point, curved so as to be at a right 
 angle with the shaft ; the blade, from the center of 
 
EXCAVATORS. 107 
 
 the curve to the edge, being from one and a half to 
 three lines, and the edge straight. Four sizes. 
 
 In each of the foregoing the edges should expand 
 slightly in width. 
 
 No. 5 has a flat point with a square edge, which is 
 parallel with the shaft, and rises at a right angle from 
 it. The blade is from one-half to two and a half lines 
 in length, and from one-half to one line in width, with 
 no expansion at the edge. Six sizes, with some vari- 
 ety of form. 
 
 Nos. 6 and 7 are right and left excavators, with 
 flat points and double curves ; the first curve being 
 at an angle of about twenty degrees, and the other 
 lateral, right and left, reaching from the beginning of 
 the first curve to the point. The length of blade is 
 from one to four lines. Four sizes. 
 
 No. 8 has a crescent-shaped point, the blade rising 
 by a small attachment from the shaft, and making a 
 right angle with it. The edge is a regular curve, de- 
 scribing about two-fifths of a circle, and is parallel 
 with the handle. The point should be perfectly 
 formed. Six sizes. 
 
 No. 9. The form of the point is the same as in No. 
 8, the difference being in the position of the blade. 
 the edge of which is transverse to the shaft, and rises 
 from it at an angle of one hundred and thirty degrees. 
 Six sizes. 
 
108 INSTRUMENTS FOR FILLING. 
 
 In No. 10 the point has the same shape as .in Nos. 
 8 and 9. The cutting edge is transverse to the shaft, 
 and rises by a small neck at a right angle from it. 
 Six sizes. 
 
 Such are the most important forms of excavators ; 
 though modifications will be required for particular 
 cases. While Nos. 8, 9, and 10 are not in extensive 
 use, a few operators have used them for some years, 
 and prize them very highly. In many difficult cases 
 they are far more applicable than any other instru- 
 ment we have. For instance, in the formation of the 
 cervical wall of a proximal cavity in any of the teeth, 
 but particularly in the superior bicuspids and molars, 
 there is no other instrument so applicable and efficient 
 as No. 9 : with it, that part of the cavity, so fre- 
 quently neglected, is just as easily formed as any 
 other. 
 
 Cases will occasionally be presented, in which some 
 curvature of the shaft of the instrument will be requi- 
 site. But no more curve should be given to any in- 
 strument than may be absolutely necessary, for it is 
 impossible to manipulate with the same precision and 
 delicacy with curved as with straight instruments. 
 The degree of curve necessary in any given case will 
 be determined by the position of the decay on the 
 tooth, and the location of the latter in the mouth. 
 
 Since the first edition of this work was written, 
 
EXCAVATORS. 
 
 109 
 
 some variations have been made from these forms ; 
 embracing, however, the general principles. For in- 
 stance, the diamond point, as it is familiarly, called, is 
 a modification of No. 3 in Fig. 18, varying from it in 
 that it has a sharp point instead of a square edge, and 
 is three-sided from shaft to point, each angle being a 
 cutting edge. This instrument is especially valuable 
 for forming grooves or furrows within cavities, and for 
 dressing the borders. 
 
 Fig. 19. 
 
 11 
 
 r^ 
 
 12 
 
 After being much reduced by use, it may still be 
 kept in form, and sharp, and used as a drill for making 
 under-cuttings, for which it is very efficient. No. 11 
 (Fig. 19) represents this instrument. 
 
 A modification of No. 9, (Fig. 18), commonly known 
 as the scoop or spoon-shaped instrument, is exten- 
 sively used. The sharp corners of No. 9 are removed 
 in this instrument. It is shown in No. 12, (Fig. 19.) 
 
 Of the Manufacture of Excavators.— For making 
 these instruments, the best cast-steel wire, No. 8. 
 should be selected. This should be forged down 
 so as to leave the end large enough to form the 
 
110 INSTRUMENTS FOR FILLING. 
 
 intended point. Nos. 1 to 6 inclusive, may be formed 
 by forging, and afterward dressing up with the file. 
 Nos. 7 to 12 must be formed by the files out of a 
 bulb left from the forge ; for which purpose different 
 forms and sizes of files will be required, in order 
 definitely to shape all the angles and points. In heat- 
 ing steel, either for forging or tempering, a full red 
 heat should in no case be exceeded, since a higher de- 
 gree than this spoils it. After the points are formed, 
 and made smooth with an emery stick or wheel, they 
 are to be tempered ; which is a delicate process, re- 
 quiring much experience and care. The point should 
 be warmed in a spirit-lamp, and then covered with 
 soap, to prevent o'xydation and scaling. The instru- 
 ment is then brought up to a full red heat with a 
 spirit-lamp, blow-pipe, and charcoal, and suddenly 
 plunged into a cake of soap or into cold water ; when 
 it will present a silvery whiteness : the steel in this 
 condition is extremely hard and friable, it then 
 should be polished off with an emery stick or oil- 
 stone, and drawn down to the proper temper. This 
 tempering is accomplished by placing the edge of the 
 instrument on a piece of cold polished steel or iron, 
 and its shaft placed near or in the flame of a small 
 spirit-lamp, and retaining it there till it changes to a 
 deep blue color, graduated down to the point in a deep 
 straw or copper hue. The purpose in holding the 
 
PLUGGING INSTRUMENTS. Ill 
 
 point of the instrument on a piece of cold polished 
 iron or steel is, that the heat there may be subject to 
 complete control. The precise shade will be governed 
 by the purpose for which the instrument is to be used ; 
 if for a drill, the edge or point should be of a light 
 straw color ; indeed, some operators prefer to have 
 them scarcely changed at the cutting edge, while ex- 
 cavators and chisels should be brought to a deep straw 
 or copper color ; this will be modified, however, by 
 the manner of working the steel, and its quality. 
 Skillfully hammering steel at a low heat — below a 
 red — adds much to its quality for a fine cutting instru- 
 ment, and gives an improved texture. Indeed, some 
 assert that those instruments that can be forged to 
 nearly their proper shape, can be as well, if not better, 
 tempered by the hammer as by any other means. 
 
 The instrument is then to be polished by the emery 
 wheel and dressed up with the oil-stone. Of the va- 
 rious methods of tempering, the foregoing is equal in 
 efficiency, and in convenience superior, to any other. 
 
 PLUGGING INSTRUMENTS. 
 
 For introducing and consolidating fillings, a great 
 variety of instruments is in use. In filling with gold 
 in some of the forms in which it is employed, the 
 plugging-pliers are required, for picking up the pieces 
 of gold and placing them in the proper positions in 
 
112 INSTRUMENTS FOE, FILLING. 
 
 the cavity ; in cylinder or block-filling they are indis- 
 pensable. These instruments are made of different 
 forms and sizes — of different forms, to facilitate 
 access to cavities inconveniently located ; of different 
 sizes, to accommodate cavities of various capacities. 
 For a large majority of cases, they require a slight 
 curve, about half an inch from the point ; for some 
 cases, however, the curve should be a right-angle. 
 (Fig. 20.) 
 
 Fie. 20. 
 
 The points of the pliers, when shut together, should 
 form the point of a plugging instrument, so that it 
 may be used to some extent for consolidating the 
 gold. This instrument should be about five inches 
 long. 
 
 The forms of condensing instruments may be mul- 
 tiplied to an almost indefinite extent. They are all, 
 however, but modifications of two or three general 
 principles. The particular form of the plugging point 
 will be determined by the form in which the gold is 
 used. With non-aclhesive gold, small square, round, 
 sharp points, of various curves, will be required. 
 (Fig. 29.) These points are easily kept in proper 
 condition, and, in some instances, are used for years 
 without any change or repair. 
 
PLUGGING INSTRUMENTS. 
 
 113 
 
 A favorite method of filling with non-adhesive 
 gold, by many excellent operators, is in the use of 
 cylinders or blocks; for this method, instruments 
 especially adapted have been devised, which the 
 following cuts represent. 
 
 Fig. 21, represents the lateral condensing instru- 
 ments, used for consolidating the cylinders upon each 
 other as they are introduced. 
 
 Fig. 21. 
 
 Fig. 22, is square from the curve to the point, and 
 
 Fig. 22. 
 
 is used in the same manner, and for nearly the same 
 purpose as Fig. 21. 
 
114 
 
 INSTRUMENTS FOR FILLING. 
 
 For introducing and condensing key-blocks — those 
 intended to bind the filling in place— Fig. 23 is the 
 proper form. 
 
 Fis. 23. 
 
 Figs. 24 and 25, are designed for condensing the 
 surface of crown fillings, in the superior and inferior 
 molars respectively. 
 
 Fig. 24. 
 
 Fis. 25. 
 
 The instruments represented by the following, are 
 for condensing the surfaces of proximal fillings. 
 
 Fig. 26. 
 
PLUGGING INSTRUMENTS. 
 
 115 
 
 Fig. 27, represents round right and left condensing 
 points, to be used in filling proximal cavities. 
 
 Fig. 27. 
 
 Fig. 28, flat right and left condensing points, for 
 same cavities as Fig. 27. 
 
 Fig. 28. 
 
 With adhesive gold in any of its forms, the points 
 all require to be serrated. There are three or four 
 varieties of these, which it will be proper to describe. 
 The first is square, and slightly bent about half an 
 inch from the end, which is formed into four or six 
 definite sharp points with the ei]ge of a thin file. Of 
 
116 
 
 INSTRUMENTS FOR FILLING. 
 
 this variety there should be about five sizes, the 
 largest entering No. 18 of Stub's gauge, and the 
 
 Fig. 29. 
 
 smallest No. 25. The former should have six points, 
 and the other two sizes four. (Fig. 30.) The cuts 
 
 Fig. 30. 
 
 upon these are made directly across the end. In 
 another variety, the end is rounded, and the file 
 placed upon it at an acute angle with the side of the 
 instrument, and the cuts, three in number, are made 
 to the centre of the point, which thus becomes 
 
 Fig. 31. 
 
 ^ 
 
 triangular, or three-pointed, from a common center. 
 (Fig. 31.) Four or five sizes of these may be 
 
PLUGGING INSTRUMENTS. 
 
 117 
 
 employed, ranging from 18 to 26, Stub's gauge. A 
 thin double point, from 26 to 28, is in many cases 
 very valuable. Instruments with a condensing sur- 
 face on the side, instead of the end, will frequently 
 be required for filling lateral cavities ; these may be 
 denominated lateral pluggers. (Fig. 32.) This COn- 
 Fig. 32. 
 
 densing surface should also be serrated, as already 
 described. An instrument square at the point, 
 ranging from 18 to 22, and cut upon the end by 
 passing it along the cuts of a file both ways, thus 
 making a large number of small serrations at right 
 angles across the point, is valuable for consolidating 
 
 Fig. 33. 
 
 the surface of a plug. (Fig. 33.) Operating super- 
 ficially, on the principle of the more deeply serrated 
 instruments, it yet leaves the surface free from deep 
 
118 INSTRUMENTS FOR FILLING. 
 
 pits or indentations, and still so impressed that it 
 will receive and retain more gold, if necessary, as it 
 would not clo, if the end of the instrument were per- 
 fectly smooth. A smooth-pointed instrument or bur- 
 nisher may be applied after all the gold has been added. 
 
 Fig. 34. 
 
 Fig. 34 is an instrument with file-cut sides. It is 
 valuable for dressing down proximate fillings to a 
 uniform surface. There may be two, one with the 
 sides parallel with the shaft, and one with its sides 
 transverse to the shaft ; it terminates in a sharp edge. 
 
 In many cases a valuable instrument for consoli- 
 dating is the plugging forceps, the general form of 
 which, except the beaks, is that of the ordinary 
 straight extracting forceps. The beaks are formed 
 into sockets for the reception of the plugging points, 
 one of which is of the common construction, but the 
 
 Fig. 35. 
 
 other has a broad flat surface, to rest against the 
 tooth. (Fig. 35.) This instrument is applicable only 
 
THE FILE. 119 
 
 in certain cases, principally in filling proximal cavi- 
 ties. Its main advantage consists in its capability of 
 applying a strong pressure upon the filling, without 
 affecting the socket. Manipulation with it is less 
 rapid and definite than with the ordinary condensing 
 instruments ; and with it, too, there is much danger 
 of fracturing friable teeth. 
 
 There has been within the last few years, very 
 great improvement made in the serrated plugging 
 instruments — those employed for working adhesive 
 foil. It consists in delicacy and perfection of form, 
 a large addition to the variety, and a good systematic 
 arrangement. 
 
 These instruments are now manufactured and put 
 up in sets, embracing every requisite form, number- 
 ing from forty to sixty ; this includes surface con- 
 densers and burnishers. 
 
 The profession is largely indebted to the efforts of 
 Drs. W. H. Atkinson and F. Abbott, of New York, 
 for the perfection obtained in the production of these 
 instruments. 
 
 THE FILE. 
 
 Of this valuable .and indispensable instrument 
 there is a variety of forms used by the dentist. The 
 thin files (Fig. 36) are chiefly applicable to the ante- 
 
120 
 
 INSTRUMENTS FOR FILLING. 
 
 rior; the thick, heavy, knife-shaped (Fig. 37), to the 
 posterior teeth. The latter, to facilitate their ap- 
 proach to the points operated upon, have various 
 curves, some single, others double ; the double being 
 preferable, since they bring the handle of the instru- 
 
 Fig. 36. 
 
 ment on a line with its cutting edge. The cuts upon 
 this instrument, too, are quite various; in size 
 
 Fig. 37. 
 
 %MME 
 
 lllllillllllillillllilllliliiiiiiiiiiiiiiiifill iiiiliiiiliiiiiiiiiiilliliilllillllllllilillllliP 
 
 ranging from very coarse to very fine, and in obli- 
 quity from a line almost at right angles across it, to 
 one at an angle of forty-five degrees. These cuts, 
 too, are either single or double, the double being 
 those made across one another. The single, however, 
 
THE FILE. 
 
 121 
 
 are preferable for all operations on the teeth; and 
 the more oblique are to be recommended, since they 
 cause less of that jarring unpleasant sensation to the 
 patient. 
 
 There are in use various forms of file-carriers, two 
 of which are represented in Figs. 38 and 39. Fig. 
 
 Fig. 38. 
 
 Fig. 39. 
 
 39, denominated " Redman's file-carrier," is the best 
 form yet introduced ; one principal advantage of this 
 instrument, consists in the facility with which it may 
 be changed from the one side to the other. Files 
 are made adapted to the instrument. The chief 
 advantage of which is, that they retain the file much 
 more firmly than it can be held in the fingers. 
 
122 INSTRUMENTS FOR FILLING. 
 
 These carriers are made with a variety of curves, to 
 accommodate different positions. There is also a 
 great variety of small file-point instruments for dress- 
 ing down fillings, the more important of which are 
 represented in Fig. 40. 
 
 Fig. 40. 
 
 The Use of the File. — When a separation of the 
 teeth is requisite, preparatory to filling, it is accom- 
 plished, either in whole or in part, with the file. 
 Principally, in such a case, its use is restricted to 
 finishing and smoothing, after the greater portion of 
 the work has been done with the heavy cutting 
 instrument. The file is valuable for removing super- 
 ficial decay, being called into frequent requisition in 
 caries of this kind. It is employed to dress off fangs 
 preparatory to the insertion of pivot teeth ; for which 
 purpose it is required to be of a round or half-round 
 form. It is used for dressing off sharp portions or 
 edges of the teeth, that may be injurious to the soft 
 parts, and in some cases for dressing down a tooth 
 that is elongated. In finishing fillings it is indispens- 
 able. It was formerly used to some extent in the 
 
THE FILE. 123 
 
 treatment of irregularity; but for this purpose it is 
 now, or should be, abandoned. 
 
 Mode of Using the File. — The patient should be 
 conveniently seated, with the head on a firm support, 
 and under the control of the operator, who should 
 occupy a position at the right of the patient in most 
 cases, so disposing the head of the latter as to give 
 the free access to that point which is to be operated 
 upon. In manipulating with the file, considerable 
 skill and delicacy are requisite. It should not be 
 held with a stiff, unyielding grasp, so as to catch and 
 jar, but should be applied with a gentle pressure, and 
 drawn across the tooth with a free and flexible 
 motion. It should be frequently moistened, and not 
 allowed to clog with the filings, being kept free of 
 these by constant applications of the brush. A 
 sharp, new file, with a quick, light movement, will 
 cut far more rapidly, and less unpleasantly to the 
 patient, than one that is dull or clogged, applied 
 with a heavy pressure. If the tooth bone is sensi- 
 tive, the file should be moistened in warm water. 
 When a file has become clogged with the dentine, it 
 may be perfectly cleaned by immersing it a few 
 hours in dilute hydrochloric acid, and then washing, 
 boiling, and finishing with oil. The form of a file 
 may be changed by drawing the temper, bending it 
 as desired, and then re-tempering it. It is better. 
 
124 INSTRUMENTS FOR FILLING. 
 
 however, to have them made of the proper form at 
 first. 
 
 The teeth, while being filed, should be supported 
 by the fingers, or by an instrument for the purpose ; 
 or a cork or piece of soft wood may be inserted 
 between the tooth being filed and the teeth of the 
 opposing jaw, and the pressure thus used as a sup- 
 port. The tooth being sustained in this manner, 
 there is less jarring experienced by the patient, and 
 less liability to produce irritation of the periosteum. 
 When riling the anterior teeth, it is generally better 
 to hold the file in the fingers. For filing the incisors 
 and canines, a thin, bevel-edged file is to be pre- 
 ferred. In dressing a tooth with a file, the last that 
 is used should be a fine one ; after the application of 
 which, the surface operated upon should be made as 
 smooth as possible with a stone and burnisher, or 
 with a buff charged with rotten-stone. 
 
 In separating teeth with the file, where but one is 
 decayed, care should be taken not to cut the sound 
 one. For this purpose, it will usually be necessary 
 to have a safe sided file — one side smooth to present 
 to the sound tooth ; and even then the cutting edge 
 should be somewhat beveled from the safe side, that 
 the sharp angle of that edge may not rasp the sound 
 tooth ; in no case of this kind should a square-edged 
 file be used. In cases in which it is necessary to 
 
THE FILE. 125 
 
 file teeth that are somewhat loose in the sockets, and 
 whose periosteum is in a state of irritation, to build 
 up a wall of plaster of Paris round them, permitting 
 it to harden, will v.ery much facilitate the operation. 
 Perhaps a preferable method in some respects, for 
 accomplishing the same object, is to mould softened 
 gutta-percha to the tooth and the parts about it. 
 After it has become hard, hold it firmly in place 
 while the filing is accomplished. Either of these 
 methods will be found valuable in cases where it is 
 necessary to dress off a considerable portion from the 
 end of one or more inferior front teeth. There are 
 some teeth upon which the use of the file is hardly 
 admissible ; as, for instance, those which are highly 
 predisposed to inflammation and sensitiveness of the 
 dentine. The teeth of young persons being usually 
 of this character, they should be filed with great 
 caution; but, in general, those of adults may be 
 filed, if properly, with more freedom. The file 
 should not be used upon the teeth, when the perios- 
 teum, the gums, or the mucous membrane is dis- 
 eased, or strongly predisposed to such a condition. 
 It should never be used for the correction of irre- 
 gularity of the teeth, especially when they are 
 sound; nor should it be employed to separate 
 sound teeth to introduce clasps. 
 
 Filing the teeth is an operation against which 
 
126 INSTRUMENTS FOR FILLING. 
 
 there has been, and still is, much prejudice, though 
 without sufficient cause : whatever injury results 
 from this operation, is mostly from the imperfect 
 manner in which it is performed, and from subse- 
 quent neglect of the tooth which has been subjected 
 to it. A tooth skillfully treated with this instru- 
 ment, and properly cared for afterward, will not be 
 more liable to decay at the point operated upon, than 
 at any other where the dentine may be exposed. 
 
CHAPTER V, 
 
 SEPARATION OF THE TEETH. 
 
 In most cases of proximal decay, the teeth, before 
 the operation of filling can be performed, must be 
 separated ; though cases are not unfrequent, where 
 the space between them is sufficient to admit of free 
 manipulation without this preliminary.. An imper- 
 fect accomplishment of this first step in the process 
 of filling, is a prolific source of the many failures, in 
 proximal cavities, to attain to efficient and durable 
 results ; for, unless this step be thoroughly performed, 
 so as to make room for the free introduction and 
 use of the various instruments requisite, no part of 
 the work can be complete. Though the most com- 
 mon object for which teeth are separated, is, to 
 obtain space for free manipulation with the instru- 
 ments in filling, yet there are various other objects 
 for which they have been separated, but many of 
 which are now better accomplished by other means. 
 It is sometimes necessary to cut away more than 
 would otherwise be requisite, in order to remove thin. 
 friable edges of the cavity, so as to obtain sufficiently 
 
128 SEPARATION OF THE TEETH. 
 
 firm borders. Teeth are in some instances separated 
 for the introduction of clasps; a practice always to 
 be deprecated, since it usually proves highly injurious. 
 Though the practice was once very common, yet 
 many of our best operators have now, with good 
 reason, abandoned it altogether. At one time, too, 
 it was a general practice to separate the teeth with 
 the file to relieve a crowded condition ; but this, also, 
 has been abandoned. 
 
 There are two methods of separating the teeth : 
 the one, to cut away a portion ; the other, to force 
 apart by pressure, acting upon one or more teeth, as 
 the circumstances admit. Formerly, all separations 
 were effected with the file, and this of very crude 
 form and cut; by which instrument, especially in 
 unfavorable cases, much injury has been done. 
 Though the file is a valuable instrument, one that 
 no other could supply, yet, for removal of any con- 
 siderable portion of dentine, it is not to be recom- 
 mended. Its action upon inflamed dentine is exceed- 
 ingly painful, besides being tedious and wearisome to 
 patient and operator ; and it is liable to irritate the 
 periosteum, and to increase inflammation. When a 
 separation is to be made that requires the removal 
 of a considerable portion of the tooth, the chisel, or 
 heavy cutting instruments, are to be preferred. 
 These, if of the proper form and temper, and 
 
SEPARATION OF THE TEETH. 129 
 
 in good condition, are very efficient for the purpose, 
 performing the work far more rapidly than the file, 
 and far less unpleasantly to the patient. They effect 
 the removal of sensitive dentine with but little or no 
 pain, and without liability to increase the inflamma- 
 tion, or to produce irritation or disease of the perios- 
 teum. The force of these instruments is sustained 
 by the entire attachment of the tooth, their pressure 
 being applied almost in a line with its axis. Besides, 
 by their use, the contiguous teeth are not liable to 
 injury, as by the use of the file they often are. 
 
 The manipulation with these instruments is very 
 simple. For separating front teeth, the instrument 
 is firmly grasped in the hand, the thumb placed on 
 the points of the teeth, and the edge applied at the 
 point or crown surface of the tooth from which the 
 portion is to be removed, and pressed gradually 
 toward the gums, but not thrust into tli€ interval as 
 a wedge before it has freely cut its way. In this 
 manner, as much of the dentine as it is desirable to 
 remove, is cut off in a few moments. This class of 
 instruments is invaluable for forming the V-shaped 
 spaces between the bicuspids and the molars that 
 have been popular with many operators, but are 
 pointedly condemned by others. It requires a pro- 
 longed use of the file to make these separations pro- 
 perly; and hence the practice of attempting to fill 
 
130 SEPARATION OF THE TEETH 
 
 proximal cavities without any separation at all, by 
 operating through a small opening at the crown angle 
 of the tooth, or a small hole drilled through its outer 
 or inner portion. With the heavy cutting instru- 
 ments, points upon the teeth, that the file cannot 
 touch, are approached and operated upon with facility. 
 
 But the method of separation by pressure is, in 
 many cases, to be preferred, especially in the case of 
 anterior teeth, whose natural form it is important to 
 preserve. 
 
 Till within comparatively a recent period, it has 
 been the general practice to separate by gradual pres- 
 sure ; and it is even yet the favorite method with 
 many operators. But in almost all cases where 
 separation is to be made by pressure, it can be done 
 at once quite as well, if not better, than to prolong 
 the process through several days ; there is economy 
 of time, and the patient has far less to endure, and 
 there is less liability of doing injury to the teeth or 
 the parts about them. 
 
 The anterior teeth, or those of single roots, yield 
 very readily to a strong separating force, applied in 
 the form of a wedge, notwithstanding the teeth may 
 all be in contact with each other; though in some 
 cases the teeth are so firmly set, and the parts about 
 them so dense and unyielding, that it is with great 
 difficulty they can be moved, without too much 
 
SEPARATION OF THE TEETH. 131 
 
 violence to the parts. It is not generally practicable 
 to attempt to separate the molar teeth by pressure. 
 
 The method of effecting immediate separation is 
 very simple ; it consists in forcing a wedge of some 
 fine grained wood of medium resistance — orange or 
 box wood — between the teeth to be separated, either 
 by pressure with the hand, or better by the blows of 
 a mallet. The wedge should be driven in at the necks 
 of the teeth; and when they are very firm, an 
 assisting wedge may be used, inserted between the 
 points of the teeth, and receiving strokes alternately 
 with the other. The assisting wedge should be of 
 very dense wood, and driven in with great care, for 
 its leverage upon the teeth is very great. When 
 the required space is obtained, the wedge at the 
 necks of the teeth should be driven tightly in, and 
 the other withdrawn. If all the teeth in the vicinity 
 of those to be separated stand in contact, the resist- 
 ance to separation, whether by immediate or gradual 
 effort, will be greater. 
 
 The rapidity with which the operation may pro- 
 ceed, and the extent to which it may be carried, 
 will be determined by the tolerance of the parts to 
 the movement, which should not be greater than the 
 elasticity of the tissues will permit, not the slightest 
 laceration or rupture should be made ; again great 
 care should be observed, lest strangulation of the ves- 
 
132 SEPARATION OF THE TEETH. 
 
 sels that enter the roots, pass to and supply the 
 pulp, he effected; this would be far more liable to 
 occur in the teeth of young persons, or before ma- 
 turity. There is in adults, however, a great diversity 
 in their susceptibility to injurious influences. 
 
 Mimy operators still prefer gradual separation, by 
 pressure. In order to secure the most successful 
 results, the conditions of the parts should be strictly 
 observed. The gums, periosteum, etc., should be in 
 a healthy condition; for much injury may be done 
 by attempting to separate teeth by pressure, when 
 the contiguous parts are in an irritable state. In 
 persons of a neuralgic diathesis, in those whose vital 
 energy is weak, and particularly in those whose con- 
 stitutional tendency is inflammatory, this operation 
 is scarcely admissible. If, in such cases, it is at- 
 tempted at all, it should be proceeded with very 
 carefully and gradually, and should be preceded by 
 constitutional treatment. There are many cases in 
 which it is best to make the separation partly by 
 pressure, and then to complete it by dressing off the 
 thin, friable edges of the cavity with the cutting 
 instrument or file. Whether the process is to be wholly 
 or only partly accomplished by pressure, should be 
 determined beforehand. 
 
 Various materials have been employed for sepa- 
 rating the teeth by gradual pressure, the chief of 
 
SEPARATION OF THE TEETH. 133 
 
 which are cotton, wood, India rubber, and ligatures. 
 The condition and character of the parts to be 
 operated upon, will indicate the material best adapted 
 in any given instance. In a good constitution, with 
 the teeth firmly set, and the contiguous parts healthy, 
 wood or India rubber may be applied ; but in cases 
 of an opposite character, a more yielding and tract- 
 able material is indicated. The degree of pressure 
 to be applied and continued, will be determined by 
 the susceptibility of the parts to irritation. Soreness 
 usually occurs in a few hours after the introduction 
 of the material. The pressure should be gradual and 
 constant, slight at first, and increased in force as the 
 patient will bear ; the increase being made every clay, 
 and continued till ample space is obtained. The 
 time necessary for the completion of this process is 
 from ten to twelve days ; only one separation should 
 be made at a time. The teeth should be retained 
 apart till the soreness has abated, before the opera- 
 tion. If not thus retained too long, they will return 
 to their former position. It is by some supposed that 
 separation by pressure is admissible only in the case 
 of the young, or those under thirty years of age. It 
 is true that they are the most susceptible ; but the 
 operation is, under favorable circumstances, proper at 
 any age. 
 
CHAPTER VI. 
 
 FILLING TEETH. 
 
 The operation of filling teeth is an interesting and 
 important one, requiring for its successful accomplish- 
 ment peculiar talent and large experience. It is the 
 only means as yet ascertained of completely effecting 
 the object for which it is employed, namely, arrest of 
 decay and preservation of the organs. Therapeutic 
 agents avail but little here, so low is the organization, 
 and so feeble the vital power. Nature, so efficient in 
 more highly organized structures, does comparatively 
 but little, in disease of the teeth, toward arrest or 
 restoration. Yet, on the other hand, these organs 
 are less liable to decomposition by the action of 
 foreign substances ; indeed, the enamel is almost 
 invulnerable to any agents to which it is ordinarily 
 exposed. The dentine, however, is more easily acted 
 upon, and, when there is defect in the enamel, is very 
 liable to injury. 
 
 Scarcely an individual in our country arrives at 
 mature age with a perfect set of teeth ; indeed, nine- 
 tenths of our people have decayed teeth at an early 
 period of life. Hence, for beautifying, preserving, 
 
EXAMINATION. 135 
 
 and supplying these organs, art is in constant requi- 
 sition ; and, in these respects, great achievements 
 have been made. In the operation of filling the 
 teeth, especially, the achievements are conspicuous ; 
 and here is scope for the highest skill. Every suc- 
 cessive step in the process of filling a tooth demands 
 a complete and conscientious application of the most 
 efficient and best adapted formulas of the art. In 
 the following remarks, it is proposed to analyze this 
 whole process, examining, in their order, the various 
 steps necessary to be taken, and endeavoring to incul- 
 cate the true methods of accomplishing them. 
 
 EXAMINATION. 
 
 When a case is presented, there should first be a 
 thorough examination, since by this all the subse- 
 quent work will be modified. The points to be noted 
 in the examination are as follows : 
 
 The temperament ; the present health ; the consti- 
 tutional tendencies ; the secretions, — the saliva and 
 mucus ; the mucous membrane and the gums ; the 
 constitution and condition of the teeth; the num- 
 ber of them remaining in the mouth ; the number 
 affected ; and the extent and nature of the decay, 
 and the character of the agents producing it. By 
 the examination we ascertain how to proceed in the 
 
136 FILLING TEETH. 
 
 operation ; if much or but little labor is required ; 
 whether the operation will be a simple or a difficult 
 one; and if difficult, what circumstances render it so; 
 and, besides, some conclusion is arrived at in regard 
 to the precise means to be employed for obtaining the 
 desired result, as well as the permanency of that 
 result. 
 
 OPENING. 
 
 The next step is to open the cavity of decay, so 
 that it may be approached and operated upon at all 
 points. The particular manner of performing this is 
 determined by the extent of the decay, and its posi- 
 tion upon the tooth. In all cases the opening should 
 be such as to give free access to all parts of the 
 cavity, for effectually removing the decayed portion, 
 for perfectly forming the cavity, and for introducing 
 and thoroughly consolidating the filling. In central 
 crown cavities of the molars and bicuspids, the pro- 
 jecting or pendent portions of enamel should be cut 
 away. There are cases, however, where such por- 
 tions are firm and not liable to be broken, and where 
 they can be well sustained by filling under, in which 
 it is admissible to leave some projection. This is 
 true of only those teeth which are of good, firm 
 texture. There are two objections to these abrupt 
 
OPENING. 
 
 1ST 
 
 projections of enamel : it is very difficult, and in 
 many cases impossible, to fill perfectly beneath such 
 portions ; and again, they are liable to be broken 
 down during mastication. 
 
 For opening up these cavities, in many cases the 
 bur drill alone will be quite sufficient ; those of dif- 
 ferent sizes being employed, to open up the orifice 
 gradually, so that too much violence may not be clone 
 to the teeth. In all very small cavities, the bur is 
 all that is required, except in decayed fissures. 
 
 In cases where the decay is more extensive, and 
 the cavity larger, the chisel or heavy cutting instru- 
 ment, in connection with the drill, will be found very 
 useful. Fig. 41 represents valuable forms of these 
 instruments. 
 
 Fig. 41. 
 
 An instrument first brought to the notice of the 
 profession by Dr. I. Forbes, is very valuable for open- 
 ing and enlarging crown cavities of the molars. It 
 consists of a socket-handle, which receives a screw- 
 clamp, and this receives the bits; which arc o^ 
 
138 
 
 FILLING TEETH. 
 
 various forms, such as the gouge-, chisel-, and V- 
 shape : these fit into the clamp, and are grasped by 
 
 Fie. 42. 
 
 zn 
 
 it, as it is screwed into the handle. (Fig. 42.) By 
 the use of these instruments the operation will be 
 very much facilitated, and less jarring communicated 
 to the tooth ; but after it is used, the bur or fine file 
 will be required to give a smooth, uniform border to 
 the cavity. In these cases, the orifice should be 
 almost or quite as large as the cavity within. In 
 proximal decay, the cavity must be sufficiently 
 exposed to enable the operator to see distinctly into 
 it, and to manipulate freely, in all parts of the 
 operation. These cavities may be exposed by the 
 use of the chisel, file, or pressure. 
 
 REMOVAL OF DECAY. 
 
 After the cavity is opened, the next step in order 
 is the removal of the decayed dentine. As a general 
 rule, this should be entirely removed. There is, 
 
REMOVAL OF DECAY. 139 
 
 however, some variety of opinion upon this subject. 
 This difference of opinion is in regard to cases where 
 an entire or a partial decomposition of the dentine 
 has taken place quite to the pulp, where, by its 
 removal, the pulp would be exposed. It is main- 
 tained by some that decayed dentine affords a better 
 protection to the pulp than any artificial covering; 
 and hence it is better to let it remain, since its 
 adaptation is more complete ; and it is not in every 
 sense a foreign substance. 
 
 On the other hand, it is contended that the de- 
 cayed dentine, being in an abnormal condition, will 
 irritate, and in many cases ultimately destroy the 
 pulp. And again, that there is danger of making 
 undue pressure upon the pulp, in filling on such soft- 
 ened portion. 
 
 In many cases, it is maintained that partially de- 
 composed dentine will become dense again, if pro- 
 tected from the influence of foreign agents that 
 decompose it. This sometimes would seem to be 
 true. For in some cases, where fillings have been 
 introduced into cavities, at the bottom of which a 
 softened portion of dentine covered the pulp, on 
 removing them in from one to five years afterward, 
 the whole walls of the cavity were found to be 
 equally and normally dense. This, perhaps, would 
 occur only in good constitutions, and under favorable 
 
140 FILLING TEETH. 
 
 circumstances ; but with such constitutions and cir- 
 cumstances, where the softening is not too extensive, 
 and the decomposition but partial, it may be per- 
 mitted to remain, with a strong probability of a 
 favorable result. This would certainly be better 
 than to cut it all away and expose and perhaps 
 wound the pulp, and then endeavor to cover it with 
 some wholly foreign material that would not be per- 
 fectly adapted to it, that would press a little too hard 
 at one point, and not touch at another, and that would 
 be quite as liable to be pressed down on the pulp as 
 the softened dentine. ' 
 
 In this discussion, much depends upon the point 
 whether partially decomposed dentine can retain its 
 vitality. This it is not now proposed to consider. 
 There are some particulars in regard to the removal 
 of decay, however, about which there is no diversity 
 of opinion : first, that all decomposed dentine should 
 be removed from all parts of the cavity, where the 
 pulp would not be exposed or injured thereby; and 
 that in all cases it should be entirely removed from 
 the lateral walls of the cavity, and especially from 
 the vicinity of the orifice. Even discolored dentine 
 should be removed from this point. 
 
 Dentine often becomes changed in color when 
 there is no apparent decomposition; such portion is 
 usually, though not always, without vitality. It is 
 
REMOVAL OF DECAY. 141 
 
 not important to remove such changed portion, except 
 for the appearance of the tooth ; it will produce no 
 change upon the living or normal part beyond it; 
 and it is better material to be in contact with the 
 living part than the metal of which the filling is 
 made. 
 
 Decayed dentine is readily removed with the exca- 
 vators. In any given case, such instrument should 
 be selected as would he best adapted for the purpose, 
 as well in regard to size and the form of its edge, as 
 to the curvature, or inclination, of its shaft. The 
 edge of the instrument should come upon the walls 
 of the cavity at such an angle as to accomplish the 
 work most efficiently. It should be very sharp, and 
 pressed firmly to the bottom of the decay at one side, 
 so as to remove the principal part at one cut. With 
 the proper instrument, and that in the right con- 
 dition, all the decay should be removed from any 
 cavity by a very few, firm, steady strokes. By this 
 method less pain is caused the patient, and the work 
 of the operator is facilitated. It is intolerable to 
 think of being subjected to an awkward, clumsy 
 hand, with a dull, ill-shaped excavator, scratching 
 upon the surface of a decayed tooth, for a length of 
 time, apparently to the patient, interminable. 
 
142 FILLING TEETH. 
 
 FORMING CAVITIES. 
 
 The next step in the operation is the formation of 
 the cavity. By this the cavity is so formed that it 
 will retain the filling when properly introduced. In 
 very few cases is the cavity of proper form when the 
 decay is removed. Much time, patience, and labor 
 are required of the operator, for the proper accom- 
 plishment of this part of the work, and much endu- 
 rance on the part of the patient. Excavation is often 
 necessary to give a regular form to the cavity ; and 
 in this process there are several particulars worthy of 
 consideration. The great object, however, is to give 
 to the cavity such a form as will most certainly re- 
 tain the filling in place. The cutting for the forma- 
 tion of the cavity should be accomplished with the 
 least possible loss of healthy dentine ; this is a point 
 upon which good judgment should be exercised. 
 The strength of the walls of the cavity, and the 
 ability of the parts to withstand the pressure, both in 
 the introduction and consolidation of the filling and 
 in the act of mastication, should be well noted. It 
 may be regarded as a rule from wdiich there should 
 scarcely ever be a departure, that the enamel should 
 never be encroached upon in excavating to give form 
 to a cavity. When there is but a lining of dentine 
 
FORMING CAVITIES. 143 
 
 at any given point on the enamel, after the decay is 
 removed, it should remain for the preservation of the 
 enamel ; it should not he cut through either by pits 
 or by grooves, much less should any considerable por- 
 tion be removed. 
 
 There are cases occasionally in which the dentine 
 is wholly decayed, and its removal lays bare the 
 enamel ; when such a case occurs, the enamel should 
 be retained as perfect as possible, and no attempt 
 made to form pits or grooves in it. The reason for 
 this is found in the friability of the enamel. 
 
 It may be. regarded as an axiom, that where it is 
 necessary to cut the healthy dentine to give proper 
 form to a cavity, it should be done at that part of 
 the cavity, where the tooth will suffer least from the 
 loss. The precise point and amount of cutting will 
 be determined by the form and size of the cavity, and 
 the amount of solid dentine remaining after the decay 
 is removed. 
 
 In small cavities, where there is sufficient material 
 to work upon, the object is to give the cavity a 
 regular form, and make the retaining points where it 
 is most convenient. 
 
 In large cavities, where one side of the tooth is 
 weak, places must be selected for making the retain- 
 ing points, that will not affect the weak point. Fre- 
 quently, in proximal decays of the anterior teeth, the 
 
144 FILLING TEETH. 
 
 labial and palatal walls are friable, and would be 
 easily broken ; much cutting upon such walls would 
 not be admissible. Again, the decay often extends 
 toward the point of the tooth, down to the union of 
 the labial and palatal plates of the enamel; in cases of 
 this kind, all that can be done at this point is to re- 
 move the decay; and fracture will sometimes occur, 
 even in accomplishing this. 
 
 In some instances, as in the crown cavities of the 
 molars, the cavity will be nearly or quite of proper 
 form when it is perfectly opened up, and the decay 
 all removed. This is the case when the decay is 
 confined to a simple perforation of the dentine, with- 
 out any lateral extensions. In proximal cavities, 
 there is always more or less excavation of the solid 
 dentine required, to give the cavity proper form. 
 
 There is no definite rule for the formation of cavi- 
 ties, that will be applicable in all cases. The form 
 will be modified by the tooth, the position of the 
 decay upon it, and the extent and ramifications of 
 the decay and the manner in which it is to be filled. 
 ' It is given, by some, as a rule, that the depth of a 
 cavity should be equal to its least diameter. This is 
 a direction, however, of no general application, for 
 many cavities will be much deeper than the greatest 
 diameter, as in crown cavities of the molars ; and the 
 reverse will often occur, as in labial cavities of the 
 
FORMING CAVITIES. 145 
 
 superior incisors, and in proximal cavities of the 
 molars, in which it would be impossible to make 
 anything like an approach to this rule, without ex- 
 posing the pulp, and even cutting through its chamber. 
 
 A general direction, and one that we think good, 
 and applicable in many cases, especially in crown 
 cavities of the molars, and in almost any of the deep 
 perforations by decay, is, to make the walls of the 
 cavity as nearly as possible parallel with one another. 
 This rule is applicable in almost all small cavities. 
 
 In medium or large-sized cavities, it is admissible 
 to leave them slightly larger at the bottom than at 
 the orifice, if circumstances require ; a large cavity of 
 this form can be perfectly rilled, when a small one 
 could not, from the fact that, in the former, there is 
 more room to operate in introducing and consolidating 
 the filling. 
 
 Cavities that are larger within than at the orifice, 
 should have their walls perfectly plain, smooth sur- 
 faces, free from transverse grooves or depressions, so 
 that the gold may be perfectly adapted to them. 
 
 It is sometimes necessary to leave a cavity slightly 
 larger at the orifice than at the bottom. This may 
 be done by a converging inclination of the wall of 
 one or more sides of the cavity. When there is an 
 inward inclination of the wall at one side of the 
 cavity, the general form may be such as to retain a 
 
146 FILLING TEETH. 
 
 filling perfectly, for there may be two opposite sides 
 parallel, or even divergent ; in that case, the axis of 
 the cavity will not be in the direction of the center 
 of the crown. 
 
 Two opposite sides may converge and the others 
 diverge, and a filling be retained firmly. When two 
 contiguous sides have the same converging inclina- 
 tion, making the orifice larger than the interior, if 
 the walls are smooth, plain surfaces, a filling will not 
 be retained ; but retaining points may be made by 
 forming transverse grooves, or pits upon them, and 
 by this means the filling be firmly retained. As a 
 general rule, it will be necessary, when the orifice is 
 larger than the cavity within, to make grooves or pits 
 on the walls. For this purpose the diamond point 
 excavator is invaluable. 
 
 If the cavity is large, and the walls near the orifice 
 thin, and liable to be broken, the situation of the 
 grooves or under-cutting should be farther within the 
 cavity than if the walls are firm out to the edge. 
 Sometimes it is best to make little pits at the bottom 
 of such cavities for retaining points. In cases where 
 it is necessary to make an under-cutting, one or two 
 little transverse grooves upon one side will be suffi- 
 cient, and in no case on more than two sides, leaving 
 the others perfectly plain surfaces. 
 
 In the formation of retaining points in difficult 
 
FORMING CAVITIES. 147 
 
 cavities, there is considerable diversity of practice — 
 under-cutting and grooving have been very com- 
 monly employed. Another method has been very 
 frequently adopted during the last three or four 
 years, namely, that of drilling little holes or pits into 
 the dentine at the most favorable points, these taking 
 different directions. This kind of retaining points is 
 much better calculated to answer the purpose, in 
 filling with crystal gold, or adhesive foil by Dr. 
 Arthur's method, than with the ordinary foil after 
 the old methods. When these perforations are made 
 at different inclinations, and then perfectly filled with 
 adhesive gold of any kind, the filling will certainly 
 be retained in place. For making these perforations, 
 a small square-edged drill is the proper instrument. 
 
 Such retaining points are seldom or never required 
 in crown cavities of the molars ; but in proximal 
 cavities they are frequently employed with great 
 advantage. In forming them, great care should be 
 exercised, lest the pulp-chamber is encroached upon 
 by the instrument. In almost all cases, the proper 
 point for forming them is in the cervical wall of the 
 cavity. 
 
 Another particular to which attention should be 
 given is the border of the orifice. It should always 
 be an object to secure an even, smooth, and strong 
 border to the orifice of the cavity. It is impossible 
 
148 FILLING TEETH. 
 
 to make a good finish with a rough, uneven border ; 
 the filling is also more exposed to injury by mastica- 
 tion. The integrity of a smooth, plain surface is per- 
 fectly retained under influences that would break up 
 and destroy an uneven one. It is also very desirable 
 to have a firm margin; to obtain this, it is often 
 necessary to cut away more, than would otherwise be 
 desirable. A smooth, firm border should not be sacri- 
 ficed for the form, and especially in the posterior 
 teeth. It is very objectionable to some persons to 
 have the perfect form of the front teeth marred or 
 changed ; but it should be remembered that even a 
 front tooth, one-third cut away, and so filled as to be 
 permanently preserved, is far more valuable than an 
 artificial one. 
 
 Another particular that should always be observed, 
 is, to obviate all acute angles. These are seldom or 
 never found in proximal cavities of the molars and 
 bicuspids ; occasionally they are found in proximal 
 cavities of the cuspids, and frequently in proximal 
 cavities of the incisors, particularly at that part of 
 the cavity next to the cutting edge of the tooth. 
 Such angles are very often found also in crown 
 cavities of the molars, where there is an extension 
 of the decay along one or more of the fissures of the 
 crown. 
 
 It is difficult— almost impossible — to fill perfectly 
 
FORMING CAVITIES. 149 
 
 a sharp angle, and hence the necessity of obliterating 
 such when they occur. This may be done either 
 with a small delicate cutting instrument, or with a 
 small bur drill. It is an operation requiring great 
 care and delicate manipulation, at least so far as the 
 anterior teeth are concerned. When a sharp angle 
 occurs in the proximal cavities of the front teeth, 
 it is usually near the cutting edge of the tooth, 
 just at the union of the labial and palatal plates of 
 enamel. A small chisel-shaped instrument is very 
 good for cutting out such angles : indeed, in fissures 
 of crown cavities of molars, where the decay extends 
 backward, the straight, chisel-shaped instrument is 
 just adapted to this purpose ; but when there is an 
 anterior extension, the instrument should be curved 
 to almost a right angle, and forced down by pressure 
 of the thumb of the left hand. Some good operators 
 recommend a slight reaming at the orifice of all cavi- 
 ties, where it can be accomplished. The object of 
 this is twofold : to remove the sharp angle at the ori- 
 fice of the cavity, as it is liable to be roughened in 
 putting in the filling ; and to give a better margin to 
 the filling. In making this bevel, the bur, if one is 
 used, should be but little larger than the orifice of the 
 cavity. The cutting should be but slight — just suf- 
 ficient to remove the sharp corners ; much cutting here 
 would give too thin and yielding an edge to the filling. 
 
150 FILLING TEETH. 
 
 DRYING CAVITIES. 
 
 After a cavity is properly formed, it should be 
 thoroughly cleaned and dried. Every particle of de- 
 tached bone or foreign substance should be removed ; 
 during the excavation every thing should be kept 
 out, every fragrant removed as soon as it is de- 
 tached ; but generally there is something of the kind 
 to remove after the cavity is formed. This may be 
 done probably better with a syringe than by any 
 other method ; this, however, used in connection with 
 a moist lock of cotton on a probe, will serve to re- 
 move every extraneous material that may be in the 
 cavity. Any foreign substance remaining in the 
 cavity prevents a perfect adaptation of the gold to 
 the part, and consequently as perfect an attachment 
 as would otherwise be obtained. After washing out 
 thoroughly, wipe out with successive locks of dry cot- 
 ton, till all the moisture is removed. The ordinary 
 cotton will not accomplish this very effectually. By 
 washing cotton in sulphuric ether, it is much im- 
 proved for this purpose. The ether removes a peculiar 
 oily substance from it, and thus increases its capacity 
 to absorb moisture. Ether or chloroform will either 
 answer the purpose ; or boiling the cotton in water 
 in which there is a small portion of carb. soda, or 
 
DRYING CAVITIES. 151 
 
 some such alkali, for a short time, will accomplish 
 the same thing. Bibulous and blotting paper have 
 been employed for this purpose ; and by some they 
 are preferred. Prepared flax has likewise been used. 
 Either of these is no better than cotton well prepared. 
 The respect in which the paper is any better than 
 common cotton, is, that it has the same treatment in 
 effect as the prepared cotton. 
 
 With none of these things can a cavity be made 
 absolutely dry. It is not necessary to have absolute 
 dryness to make a good filling, yet a more perfect 
 filling can be made where that condition is obtained. 
 Gold takes a better hold upon a perfectly dry, than 
 upon a moist surface. This is quite apparent in the 
 following experiment : Place two or three blocks of 
 gold in any ordinary cavity, wiped as dry as possible, 
 and press them firmly in place, consolidating them as 
 much as would be done in filling, and then test the 
 attachment by removal. Afterward reduce the same 
 cavity to absolute dryness, take the same amount of 
 gold, in the same form, and place it in the cavity, 
 and consolidate as before, at the same point in the 
 cavity; and then test its attachment in the same 
 manner. The latter will be found much more firmly 
 attached than the former. 
 
 But it is objected that this is useless, inasmuch as 
 the natural moisture of the tooth is removed, by pro- 
 
152 FILLING TEETH. 
 
 during absolute dryness, and that this will soon 
 return, and then the cavity will be no dryer than it 
 could have been made with good cotton or paper. 
 Admitting this, perfect dryness will remain long 
 enough for the introduction of the rilling. And if 
 this is facilitated by absolute dryness, and a better 
 adaptation and attachment obtained, then it is de- 
 sirable to obtain that condition. 
 
 It has already been remarked that perfect dryness 
 can not be obtained with cotton or paper. To warm 
 these on a hot metallic plate, after being wrapped on 
 the instrument, will very much increase their effi- 
 ciency in removing moisture. Asbestos wrapped on a 
 small bulb-pointed instrument, and heated, is very 
 good for drying out cavities ; with it, perfect dryness 
 can be obtained, as it can be reheated and applied 
 as often as necessary. To prepare this, select a 
 proper-sized bulb-pointed instrument; a worn-out bur 
 drill answers well ; and fold over its fibers of asbestos, 
 passing them a little way beyond the bulb on the 
 shaft of the instrument, and there binding them 
 firmly on with fine platinum wire ; and the instru- 
 ment is ready for use. Another method of obtaining 
 perfect dryness — one that is very certain in its 
 result — is to throw a jet of warm air into the cavity. 
 This is accomplished by a little instrument, simple 
 in structure and easily used. (Fig. 43.) It consists 
 
DRYING CAVITIES. 153 
 
 of a small blowpipe with a cylinder an inch long, 
 and half an inch in diameter ; this is placed down 
 within two inches of the point of the instrument. 
 
 Fig. 43. 
 
 This cylinder is either made of very heavy metal, or 
 rilled with wire or something that will retain heat ; 
 on the other end is attached a stiff India-rubber ball 
 with an eyelet opening one-fourth inch in diameter. 
 By placing the thumb upon this opening, and making 
 compression, a jet of air is forced through the point 
 of the pipe, and the cylinder being previously heated, 
 the temperature of the jet will be governed by that 
 of the cylinder, and the velocity with which it is 
 forced through the instrument. This jet thrown 
 into a cavity that has been made as dry as possible 
 by wiping, soon makes a very perceptible change, the 
 walls becoming whiter than before. This we con- 
 sider the most desirable condition in respect to dry- 
 ness, that can be obtained. 
 
154 FILLING TEETH. 
 
 INTRODUCING THE FILLING. 
 
 Having, in all the steps for the preparation of the 
 cavity, made thorough work, the next thing to be 
 accomplished is the introduction and consolidation of 
 the filling. The manner of performing this part of 
 the work will be governed by the kind of material 
 employed, and also, somewhat, by the form of the 
 particular material, as well as the method adopted. 
 Some materials, as gold, for instance, may be used in 
 three or four different forms, each involving a princi- 
 ple peculiar to itself; and each of these forms is 
 susceptible of being used in different ways. It is 
 proposed to describe, as clearly and concisely as 
 possible, the various methods of filling that have 
 been found efficient. This is the more important since 
 different operators differ in their election of methods ; 
 some preferring one, others another; the result of 
 mere choice, habit or some peculiar fitness. 
 
 The first method for consideration is that of filling 
 with ordinary non-adhesive gold foil. The principles 
 applicable to the use of this kind of foil also obtain in 
 the use of foils of other metals. Gold is used far more 
 than any thing else. The common, and, indeed, the 
 almost universal method of using foil, in the early 
 periods of the profession, was in the form of a roll, or 
 
INTRODUCING THE FILLING. 155 
 
 rope, as it was sometimes called. By this method, 
 the foil is cut into strips from one-third of an inch to 
 two inches wide, the w 7 idth being governed somewhat 
 by the size of the cavity to be filled. This strip is 
 then rolled lengthwise, forming a loose roll. The 
 compactness of the roll should depend upon the thick- 
 ness of the foil, and the size of the points with which 
 it is to be condensed; the smaller the points, the 
 more compact the roll may be. 
 
 It may be introduced either with the condensing 
 instrument or with the plugging pliers (improperly 
 sometimes called plugging forceps). 
 
 If with the former, it is taken up at one end on 
 the point of the instrument, and passed to the bottom 
 of the cavity; and that portion within the cavity is 
 pressed firmly against the wall where it is desirable 
 to begin the filling. There is no definite uniform 
 point in cavities, at which to begin the introduction 
 of the gold ; usually, however, in crown cavities of 
 the molars, at the posterior wall. At whatever point 
 the filling is commenced, the cavity should be so 
 formed that it will retain the first portion of gold 
 introduced; and this may be done by forming a little 
 pit or groove for the reception of the portion first 
 introduced. This is a particular that can not with 
 impunity be neglected. The gold should never change 
 its position after it is pressed to the wall of the cavity; 
 
156 FILLING TEETH. 
 
 for its position can not be changed, except at a sacri- 
 fice of the adaptation, after it is condensed. The end 
 of the roll being placed in the cavity, it is seized far 
 enough without the cavity to form a fold that will 
 extend to the bottom, and protrude about one line 
 beyond the border of the orifice. This fold is pressed 
 firmly upon the preceding portion of gold and adjacent 
 walls. Thus fold after fold is introduced, passed to 
 the bottom of the cavity, and, protruding from the 
 orifice, consolidated firmly, each portion as it is intro- 
 duced, being perfectly adapted to the walls of the 
 cavity and the preceding portion of the filling. 
 
 It is important to obtain as complete an adaptation 
 of the filling to the walls of the cavity as possible ; 
 and in order to accomplish this the center should not 
 be filled too rapidly. The gold is thus introduced 
 fold after fold till the cavity is full. When it is filled 
 to two-thirds of its diameter, the gold should then be 
 adjusted to all the remaining walls of the cavity, and 
 the last portions of gold introduced somewhere in 
 the body of the filling, certainly not next to any wall 
 of the cavity. A more thorough adaptation of the 
 gold can be made to the walls of the cavity, by this 
 manner of arranging it, than by introducing the last 
 portion at one side of the cavity. There is less lia- 
 bility of fracturing a frail tooth by placing the gold 
 on the walls first, and terminating the introduction 
 
INTRODUCING THE FILLING. 157 
 
 of it at or near the center of the filling. It is a very 
 common practice to introduce the gold rather loosely, 
 or without much condensing, and after being intro- 
 duced in this manner, to condense by forcing into it 
 a wedge-shaped instrument at various points, and 
 rilling these perforations with small rolls of gold ; 
 continuing to use the wedge-shaped instrument as 
 long as it can be forced into the filling. This method 
 is by no means as efficient as that of condensing each 
 portion as it is introduced. By the latter plan the 
 filling can be made uniformly dense from the surface 
 to the bottom of the filling. This can not be done 
 by the use of the wedge-shaped instrument ; it will 
 compress most at its largest diameter, that is, at the 
 surface of the plug. 
 
 In no filling, even when the walls of the cavity are 
 parallel, will a uniform density throughout be ob- 
 tained by perforating with the wedge. The filling 
 would be most dense at the surface, and less so the 
 farther into the filling we go. This method is objec- 
 tionable for condensing the fillings on the masticating 
 surfaces of the molars ; for in the act of mastication 
 the inner portion would yield, and the surface of the 
 filling would be crowded down into the cavity, and 
 the dentine within the orifice become exposed and 
 decay be the result. In proximal fillings this objec- 
 tion would not have the same force. In pressing an 
 
158 FILLING TEETH. 
 
 instrument of a wedge form into a filling with suffi- 
 cient force to condense the mass, there would be great 
 danger of breaking a weak wall of the cavity. The 
 principal pressure is lateral, and would consequently 
 come upon the side of the tooth. 
 
 In crown cavities of the molars where there is any 
 considerable inward expansion of the cavity, that 
 method of condensing would be wholly inefficient ; it 
 would not render the inner portion dense enough to 
 support the surface of the plug, and it would be 
 forced dowii, and necessarily be loose. In filling the 
 proximal cavities of the incisors, it is very objection- 
 able on account of the great liability of breaking the 
 inner and outer walls, which are usually quite thin. 
 
 In preparing the foil for filling, some operators tear 
 off the foil in irregular pieces, and form into little 
 balls or pellets, round and loosely rolled, correspond- 
 ing in size with the cavity to be filled. These pellets 
 are placed in the bottom, if a crown cavity, and at 
 one side, if a proximal cavity, and condensed with a 
 sharp-pointed instrument, attaching one pellet to 
 another till the cavity is full. This mode is not so 
 good as that previously referred to, unless the gold is 
 in a condition to weld perfectly; there is no con- 
 tinuous portion from the bottom to the orifice of the 
 cavity ; and the outer portions are liable to become 
 detached. Both of these methods of arranging the 
 
CYLINDER OR BLOCK FILLING. 159 
 
 gold are objectionable in one particular, namely, the 
 irregularity of the leaves or laminae of the foil ; these 
 are placed in the cavity without any regard to regu- 
 larity, and the consequence is, that without very 
 great care, far less gold will be introduced than by 
 some other arrangement. Far more difficulty is 
 experienced in obtaining a uniform and equal density 
 than when the laminae are placed smoothly together. 
 Another method of preparing the foil is to fold it 
 into from ftmr to twelve thicknesses, then cut off 
 strips in width corresponding to the diameter of the 
 cavity. The strip thus prepared is introduced in the 
 same manner as the roll, except that as each fold is 
 inserted, it is placed smoothly against the preceding 
 portion, and kept smooth and free from wrinkles. 
 By this arrangement very little force is required to 
 bring the folds in perfect contact. Some care and 
 skill will be necessary to bring the instrument to 
 bear upon the whole surface of the fold. More gold 
 can be put into a cavity in this manner than in rolls 
 or pellets, unless these are used in very small portions, 
 and condensed very thoroughly as they are put in. 
 
 CYLINDER OR BLOCK FILLING. 
 
 Another and in some respects far preferable 
 method, is filling with cylinders or blocks. Some 
 
160 FILLING TEETH. 
 
 of the advantages of this method over that just 
 described, are the following: the rilling can be intro- 
 duced far more rapidly ; and the laminae, or leaves of 
 foil, take a more perfect position in the cavity, and 
 consequently the structure of the rilling is better. 
 The form of the cavity should be much the same as 
 that for any other method of rilling; there should be 
 some retaining point so situated that the first block, 
 or blocks, can be fixed firmly in place, so that there 
 will be no liability of loosening during the subsequent 
 part of the process. It is important to have such an 
 arrangement, as otherwise it would be necessary to 
 employ an instrument in the left hand to retain the 
 first blocks in situation, till enough were introduced 
 to bind the whole by pressure upon two opposite 
 points in the cavity. 
 
 Forming Blocks. — For forming blocks, use any 
 number of foil that may be desired, usually No. 4 or 
 6, and either lay four to six sheets together, or fold a 
 single sheet into that number of thicknesses; then 
 cut off, from the sheets thus prepared, strips about 
 one-third to one-fourth wider than the depth of the 
 cavity to be rilled; which are then rolled on a 
 small three or four-sided broach — the three-sided is 
 better; this instrument should be very small; no 
 larger, indeed, than is necessary for strength. Its 
 sides should be perfectly smooth, and its angles 
 
CYLINDER OR BLOCK FILLING. 161 
 
 sharp ; ordinarily it should not taper, or at least very 
 slightly. For forming the conical blocks, some prefer 
 the tapered broaches, but they can be as well made 
 on the parallel-sided instruments. The strip being 
 taken between the thumb and the index ringer, is 
 rolled on the broach equally, till the block or cylinder 
 is large enough, when the strip is broken off. The 
 sizes of the principal part of the blocks should cor- 
 respond with the sizes of the cavities to be filled. 
 Different sizes and forms will be required in almost 
 all cases. Relatively large cylinders may be em- 
 ployed for the principal part of the filling. If the 
 walls of the cavity are parallel, almost all the blocks 
 may be truly cylindrical; but if there is an under- 
 dipping of one or more of the walls, the blocks 
 adjusted to that particular part should be cone-shaped, 
 corresponding to that under-dipping. A number of 
 small graduated cone-shaped blocks, of different de- 
 grees of density, will be required for completing each 
 filling; as the aperture becomes smaller, smaller 
 blocks will be needed. The cone-shaped blocks are 
 formed, by gradually running the strip back from the 
 point of the instrument as it is wound on ; greater or 
 smaller taper can be given to it, as the strip is run 
 less or more rapidly back from the point. The 
 density of the block can be regulated by the firmness 
 with which the strip is held between the thumb and 
 
162 FILLING TEETH. 
 
 finger; upon which it is well to have a fine silk or 
 India-rubber covering to protect the gold from the 
 perspiration of the hand. There -are other methods 
 of forming blocks. They may be made square, by 
 making a great number of folds — fifteen to thirty — 
 and from this, cutting strips as before directed, and 
 then from these heavy strips cutting off the blocks of 
 the desired size, which will then be flat or nearly 
 square. In one respect these blocks are objection- 
 able : the edges, when they have been cut off, are 
 rendered dense by the action of the shears, so that 
 they clo not possess the uniform density or consistence 
 of the rolled blocks, and it is impossible to adapt 
 them as perfectly to the walls of the cavity, or to one 
 another. This objection, however, may be obviated 
 by cutting off the blocks with a very fine saw. 
 
 Another method of forming blocks, first employed 
 by Dr. Blakesley, is to roll a sheet of No. 5 foil into a 
 rope, and cut off from it blocks corresponding with 
 the size of the cavity to be filled. These are liable 
 to the same objection as those last mentioned, the 
 shears hardening them, when they are cut off. They 
 are subject to the additional objection, that the folds 
 of foil are not as regular as by either of the other 
 methods. But by proper manipulation, with the gold 
 prepared in this manner, superior fillings may be 
 made. Another method of preparing blocks is by 
 
CYLINDER OR BLOCK FILLING. 163 
 
 cutting a sheet of foil into two or three pieces, then 
 roll them diagonally on a steel wire or rod; the size 
 of this wire will he determined by the required length 
 of the blocks, as there should be blocks of different 
 lengths, the wires should be of different sizes, and range 
 from No. 2 to No. 12 of White's bur gauge plate. 
 The size of the wire will be determined by the depth 
 of the cavity. The wire being withdrawn, the foil is 
 compressed to a strip. These strips are now rolled 
 squarely upon a No. 20 steel wire ; the size of the 
 cylinder being determined by the size and form of the 
 cavity to be filled. These may be used either in 
 their cylindrical form, or compressed and doubled. 
 The cavity formed, and the blocks prepared,. the next 
 step is their introduction. 
 
 Introducing the Blocks. — For placing the gold into 
 the cavity the plugging pliers will be required ; the 
 points of which should be curved, so as to make the 
 most perfect approach to the cavity. The points, 
 too, if properly formed, may be used to some extent 
 for condensing the blocks. All things being ready, 
 with suitable napkins and guards for the protection of 
 the cavity against the encroachment of moisture from 
 the saliva and breath, the fingers of the left hand 
 should press upon the napkin, and also hold away the 
 soft parts. If there is an angle, a small block should 
 be first introduced with the pliers into the proper 
 
164 FILLING TEETH. 
 
 position, one end upon the bottom of the cavity, and 
 the other protruding from the orifice, and pressure 
 then be made upon it to consolidate it, and force it* 
 into its position against the wall of the cavity. This 
 may be done with the pliers, or better with the 
 instrument represented by Fig. 21. The part of the 
 instrument brought to bear upon the gold should be 
 roughened either longitudinally or transversely, so 
 that a proper surface may be left for the reception of 
 the succeeding portions. The largest blocks are then 
 introduced and consolidated successively as described, 
 the end of each left protruding, till the cavity is 
 filled; each portion as it is introduced, should be per- 
 fectly condensed. The gold should be filled in faster 
 at the sides of the cavity than in the center, thus 
 being disposed round the walls till it meets at a point 
 opposite the place of beginning; and thus it is adapted 
 to all the walls of the cavity before it is entirely 
 filled, the last portions being introduced somewhere 
 near the center of the filling. As the cavity dimin- 
 ishes by the introduction of the gold, the small and 
 more dense blocks will be required ; which should be 
 forced in and condensed, by crowding the instrument 
 (Fig. 23) down against the side of the cone. Some 
 operators terminate the filling against the wall of. the 
 cavity, forcing down the blocks and compressing, as 
 above, till it is full. By this method there is danger 
 
CYLINDER OR BLOCK FILLING. . 165 
 
 of fracturing the tooth, breaking down the wall of 
 the cavity, where the filling is terminated. Another 
 method is to fill up the cavity principally with blocks, 
 and to put in the last part of the filling in the strip, 
 fitted in from the bottom to the orifice. The objec- 
 tion to this method is, that unless adhesive foil is 
 employed, the portion inserted in the strip is liable 
 to be displaced, and in this way the whole, filling 
 become destroyed. 
 
 Another method of arranging this kind of filling, 
 particularly when the bottom of the cavity is irreg- 
 ular, is to make a large, flat pellet, condense it firmly 
 to the bottom, and set the blocks upon this for a 
 foundation. By this method there is a more perfect 
 adaptation of the gold to the bottom of the cavity, 
 than by placing the ends of the blocks down upon an 
 uneven surface. After the gold is all introduced, a 
 small-pointed plugger must be passed all over the 
 surface, to consolidate the protruding portions and 
 form a surface to the filling. These protruding por- 
 tions should be sufficient to make the surface perfectly 
 flush with the border of the cavity ; for a depression 
 here is fatal to a complete finish. After the surface 
 is condensed with the fine and large points, it may 
 be rubbed down with an instrument serrated upon 
 the side, and afterward with the coarse file, and then 
 with the fine, etc. 
 
166 TILLING TEETH. 
 
 Dr. Badger describes a method of filling a small 
 cavity on the posterior proximal portion of a second 
 molar, the third molar gone. The cavity is formed 
 with a bur drill. A cylinder is then formed in the 
 usual manner, and forced through a series of holes in 
 a drawplate, down to the size of the bur with which 
 the cavity is formed. The block is thus rendered 
 quite dense. The cavity is then dried, and the block 
 forced into it, which it exactly fits, protruding a little 
 from the orifice. This block is pierced in the center 
 with a sharp instrument, and a small dense roll forced 
 into it ; and all is then condensed and finished in the 
 usual manner. 
 
 Pellets. — Pellets made by rolling fragments or 
 pieces of foil between the thumb and fingers, are used 
 by some operators, and with them they profess to 
 make as good filling as by any other method. They 
 are made of various sizes, and packed into the cavity 
 with sharp-pointed or serrate-pointed instruments. 
 The pieces may thus be very solidly worked to- 
 gether, and a good filling made, provided the pellets 
 are not too large ; they should be small enough to 
 permit the point or points to work through them into 
 the preceding portions. Some operators use pellets 
 and crystal gold together. This may do very well, 
 if the adhesive property of the gold is employed; but 
 in that case, either form of the material would answer 
 
CYLINDER OR BLOCK FILLING. 167 
 
 alone. There cannot be as much gold put in by 
 pellets as by blocks or cylinders well adjusted. 
 
 Adhesive Foil. — By this we understand that condi- 
 tion of gold foil in which the leaves unite readily and 
 firmly together. This property of cohesion is pos- 
 sessed, in the greatest degree, by properly manufac- 
 tured foil, immediately after annealing. Not that 
 annealing imparts any new property to the gold, but 
 it removes obstacles to the manifestation of a principle 
 possessed by all gold under favorable circumstances. 
 It is now about twelve years since this property was 
 first employed in gold foil for filling teeth. To Dr. 
 R. Arthur is due the credit of first directing the 
 attention of the profession to it. He not only did 
 this, but he entered most fully into the details of the 
 manipulations, instruments, etc., pertaining to this 
 mode of operation. Almost all recently prepared 
 gold foil possesses this property to a greater or less 
 degree ; there are methods of preparing it, however, 
 by which it possesses it most fully ; all recently 
 annealed foil is adhesive. If the foil is adhesive 
 when we wish to use it, nothing further is required 
 in the way of preparation. But if it is not adhesive 
 — as almost all foil is not, especially if it has been 
 exposed to the influence of the atmosphere — it will 
 require to be made so by some process : there are two. 
 either of which will perfectly accomplish the object, 
 
168 FILLING TEETH. 
 
 The one most frequently employed, is that of heat- 
 ing the gold, either in the sheet, in the roll, or in 
 fragments, over the flame of a spirit-lamp, almost or 
 quite to a red heat ; if in the sheet, it should be laid 
 upon a piece of wire gauze, and passed over the flame 
 of the lamp for a moment or two ; if in the roll, it 
 may be taken in the center with fine pliers and 
 passed rapidly through the flame ; if in small frag- 
 ments or pellets, placed upon a piece of charcoal and 
 a light flame thrown upon them with a blowpipe. 
 The other method is that adopted by Dr, Coates. 
 Into a little platinum pan, large enough to hold an 
 unfolded sheet of foil, are put one or two gills of rain 
 water, to which are added about forty drops of sul- 
 phuric acid ; and in this liquid the foil is boiled a 
 few moments over the flame of a spirit-lamp. The 
 acid removes all foreign substances from the surface 
 of the gold. Remove it from the boiling liquid, and 
 in a moment it is dry and ready for use, and will be 
 most thoroughly adhesive. 
 
 There are different methods of using gold in this 
 condition ; but in general the cavity should be formed 
 about as for the other methods of filling, except that 
 to retain the first piece, there should be two or three 
 small pits or holes made for retaining points in the 
 most available position. The first portion of gold 
 should be a little pellet ; this forced into these re- 
 
CYLINDER OR BLOCK FILLING. 169 
 
 taining points, serves as a foundation for the remain- 
 ing portion of the filling. Dr. Arthur's method is, 
 then, to tear off fragments from the sheet, and pass it 
 into the cavity without folding up, and condense it 
 with an instrument of fine serrated point, so that it not 
 only unites by cohesion, but it is worked into the 
 surface of the preceding portion of gold ; and in this 
 manner portion after portion is introduced and con- 
 densed, until the cavity is full. The filling may be 
 commenced in any part of the cavity that is most 
 convenient ; in many, as in crown cavities of the 
 molars, at the bottom, and filled to the orifice. In 
 putting in the gold, it should, during its introduction, 
 be kept fuller about the walls of the cavity than in 
 the center; by this means the adaptation will be 
 most perfect to the walls, and there will be no liabil- 
 ity of clogging up the center. The gold may thus be 
 built up to any desired extent if the filling is kept 
 dry ; moisture is fatal to its adhesiveness. 
 
 Others use the adhesive gold in a different manner. 
 To Dr. Blakesley belongs the honor of first detailing 
 the following plan : The sheet of gold may be folded 
 or not at the pleasure of the operator, and then each 
 sheet cut into from two to six strips, and these formed 
 into a loose roll between the thumb and fingers. It 
 may now be passed rapidly through the flame of a 
 spirit-lamp to remove any foreign substance that may 
 
170 FILLING TEETH. 
 
 be upon it ; when it is cut into little blocks or pellets 
 of various sizes ; these to be regulated by the size of 
 the roll and the amount cut off. For the introduction 
 of the gold thus prepared, about three sizes of instru- 
 ments are required, those having fine serrated points 
 being preferable. As to the sizes of these points, 
 Dr. Blakesley remarks, "they should just enter, 
 respectively, Nos. 22, 24, and 26 of the wire-gauge." 
 A larger than either of these, however, is desirable 
 for many cases. As before, the filling may be com- 
 menced at the bottom of a cavity or at one side, if 
 desirable, with a pellet sufficiently large to be set 
 firmly into the retaining points. Then take up the 
 small pellets or blocks upon the point of the plugging 
 instrument, and place them exactly in the desired 
 position, and consolidate them thoroughly, building 
 up next to the Avail all around higher than the center 
 with the smaller pieces, filling up the little corners 
 and interstices ; for which manipulation the smaller 
 points will be required. The gold is then packed in 
 till the cavity is full, when it is finished as usual. 
 Another method is to tear off fragments from the 
 sheet, and roll these up into round pellets, and fill 
 with these, with the same instruments and upon the 
 same principle as above described. But by this 
 method it is difficult to make a perfect filling; the gold 
 is liable to clog in the cavity, and fail in adaptation. 
 
THE MALLET. 171 
 
 Adhesive gold must be consolidated as it is intro- 
 duced ; for if a cavity is full, it is very difficult then 
 to condense it more, even though the consolidation is 
 but partial ; and the same is true to some extent of 
 non-adhesive foil. 
 
 THE MALLET. 
 
 Within the last seven years quite a change has 
 been effected in the theory and practice of consolida- 
 ting gold in filling teeth. Prior to this period it was 
 accomplished entirely by the pressure or force exerted 
 by the hand. There was very considerable diversity 
 of opinion as to the best mode of this manipulation. 
 Some maintaining that great force is always required 
 to make a filling sufficiently dense ; assuming that it 
 is better to use comparatively large points, great 
 pressure and rapid execution, thus securing the ut- 
 most economy of time, both to the operator and 
 patient. Others entertain the opinion that with 
 smaller points, less pressure and more time, a more 
 definite and. satisfactory result is attained. 
 
 Notwithstanding the diversity of opinion and prac- 
 tice upon this subject, we would suggest that young 
 operators, at least should bear in mind, that in so 
 important a matter as filling teeth, efficiency should 
 never be sacrificed to rapidity. 
 
172 FILLING TEETH. 
 
 About the year 1861, condensing gold, in filling 
 teeth, by the use of the mallet was introduced to the 
 profession by Dr. W. H. Atkinson. This method is 
 especially applicable and effective for the condensation 
 of adhesive gold, and indeed, gold in any form when 
 the aim is to condense each portion as it is introduced. 
 A more thorough condensation is made by the use of 
 the mallet than is possible by the hand alone ; greater 
 precision of manipulation is attainable ; it is easier 
 for the operator ; and usually less unpleasant to the 
 patient. 
 
 The character of the results in the use of this 
 instrument depends much upon the skill of the assis- 
 tant. It requires time, care and patience to famil- 
 iarize the assistant with the use of the instrument. 
 The plugger should be held firmly in position by the 
 operator, and receive the stroke squarely upon the 
 end ; it should be a sharp springing tap. "Very much 
 depends upon the character of the blow; a dead 
 heavy stroke will not unite the gold as it should be. 
 It is important that the assistant be able to follow 
 the indications of the operator, without loss of time. 
 Many assistants are disposed to give time strokes 
 instead of following indications; which are not ad- 
 missible except in very simple cases. 
 
 In order to avoid the employment of an assistant, 
 and to place the strokes of the instrument more under 
 
THE MALLET. 173 
 
 the control of the operator, various forms of automatic 
 mallet pluggers have been invented and constructed. 
 Two or three principles embrace the whole, though 
 perhaps twenty different forms have been made. Those 
 operated by the action of spiral springs have been the 
 more common ; the objection to almost all of these is, 
 that the stroke lacks the desired elasticity. This 
 class of instruments is represented in general aspect, 
 by Fig. 44. 
 
 Fig. 44. 
 
 
 This instrument was invented by Dr. I. A. Sal- 
 mon, and is one of the best of this form ; and operates 
 well in the hands of those who become familiar 
 with it. 
 
 Another form of mallet plugger is represented in 
 Fig. 45, in which the blow is communicated by a 
 spring of another form, and of such an arrangement 
 as to give a springing stroke. This instrument was in- 
 vented and made by Dr. W. Gr. Redman. It would be 
 objectionable in the hands of some, because of its size, 
 weight and form : use and custom will remove great 
 apparent, and even real, difficulties. 
 
 Both of these instruments are less under the control 
 of the operator, in respect to the force of the blow, 
 
174 
 
 FILLING TEETH. 
 
 than 
 
 Fig. 45. 
 
 they should be. It is true that in both, the 
 
 force can be regulated 
 to the most minute de- 
 gree, between a very 
 light and a very strong 
 stroke ; it cannot be 
 done however, without 
 giving special attention 
 to that particular; which necessitates an 
 arrest of the operation of the instrument. 
 
 An instrument is made by Dr. S. B. Pal- 
 mer, in which the force of the blow is placed 
 completely under the control of the opera- 
 tor, while it is being used. The operation 
 of this instrument is perhaps less objection- 
 able, in respect to the character of the 
 stroke, and its control by the operator, than 
 any other as yet employed. Any of these 
 instruments are valuable in the hands of 
 those who become familiar with their use. 
 
 CRYSTAL OR SPONGE GOLD. 
 
 The form of the cavity for crystal gold filling, 
 should be much the same as that described for other 
 fillings, except that the same care is not necessary for 
 special retaining points; for the first portion of good 
 
CRYSTAL OR SPONGE GOLD. 175 
 
 crystal gold that is introduced into the cavity, will 
 attach to the walls of a cavity without any such special 
 retaining points : such a form should be given, however, 
 as to secure the first piece firmly in place. The gold 
 should be cut or broken into pieces corresponding in 
 size to the cavity, so that they will enter freely 
 into it. 
 
 The filling may be commenced upon the bottom of 
 the cavity, or upon one of its sides ; such a point 
 always being selected as will most effectually retain 
 the gold in place. The pluggers should be of various 
 sizes — the first one as large as can be used in 
 the cavity, and smaller ones for condensing more 
 thoroughly; and all should be serrated with from two 
 to six sharp points, usually four. The blocks may be 
 taken up on the point of the plugger, or perhaps bet- 
 ter with the pliers, and passed to the proper position 
 in the cavity, and there condensed. The sharp, ser- 
 rated point leaves the surface in good condition for 
 the reception of the next piece. The gold should be 
 packed to the walls of the cavity a little in advance 
 of the center, so that its adaptation may be more 
 complete. In this manner, the filling is built up as 
 much as is desirable, if it is kept dry — and unless 
 it is, cohesion is very much diminished, or lost 
 altogether. 
 
 The gold, after it is cut up, is passed through the 
 
176 FILLING TEETH. 
 
 flame of a spirit lamp to anneal it, and dispel all 
 foreign substances; it should in no case be brought 
 above a perceptible red heat; and usually not to that 
 point; it should be done carefully, so as not to fuse 
 any of the particles, as that would impair their facility 
 of cohesion in this process: small portions are often 
 required to fill up small interstices, or notches. 
 
 In crown cavities, the filling should begin at the 
 bottom; in proximal cavities, at the cervical wall. 
 By introducing the gold in this manner, the pressure 
 is made on a line with the axis of the tooth ; which 
 is an important consideration. The surface of the filling 
 should be made to conform to that of the lost portion of 
 the tooth; this can always be done except where the 
 tooth is largely broken away, and even then very 
 much may be accomplished, in many cases, to restore 
 the lost form; that will depend, however, upon the 
 method of using the gold. In crown fillings of the 
 molars and bicuspids, the antagonism of the teeth 
 must be regarded ; they should be formed for the 
 reception of the cusps of the opposing tooth. Proxi- 
 mal fillings should usually be convex; yet many good 
 fillings of this class are effected with a surface per- 
 fectly plain with the borders of the cavity. The 
 borders of the filling, however, are better protected 
 when it is somewhat convex. 
 
 Crystal gold, of perfect character, presents to the 
 
CRYSTAL OR SPONGE GOLD. 177 
 
 walls of the cavity a surface better calculated to be 
 retained, than foil in any of its forms; though adhe- 
 sive foil possesses this advantage to a greater extent 
 than foil in any other condition. The points and 
 edges of the crystals are brought in contact with the 
 walls, and take a firmer hold upon the dentine. 
 
 In forming crystal gold into a solid mass, two 
 principles are operative : cohesion acts upon it as 
 potentially as upon gold in any other form, and, in 
 addition, there is the interlacing, or locking, of the 
 crystals with one another ; so that a more perfect 
 union of the different portions of which a filling is 
 composed, is obtained with crystal gold than with 
 foil. Yet good adhesive foil, when thoroughly 
 worked in, attains almost the same condition. With 
 perfect crystal gold, however, some advantages may 
 be secured, that can not be had with foil. The gold 
 will be retained in a cavity that will not retain a foil 
 filling; it is more easily formed into a coherent mass; 
 it can be built out with more ease ; cavities can be 
 filled with it that can not be rilled with foil at all ; 
 and a filling of it is susceptible of a better finish, with 
 the same labor, than a filling of foil. 
 
 It is important to keep the gold perfectly free from 
 moisture, while being introduced and consolidated ; 
 for moisture instantly destroys its cohesive property. 
 And the more complete the exclusion of moisture 
 
178 
 
 FILLING TEETH. 
 
 from the cavity, during the process, the better for 
 the success of the operation. The surface of every 
 filling should be consolidated for finishing, before 
 it is allowed to become moist; for, if it becomes 
 saturated with moisture before consolidation, it is 
 impossible to make a perfect finish. There should 
 always be gold enough superadded to insure this; 
 and the consolidation of the surface should be effected 
 with a burnisher of the proper form, used with the 
 mallet, consolidating the entire surface as thoroughly 
 
 Fig. 46. 
 
 €S c> 
 
 i u 
 
 j> j> 
 
 )) 
 
 and smoothly as possible, exercising great care about 
 the borders of the filling. Fig. 46 represents the 
 forms of the burnishers suitable for almost all cases. 
 
FINISHING FILLINGS. 179 
 
 FINISHING FILLINGS. 
 
 The method of finishing a filling, and the manipu- 
 lation required, will depend somewhat on its locality. 
 When the filling has been thoroughly consolidated 
 over all the surface, and especially all round its 
 border, the file should be applied to dress off any 
 projecting portion, and render it smooth. In consoli- 
 dating the surface, an instrument should be used that 
 would not pit it, and the file should remove all inden- 
 tations. The work of the file, however, should be 
 but partially performed at first, and the surface 
 burnished again. To obtain the most perfect finish, 
 the surface should be brought to a uniform consist- 
 ence ; and this condition can not be reached by the 
 use of sharp-pointed instruments, nor fully by that of 
 the blunt plugger at the first effort, but by the alter- 
 nate use of the file, the blunt condenser, and the 
 burnisher. A coarse file should be employed in this 
 part of the process ; but when the filling is dressed 
 sufficiently, and in good condition, the fine file should 
 be used, alternately with the burnisher, till a perfectly 
 uniform surface is obtained. In all cases, after the 
 file has been applied, the plug should be washed off 
 with a brush, to remove all detached pieces of gold, 
 before the burnisher is put upon it ; and after the 
 
180 FILLING TEETH. 
 
 fine file and burnisher, the Scotch- or Arkansas-stone. 
 or corundum slips of the proper form, used with the 
 port-polisher, or very fine pumice should be employed 
 to remove the filemarks. The pumice may be applied 
 with water on a strip of chamois skin, a piece of 
 linen tape, or a stick of soft wood — the latter being 
 the most convenient, as it can be used with one hand 
 and shaped to suit any place or position. 
 
 After the stone or the pumice has accomplished its 
 work, and the filling has been thoroughly washed, a 
 fine burnisher, with a solution of castile soap, is em- 
 ployed to give the finish. The burnisher should be 
 of the best cast steel, and of high temper and fine 
 polish. Considerable skill is requisite to give the best 
 effect with the burnisher; it should pass smoothly 
 and gently over the surface, throughout its whole 
 extent, and in parallel lines, with a pressure neither 
 too light nor too heavy. It should also be applied 
 very thoroughly upon any portion of the tooth about 
 the border of the filling, that may have been cut by 
 the file or any other instrument. Indeed, quite as 
 much, if not more, care should be exercised upon 
 this as upon the plug itself: it should be polished as 
 smooth as the enamel, if possible; for the more nearly 
 perfect it is in this respect, the better will it resist 
 the action of the deleterious agents. 
 
 This method of finishing gives to the filling a per- 
 
FINISHING FILLINGS. 181 
 
 feet metallic luster; which, under some circumstances, 
 is objectionable. Two other methods are in use : 
 after the burnisher has been applied, as above, the 
 buff or tape, with rouge, may be employed, by passing 
 it rapidly over the filling, till the metallic luster is 
 
 l destroyed, or deadened, so as not to reflect the light 
 as before, thus leaving a very desirable finish ; and 
 the other method is, to stipple over the surface of the 
 burnished filling with the end of a piece of hard 
 wood — sandal wood is recommended — charged with 
 finely pulverized pumice. This gives a beautiful, 
 velvet-like surface, and is fine for fillings in the an- 
 
 * terior portion of the mouth, where they are exposed 
 to view. Rotten-stone, applied either with the buff 
 or with hard wood, imparts a finish which, though a 
 little different, is equal to any of the others. 
 
 For finishing, some operators prefer to cut and 
 polish, instead of filing and burnishing. But neither 
 so good nor so fine a finish can be effected in this 
 way, and it is probable that economy of time and 
 
 . labor, especially the latter, suggested the method. 
 In all cases, the filling should have a distinct and 
 definite margin: the gold should be trimmed off quite 
 up to the border of the cavity, by passing round it a 
 small, sharp instrument, so as to detect and pare 
 down any portion that might overlap the tooth. 
 For, if overlapping portions are permitted to remain, 
 
182 FILLING TEETH. 
 
 foreign substances will lodge beneath, and induce 
 decay. Neglect in this particular has occasioned the 
 loss of thousands of teeth that otherwise might have 
 been saved. This direction does not apply to those 
 cases elsewhere mentioned, in which it is recom- 
 mended to form a thick firm overlapping portion, for 
 the protection of a thin friable border. 
 
 The subject of finishing is almost entirely over- 
 looked by very many operators ; but by the neat and 
 skillful it is esteemed of sufficient importance to 
 demand as great labor and pains as any other part 
 of the operation. 
 
CHAPTER VII. 
 
 CLASSIFICATION OF DECAYED CAVITIES. 
 
 The following classification of decayed cavities in 
 the teeth, though from the very nature of the subject 
 imperfect, will be found sufficiently accurate for the 
 ^purposes of the dental student and the practitioner. 
 It is based primarily on the position of the cavities, 
 and secondarily on the extent of the decay ; the classes 
 having reference to the former, and the modifications 
 to the latter. The classes are numbered according to 
 the accessibility of the cavities, beginning with those 
 most easily approached and operated upon ; and the 
 modifications according to the extent of the decay, 
 beginning with the smallest and simplest in form. 
 
 First Class. — Central crown cavities in the molars 
 and bicuspids. 
 
 1st Mod. — Extension of the decay along one or 
 more fissures or depressions. 
 
 2d Mod. — Two decays in close proximity on the 
 same crown, which may be formed into one cavity 
 for filling. 
 
 Second Class. — Cavities in the buccal and palatal 
 
184 CLASSIFICATION OF DECAYED CAVITIES. 
 
 surfaces of the molars and bicuspids, and in the labial 
 and palatal surfaces of the canines and incisors. 
 
 1st Mod. — Extension of the decay beneath the 
 margin of the gums. 
 
 2d Mod. — Extension of the decay so as to involve 
 a portion of the crown surface. 
 
 Third Class. — Anterior proximal cavities of the 
 bicuspids and molars. 
 
 1st Mod. — Extension of the decay toward the neck 
 of the tooth, beyond the termination of the enamel. 
 
 2d Mod. — Extension of the decay so as to involve 
 a portion of the grinding or crown surface. 
 
 Fourth Class. — Proximal cavities of the incisors 
 and canines. 
 
 1st Mod. — Palatal wall of the cavity broken away. 
 
 2d Mod. — Labial wall broken away. 
 
 3d Mod. — The cavity at the point of the tooth, ter- 
 minating at the surface. 
 
 Ath Mod. — The borders of the cavity very thin, and 
 the lateral walls inclining to the center. 
 
 Fifth Class — Posterior proximal cavities of the 
 molars and bicuspids. 
 
 Modifications same as those of third class. 
 
 Modifications common to all the classes : — 1st. Su- 
 perficial cavity and a large orifice. 2d. Deep cavity 
 and a small orifice. 
 
 Modification common to classes three, four, and 
 
FILLING BY CLASSES AND MODIFICATIONS. 185 
 
 five : — Transverse extension of the decay round one 
 or more angles of the tooth, under the termination of 
 the enamel. 
 
 FILLING BY CLASSES AND MODIFICATIONS. 
 
 First Class. — Central cavities of the molars and 
 bicuspids. These decays always begin in the depres- 
 sions on the masticatory surfaces, which are vulner- 
 able points, the enamel-membrane folding together 
 here, and often being imperfectly united, so that an 
 opening is left through it to the dentine: besides, 
 these indentations afford lodgment for foreign sub- 
 stances, which may be forced into them in the process 
 of mastication, and there retained, till, becoming 
 vitiated, they produce decay. Examine carefully the 
 extent and the nature of the decay, and the form of 
 the cavity, which, of course greatly varies. In some 
 cases, the cavity is found with a small diameter and 
 a comparatively great depth, the diameter at the 
 orifice being the same as within; in others, with a di- 
 ameter larger at the orifice — as occurs in cases in which 
 a considerable portion of the enamel at the depres- 
 sions on the crown is imperfect. In the majority of 
 instances, however, the diameter of the cavity is 
 much larger within than at the orifice. Sometimes 
 the decay is found to burrow directly beneath the 
 
186 CLASSIFICATION OF DECAYED CAVITIES. 
 
 enamel more rapidly than in any other direction; as 
 where there is an imperfect union between the enamel 
 and the dentine. In other instances, the cavity seems 
 to expand uniformly as it extends into the tooth. 
 
 The manner of opening up and preparing the 
 cavity for filling, will depend somewhat on the form 
 given to it by the decay. If it is larger at the orifice 
 than within, there will be little or no cutting of the 
 cavity about the orifice necessary, except to make it 
 even and smooth; and its preparation will consist in 
 an entire removal of the decay, and such a shaping of 
 the interior as will insure a retention of the filling. 
 This may be effected either by enlarging the cavity 
 within, till its walls are parallel with each other, or, 
 if these are left converging, by forming pits or grooves 
 upon them at proper points. Converging walls pre- 
 sent one or two advantages, which will be hereafter 
 considered. Usually, where the decay has formed a 
 cavity of nearly uniform diameter from the orifice to 
 the bottom, about all the preparation for filling that 
 is requisite, is a thorough removal of the decay. In 
 cases in which the decay burrows under the enamel, 
 the projecting portions are to be cut down, either with 
 a bur drill, or, what is generally better, a heavy 
 cutting instrument. In most instances, it is best to 
 cut away the enamel as far as the decay has extended 
 beneath it, since it is difficult to make a perfect filling 
 
FILLING BY CLASSES AND MODIFICATIONS. 187 
 
 under a projecting portion. In some cases, however, 
 where the enamel is thick and firm, it is admissible to 
 leave a slight projection, so as to form, as it were, a 
 shallow groove. 
 
 The walls of these cavities will be of various in- 
 clinations. If they converge, pits or grooves may be 
 required upon them for retaining points, especially if 
 the enamel be cut away at the orifice to the solid 
 dentine. If, however, the walls, or two opposite 
 walls, are parallel, or but slightly divergent, these 
 special retaining points will not be necessary, except 
 for the reception of the first pieces of gold. Small 
 cavities of this class may be opened up and formed 
 principally with the bur drill ; but in large cavities, 
 this instrument is not available. Thus the orifices of 
 the small cavities would be round, while those of the 
 large would be of various forms, determined by the 
 direction of the decay; as, round, square, triangular, 
 elliptical, parallelogramic. Cavities should not be 
 formed much larger within than at their orifices, unless 
 the filling can be consolidated so perfectly that it will 
 not yield in the least u.nder the greatest pressure of 
 mastication ; for, if there is any yielding in such cases, 
 under direct pressure, the filling being forced into a 
 larger part of the cavity, withdraws from the walls, 
 leaving an interval coextensive with the depression 
 it has undergone ; and thus fluids would be admitted 
 
188 CLASSIFICATION OF DECAYED CAVITIES. 
 
 between the walls and the filling, and the purpose for 
 which this was inserted would be entirely defeated. 
 
 Many operators ream the orifices of all the small 
 and medium-sized cavities of this class, in order 
 thereby to make a better finish to the border of the 
 rilling. Some operators prefer in all cases to remove 
 the angle formed by the wall of the cavity and the 
 surface of the tooth about the orifice, giving a rounded 
 form to the border of the orifice, the object being to 
 avoid fracturing or comminuting the edge of the 
 enamel or dentine about the cavity. All acute angles 
 in these cavities, especially if they extend to the 
 orifice, should be obliterated, since it is impossible to fill 
 them perfectly. This obliteration can be effected with 
 a miniature chisel, or with the appropriate excavator. 
 
 After the formation of the cavity, the next particu- 
 lar is so to arrange as entirely to exclude moisture, 
 whether from the saliva or from the breath. Ordi- 
 narily, in operations on the superior teeth, the follow- 
 ing arrangement will be sufficient for the purpose : 
 Wipe dry the mucous membrane about the mouth of 
 the duct of Steno ; lay directly upon this a piece of 
 heavy blotting paper, or a roll of bibulous paper; then 
 take a napkin folded cornerwise, place the end of it 
 upon the paper, between the cheek and the gum, 
 passing it back of the tooth to be operated upon, 
 along the palatal surfaces of the teeth and the gums 
 
FILLING BY CLASSES AND MODIFICATIONS. 189 
 
 to the anterior part of the mouth, and letting a fold 
 of it extend down from this, and out over the inferior 
 front teeth and the lip, so as to protect the tooth 
 from the breath, and catch any fragments of gold that 
 may drop from the instrument. The napkin and 
 paper thus arranged, are to be kept in their place by 
 the fingers of the left hand of the operator; and, if 
 the mouth of the duct is kept closed by the paper, a 
 complete exclusion of moisture is secured. In some 
 cases, pressure of the ringers on the napkin over the 
 duct is necessary; in others, the paper adheres to the 
 mucous membrane, and effectually prevents the egress 
 of saliva. The cavity should now be dried by the 
 method heretofore described, and it is ready for the 
 filling. 
 
 In operations on inferior teeth, more care is requisite 
 to protect them from moisture. Bibulous paper should 
 be packed in on the mouths of the sublingual and 
 submaxillary ducts, and a roll of paper placed between 
 the cheeks and the teeth. A larger roll of napkin, 
 too, than that used for the upper teeth, should be 
 disposed in the same manner as above suggested, and 
 held in place by the patient with a speculum (Fig. 
 47), or by the fingers of the operator. 
 
 Cases are frequently presented in which the flow 
 of saliva is so abundant, and of such a peculiar char- 
 acter, as to render it difficult to protect the teeth from 
 
190 
 
 CLASSIFICATION OF DECAYED CAVITIES. 
 
 its contact during an operation, and especially the 
 inferior, teeth. 
 
 Various appliances and methods have been devised 
 
 Fig. 47. 
 
 and employed for overcoming this difficulty. The 
 idea was several years ago conceived, of removing the 
 saliva as it accumulates; and hence the construction 
 and employment of the saliva pump represented in 
 Fig. 48. This instrument, though very good in its 
 
 Fig. 48. 
 
 operation and accomplishing much in the right direct- 
 ion, does not completely fulfill the requirements. 
 
FILLING BY CLASSES AND MODIFICATIONS. 191 
 
 An instrument recently brought to the notice of the 
 profession, by Dr. W. H. Dibble, called "Dibble's 
 Saliva Pump," performs the work of both the saliva 
 pump and speculum, or tongue holder. As a saliva 
 pump it is much superior to the instrument repre- 
 sented in Fig. 48, which is in common use. 
 
 It is operated by the patient, and removes the 
 saliva immediately after it enters the mouth, and 
 may be in constant action, without the slightest in- 
 terruption of the operation of filling; the saliva passes 
 into a reservoir, and is perfectly enclosed, till the 
 operation, however protracted, is completed. 
 
 That part of the instrument designed to hold the 
 tongue, and the buccal surface, from the tooth to be 
 operated upon, and to hold the jaws apart, is of a 
 very excellent form, and accomplishes its work well. 
 It is in three parts, one adapted to each side of the 
 mouth — in these the saliva is taken up by the instru- 
 ment opposite the lingual surface of the second inferior 
 molar — and one for the front, with a compressor 
 passing on -to the tongue and holding it firmly down, 
 and the pump-tube, taking the saliva from the immedi- 
 ate vicinity of the sublingual ducts. 
 
 This latter part of the instrument is the device of 
 Dr. B. F. Arrjngton. The instrument is well repre- 
 sented in Fig. 49. 
 
 In the use of the common speculum, much difficulty 
 
192 
 
 CLASSIFICATION OF DECAYED CAVITIES. 
 
 Fie. 49. 
 
 is often experienced by 
 the patient relaxing the 
 hold, or compression, or 
 moving it from one side 
 to the other, on account of 
 fatigue of the parts upon 
 which it bears. This fact 
 induced the idea, and sub- 
 sequently the production 
 of the Tongue Compressor 
 or Clamp Speculum. This 
 instrument in many cases 
 serves a very valuable 
 purpose, holding the ton- 
 gue in a fixed position; 
 and in connection with 
 it, by the proper adjust- 
 ment of pads of bibulous 
 or blotting paper upon 
 and beneath the tongue, 
 entirely arresting the dis- 
 charge of saliva from the 
 sublingual and submaxil- 
 lary ducts. This instru- 
 ment is represented in 
 Fig. 50. 
 Many experiments have 
 
FILLING BY CLASSES AND MODIFICATIONS. 
 
 193 
 
 been made with the view of excluding the saliva by 
 building a fortification of some proper material about 
 
 Fig. 50. 
 
 the tooth. But while in some cases this method will 
 accomplish the desired result, in the greater propor- 
 tion of instances it will prove a failure. 
 
 Afar better and more efficient method — one recently 
 adopted — is the use of fine rubber cloth, forming with 
 it a coffer-dam ; which is done by making a round hole, 
 or series of holes, from two to four lines in diameter 
 through a piece of the cloth, which should be from four 
 to six inches square ; draw this over the tooth to be pro- 
 tected and those immediately adjoining; it should be 
 manipulated well up on the neck of the tooth, even 
 beneath the free margin of the gum; if a proper adjust- 
 ment is made, the saliva will be entirely excluded, and 
 for afar longer time than by any other method now used. 
 
194 
 
 CLASSIFICATION OF DECAYED CAVITIES. 
 
 It is often the case, that the finger is too short to 
 reach a desired point, to hold down a napkin, or 
 paper, or hold away the soft parts, or so large as to 
 fill the space inconveniently, obstructing the view or 
 the operation. To overcome both of these difficulties 
 an extension thimble is used; it may be made of silver 
 or rubber, though better of the former. In addition 
 to the uses mentioned it may by having a fine steel 
 point, be used to aid in introducing fillings. (Fig. 51.) 
 
 Fia 51. 
 
 Various appliances have been used for holding 
 away the cheek, keeping down the tongue, and re- 
 
 Fie. 52. 
 
 taining the jaws apart. A good instrument, however, 
 for this purpose is shown in Fig. 52. 
 
FILLING BY CLASSES AND MODIFICATIONS. 195 
 
 Filling with Foil. — If non-adhesive gold is employed, 
 it should be formed into blocks, by cutting from four 
 to eight thicknesses into strips one fourth wider than 
 the cavity is deep, and rolling them on a broach suit- 
 able for the purpose, into cylindrical blocks corres- 
 ponding in size with the cavity to be filled, and 
 varying not only in size, but in form and density. 
 The blocks first to be introduced should be largest, 
 followed by those dimishing in size, the last portions 
 being small, dense, conical rolls. Where there is an 
 inward or outward inclination of the walls of the 
 cavity, the first blocks should be cone-shaped. For 
 introducing the blocks, the plugging pliers will be 
 required. The first block is taken up with this in- 
 strument, and placed against the posterior wall of the 
 cavity with one end on the bottom and the other pro- 
 truding from the orifice, and there compressed firmly 
 to its place with the appropriate condensing instru- 
 ment; and, unless there is some special retaining 
 point, it may be necessary to hold it in its position 
 with a second instrument, till the next portion is 
 added. As the successive blocks are introduced, each 
 is to be thoroughly consolidated, so as to be immov- 
 able. The filling is to proceed from the posterior walls 
 to the center. After the cavity has thus been rilled to 
 the center, commence in the same manner at the an- 
 terior wall, rilling from thence toward the center, and 
 
196 CLASSIFICATION OF DECAYED CAVITIES. 
 
 condensing the last blocks by forcing in at their side 
 a small sharp-pointed instrument: the final portion 
 introduced will be the small, dense, conical roll already 
 mentioned. The gold being all introduced, a smooth- 
 pointed instrument or burnisher condenses the project- 
 ing portion of the filling till it is perfectly solid, when 
 it is finished with a fiJe, stone and burnisher, in the 
 manner already described. The particular shape of 
 the surface of the filling will be suggested by the 
 form of the antagonizing tooth. If there is nothing 
 to prevent, the surface may be slightly convex; but 
 if there are cusps striking upon the center of the 
 crown, it should be concave. 
 
 For dressing down the filling when a concave sur- 
 face is required, the instrument represented in Fig. 53 
 is very efficient. It consists of a spherical file, or bur, 
 
 Fig. 53. 
 
 finely cut, and on a proper shaft or handle ; and may 
 be used in the manner of the ordinary bur drill. A 
 variety of sizes and forms should be at hand, in order 
 to operate properly upon fillings of various sizes. 
 
 Adhesive Foil. — For filling these cavities with adhe- 
 sive foil, definite retaining points should be formed in 
 them, or the bottom of the cavity of such a form as to 
 retain firmly in position the first pieces of gold intro- 
 
FILLING BY CLASSES AND MODIFICATIONS. 197 
 
 duced. The gold, prepared in the manner already de- 
 scribed, is taken up with a serrate-pointed plugger or 
 plugging pliers, introduced into the retaining point or 
 points, and there fixed; it is then built across from one 
 to the other, and over the floor of the cavity, till this 
 is completely covered, and then up from the bottom to 
 the orifice. When a portion of gold is taken on the 
 point of the instrument, the precise spot at which to 
 deposit it should be selected, and there it should be 
 placed, and, by the first pressure of the instrument, 
 fixed immovably; a few subsequent strokes of the 
 instrument close about the first point of attachment, 
 will be required. These strokes should be close, 
 because if the instrument is lifted up and pressed 
 upon the piece at a distance from the first point 
 of contact, the attachment is liable to be broken. 
 The character of the gold, and the condition of the 
 receiving surface will govern to some extent the pre- 
 cise method of manipulation. Very much depends 
 upon keeping the surface in a good condition for the 
 reception of the gold to be added. The best receiving 
 surface is obtained by having the condensing instru- 
 ment sharp and in good condition, and then in using 
 it, let there be a little space between its impressions — 
 the surface not stamped completely over by the con- 
 densing instrument. In constructing the filling, we 
 consider it preferable to keep it built up a little higher 
 
198 CLASSIFICATION OF DECAYED CAVITIES. 
 
 all around next the walls than at the center, for the 
 reason that a more complete adaptation of the gold 
 can thus be made, than by any other plan. Some, 
 however, advocate the opposite practice ; that is, of 
 keeping the rilling higher in the center than at the 
 walls, and thus forming an angular space into which 
 to crowd the gold ; because the gold is thus kept in 
 more thorough contact with the walls of the cavity; 
 and it is objected that, to add and consolidate the 
 gold to the center, while the edges are left higher, 
 tends to draw them from the walls. This objection, 
 however, has no force, if the gold is thoroughly con- 
 solidated as it is introduced. 
 
 The cavity is thus filled up, consolidated, and fin- 
 ished in the usual manner. In adding the last por- 
 tions of gold, great care should be taken to make a 
 perfect border to the filling. Crystal gold may be 
 very advantageously used as a foundation for adhe- 
 sive foil fillings, as it will retain its position perfectly 
 in a cavity, where foil would not. 
 
 Crystal Gold. — The method of filling this class of 
 cavities with crystal gold is very simple. The mate- 
 rial should be annealed just before its use, and then 
 cut or broken into blocks corresponding with the size 
 of the cavity to be filled : they may be used as large 
 as will freely enter the cavity; many small pieces 
 will be required to fill up interstices or angles. The 
 
FILLING BY CLASSES AND MODIFICATIONS. 199 
 
 filling may be commenced at the bottom of the cavity, 
 and built up from that to the orifice, the same plan 
 being followed in adapting it to the walls as with ad- 
 hesive foil, the pieces being passed into the cavity 
 with either the plugging pliers, or a condensing in- 
 strument. Each piece should be well consolidated 
 before another is added. For condensing the filling 
 next to the walls, a small wedge-shaped instrument is 
 valuable. In all cases where there is a divergence of 
 the anterior wall, much care is required in order to 
 make a perfect filling; and too much care can not be 
 exercised in perfecting the filling round the border of 
 the cavity. In condensing adhesive foil or crystal 
 gold, the force may be applied almost exclusively in 
 a line with the axis of the tooth; and this is always 
 preferable to lateral pressure. 
 
 1st Mod. — Extension of decay along one or more 
 crown fissures. In a case of this kind, the central 
 cavity is first to be opened and excavated, according 
 to the principles already announced. Decay in the 
 fissures is in some cases an extension of this central 
 decay, and at the point of its termination there will 
 be found an acute angle ; but in others, it will be the 
 effect of an equal attack all along the fissure, or of 
 an extension from some other point than the central 
 cavity. This modification of decay may terminate 
 either in an acute angle, or in an expansion. 
 
200 CLASSIFICATION OF DECAYED CAVITIES. 
 
 These decayed fissures should be opened up by 
 cutting away any projecting portion of enamel, and 
 the cavities formed with a small chisel-shaped instru- 
 ment, beginning at the juncture of the fissure with 
 the main cavity, and cutting down to the bottom of 
 the decay in the manner of a mortise, thus cutting 
 out the entire fissure and the acute angle at its ter- 
 mination — the latter an important consideration. In 
 case there is a very considerable expansion of decay 
 at the termination of the fissure, the* bur drill may be 
 introduced into it, and the rest of the fissure cut out, 
 as the form of the cavity may indicate. 
 
 If blocks are used to fill these cavities, they should 
 be set in and compressed against the end of the fis- 
 sure, protruding from it sufficiently to admit of a 
 proper finish; and block after block added, till the 
 fissure is filled up to the main cavity. Where there 
 are two or three of these decayed fissures in one 
 tooth, it may be quite as much as can be done at 
 one sitting, to fill them, the main cavity being left 
 for another time. In such cases, the filling intro- 
 duced at the first sitting, should then be consolidated 
 and burnished, so that it may not absorb moisture till 
 the main cavity is filled, as already described. Much 
 care should be exercised to prevent the gold from 
 overlapping the enamel at the sides of these fissures. 
 In filling this modification with crystal gold or an- 
 
FILLING BY CLASSES AND MODIFICATIONS. 201 
 
 nealed foil, it is better to begin at the bottom of the 
 cavity and build up to the orifice, first completing the 
 fissure, as we have already described, and afterward 
 the main cavity. 
 
 Id Mod. — Two cavities on the same crown in close 
 proximity. The thickness of the portion of tooth in- 
 tervening between two cavities on the grinding surface 
 of the same crown is determined by the extent of the 
 decay and by the form of the cavities; and these two 
 conditions will suggest the method of operation. If 
 this intervening portion is thin throughout, and devoid 
 of vitality, it should be cut away, and the two cavities 
 formed into one ; but if it is thick within, though it 
 may be thin at the surface, the cavities should be 
 filled separately. In some cases it is proper to leave 
 a part of it standing, as a sort of ridge between the 
 cavities, though not as a definite partition; in which 
 case the filling would be begun as in two cavities, 
 and finished as in one. In no case, however, when 
 the tooth is living, should this intervening portion re- 
 main, if its vitality is gone. The details of the pro- 
 cess of filling crown cavities have already been indi- 
 cated. 
 
 Second Class. — Buccal and palatal cavities of the 
 molars and bicuspids, and labial and palatal cavities 
 of the canines and incisors. In the molars, this class 
 of decay begins either at the margin of the gum, in 
 
202 CLASSIFICATION OF DECAYED CAVITIES. 
 
 the form of a transverse groove, or along the vertical 
 depression on the buccal surface of the tooth, or at its 
 termination. These groove-like decays, extending 
 along the side of the tooth at or near the margin of the 
 gum, are ordinarily not very deep; but they burrow 
 considerably under the enamel, particularly at the side 
 next the grinding surface. In preparing these cavi- 
 ties, the projecting portion of the enamel must be 
 mostly cut away, leaving them but slightly larger 
 within than at the orifice. These grooves, at their 
 ends, are shallow; but in their preparation for filling; 
 they should be cut as deep at the ends as elsewhere, 
 and, when the main part of the cavity is comparatively 
 shallow, deeper. Much difficulty is often experienced 
 in protecting these cavities from moisture while being 
 filled. The rubber coffer-dam when well applied ac- 
 complishes the object better than any other appliance; 
 it is in such cases invaluable. 
 
 The method of introducing gold in the form of blocks 
 into these cavities, is, to set in the first block at the 
 posterior part of the cavity, and consolidate it, and so 
 one block after another till the cavity is nearly full; 
 and then proceed in like manner with the anterior end, 
 back toward the middle, the blocks, of course, being 
 permitted to protrude sufficiently for the purposes of 
 a finish. For filling with crystal gold or adhesive foil, 
 the method is, to form pits at the end of the groove, 
 
FILLING BY CLASSES AND MODIFICATIONS. 203 
 
 into which the gold is consolidated, and built across 
 from one to the other, and then up from the bottom 
 to the orifice, when it is finished as usual. Care is 
 requisite to prevent the gold from overlapping the 
 tooth. Any projection of the filling, especially beyond 
 the margin of the cervical wall of the cavity, is very 
 objectionable; it would afford a lodgment for extrane- 
 ous substances. The tendency of which is to produce 
 irritation and decay. 
 
 Cavities of this class, which are formed in the de- 
 pressions of the buccal portions of the teeth, are more 
 easily filled. Often a simple round cavity is formed, 
 which may be Entirely prepared with a bur drill. The 
 method of rilling these cavities will be readily inferred 
 from the remarks before made. If, however, the decay 
 extends along the depressions, making a groove-like 
 cavity, this should be filled by commencing the intro- 
 duction of the gold at that side of the cavity next the 
 gum. 
 
 1st Mod. — Decay at or near the neck of the tooth, 
 and partially or wholly overlapped by the free border 
 of the gum. In this modification the gum is a great 
 obstacle to the various steps in the process of filling : 
 it is liable to be wounded and to bleed at every touch; 
 it exudes mucus constantly; and it conducts saliva to 
 the parts with great facility. To obviate these diffi- 
 culties, the gum must be removed somewhat From the 
 
204 CLASSIFICATION OF DECAYED CAVITIES. 
 
 cavity before the filling is practicable. This removal 
 of the free margin of the gum may be made either by 
 cutting away; or by pressing away with pledgets of 
 cotton or other appropriate substance placed in the 
 cavity and projecting from it, so as to make pressure 
 upon and absorption of, to a sufficient extent, the free 
 margin of the gum, which will usually be accomplished 
 in a day or two. The former method, however, 
 accomplishes the object at once : some good hemo- 
 static, as creosote and tannin, is all that is then 
 necessary to render the filling immediately practica- 
 ble. By means of this application the exudation 
 is checked — which, where there is much mucus eli- 
 minated, is an important item — and also such a 
 surface is given to the part that it will not so readily 
 conduct the saliva. It is, perhaps, preferable in 
 many cases to cut away this free margin, so that 
 it shall not be in contact with the filling after the 
 operation is completed. 
 
 After this preparation, the cavity is formed and 
 filled as usual. The napkins and paper, if these are 
 used, are to be placed in the precise position, and 
 carefully retained there. Two or three thicknesses 
 of paper should be laid on the gum up to the margin 
 of the cavity, and kept there during the process of 
 filling, so as to exclude all moisture. In filling cavi- 
 ties of the buccal portions of the denies sapientice, 
 
FILLING BY CLASSES AND MODIFICATIONS. 205 
 
 peculiar difficulties are met with: the decay is fre- 
 quently found two-thirds covered by the gum;, the 
 muscles of the cheek, thick and rigid, lie close against 
 the side of the tooth; and, in most cases of this kind, 
 the view, at best, is but partial. In operating upon 
 these cavities, an instrument for holding out the cheek 
 is required. 
 
 Third Class. — Anterior proximal cavities of the 
 molars and bicuspids. This class of cavities in teeth 
 with short, broad crowns, takes place at their necks; 
 but in those with long crowns, and with a diameter 
 less at the neck than at the masticating surface, it 
 begins at some distance from the neck, toward the 
 crown surface, or at the first point of contact of the 
 crowns. In almost all cases of proximal fillings sepa- 
 ration of the teeth is required; the method and extent 
 of this will be determined by circumstances. If all 
 the neighboring teeth stand in contact, it cannot be 
 easily accomplished by pressure ; in this respect, how- 
 ever, there will be found a great variety; but, if a 
 tooth has been extracted in the vicinity, or there are 
 natural spaces between the others, it can be either in 
 whole or in part. When, however, the teeth stand 
 close together, they must in such case be separated 
 chiefly with the chisel and file. If but one is decayed, 
 the cutting should be exclusively from that. If two 
 are alike affected on their proximal surfaces, it should 
 
206 CLASSIFICATION OF DECAYED CAVITIES. 
 
 be mostly from the posterior surface of the anterior 
 tooth. In regard to the form of the separation effected 
 by cutting, the general practice formerly was to cut 
 down the whole proximal side of the affected tooth, 
 making between it and the adjoining one a V-shaped 
 space, sufficient in extent to admit of free manipula- 
 tion in all parts of the operation of filling. By thus 
 cutting the teeth, the form is marred, and often to 
 great disadvantage in use, as by it the masticating 
 surface is lessened, and food being crowded into 
 such a space produces very unpleasant pressure. In 
 order to preserve the form and the greatest amount 
 of masticating surface to the tooth, a preferable 
 method is to cut a mortise down from the masticating 
 surface to the cavity of decay, leaving the lingual and 
 buccal sides of the tooth untouched, except, perhaps, 
 a little dressing that may be rendered necessary by 
 the thinness and roughness of the margins. This 
 cutting should extend about as far toward the center 
 of the tooth as the decay has penetrated, and be 
 nearly as wide as the extent of the decay across the 
 tooth. When it is necessary to cut from the whole 
 proximal surface there should be no shoulder or pro- 
 jection left at the neck of the tooth, but the cut sur- 
 face should be plain from the crown to its termination 
 at or near the neck. The space of whatever form it 
 may be should be large enough to enable the operator 
 
FILLING BY CLASSES AND MODIFICATIONS. 207 
 
 to manipulate with facility, and to see as directly as 
 possible into the cavity. 
 
 Cavities of this class are various in form; and they 
 require much skill in their excavation and formation. 
 Great care is to be exercised not to leave any portion 
 of decay in them. By a fatal oversight, decayed den- 
 tine is often permitted to remain on that side next to 
 the neck of the tooth; and we have seen fillings that 
 in other respects were good, very deficient here; so 
 deficient, indeed, that a sharp instrument would 
 readily penetrate the softened dentine above them, 
 or even pass between the filling and the wall of the 
 cavity. The removal of the decay from the cervical 
 walls of all proximal cavities is an important particu- 
 lar, neglect of which occasions thousands of failures. 
 This class of cavities at this point should be most 
 thoroughly filled; for it is a point more vulnerable 
 than any other, on account of the facility with which 
 foreign substances are here lodged and retained. 
 
 In the formation of these cavities the cervical wall 
 should be made to incline slightly inward, and the 
 lateral walls, if the tooth will bear the loss, made at 
 least parallel with each other;' but if that would im- 
 pair its strength, grooves or pits may be made upon 
 them for this purpose at proper points. When these 
 cavities are large, the dentine is usually all decayed 
 in that part of the cavity next to the masticating sur- 
 
208 CLASSIFICATION OF DECAYED CAVITIES. 
 
 face of the tooth, leaving only the enamel, which by 
 the mode of separating or opening, already described, 
 would be cut away. 
 
 Great care must be taken to arrange and dispose 
 the napkins and bibulous paper so as to protect the 
 cavity from moisture during the process of filling. A 
 roll of paper should be placed on each side of the 
 tooth, and on the paper the napkin, properly folded, 
 should be laid, and kept in place by the operator with 
 the left hand, or by the patient with the speculum. 
 The gum between the teeth is liable to secrete mucus 
 sufficient to moisten the work, or to be touched by 
 the instrument so as to bleed; to obviate these diffi- 
 culties, a wedge of wood, of the proper form, should 
 be driven firmly in between the teeth below the 
 cavity, so as to press the gum out of the way, and 
 thus provide against both contingencies. In addition 
 to these preparations, it will, in many cases, be ad- 
 vantageous to place some appliance between the jaws, 
 in order to keep them apart during the operation; in 
 the absence of anything better a cork may be used. 
 By this arrangement the mouth being propped open, 
 the soft parts are sustained more in repose, and less 
 saliva is eliminated from them to interfere with the 
 work. 
 
 With this preliminary the cavity is ready for the 
 filling, which is introduced, if in blocks, as before de- 
 
FILLING BY CLASSES AND MODIFICATIONS. 209 
 
 tailed, beginning with the cervical wall. The caution 
 may here again be urged, not to let the gold overlap 
 the tooth, particularly at the cervical wall. In filling 
 with crystal gold or adhesive foil, special retaining 
 points will be required in this wall, two being gene- 
 rally sufficient, one toward the outer and the other 
 toward the inner lateral wall, on both of which, 
 grooves may be made, if the walls are thick enough 
 to admit of it. If, however, these walls are not 
 parallel, and will not admit of grooves, the crown and 
 the cervical walls should be so shaped as to retain the 
 filling. But in some cases the attachment of the fill- 
 ing is made entirely at the cervical wall; and best by 
 means of three pits, made with the square-pointed 
 drill, at different angles, and in such directions as not 
 to interfere with the pulp. This kind of attachment 
 will serve only for adhesive gold, which is to be very 
 thoroughly consolidated into the pits, making little 
 projections, which are so many anchors for fastening 
 the filling, and built very firmly across from one to 
 the other. 
 
 2d Mod. — Decay involving a portion of the masti- 
 cating surface. . There are two methods of filling this 
 modification. One is, to cut down the tooth or the 
 projecting angles, and make a plain, oblique border 
 to the cavity by the V-shaped separation already re- 
 ferred to, and then fill up flush with this border. The 
 
210 CLASSIFICATION OF DECAYED CAVITIES. 
 
 filling will thus exhibit a single, uniform surface, at a 
 considerable angle with the axis of the tooth. When 
 a portion of the crown breaks down in consequence 
 of proximal decay, it is toward the center of the tooth; 
 usually the inner and outer corners remain. If these 
 projections are feeble and liable to be broken away, 
 they should be cut down, and the cavity filled as 
 before described. If, however, they are firm, they 
 should remain, and the cavity,* properly formed, may 
 be filled so as to restore the tooth's original form, 
 which in the molars and bicuspids should be accom- 
 plished as nearly as possible, in order that the func- 
 tion of mastication should be perfectly preserved. By 
 properly directed effort the crowns of the teeth can 
 in almost all cases be well restored. Non-adhesive 
 foil is not adaptable to this kind of filling, as it cannot 
 be built in so as to withstand the pressure of masti- 
 cation. In no case should a proximal filling be left 
 in contact with the adjoining tooth. 
 
 Fourth Class. — Proximal cavities of the incisors 
 and cuspidati. If the teeth are not in a crowded 
 condition, and the file is not required by the extent 
 of the decay, separation may be made by pressure; 
 but if the cavity is large, and the walls are thin and 
 friable, cut with a thin chisel and file, only till a good 
 border is obtained about the cavity. Much has been 
 said as to the form of these separations, some recom- 
 
FILLING BY CLASSES AND MODIFICATIONS. . 211 
 
 mending that they be larger at the palatine part 
 than at the labial; others, that they be larger at the 
 points than at the necks of the teeth; some, that a 
 shoulder be left at the necks; and others, that there 
 be no shoulder at all. In making these separations, 
 however, the operator must be governed somewhat 
 by circumstances, no general rule being applicable to 
 all cases. The form of the teeth and the extent of 
 the decay, together w T ith the character of the remain- 
 ing enamel and dentine, will modify the form of the 
 space, between them. If the inner wall is thin or 
 broken away, — and it is usually more friable and 
 more broken than the labial wall, — it should be cut 
 off more than the outer; in which case the palatine 
 portion of the separation will be the largest — as, in- 
 deed, some prefer to make it in all cases, performing 
 the remainder of the operation from the inside. Almost 
 every operation upon these teeth will require attention 
 and manipulation, in every step, from both the pala- 
 tine and labial sides, in order to make secure every 
 point. The precise mode of procedure nlust be de- 
 termined by the case to which it is to be applied. 
 The most direct approach is always to be employed 
 when practicable. 
 
 In some cases separation will be larger at the points 
 of the teeth than elsewhere; as, where there has boon 
 a partial fracture at the points. In cutting away to 
 
212 CLASSIFICATION OF DECAYED CAVITIES. 
 
 make the separation, no shoulder should be left at the 
 neck of the tooth that is not to be protected by filling; 
 any projection of that kind is always objectionable: 
 foreign substances lodge upon and adhere to it, and, 
 becoming vitiated, render it very liable to decay. The 
 cutting should always extend entirely beyond the 
 decay, but only far enough to make a perfectly plain 
 border to all the cavity, and should terminate without 
 any projection. It is highly important, in separating 
 the anterior teeth, to make as little alteration as pos- 
 sible in their form. But the preservation of the tooth 
 should not be jeopardized for the sake of maintaining 
 the integrity of its natural form. The first consider- 
 ation should be to obtain a space sufficient for the 
 purposes of a perfect operation; the second, to have 
 the walls and border of the cavity in such a condition 
 that an efficient filling can be made; and the form and 
 beauty of the tooth should be scrupulously preserved 
 and protected so far as the above requirements will 
 permit. 
 
 The excavation of these cavities requires very deli- 
 cate and skillful manipulation, since they are very 
 readily injured by cutting too much or at a wrong 
 point. All decayed and discolored portions must be 
 entirely removed, as well for the appearance of the 
 tooth as for the permanency of the operation; after 
 which the cavity is to be formed with great care. At 
 
FILLING BY CLASSES AND MODIFICATIONS. 213 
 
 the point of the tooth the dentine often has all been 
 displaced by decay, leaving only the two plates of 
 enamel joined at the edge, and thus forming an acute 
 angle, the obliteration of which is always attended 
 with risk, unless great care is exercised, and in many 
 teeth it is wholly impracticable ; and still it is difficult 
 perfectly to fill a very acute angle. The inclination 
 of the inner and the outer walls of the cavity will 
 depend on its size: when it is small or medium, 
 they may be parallel, or, if necessary, slightly diverg- 
 ent; but when large, it is better not to cut much of 
 the healthy dentine from them, lest they be thus 
 weakened. Small grooves, however, are admissible 
 on these walls, near the bottom of the cavity, when 
 they incline to the center, and are generally, in such 
 case, to be preferred to pits. In the formation of 
 grooves or pits for anchorages, the dentine should 
 never be cut through to the enamel; but always den- 
 tine sufficient to protect the enamel should remain. 
 More cutting is allowable on the cervical wall than 
 elsewhere, as there is less danger here of weakening 
 the tooth by excavation. In filling with adhesive 
 gold, we may, if necessary, rely exclusively on this 
 part of the cavity for the retention of the plug; and 
 the best method of preparing it is, to make two or 
 three little pits in it at different angles with a fine, 
 square-pointed drill. Another method is, to form two 
 
214 CLASSIFICATION OF DECAYED CAVITIES. 
 
 pits, and make a groove from one to the other. Some 
 operators prepare these cavities by making pits in 
 each of the walls. This, however, is unnecessary, if 
 the cervical wall is properly prepared. 
 
 The cavity being prepared, the rolls of bibulous 
 paper or napkin should be placed on the gum inside, 
 and between the gum and the lip; and if the former 
 has been wounded between the teeth, or if it elimi- 
 nates mucus, a small piece of soft wood or of rubber 
 should be crowded down upon it below the cavity. 
 The gold, prepared as already described, should then 
 be introduced with a small plugger serrated with four 
 points, and somewhat flattened about a line above the 
 point, so as to be freely used' when introduced into 
 the cavity. The gold is taken up on the point of this 
 plugger, and condensed in the pits of the cervical wall; 
 which being completely rilled, and the gold extending 
 from one to the other, the foundation is ready for the 
 remainder of the rilling. 
 
 Great care is requisite in packing the gold into these 
 cavities, perfectly to adapt and adjust it to all points, 
 so as to insure its thorough contact with every part 
 of the interior. If the form of the tooth has been 
 measurably retained, and the border of the cavity is 
 even, the surface of the plug should, when finished, 
 be slightly convex, or as nearly the original form of 
 the tooth as practicable; and, in introducing the fill- 
 
FILLING BY CLASSES AND MODIFICATIONS. 215 
 
 ing, reference should be had to this particular. Two- 
 thirds of the cavity may be filled by introducing the 
 gold upon and in the direction of the cervical wall, 
 and the remaining portion filled from the point back 
 to the preceding filling; or, what is probably better, 
 begin at the bottom and fill to the surface, and then 
 finish in the usual manner. 
 
 For filling these cavities with non-adhesive foil, the 
 special retaining points already described are not re- 
 quired ; but the cervical wall of the cavity is slightly 
 cut under, and the lateral walls so shaped as to secure 
 the filling in place. These cavities are in some cases 
 very difficult to fill with non-adhesive foil, whether in 
 the form of blocks or otherwise, especially where they 
 are large, with the walls inclined to the center, and 
 the tooth bone friable. To force a .wedge-shaped in- 
 strument into these fillings, for the purpose of con- 
 densing them, is inadmissible, since there is thus great 
 danger of breaking the walls of the cavity, and, in 
 many cases, of moving the filling from its place. 
 
 1st Mod. — The palatal wall broken away. Fractures 
 of this kind assume different forms; sometimes trian- 
 gular, extending from the border of the cavity toward 
 the center of the tooth, and terminating in an acute 
 angle; and sometimes the border of the cavity is 
 broken away irregularly, or so as to form part of a 
 circle. When a triangular notch is broken out of the 
 
216 CLASSIFICATION OF DECAYED CAVITIES. 
 
 wall, the operation of filling may be performed in one 
 of two ways: If the portions of the wall remaining at 
 each side of the fracture are thick and firm, they may 
 be left, and the cavity filled, so as to restore the form 
 of both the proximal and the palatal surface of the 
 tooth, the latter being thus restored with gold to the 
 extent of the fracture or notch. If, however, the re- 
 maining portions of the wall are frail, they should be 
 cut away till a border is reached sufficiently firm to 
 sustain the filling. Such cutting will leave the notch 
 of a circular form, and, in many cases, will remove 
 almost the whole of the inner wall of the cavity. As 
 the decay extends toward the center of the tooth, 
 owing to the concavity of its palatal surface, this wall 
 becomes very thin and easily broken, this rendering 
 it necessary to cut it almost all away; but, in all cases, 
 the excavation should be such as to leave a definite 
 wall, though it be but slight, all along that part of the 
 cavity. In such a case, good retaining points must be 
 made in the cervical wall, since the permanency of 
 the filling will depend almost entirely upon these. 
 
 The surface of the filling, when finished, may be 
 slightly convex from one lateral wall to the other; the 
 palatal portion of the surface, from the point of the 
 tooth to its neck, will partake of the curvature of the 
 border of the palatal wall; but the anterior portion 
 will be only flush with the anterior wall. Much care 
 
FILLING BY CLASSES AND MODIFICATIONS. 217 
 
 is requisite to give these fillings a perfect finish, on 
 account of the irregularity of surface, this, in many 
 instances, being both convex and concave. As a 
 material for filling these cavities, adhesive gold is 
 much to be preferred. Indeed, in many of them it 
 is impossible, with non-adhesive gold, to make a per- 
 fect filling, because they have no general embracing 
 form. In such cases, the filling should be introduced 
 from the palatal side of the tooth. 
 
 2d Mod. — The labial wall of the cavity broken. 
 The fractures of this wall are of various forms, and 
 in extent corresponding with the amount of decay 
 and the friability of the enamel. There is sometimes 
 the triangular notch, extending far toward the middle 
 of the tooth; and sometimes there are two or three 
 small notches; and still in other cases, almost the 
 whole of the wall will be broken away from the point 
 to the neck of the tooth. When there is simply a 
 notch in the enamel, it is important for the appear- 
 ance of the tooth to fill it up; and when there is any 
 prospect of success, the remaining portion of the wall 
 being retained, the operation is to be performed as 
 already described for the palatal wall. It will, how- 
 ever, in many cases, be necessary to cut away part of 
 the remaining portions of the wall, leaving the general 
 form of the border somewhat circular; though the notch 
 form, in some instances, is not wholly obliterated. 
 
218 CLASSIFICATION OF DECAYED CAVITIES. 
 
 In filling this kind of cavity it is desirable to re- 
 store as much as possible the form of the tooth. The 
 filling should be built out from the border of the wall 
 almost to a line with the tooth's original proportions, 
 so that the whole surface of the rilling will be convex; 
 and should be finished with great care, the Scotch- 
 stone or stipple finish being preferable for that part 
 exposed to view. 
 
 3d Mod. — The cavity extending almost to the point 
 of the tooth, and terminating, or cropping out at the 
 surface. In the preparation of this cavity, that part 
 next the point of the tooth should be cut in enough 
 to form, a definite wall there, and to give room for 
 sufficient thickness and strength in that portion of 
 the plug. Many operators attempt to fill this kind 
 of cavity without such precaution, terminating that 
 part of the plug in a thin edge. This method is very 
 objectionable; for the thin edge will become more or 
 less separated from the tooth, and foreign substances 
 will be forced under it, and, becoming vitiated, induce 
 decay. Indeed, a defect of this kind is a sure pre- 
 cursor of the destruction of the filling. The introduc- 
 tion and finish of the filling in this kind of cavity are 
 the same as first described for this class; and the ad- 
 monition may be repeated, that there be left no thin 
 overlappings of the filling that may become changed 
 in position. 
 
FILLING BY CLASSES AND MODIFICATIONS. 219 
 
 4th Mod. — The cavity large, and the lateral walls 
 thin and friable. In this kind of cavity the dentine 
 is almost entirely removed from the lateral walls, 
 leaving little else than the enamel after the excava- 
 tion of the decay. These walls will, of course, admit 
 of no cutting for the purpose of giving them a more 
 desirable form. The cervical wall must be shaped 
 with special reference to a retention of the filling, to 
 consolidate which the requisite pressure must be ap- 
 plied almost exclusively toward this wall. It requires 
 extreme care to condense the gold in cavities of this 
 kind and adapt it to the lateral walls without fractur- 
 ing them; and various methods have been suggested 
 to prevent such an accident. Pluggers with very fine 
 points are recommended, ^as consolidating the gold 
 with much less pressure than would be necessary with 
 large-pointed instruments. But it has been maintained 
 that a perfect adaptation of the gold to the inner parts 
 of these walls is not important, provided the adapta- 
 tion at the border is perfect. It is certain, however, 
 that a filling thus imperfectly adapted, is not so good 
 as though the gold were in contact with all points of 
 the cavity; and besides, the liability of fracturing the 
 wall is just as great in consolidating at the border as 
 within. The walls may be sustained by enveloping 
 the tooth to the borders of the cavity with some ma- 
 terial perfectly adaptable to it, and capable of resisting 
 
220 CLASSIFICATION OF DECAYED CAVITIES. 
 
 the force applied in the process of consolidation, as 
 gutta percha or plaster of Paris. If the former is 
 employed, it should be softened by warming, moulded 
 upon the tooth, and then permitted to harden. The 
 hardening may be facilitated by throwing cold water 
 on it from a syringe. It is then to be trimmed even 
 with the border of the cavity, so as to admit the fill- 
 ing. If plaster of Paris is used, it should be the best 
 article. Yet gutta percha is to be preferred. But a 
 better protection than either may be made of cheo- 
 plastic metal, taking an impression of the tooth, and 
 from that moulding the shield ; and this material is 
 always to be recommended in extreme cases. In 
 these fillings, when the enamel is clear and translucent, 
 the gold will be visible through it. To obviate this 
 difficulty, some appropriate substance may be placed 
 between the outer wall and the gold — some substance 
 that will restore the natural color of the tooth. Quill, 
 horn, paper, and asbestos have each been employed 
 for this purpose. Horn is, perhaps, the best material, 
 as it can generally be selected of a suitable color. A 
 thin lamina of this may be obtained by pounding a 
 piece of the horn for a few moments, till a layer is 
 detached; which may then be dressed down to the 
 proper size, softened in warm water, and placed in 
 the cavity next to the outer wall, yet so as not to 
 extend quite to the border. The presence of this 
 
FILLING BY CLASSES AND MODIFICATIONS. 221 
 
 substance makes the operation of filling a little more 
 complicated; but the horn being softened, is easily 
 pressed to the side of the cavity and conformed to it; 
 and it may be made to retain its place, when first in- 
 troduced, by touching it at one or two points with 
 some adhesive material; or it may be made very soft, 
 adjusted in the cavity, and then conformed completely 
 to the wall by a temporary filling of gutta percha, 
 which, after having chilled and stiffened, may be re- 
 moved, leaving the horn thoroughly adapted and ready 
 for the gold. 
 
 Another method, which in many cases is preferable 
 to either of the above is, after the cavity is formed 
 and thoroughly cleansed, to fill it with os artificial, 
 and after it has become hard, cut it out, leaving enough 
 to constitute a good lining and support to the thin 
 walls. The natural color of the tooth may be in this 
 way so well restored and maintained as to elude de- 
 tection; at the border of the orifice the gold should 
 come in contact with the dentine or enamel. In 
 almost all cases of thin weak borders, the gold should 
 be built on and over them, so as to form a shield or 
 protection against fracture or undue wear. All such 
 overlapping portions should be made so thick and firm 
 as not to be displaced or moved. 
 
 The loss of a portion of the cutting edge of the in- 
 cisors by extensive decay is often met with. In all 
 
222 CLASSIFICATION OF DECAYED CAVITIES. 
 
 such cases, when the dentine is of good structure, it 
 is practicable to restore the lost part to a greater or 
 less extent by building up with gold. In order to 
 make successful operations in such cases several points 
 must be regarded; the dentine and enamel should be 
 of good structure ; the cavity toward the neck of the 
 tooth of such a form as to afford the best anchorage; 
 this may consist of pits with grooves running out from 
 them. Teeth with thick short crowns present the 
 best opportunity for such an operation; indeed, upon 
 that class of incisors with long thin crowns, such an 
 operation is not usually practicable; and, generally, 
 these teeth present such a contrast in color with the 
 gold as to be quite objectionable. In the operation 
 the manipulation must be such as to secure the 
 most thorough welding of the portions of gold. of 
 which the filling is composed. With good attach- 
 ments, gold well prepared and in good condition, and 
 properly manipulated, the golden portion of a tooth 
 may be built up to any desired extent without danger 
 of being either drawn out or broken down. The finish 
 should be such as has already been described for fill- 
 ings exposed to view. 
 
 Fifth Class. — Posterior proximal cavities of the 
 molars and bicuspids. These are separated like ante- 
 rior proximal cavities, except that, ordinarily, to open 
 them up, more is to be cut from the tooth, on account 
 
FILLING BY CLASSES AND MODIFICATIONS. 223 
 
 of the greater difficulty of approaching, inspecting and 
 operating in the cavity. The same general principles 
 are applicable to the opening of this class of cavities, 
 as to that of the third class, except that pressure can- 
 not be as frequently employed, since the cavity will 
 not be as well exposed by this as by cutting, nor ren- 
 dered so easy of approach. Indeed, in operating on 
 these cavities the use of the mirror is often necessary, 
 it being impossible to obtain a direct view into them, 
 after having cut away all that it is admissible to re- 
 move. This difficulty is almost wholly obviated by 
 the method of working through the masticating sur- 
 face of the tooth into the cavity of decay, as already 
 described. The accessibility of these cavities will 
 depend on circumstances; such as the location of the 
 tooth, its inclination, the size of the mouth, the flexi- 
 bility of the muscles, and the ability of the patient to 
 open the mouth and keep it open. Generally, in ope- 
 rating on these cavities, for the removal of decay, for 
 the formation, and the filling, curved instruments will 
 be required ; but their curvature should not be greater 
 than the necessity of the case demands. 
 
 The cavity, during its preparation, must be fre- 
 quently examined. Its general form, and the size, 
 kind, and location of. the retaining-points will be the 
 same as in class third. The lateral walls, if the cavity 
 is not too large, should be made parallel with each 
 
224 CLASSIFICATION OF DECAYED CAVITIES. 
 
 other; the undercutting at the crown wall will be less 
 than in anterior proximal cavities; and the cervical 
 wall should have the same general form as in other 
 cases. In this latter there should be made, at differ- 
 ent angles, pits for retaining-points — three, if the tooth 
 is a molar, and two if a bicuspid. For making these 
 pits, Merry's drill will be found more convenient than 
 any other instrument. 
 
 Preparatory to introducing the rilling, the same ap- 
 pliances should be used to protect the cavity from 
 moisture that have been indicated in modification first 
 of class third. Crystal gold makes a better beginning 
 for these fillings than foil; and hence the retaining- 
 points should be filled up with it, and an attachment 
 made from one to the other; on which foundation 
 adhesive foil may be built, almost up to the crown 
 wall of the cavity, and then the remaining portion 
 filled from the bottom to the orifice, when the sepa- 
 ration has been made by a V-shaped space, the filling 
 should have a single plain surface, which will be at a 
 greater or less angle with the axis of the tooth, accord- 
 ing to the greater or less portion cut away in the 
 separation. It is impracticable to build these fillings 
 up as some of those in the anterior proximal cavities 
 may be, because of the difficulty of thoroughly con- 
 solidating and finishing their proximal portions, 
 especially near the neck of the tooth; though the 
 
FILLING BY CLASSES AND MODIFICATIONS. 225 
 
 difficulty is somewhat obviated by placing a piece of 
 polished metal, of the proper thickness, back of the 
 cavity, against the adjoining tooth, introducing the 
 filling, and consolidating it firmly up to this piece of 
 metal : the lost portion of the crown being thus 
 restored, the metal is then removed, and the filling 
 dressed off and finished in the manner described 
 heretofore. But when the opening is made by cut- 
 ting in. from the masticating surface, the entire 
 opening, made in the tooth, both by the decay and 
 the operation will be completely filled, and the form 
 of the tooth entirely restored ; the filling will then 
 present a proximal and crown surface. When the 
 teeth, molars and bicuspids, are decayed upon their 
 contiguous sides, the cavities in both may be prepared 
 as already described, the proper separation and 
 excavation having been made, both are filled together, 
 the gold extending across the space, and after being 
 filled up flush with the masticating surfaces, the 
 separation is effected by dividing the gold with a 
 separating file : thus, each cavity is completely filled 
 and there is always gold enough upon the proximal 
 parts to secure a complete finish. This method is 
 not always practical, as for instance, when there is a 
 large space, or when it is not desirable to fully restore 
 the form of each tooth, but in some cases it may be 
 used with decided advantage. The labor, tedium. 
 
226 CLASSIFICATION OF DECAYED CAVITIES. 
 
 and difficulty of manipulation are increased the farther 
 back in the mouth the decay is situated. The modi- 
 fications of this class are the same as those of the 
 third class of cavities, and, except the second modifi- 
 cation are susceptible of the same methods of filling. 
 Special Cases. — The first case that we shall con- 
 sider here, consists in a complication of proximal 
 decay with decay on the buccal or palatal portion of 
 the tooth, thus undercutting one of the crown angles. 
 Sometimes these decays are on both sides, in the 
 form of transverse grooves, meeting at the corner of 
 the tooth. In such cases, if the pendent crown 
 angle of the tooth is firm and strong, the cavities 
 may be formed in the proper manner, and filled 
 without interfering with the masticating portion of 
 the tooth at all ; but, if the pendent portion is friable, 
 it should be cut away, and the corner built up with 
 gold. The method of forming the part to be filled 
 will depend on the extent of the decay. When this 
 is large, a greater number of retaining-points will be 
 required than when it is small ; and these should be 
 located at such parts as will make them most tena- 
 cious of the gold, and least subversive of the strength 
 of the tooth. The filling may be built up so as to 
 restore the original form of the tooth, thus presenting 
 three surfaces, the proximal, the buccal or palatal, 
 and the masticatory ; or, it may be made with a single 
 
FILLING BY CLASSES AND MODIFICATIONS. 227 
 
 slightly convex surface, adapted and finished most 
 completely at all its borders. This kind of filling 
 can be made only with adhesive gold. 
 
 The palatal portion of the crown broken away, leav- 
 ing the outer portion standing — nerve not exposed. — The 
 tooth, in such case, is decayed away so that the floor 
 of solid dentine is near the margin of the gum, the 
 labial third of the crown still standing. The decay 
 having been all removed, four or five little pits 
 should be made on this floor, as near its circumfer- 
 ence as practical ; and a small groove may be cut 
 from one of these pits to another all round near the 
 edge of the floor. Then two little pits should be 
 made at the base of the standing portion of the 
 crown, if practicable, without interfering with the 
 pulp, provided it is still living. The decayed part 
 thus prepared, a sufficient shield, in the form of 
 paper, folds of napkin, or the rubber-dam which is 
 preferable, is to be thrown round the tooth, to protect 
 it against moisture during a protracted operation : in 
 this particular great care is necessary. 
 
 For building up a crown of this kind, only adhesive 
 gold can be used ; and this should be of the best prep- 
 aration, and in the most perfect condition, since it 
 is important that the different portions of the filling 
 be most thoroughly united. The instruments em- 
 ployed in the operation should be of the best kind 
 
228 CLASSIFICATION OF DECAYED CAVITIES. 
 
 and in the best condition, the serrate points being 
 definite and sharp, though not too long : those with 
 four, six, or eight points may be advantageously used 
 for packing the gold. But care must be exercised 
 lest these fine points be turned ; for when that is the 
 case, the instrument is liable to displace the portion 
 of gold, and thus break up its first attachment during 
 the process of consolidation ; and when this is broken, 
 the piece of gold can not again be made to adhere as 
 perfectly as before. 
 
 With every thing thus in readiness, the retaining- 
 points are all to be filled, the gold extending from 
 one to the other ; which is then to be built all over 
 the bottom of the part to be restored, projecting a 
 little beyond the periphery, and being perfectly con- 
 solidated there, and kept somewhat higher round the 
 border than in the center. The gold should be built 
 on in this manner till the crown is large enough, 
 after dressing, to give the desired size and form. In 
 finishing up, the aim should be, to restore as perfectly 
 as possible the lost form of the tooth. The adaptation 
 of the gold, too, to the standing portion of the crown 
 should be most complete ; imperfection in this respect 
 impairs the appearance of the work, and jeopardizes 
 the security of the operation. 
 
 Occasionally the crown of a molar tooth is found 
 decayed off all round, almost to the margin of the 
 
FILLING BY CLASSES AND MODIFICATIONS. 229 
 
 gum, the pulp having previously receded so as not 
 to be exposed. It is, in such case, desirable to re- 
 store the lost portion of the crown, and make a mas- 
 ticatory surface such as shall antagonize properly 
 with the teeth of the opposite jaw. As yet, there is 
 no other method of accomplishing this, than by build- 
 ing it up with gold — adhesive gold foil or crystal 
 gold. In the preparation for this crown of gold, the 
 edge should be dressed smooth and even all round 
 the tooth ; then six or eight deep pits should be made 
 at different angles about on the base thus prepared ; 
 and they should be bored with a drill larger than is 
 commonly used for retaining-points. These pits may 
 be slightly enlarged within. The method of building 
 up the crown is just the same as that described for 
 building up part of a crown, the pits being first filled, 
 then joined together, and the gold extended all over 
 the part to be covered by the filling. In extending 
 the gold from a retaining point or points, it is neces- 
 sary to build up to a considerable thickness above the 
 orifice of the pit. The portion of gold extending 
 along on the tooth from the pit, should be quite thick 
 and firm, so as not to curl up from its position, on 
 the addition of subsequent portions. Every particle 
 of gold, indeed, should be so manipulated, that it will 
 securely maintain its first position. The permanency 
 of the operation will depend very much upon this 
 
230 CLASSIFICATION OF DECAYED CAVITIES. 
 
 precaution. The gold should extend somewhat be- 
 yond the circumference of the tooth all around, in 
 order to a thorough adaptation and finish. 
 
 The foundation thus prepared, and kept free from 
 moisture, the crown is easily built up by the ordinary 
 method of packing the gold. Any desired shape can 
 be given to this artificial crown ; but, of course, that 
 which most nearly resembles the form of the natural 
 crown, is in all cases to be desired. The masti- 
 cating surface of this gold crown is to be formed from 
 the indications given by the antagonizing teeth. 
 Such crowns will wear for years, and perform all the 
 functions of the natural organs. Artificial crowns of 
 this kind have been attached to the tooth, by screw- 
 ing into the pits small pieces of gold wire at different 
 angles, and then building up round and between 
 them with the gold foil, on the principle already 
 described, thus making these wires serve as so many 
 anchors for fastening the work. This, however, is a 
 less efficient method than the one first described, 
 since there is no cohesive attachment of the foil to 
 these gold anchors, and it is retained in place only 
 by the mechanical arrangement of the wires ; but by 
 barbing or roughening them, or giving them abrupt 
 curves, they may be made to retain the crown well, 
 if it is thoroughly consolidated and united. But the 
 method of anchoring with foil, as before observed, is 
 
FILLING BY CLASSES AND MODIFICATIONS. 231 
 
 always to be preferred, since by this there is a weld- 
 ing of the entire mass, and an anchorage, too, quite 
 sufficient in all cases to retain it in its place. 
 
 Filling large cavities on the labial surfaces of the 
 superior incisors. — These cavities are usually super- 
 ficial, and frequently co-extensive with a considerable 
 part of the surface of the tooth. A method of filling 
 them, somewhat novel, though not without merit, has 
 been introduced to the notice of the profession by 
 Dr. Volck, it having been first suggested to him how- 
 ever, by Dr. Maynard. It consists in filling up the 
 cavity principally with a piece of enamel, as near the 
 color of the tooth as possible. The cavity, when 
 nearly round, should be formed with a wheel bur of 
 the proper size ; and after having been thus reamed 
 out, a slight under-cutting should be made all round 
 with an excavator. Then a piece of enamel being se- 
 lected, it is dressed to a proper thickness, which should 
 be slightly greater than the cavity's depth, and' to a 
 perfectly circular form, its size being such as to let it 
 drop, with a little play, into the cavity, and the edge 
 of it being beveled from without. For fastening this 
 in the cavity, roll a strip of several thicknesses of 
 gold foil round its edge, and add as much as can be 
 forced in with it ; set it all in place in the cavity, 
 and then condense the gold down into the groove all 
 round with a thin-pointed plugger, more gold being 
 
232 CLASSIFICATION OF DECAYED CAVITIES. 
 
 added, if necessary, to fill the groove completely full. 
 Afterwards, with the file, stone, and burnisher, dress 
 off the whole to a proper level with the surrounding 
 tooth, finishing very carefully with the burnisher. 
 The unsightliness of a large gold filling on a front 
 tooth is thus obviated, no metal except that compo- 
 sing the ring of attachment in the groove being ex- 
 posed to view. It is a beautiful operation, and one 
 whose successful accomplishment will require con- 
 siderable constructive talent and skill. 
 
CHAPTER VIII. 
 
 PATHOLOGICAL CONDITIONS. 
 
 Hitherto, in our consideration of the treatment of 
 caries, we have postponed the subject of the vitality 
 and pathology of the teeth altogether. It now re- 
 mains to describe the diseased conditions to which 
 the teeth are subject, and the treatment which those 
 respective conditions indicate. This is an important 
 department of the practice, since upon skill in this, 
 as well as upon the manner of performing the work, 
 the success of the operation depends. 
 
 Premising that our remarks on this branch of the 
 subject are predicated on the fact admitted, that the 
 teeth possess vitality, we proceed to consider the 
 pathological conditions to which, in common with all 
 vital tissues, they are liable. There is but one diseased 
 condition of living dentine, anterior to decay, that pre- 
 sents any considerable difficulty in the ordinary opera- 
 tion of filling teeth, and that is, inflammation, or exalted 
 sensibility. This condition was referred to in the 
 remarks on the treatment of caries, as being one that 
 most generally accompanies decay of the teeth. 
 Whether or not this affection is real inflammation, is 
 
234 PATHOLOGICAL CONDITIONS. 
 
 a point that has been considerably controverted ; and 
 the assertion has been made, that it is of no conse- 
 quence whether it is or not, provided we understand 
 the true method of treating it. This, however, is 
 not to be so readily conceded ; for the confession that 
 we do not know what to call a thing, generally im- 
 plies an ignorance of its character and phenomena; 
 while the term inflammation conveys a more definite 
 notion, the phrase exalted sensibility is very vague 
 in meaning. That it is true inflammation, is the 
 opinion of our best dental writers. 
 
 The dentine is endowed with the functions of 
 absorption, nutrition, and secretion — characteristics 
 that always imply a susceptibility of inflammation. 
 In inflammation of the soft parts, there are present 
 various indications ; as, pain, redness, swelling, and 
 increased heat. But in dentine, on account of its 
 peculiar structure, all these indications can not be 
 manifested : for instance, redness, since the red 
 globules do no circulate through it; nor swelling, 
 since the structure is too dense; nor perceptibly 
 increased heat, since the circulation is of too low a 
 grade. But, one of the most definite indications of 
 inflammation, namely, exalted sensibility, is present 
 here in all its force. And there are various other 
 circumstances that indicate this condition to be real 
 inflammation : the same irritating causes that induce 
 
PATHOLOGICAL CONDITIONS. 235 
 
 inflammation in the more highly organized parts, 
 occasion it in the living dentine ; this condition of 
 the teeth is always affected by a general inflammatory 
 diathesis, and their sensitiveness, when there is this 
 general tendency to inflammation, is always increased, 
 and local treatment in such case will commonly be 
 inefficient ; a modification of such a condition of the 
 system produces a very corresponding change in the 
 affected teeth ; and those remedial agents which are 
 employed in the topical treatment of inflammation 
 elsewhere, are successfully used in the treatment of 
 inflamed dentine. From all these circumstances we 
 infer that this affection of the teeth is a real inflam- 
 mation. 
 
 As it has been already remarked, the only definite 
 and direct indication of inflammation of the dentine, 
 is exalted sensibility ; though this is not an immedi- 
 ate consequence of that condition, independent of 
 external circumstances; for the pain resulting directly 
 from inflammation in the soft parts, is not experi- 
 enced here, by reason of the low grade of vitality and 
 the feeble circulation. But the teeth, in a state of 
 inflammation, will suffer pain when subjected to sud- 
 den variations of temperature, whether induced by 
 the air, by fluids, or by any hard substance; and 
 w 7 hen subjected to the influence of agents that irri- 
 tate the nerve-tissue anywhere, such as acids, some 
 
236 PATHOLOGICAL CONDITIONS. 
 
 alkalies, salts, &c. In regard to degree, extent, 
 and location, this affection exhibits a variety of 
 manifestations; in degree, from the most mild to 
 the most intense — sometimes fixed at a uniform pitch 
 of pain, and sometimes passing through the gamut of 
 torture up to the most acute anguish. The character 
 of the affection is modified by differences in the 
 organic structure of the teeth, those most vascular 
 and most highly organized being most readily and 
 most extensively involved ; and therefore the teeth 
 of the young are generally more liable to it than 
 those of the old. So, too, persons of a plethoric or a 
 strumous habit, as well as those in a febrile condi- 
 tion, are peculiarly predisposed to this affection. 
 Sometimes irritation or disturbance of other organs of 
 the system, sympathetically or secondarily induce 
 inflammation of the dentine. Uterine irritation fre- 
 quently does so ; and hence, during pregnancy or a 
 protracted suppression of the catamenia, the teeth are 
 very liable to be thus affected, and, if decayed, to 
 become very sensitive. 
 
 Inflammation of the dentine will sometimes be 
 exhibited in various degrees in different teeth in the 
 same mouth at one time. This is owing to differ- 
 ences in the organic structure of teeth developed at 
 different periods of life, to differences of their loca- 
 tion in the mouth, and to differences of exposure to 
 
PATHOLOGICAL CONDITIONS, 237 
 
 those agencies which are apt to induce the condition. 
 As to the extent of this inflammation, it may be con- 
 fined to a thin lamina of bone immediately beneath 
 the decomposed portion, or may extend deep into the 
 body of the tooth, and, indeed, in some cases, pervade 
 the dentine of the entire crown. This latter extent, 
 however, it is not likely to have, unless there is a 
 general predisposition : if it is produced by local 
 causes, it will not, in general, penetrate very deeply 
 into the dentine. Most commonly, the greatest 
 sensitiveness is at the union of the dentine with 
 the enamel; but, sometimes, it is confined to a small 
 point within the cavity, either because there is a 
 concentration of nerve-fibrils there, or because there 
 has been a determination of the irritating influences 
 to that point — the former being probably the more 
 frequent. The greatest sensitiveness, as already re- 
 marked, is generally at the surface of the dentine, 
 because that is the termination of the nerve-fibrils 
 which ramify the dentine, and wherever nerve-fiber 
 terminates, there always we may look for exalted 
 sensibility. Hence it is, that decay of the teeth is 
 often found to be more sensitive in its incipient 
 stages, than when it has become more advanced. 
 
 Treatment of Inflamed Dentine. — There are several 
 methods of treatment that may be employed to 
 remedy this condition. In many cases, whore time 
 
238 PATHOLOGICAL CONDITIONS. 
 
 and circumstances will permit, a removal of all irri- 
 tating agents from the affected parts, will enable 
 nature alone to affect a restoration to health. All 
 decomposed dentine is to be removed from the cavity, 
 every exciting influence in it withdrawn or neutral- 
 ized, and the cavity itself perfectly rilled with some 
 non-conducting material, so as entirely to exclude all 
 foreign substances. This material may be Hill's 
 Stopping, or os artificial ; — and this, in the property 
 of non-conduction, is superior to any other ; — or, in 
 some cases, it may be tin or gold ; but, when either 
 of these is employed for the purpose of such tempo- 
 rary filling, some non-conducting substance should be 
 placed between it and the sensitive dentine. The 
 length of time necessary for a restoration of the 
 affected part, under this treatment, will be much 
 varied by circumstances. The cases susceptible of 
 this kind of treatment are those in which there is no 
 constitutional predisposition, in which the vitality is 
 strong, and the recuperative power vigorous. When 
 the temporary fillings are made of metals, the patient 
 should be careful to protect them from sudden changes 
 of temperature. For such fillings, in case they are 
 required but for a short time, a lock of cotton satu- 
 rated with a solution of gutta percha and chloroform, 
 may be used. 
 
 But, in cases in which the vitality is low, the 
 
PATHOLOGICAL CONDITIONS. 239 
 
 affection chronic, the exciting cause highly irritating, 
 and the general diathesis inflammatory, nature, un- 
 aided will not affect a cure. In such circumstances, 
 therapeutic treatment is indicated. The agents em- 
 ployed in topical treatment may be divided into two 
 classes : first, resolvents, or those which have for 
 their object an entire restoration to health of the 
 part affected; and second, escharotics, or those which 
 have for their object the death of a portion or all of 
 the diseased part. The former class of agents is of 
 course preferable, when the object can be promptly 
 accomplished by their use, and especially preferable 
 to those agents which endanger the vitality of the 
 whole tooth. In very many cases in which topical 
 applications are indicated, constitutional treatment is 
 also required ; and this should be of an antiphlogistic 
 character. The immediately adjacent parts, too, as 
 the gums, the mucous membrane, etc., should be 
 carefully regarded. Indeed, treatment of the gums 
 by counter-irritation, depletion, and various prepara- 
 tions, such as the conditions may indicate, will often 
 be found pre-requisite to a successful treatment of 
 sensitive dentine by topical applications. 
 
 There are very few agents used simply as resolv- 
 ents. The properties characteristic of this class of 
 agents are tonic, stimulant, sedative, and astringent. 
 Tincture of capsicum may fitly represent the stimu- 
 
240 PATHOLOGICAL CONDITIONS. 
 
 lant; Peruvian bark, and gum myrrh, the tonic; 
 tannin the astringent ; and opiates the sedative prin- 
 ciple. Astringents, stimulants, and sedatives all tend 
 to counteract inflammation. The agents of this 
 class are not very extensively used in the treatment 
 of dentine, not because they are not ultimately effi- 
 cient, but because their action is less vigorous than 
 that of some other agents. When, however, time 
 and circumstances will permit, mild treatment, if 
 efficient, is to be preferred. 
 
 But there are many cases in which, for want of 
 time, something more rapid in its action is required. 
 Of this character is the second class of therapeutic 
 agents, namely, escharotics, or those which, by their 
 action, destroy a portion of the tissue with which 
 they come in contact. It may be well to notice, 
 separately, the preparations commonly used for this 
 purpose. 
 
 Tannin, or Tannic Acid. — This is the active prin- 
 ciple of vegetable astringents, and is found most 
 abundant in nutgalls. It unites with albumen, fibrin, 
 and gelatin, forming with them insoluble tannates. 
 Its medicinal influence is almost necessarily topical, 
 since the promptness of its action on albuminous sub- 
 stances, and the insolubility of its compounds with 
 them, prevent its admission into the general circula- 
 tion. The action of tannin on dentine has been 
 
PATHOLOGICAL CONDITIONS. 241 
 
 already explained. Either its aqueous or its alcoholic 
 solution may be employed; the latter being the better 
 and more convenient preparation. It is however 
 recently used by solution in creosote and glycerin, 
 which constitute very valuable preparations. Where 
 tannin is applied to dentine, there is formed a tannate 
 of albumen, which, being insoluble, protects from irri- 
 tation, and probably incites to healthy condition, the 
 living parts beneath it. 
 
 Creosote, or Carbolic Acid. — Formerly, creosote was 
 obtained by distillation of wood, and differed some- 
 what from that in present use, which is prepared by 
 distillation of coal tar. It dissolves freely in alcohol or 
 ether, and sparingly in water • its action may therefore 
 be modified by dilution. Creosote produces its caustic 
 effects by its affinity for albumen and gelatin, with 
 which it forms insoluble compounds ; and from its 
 modus operandi, it is evident that the popular opinion 
 that it promotes decay of the teeth is an error. 
 
 Nitrate of Silver. — This salt is a powerful caustic, 
 whether applied to soft parts or to bony tissue. Its 
 action is somewhat complex. Nitric acid is liberated 
 by the decomposition of the salt, when in contact with 
 organic matter. Nitrate of silver has a strong affinity 
 for albumen, uniting with it without difficulty ; and 
 the compound thus formed, is soluble in nitric acid. 
 When the nitrate is applied to the skin, the immediate 
 
242 PATHOLOGICAL , CONDITIONS. 
 
 result is a whitish mark, caused hj a union of the salt 
 with the albumen of the cuticle ; but this soon turns 
 black, by the reduction of the salt and the liberation of 
 the oxide of silver ; when, for each atom of this set 
 free, there is liberated an equivalent of nitric acid. 
 There is here, then, an agent that acts promptly on the 
 gelatinous portion of the tooth, destroying its vitality 
 to the extent of the combination which takes place, and 
 that, by the decomposition of part of the salt, and the 
 consequent liberation of part of the acid, also acts 
 with energy on the calcareous portion. The compound 
 formed by the nitrate with the organic constituents 
 of the tooth, is insoluble except with a few substances, 
 and therefore protects the subjacent parts ; and the 
 precipitation of the reduced oxide on the surface, it is 
 claimed, affords some additional protection. The in- 
 solubility of the compound above mentioned, prevents 
 an absorption of the nitrate by the dentine, and ren- 
 ders its action necessarily superficial. When the 
 nitrate is neutralized by a union with it of an equiva- 
 lent of the constituents of the dentine, no further 
 chemical action is possible. The compound formed by 
 this union is soluble in a dilution of the nitrate ; and 
 if this be applied in too great a quantity, there may 
 be a larger loss of substance than is desirable or at all 
 necessary; for, as long as free nitrate remains in 
 solution in the- cavity, the insoluble compound is not 
 
PATHOLOGICAL CONDITIONS. 243 
 
 precipitated, and the surface is therefore exposed to 
 the continued action. It is preferable to employ the 
 nitrate in the solid state, or, when this is not practi- 
 cable, in a concentrated solution and small quantity, 
 rather than in a copious dilution and repeated appli- 
 cation. 
 
 From the observations already made, it is quite 
 evident that no harm can result to the tooth from a 
 proper application of this agent, beyond the portion 
 of it immediately acted upon. The nitrate can not 
 be absorbed by dentine, but it stimulates the sub- 
 jacent dentine to more healthy action ; though some 
 maintain that it is not as efficient in this respect as 
 some proper chlorid. It acts to a greater depth than 
 tannin or creosote, but not so deep as chlorid of zinc, 
 nor with so much pain. Great care should be exer- 
 cised that its contact be permitted no further than its 
 action is desired. 
 
 Chlorid of Zinc, — This agent has been extensively, 
 though much less now than formerly, used in the 
 treatment of sensitive dentine. It exerts an anti- 
 septic and disinfectant, as well as an escharotic 
 influence. In its operation it decomposes, the chlorine 
 uniting with the animal and the calcareous elements 
 of the dentine. It is milder in solution than in solid, 
 and less efficient and less painful. It is soluble in 
 water, alcohol, ether, or chloroform. The etherial 
 
244 PATHOLOGICAL CONDITIONS. 
 
 and the chloroform al solutions are, in their action, 
 least painful of all the forms in which this chlorid is 
 applied. The union of this agent with the gelatinous 
 constituent of the tooth is also more prompt in solution 
 than in solid. The ether and the chloroform may 
 lessen the pain by their anaesthetic influence. In the 
 use of the chlorid or any other active caustic, it is 
 important to hear in mind the exalted vitality which 
 follows its application ; and the operation should be 
 immediately performed. In the teeth of young 
 persons, or those in which the animal constituent 
 greatly predominates, the vitality will be more 
 promptly aroused than in those of an opposite texture, 
 and the change, too, will be greater. If the inflamma- 
 tion is confined to a thin lamina, it will be almost 
 instantly allayed by the application of the chlorid, 
 and the cavity may be excavated, as though there 
 had never been exalted sensibility ; but if the opera- 
 tion be delayed any considerable time, the tooth will 
 often be found in a worse condition for excavating 
 than before the application. The remarks on absorp- 
 tion under the head of nitrate of silver, apply with 
 equal force here : there is not the least danger from 
 this source ; indeed, there can be none ; even when 
 the chlorid is applied to the soft parts. 
 
 Ter chlorid of Gold. — Of this preparation the ethe- 
 rial solution only has been employed. This acts with 
 
PATHOLOGICAL CONDITIONS. 245 
 
 great promptness on the dentine, forming an insoluble 
 compound with the gelatinous elements, and the 
 chlorine of it forming also a combination with the cal- 
 careous portion. On account of the promptness with 
 which this agent operates, neither the pain nor the 
 disturbance of the subjacent parts caused by it, is 
 great. This substance is very liable to decomposition. 
 By exposure, to air or light, the gold is precipitated 
 in the metallic form. But, protected from these, it 
 may be preserved for a long time. This agent will 
 not be absorbed by the dentine. 
 
 Arsenious Acid. — The modus operandi of this agent 
 is involved in obscurity. In regard to its topical 
 action, Professor Bache, says : "Arsenious acid, when 
 it produces the death of a part, does not act, strictly 
 speaking, as an escharotic ; it destroys the vitality of 
 the organized structure, and its decomposition is the 
 consequence. The true escharotic acts chemically, 
 producing a decomposition of the part to which it is 
 applied; a state incompatible with life." Pereira 
 says : " Though employed as a caustic, yet the nature 
 of its chemical influence on the animal tissue, is un- 
 known; hence it is termed by some a dynamic caustic." 
 Its escharotic power certainly bears no proportion to 
 its devitalizing power; but it is probable that it forms 
 definite compounds with some of the constituents of 
 living tissue; and if so, these compounds appear to be 
 
246 PATHOLOGICAL CONDITIONS. 
 
 readily and rapidly decomposed, so that the acid be- 
 comes again free to attack, with similar results, the 
 subjacent parts. The topical application of arsenic is 
 liable to be followed by constitutional effects. 
 
 All dentists are aware of the fact that a tooth-pulp 
 may be destroyed by arsenic, through a wall of con- 
 siderable thickness. To accomplish this, the agent 
 must in some way penetrate the substance of the 
 dentine; and its vitality is destroyed so far as it is 
 thus penetrated; indeed, the vitality of the whole 
 crown of the tooth, both dentine and pulp, is often 
 destroyed by the use of this remedy, applied even to 
 a small cavity. Exalted sensibility of dentine is 
 subdued by this agent, more by its devitalizing than 
 through its chemical energy. It is soluble in creosote 
 and similar oils, and, to a considerable extent, in 
 alcohol and water. It is absorbed much more rap- 
 idly when applied in solution than in solid ; and the 
 more vascular the dentine, the more rapid and exten- 
 sive will be the absorption ; and on this account there 
 is great risk in applying it to the teeth of young per- 
 sons, or to any teeth that are highly wanting in den- 
 sity ; indeed, it will destroy the vitality of very dense 
 teeth. The manner in which it passes into the den- 
 tine, is not very definitely understood. It is very 
 certain, however, that in more highly organized 
 parts, it is carried through by the circulation, and 
 
PATHOLOGICAL CONDITIONS. 247 
 
 also may be taken up by imbibition. In either of 
 these ways it may pass into the dentine, and so far as 
 concerns the results, it matters not in which way. It 
 is enough to know that there are well defined cases 
 of its specific effect on the constitution, after having 
 been applied to toothbone — demonstrating that it 
 must have been taken up by the circulation; and 
 also cases of its manifest effect on the periosteum in 
 a short time after having been applied to the cavity 
 of a tooth, the pulp of which is dead — thus proving 
 that it must have been absorbed by imbibition. 
 
 If arsenic is ever employed in the treatment of 
 sensitive dentine, it should be suffered to remain in 
 the cavity but a short time — from one to three hours 
 — and then the part with which it was in contact, 
 should be very thoroughly excavated : and in de- 
 ciding in what cases it is proper to use it, there is 
 need of careful discrimination as to the tooth's struct- 
 ure and density; for injurious results have some- 
 times followed its application, notwithstanding the 
 utmost care; if it has once been absorbed by the 
 dentine antidotes will avail nothing. On the whole, 
 therefore, it is better to refrain from its use altogether 
 in the treatment of sensitive dentine. 
 
 Alkaline caustics have been, to some extent, used 
 for the treatment of this affection. A preparation 
 made after the following formula, is said to relieve 
 
248 PATHOLOGICAL CONDITIONS. 
 
 some cases very promptly : take Canada balsam and 
 slacked lime, and, having made them into a paste, fill 
 the cavity partially full with it, and permit it to re- 
 main until the object is accomplished. 
 
 The sensitiveness of dentine may be obtunded by 
 thorough friction on the affected part with a smooth 
 burnisher. This method, however, is applicable only 
 to those cases in which there is room to use the in- 
 strument. On the surfaces of the teeth, where there 
 may be sensitiveness, it is very applicable and very 
 efficient. Simple pressure, without friction, it is sug- 
 gested, will accomplish the same object ; though 
 pressure and friction combined, are doubtless more 
 efficient. 
 
CHAPTER IX. 
 
 EXPOSED PULPS. 
 
 Usually, when the pulps of the teeth are exposed, 
 it is in consequence of decay, but sometimes of a 
 gradual wearing-down of the organs in mastication. 
 When the pulp of a tooth is found exposed, the 
 'course of remedy to be pursued, will be indicated by 
 the following considerations: — 
 
 1st. The constitution and the vital energy of the 
 system. 
 
 2d. The condition of the mouth and teeth. 
 
 3d. The condition of the pulp. 
 
 4th. The size of the orifice at which it is exposed. 
 
 5th. Whether the exposure is of recent, or of 
 remote origin. 
 
 6th. If in a tooth of more than one fang. 
 
 7th. The position of the tooth in the mouth, and 
 that of the decayed cavity in the tooth. 
 
 The propriety of attempting to preserve the vitality 
 of the pulp after exposure, has been questioned. 
 Some take the position that after the development 
 and formation of the tooth, the pulp is no longer of 
 any use, and may, without damage, be dispensed 
 
250 EXPOSED PULPS. 
 
 with; while others maintain that, when the pulp is 
 destroyed, the tooth is no longer of any value. The 
 truth is, perhaps, a medium between these extremes. 
 The pulp of the tooth is valuable in the economy, or 
 nature would dispense with it. Analogy teaches 
 that it would not be retained longer than it could 
 subserve some beneficial purpose. But it is also 
 true, that a tooth may be retained and perform its 
 proper function for a long time after the destruction 
 of its pulp, notwithstanding it is in a less perfect 
 condition; though it is always desirable to preserve* 
 the life of the tooth when practicable; for the crown 
 depends on the pulp for its vitality, and living dentine 
 presents more resistance to decay than dead; besides, 
 a dead tooth never exhibits the bright, life-like 
 appearance of a living one. The parts about a dead 
 tooth, too, are far more liable to disease than those 
 about a living one. These are only a few of the 
 considerations for retaining the nerves of the teeth. 
 
 It has been maintained that the structure of the 
 tooth-pulp is of such peculiar character, and so sus- 
 ceptible of diseased action, that after it has become 
 affected, though but slightly, it can not be restored 
 to a healthy condition. We see no ground, however, 
 for such an assumption, except it be in the imperfect 
 treatment which this organ so frequently receives; 
 for the fact of its delicate structure does not neces- 
 
EXPOSED PULPS. 251 
 
 sarily imply an impossibility of restoring it from 
 disease. The pulp of the tooth is endowed with 
 such functions as ordinarily render living tissue sus- 
 ceptible of treatment for abnormal conditions; as 
 circulation, nutrition, absorption, and a distribution 
 of nerves. The success attending the methods of 
 treating exposed pulps, practiced by the dental pro- 
 fession during the last few years, is a source of more 
 encouragement than a thousand theories. 
 
 Treatment of Exposed Palps. — In cases where the 
 conditions are favorable, — the constitution good, the 
 pulp but recently exposed at a small orifice, and in a 
 healthy condition, treatment may be instituted with 
 considerable certainty of success. If there is no 
 inflammation or irritation, therapeutic treatment is 
 not indicated ; but the decay should be removed and 
 the cavity formed without wounding the pulp, if 
 possible ; though a slight wound is of no serious 
 consequence; for immediately after the hemorrhage 
 ceases, the operation may proceed as though the pulp 
 were intact. There have been suggested various 
 methods for protecting the pulp in cases of this kind : 
 formerly, the capping of pulps was very extensively 
 practiced; by which a shield was thrown over the 
 exposed point, so as to prevent the filling from coming 
 in contact with it. Various materials have been 
 suggested and used for caps ; but gold and load have 
 
252 EXPOSED PULPS. 
 
 been chiefly used for the purpose, especially when 
 the object was to form an arch over the point of 
 exposure. These caps are cut out of thin gold plate, 
 or thick sheet lead, of the proper shape and size, and 
 stamped with a convex punch, thus receiving such a 
 concavity as fits them for covering the exposed pulp 
 without touching it. A little groove, of depth suffi- 
 cient to hold the cap and prevent it from being 
 displaced by the introduction of the filling, may be 
 made in the dentine all round the orifice of exposure. 
 The cap is then to be adjusted to its position in the 
 cavity, having been previously touched round its 
 edge with adhesive wax, the filling is then introduced 
 in the usual manner, carefully, so as not to displace 
 the cap; and if this is of lead, great caution is to be 
 observed in condensing the filling above it, since it 
 will be easily compressed. 
 
 The therapeutic influence of lead on exposed pulps 
 is supposed by some to be definite and decided ; but, 
 though lead is a less perfect conductor of heat, and 
 in this respect is better than gold, and though, in the 
 capacity of a pulp-cap, its indestructibility is probably 
 quite sufficient, yet, if no change takes place in it, it 
 is not very apparent how it exercises any therapeutic 
 action on the pulp. Experience, however, proves that 
 the success is quite as good in the use of lead caps as 
 in those of gold; and the former are more easily applied. 
 
EXPOSED PULPS. 253 
 
 Another method of shielding an exposed pulp is, to 
 form an arch over it by the filling. This operation is 
 performed by beginning the filling at that side of the 
 cavity most easily approached, building on the gold 
 from the points of its attachment almost to the point 
 at which the pulp is exposed, and then attaching 
 from one point to another without permitting the gold 
 to come in contact with the pulp. Care should be 
 taken that the gold present as smooth a surface to 
 the pulp as possible. When the orifice of exposure 
 has been well covered and protected, the remaining 
 portion of the cavity is filled as usual. This method 
 of forming a protection over a tooth-pulp, possesses 
 no advantage over the ordinary cap ; and being much 
 more difficult, it is impracticable in any but skillful 
 hands. 
 
 This practice with exposed pulps, however, has, 
 within the last few years, been almost wholly aban- 
 doned, and for the following reasons : because it so 
 frequently failed to accomplish the object, and because 
 a better method of treatment has been discovered. 
 It was found that, muier that practice, many cases 
 which at first promised well, failed to preserve the 
 life of the pulp; though the fatal results were not 
 always immediate, a year or two, and, in some in- 
 stances, a much longer period, intervening between 
 the operation and the death of the tooth. In favor- 
 
254 EXPOSED PULPS. 
 
 able cases, the pulp, even after exposure, will, if 
 protected from the influence of foreign substances, 
 throw out a bony deposit, and even close up an orifice 
 of exposure, thus forming for itself a natural shield. 
 It is submitted that the capping operation is not the 
 best protection for facilitating this jn'ocess. It is 
 probable that, in some cases, the space between the 
 cap and the pulp, though it were large, would be 
 tilled with coagulable lymph ; and, even if it were 
 thus filled, a bony deposit might not be made ; 
 and if it were not, it could not fail ultimately 
 to prove injurious to the pulp. But if the space 
 should not be filled with lymph, the difficulty would 
 be . equally as great, since the pulp would protrude 
 through into the vacuum beneath the cap, and neces- 
 sarily become diseased, since it would be irritated by 
 its contact with, and its pressure against, the sharp 
 edges of dentine at the orifice of the cavity ; and it 
 may remain thus diseased for a long time, or die at 
 once. Thus it is, no doubt, that the great majority 
 of failures occur, under this kind of treatment. In 
 order to obviate this difficulty, it has been suggested 
 that the space under the cap be filled with some 
 appropriate substance, as a thick solution of gutta- 
 percha and chloroform, or a small pledget of cotton 
 saturated with collodion. 
 
 The frequent failures which occur in capping 
 
EXPOSED PULPS. 255 
 
 pulps, have incited the profession to seek some 
 other method of treatment. A vacuum above the 
 pulp being objectionable, some suitable material is 
 employed as a shield for this, being placed on the 
 orifice of exposure, in contact with the pulp; and 
 the filling is then introduced without pressure upon 
 the point of exposure. There are several substances 
 that have been thus employed, the chief of which are 
 asbestos, oiled silk, collodion, gutta-percha, Hill's 
 stopping, and os artificial. The material for this 
 purpose should be a non-conductor of heat, should 
 not be subject to decomposition when in contact with 
 the pulp, and should present a smooth surface and be 
 easily adapted. In shielding a pulp in this manner, 
 it is important that pressure be not made upon it; 
 and there is not much liability to this, where the 
 orifice of exposure is small; but, where it is large, 
 much care is required in the introduction and con- 
 solidation of the plug. The opinion has been enter- 
 tained by some, that the pulp of a tooth will not 
 tolerate any foreign substance in contact with it; 
 but' facts refute such an opinion. By this kind of 
 protection for a pulp, secondary dentine is more 
 likely to be developed. 
 
 A very perfect covering for an exposed pulp may 
 be made by dropping on it a little collodion or 
 solution of gutta-percha, and after the evaporation of 
 
256 EXPOSED PULPS. 
 
 the ether or chloroform, filling over it. This method 
 has the advantage of completely filling and occupy- 
 ing the space, and exactly conforming to the part. 
 When the exposure is at a large orifice, if the pulp is 
 healthy, and the constitution of the patient good, the 
 same general course of -treatment may be adopted, 
 except that more care and skill will be necessary in 
 the performance of an operation. Indeed, it is 
 difficult to make a good operation in cases of this 
 kind, using for the covering only a soft or flexible 
 material. 
 
 A method of operating, that is probably more effi- 
 cient than any other, is, to prepare the cavity as 
 already directed, place on the pulp two or three drops 
 of collodion or solution of gutta-percha, letting it 
 partially stiffen, and then over this fit a gold cap as 
 exactly as possibly, so that it shall rest on the solid 
 dentine jfar enough from the orifice of exposure to 
 preclude it from injurious influence on the pulp. On 
 this, the filling is introduced as usual, care being had 
 not to displace the cap, which, in all such cases, 
 should have a seat made for it, formed at the time 
 of the preparation of the cavity. 
 
 When the pulp of a tooth becomes by exposure, 
 inflamed or diseased, some more special treatment is 
 indicated, and usually it is therapeutic. In every 
 such case, the treatment will contemplate either the 
 
EXPOSED PULPS. 257 
 
 preservation of the pulp, when the circumstances 
 will warrant; or when they will not, then its 
 destruction. The former of course is always to be 
 preferred, where practicable. Some of our best opera- 
 tors very strongly denounce the wholesale destruction 
 of the pulps of teeth, practised by many ; while some 
 dentists never attempt to restore them to health at 
 all, however slightly diseased. This, as elsewhere 
 intimated, is erroneous practice ; for there is no obvi- 
 ous reason why the pulp of a tooth may not be re- 
 stored from disease to health as readily as other parts ; 
 endowed, as it is, with circulation, nutrition, absorp- 
 tion, and the distribution of nerves. The particular 
 kind of treatment required in any given case, how- 
 ever, will be controlled by various circumstances; 
 such as the nature and extent of the disease; whether 
 it is of chronic or acute type ; and when the irrita- 
 tion, or inflammation, is but slight, and is kept up 
 solely by the contact of irritating substances, restora- 
 tion of the pulp may be effected by a removal of these 
 irritating causes, and a protection of the pulp against 
 their further influence : in such case, nature, unaided, 
 effects the restoration. In default of a vigorous con- 
 stitution, the pulp, though but slightly affected, will 
 require topical therapeutic treatment ; and meanwhile 
 general treatment may be employed to give increased 
 tone to the system. In the local treatment, neutral- 
 
258 EXPOSED PULPS. 
 
 izing agents should be applied first, and afterwards 
 such as will counteract and reduce inflammation, 
 especially if this is in an active state. But if the 
 pulp is in a morbid condition, with retarded circula- 
 tion, and a tendency to enlargement, very active and 
 stimulating applications will be indicated, and in 
 some cases escharotics, such as nitrate of silver, 
 chlorid of zinc, and chromic acid, the latter especially 
 where there is a tendency to prurient enlargement of 
 the pulp. The therapeutic principles embraced in 
 astringents, tonics, stimulants, and escharotics, are 
 mainly to be relied upon in the topical treatment of 
 exposed pulp; but a detailed account of the nature, 
 influence and effects of all the individual agents em- 
 bodying these principles, and of the respective meth- 
 ods of applying them, belongs rather to dental 
 therapeutics. 
 
 The length of time requisite for the treatment of 
 exposed pulp, will vary with different cases. In the 
 case of a recent acute inflammation, the process of 
 restoration may be completed in two or three days ; 
 while, in other cases, where the difficulty is of long 
 standing and of a more complex character, it will re- 
 quire from a week to two months. The systemic con- 
 dition of the patient also exercises a great modifying 
 influence upon the treatment. Leeching and counter- 
 irritation of the gums are sometimes resorted to in this 
 
EXPOSED PULPS. 259 
 
 treatment; but it is rare that any definite beneficial re- 
 sult ensues. Depletion of the pulp itself may often be 
 practiced with decided success : and it may be accom- 
 plished either by puncturing the pulp with a fine- 
 pointed instrument, or by excising a small portion of 
 it at the orifice of exposure with a very sharp one, 
 in either case avoiding laceration of the pulp. By 
 this means the distended vessels are relieved ; and in 
 many cases, where the difficulty is but slight, imme- 
 diately after such relief by puncturing, so soon as the 
 hemorrhage has ceased, the tooth may be filled. But 
 if the depletion is by excision, time must be allowed 
 for the recovery of the incised surface — ordinarily 
 from three to ten days. 
 
 A method of treatment of exposed pulps ; first 
 introduced to the notice of the profession by Dr. 
 Allport ; and one which in his hands has proved quite 
 successful; consists in the excision of a portion of 
 the pulp at the orifice of exposure, and drawing the 
 edges of the incised part together, and inducing their 
 union, and in this manner closing the wound, when 
 less space is occupied by the pulp than before the 
 operation. After securing this result the operation 
 of filling the tooth may be performed ; the same care 
 being observed, however, as already suggested in cases 
 of exposed pulp. 
 
 The formation of secondary dentine, by which the 
 
260 EXPOSED PULPS. 
 
 orifice of exposure is closed up, has. already been re- 
 ferred to ; and it has been suggested that treatment 
 to facilitate this process may be instituted. With a 
 view to this, temporary fillings are sometimes intro- 
 duced ; and irritation of the pulp by frequent slight 
 friction, has been adopted ; but the success attending 
 this treatment is not very manifest, indeed not definite 
 enough to warrant adoption. If a shield of secondary 
 dentine is desirable before permanent filling, the best 
 method of securing it, is, after seeing that the general 
 recuperative power is in the best condition, to place 
 in the cavity a temporary filling, of such material and 
 in such manner as shall be least offensive to the pulp, 
 — perhaps there is nothing better than Hill's stop- 
 ping, — and then leave nature to accomplish the work. 
 In many cases, especially in young persons, this 
 process would be facilitated by an administration of 
 bone phosphate. The pulps of the teeth of the young 
 are more difficult to treat successfully than those of 
 the more advanced in life. 
 
 Destruction of the Pulp. — There are cases in which 
 an attempt to restore the pulp, even when recently 
 and but slightly diseased, would prove unavailing; 
 so feeble is the vitality that it is destroyed at almost 
 the first touch. Two cases in apparently the same 
 condition pathologically, but in different constitu- 
 tions, will, under the same treatment, exhibit very 
 
EXPOSED PULPS. 261 
 
 different results. A pulp that is highly diseased, is but 
 seldom, if ever, under any circumstances, susceptible 
 of restoration ; and in such case, of course, devitaliza- 
 tion and removal are indicated. This was formerly 
 supposed to be an impracticable operation, for two 
 reasons : first, because it was very difficult and painful; 
 and second, because of the consequences likely to 
 ensue. Then, the operation was attempted only on 
 teeth having one root, and those of cylindrical form ; 
 but now, it is performed successfully on all classes of 
 teeth. When destruction of the pulp is decided upon, 
 such means should be employed as will effect the 
 object promptly and thoroughly. Every thing should 
 be entirely removed from the pulp-chamber and the 
 canal of the root ; for any remaining portion is liable 
 to induce inflammation and suppuration ; and alveolar 
 abscess, also, frequently ensues. 
 
 There are two methods of destroying the pulp : the 
 one, by an operation; the other, by the application of 
 some devitalizing agent. The choice of these methods 
 will be governed by circumstances ; such as the tem- 
 perament of the patient, the condition of the tooth 
 and parts about it, the class of the tooth to be 
 operated upon. For patients of a nervous, irritable 
 temperament, to whom a removal of the pulp by an 
 operation would occasion great pain and a severe 
 shock, it would be better to apply some agent to do- 
 
262 EXPOSED PULPS. 
 
 stroy the vitality of the pulp, and then remove it ; but, 
 on the contrary, where there is vigor, a capacity 
 of endurance, it is preferable to remove the pulp 
 at once by an operation. To accomplish this, there 
 are two or three methods of manipulation. In 
 the first place, however, by whatever method it is 
 removed, it should be fully exposed ; the orifice of 
 exposure should be as large as the pulp-chamber, and 
 the entrance as nearly as possible on a line with the 
 tooth's axis; hence it will be necessary in many 
 cases to make an opening into the pulp-chamber at a 
 point different from that of the opening caused by the 
 decay. For instance, in the incisor teeth, when the 
 decayed cavity is small, on the side, near the margin 
 of the gum, penetrating to the pulp-chamber, and 
 exposing the pulp, the entrance through this opening 
 into the canal will be almost at right angles with it ; 
 and in such case it would be impossible, through this 
 opening, to manipulate freely in the root; and it 
 would be necessary to make an opening with a drill 
 through the palatal portion of the tooth directly into 
 the canal and on a line with it ; which opening should 
 be large enough readily to allow of a removal of the 
 pulp through it, and of an unimpeded performance of 
 all the subsequent operations on the canal of the root. 
 After the pulp has been exposed by the proper 
 opening, the instrument should be selected for its 
 
EXPOSED PULPS. 263 
 
 removal. There are different forms of instruments 
 for this purpose. Some operators employ the untem- 
 pered, four- sided, barbed broach, thrusting it up into 
 the canal as far as possible, then twirling it two or 
 three times around, and thus wrapping the nerve 
 round the instrument ; when both are drawn away 
 together. This method always occasions considerable 
 pain. Others employ simply the three or four-sided 
 broach, thrusting it through the pulp all the way up 
 the canal, and thus lacerating it and breaking up its 
 structure, so, that it may afterward be removed with- 
 out much pain. Another method, and one which seems 
 preferable to all others, is as follows : take a very 
 fine untempered steel wire, round and smooth, not 
 larger than 34 to 36 of Stub's gauge-plate; flatten 
 the extreme point, and turn it to an angle of from 
 thirty to forty degrees ; place the edge of this against 
 one wall of the canal at the point of exposure of the 
 pulp ; press it steadily up the canal, with its edge 
 bearing against the wall, as far as it will go, and then 
 twirl it suddenly round : thus an excision is effected 
 near the point of the root, when the pulp with the 
 instrument may be drawn away together; or, if not 
 thus removed, it may be caught with some fine point, 
 and removed with little or no pain. This manner of 
 introducing the instrument, too, causes less pain than 
 either of the others; for there are no sharp edges or 
 
264 EXPOSED PULPS. 
 
 points presented in passing the instrument up the 
 canal, to cut or lacerate the pulp. In the removal of 
 the pulp from the teeth of young persons, care should 
 be taken lest the instrument pass entirely through 
 the foramen, at the apex of the root; but with adults, 
 there is little or no danger of such an accident. 
 
 The directions given here would be quite sufficient, 
 if closely followed, for the removal of the pulps of 
 the six anterior superior teeth. For the removal of 
 the pulps from the bicuspids, the entrance can ordi- 
 narily be effected through the decayed cavity. 
 Usually, there is some lateral compression of the 
 roots of these teeth ; and the canal through the root 
 corresponds in its formation, so that it represents a 
 mere fissure expanded a little on each side of the 
 center. It is often difficult, and requires very deli- 
 cate manipulation, to remove all the pulp from these 
 fissures : a very fine instrument may be pressed down 
 each side, and yet a portion of the pulp remain in 
 the center. This difficulty is most fully presented in 
 those cases in which there has been an apparent, 
 though abortive, effort of nature to produce two roots. 
 
 The removal of the pulps of the molar teeth is a 
 more extensive and complicated operation. The pulp 
 to be operated upon should be fully exposed, the 
 orifice of exposure being made as nearly as possible 
 of the size of the pulp-chamber; and the instrument 
 
EXPOSED PULPS. 265 
 
 to be used, should be such as last described, except 
 that it should be much larger, and is to be introduced, 
 in the same manner, to the bottom of the pulp-cham- 
 ber, and rotated suddenly, so as to cut off the ramifi- 
 cations of the pulp into the roots, thus at one sweep 
 dislodging the entire body of it without laceration. 
 The practice of plunging a large barbed or cutting 
 instrument into the pulp of a molar tooth, is barbarous 
 in the extreme. The branches of the pulp in the 
 roots should be removed in the manner already 
 directed for the reinoval of the pulps from teeth of 
 single roots. The palatal root is very easily operated 
 upon; but, as to the buccal roots, there is frequently 
 encountered the same difficulty referred to in speak- 
 ing of the bicuspids. Commonly, when a pulp is 
 removed in this manner, the wound heals by first in- 
 tention, and there is formed a permanent cicatrix. 
 
 Actual Cautery. — Formerly, for destroying tooth- 
 pulp, the actual cautery was employed to a consider- 
 able extent, and was at one time a favorite method 
 with French dentists. This consists in heating a 
 wire of proper size to a white heat, and thrusting it 
 up the canal of the root to the apex, the object being 
 to destroy the pulp the instant the wire comes in 
 contact with it. The operation requires much skill, 
 and is attended with many difficulties. It is fraught 
 with terror to the patient; if the temperature of the 
 
266 EXPOSED PULPS. 
 
 wire is not at the white heat at time of its insertion, 
 the pain of the operation is most intense; it is liable 
 to leave the parts in such a condition as often to in- 
 duce inflammation and suppuration, which may involve 
 the investing membrane and the surrounding parts. 
 Besides, by this method, the object is, at best, no 
 more successfully attained than by others. 
 
 Potential Cautery. — This term is applied to those 
 therapeutic agents which destroy vital tissue by estab- 
 lishing a condition incompatible with vitality. Many 
 preparations have been employed as topical applica- 
 tions to devitalize the pulps of teeth, but only two or 
 three to any considerable extent. A consideration 
 of the nature, and something of the specific action 
 of these agents may not here be out of place : and, 
 first, of 
 
 Arsenious Acid. — This has been more used, topi- 
 cally, for the destruction of tooth- pulp, than all other 
 applications. The first account we have of its use for 
 this purpose, dates back to 1836, when it was applied 
 by Dr. Spooner, though others claim to have employ- 
 ed it at about the same time. The specific action of 
 arsenious acid on vital tissue is not well understood. 
 It is supposed by some that it forms a compound 
 with some element of the tissue, and in this way 
 destroys the vitality. 
 
 Any such combination, however, has hitherto es- 
 
EXPOSED PULPS. 267 
 
 caped detection; and it is certain that if a compound 
 is formed, it is not fixed or permanent in its char- 
 acter, since the arsenic will be carried to different 
 parts of the system, and its specific influence mani- 
 fested wherever it goes ; which could not be the case 
 if it formed a fixed compound. The more probable 
 theory is, that it destroys vitality by its influence on 
 nerve tissue ; producing such a change in its structure 
 as to arrest its function at once; in reference to the 
 action of this agent upon living tissue, much investi- 
 gation remains to be made. Animal tissue takes it 
 up by imbibition; and it is also absorbed by the cir- 
 culation, and conveyed by it, as already suggested, 
 throughout the system. Frequently, however, it is 
 applied to living tissue under conditions that prevent 
 such absorption. It is often employed in the treat- 
 ment of carcinoma. In the application of arsenious 
 acid to the pulps of teeth, for their destruction, seve- 
 ral circumstances are to be considered; such as the 
 age of the patient, the constitutional tendency, the 
 vascularity of the dentine. Where the vascularity is 
 great, the utmost caution is required. The indiscrimi- 
 nate use of this agent in the teeth of the young, is 
 attended with great risk. Some constitutions are 
 peculiarly susceptible of its influence, experiencing 
 its effects even in remote parts of the system, after 
 its application only to the pulp of a tooth. It is 
 
268 EXPOSED PULPS. 
 
 absorbed more readily in solution than in solid. It is 
 soluble in creosote and most of the essential oils, and 
 to some extent in alcohol and water. In many 
 cases, when it is applied to the pulp of a tooth, more 
 or less disturbance of the periosteum is exhibited a 
 short time after — in some instances in a few hours, 
 and in others after several days; thus giving evidence 
 that it has, by some means, come in contact with the 
 periosteum. Its influence on this, will often be 
 manifested under percussion, in advance of any other 
 symptom. 
 
 Application. — There are two or three methods of 
 applying arsenious acid for the destruction of the 
 pulps of teeth. The ordinary arsenic of commerce is 
 used. It was formerly employed very extensively in 
 connection with sulphate of morphia, mixed in equal 
 parts, and applied to the pulp with a small pledget of 
 cotton, moistened with creosote or some essential oil, 
 the former being most frequently used. Alcohol, 
 ether, or water may be employed in stead of creosote, 
 and in some respects and in some cases would be 
 preferable. The pledget of cotton, thus prepared, is 
 introduced into the decayed cavity, with the prepara- 
 tion in contact with the exposed pulp. Another 
 pledget of cotton, saturated with a thick solution of 
 gum sandarac and alcohol, or gutta-percha and chloro- 
 form, is placed over this in the cavity, to prevent the 
 
EXPOSED PULPS. 269 
 
 escape of the preparation, or the entrance of moisture 
 or foreign substances : any preparation may be used, 
 that will accomplish these objects. In the applica- 
 tion of the pledget, care must be exercised lest too 
 much pressure be made on the pulp, and pain be thus 
 produced. In order to prevent this pressure, another 
 method has been adopted, which consists in forming 
 a cap of lead, placing in it the arsenic, in the dry 
 state or with some suitable solvent, and then fitting it 
 over the exposed pulp, and retaining it there with a 
 pledget of cotton, as above, or with Hill's stopping, 
 gutta-percha, or adhesive wax. Thus the preparation 
 comes gently in contact with the pulp, and prevents 
 any pressure on it. The morphine is used for the 
 purpose of diminishing the pain which frequently 
 results from the application of arsenic only; but its 
 influence for such a purpose is predicated more on 
 theory than on practice; for facts prove that, applied 
 to living tissue, it produces pain rather than allays it. 
 Therefore the more observing and better class of 
 practitioners have discarded it. 
 
 Other substances have been mixed with arsenic, 
 for the purpose of mitigating or altogether relieving 
 the deleterious consequences so liable to follow its 
 administration; as, for instance, pulverized charcoal, 
 which combined with it in equal parts by weight, 
 makes a favorite preparation with good practitioners. 
 
270 EXPOSED PULPS. 
 
 by some of whom it is claimed that the charcoal 
 counteracts the specific effect of the arsenic on parts 
 other than those for which it is directly designed. 
 But this theory, in the light of any elucidation yet 
 given, is very vague. The claim can not be, that 
 charcoal is an antidote to arsenic, since facts refute 
 it; for if it were, the arsenic of the preparation, when 
 applied to the pulp of a tooth, would fail of its effect, 
 because the charcoal, being also in contact with the 
 pulp, would there, if ever, counteract the poison. But 
 this it does not do ; for the pulp is destroyed about 
 as readily by this preparation as by arsenic alone. 
 And if, when the arsenic and charcoal are thus 
 together, no counteracting influence of the latter is 
 manifest, much less will there be any when the 
 arsenic, escaped from the charcoal, runs riot through 
 the tissues, whither the latter can not follow. The 
 only probable advantage, then, of this preparation, is, 
 that the arsenic is not taken up from it by the tissues 
 so rapidly, as when it is applied alone or with any 
 thing that is soluble with it; for, when thus applied, 
 the whole is very soon dissolved, and taken up by 
 the pulp and dentine. But, when combined with 
 charcoal or the like, little more of the arsenic is 
 absorbed than that which comes in contact with the 
 pulp. Hence the conclusion, that the influence of the 
 charcoal is mechanical, and not therapeutic. 
 
EXPOSED PULPS. 271 
 
 This preparation is better applied perfectly dry, 
 beneath a lead cap, which should completely close 
 the cavity. Any other material that would mix as 
 readily with the arsenic, without being soluble, and 
 that would not induce irritation when in contact with 
 the pulp, would be quite as good for this purpose as 
 charcoal. Irritating gases generated in a tightly 
 closed cavity, are absorbed by charcoal. 
 
 Cobalt, in which the active principle is arsenic, has 
 been extensively used for destroying pulps; but it 
 is in no respect superior, and in some respects it is 
 probably inferior, to the preparation of charcoal and 
 arsenic : it is applied in the same manner. 
 
 The length of time the preparation should remain 
 in the tooth, will be determined from the condition of 
 the pulp when it is applied, the age of the patient, 
 the vascularity of the dentine, the susceptibility of 
 the patient to the influence of arsenic, and like cir- 
 cumstances. It will usually be from three to twenty- 
 four hours. In some cases, a very small particle will 
 thoroughly accomplish the work; while in others, a 
 much larger quantity may remain in contact with the 
 pulp even for a much longer time, without producing 
 more than a superficial result. And cases occasion- 
 ally occur, in which it seems almost impossible to 
 destroy the vitality of a pulp with arsenic. A case 
 is on record, in which the pulp was first fairly exposed 
 
272 EXPOSED PULPS. 
 
 in a superior bicuspid tooth, the health and constitu- 
 tion being good, and the temperament sanguino- 
 lymphatic; and arsenic with morphine was applied to 
 it, directly, five times within ten days, without pro- 
 ducing any apparent effect; then an application of 
 creosote and tannin was made three or four times, 
 during as many days; afterward the tooth was tem- 
 porarily filled with gutta-percha; and finally, in ten 
 or twelve days, this filling being removed, the pulp 
 appeared in a state of perfect preservation and health, 
 with all the indications of undiminished vitality. 
 Over the exposed point there was placed a non-con- 
 ductor, and upon it a filling of gold ; and one year 
 after, the tooth presented the appearance of perfect 
 life and health, having given the patient no annoyance 
 during the whole period. Several similar, cases might 
 be cited, were it necessary. 
 
 Hence it is quite obvious that there is a great di- 
 versity of susceptibility to the influence of arsenic, 
 and that the study of these idiosyncrasies is both in- 
 teresting and valuable. The recurrence of injurious 
 consequences from the use of arsenic, has induced 
 many operators to abandon it altogether. But these 
 injurious results perhaps occur always either through 
 mal-administration, or from a peculiar susceptibility 
 to the influence of the drug; and a superior skill and 
 a more accurate diagnosis would avoid them almost 
 
EXPOSED PULPS. 273 
 
 entirely. After the desired result with arsenic has 
 been obtained, it has been thought that antidotes to 
 arrest its further operation might be made available. 
 The hydrated sesquioxyd of iron is one of the best 
 antidotes to arsenic, and has been used in the teeth 
 to counteract its injurious effects; but it is of no avail 
 here; the arsenic has the start of it, and, indeed, 
 would outstrip it, with an equal start. 
 
 From the foregoing in regard to arsenic as an ap- 
 plication for destroying the pulps of teeth, the fol- 
 lowing conclusions are justly deducible : it is, in gene- 
 ral, very efficient; it is a heroic agent*; it should in 
 all cases, be used with great caution; in some cases 
 it is entirely inadmissible; a free administration of it 
 is liable to be followed by bad consequences; and 
 skill and care, rather than counteracting agents^ are 
 to be relied upon in its application. 
 
 Filling Pulp-cavities and Canals. — After the pulp 
 of a tooth has been destroyed, whether by an opera- 
 tion or by therapeutic treatment, the part at the point 
 of its detachment should, in all cases, before the fill- 
 ing is introduced, be rendered healthy; if possible, a 
 permanent cicatrice should be formed. In cases. 
 however, of good constitution and strong recuperative 
 power, where a pulp has been removed by an opera- 
 tion, the root may be filled as soon as the hemorrhage 
 has ceased; but such cases rarely occur. Generally. 
 
 
274 EXPOSED PULPS. 
 
 the part will require treatment; and the character 
 and duration of this will be determined by the cir- 
 cumstances — as, the vital energy of the system, and 
 the method employed for the pulp's destruction. 
 When this has been effected by an operation, the 
 wound produced by the excision is restored to sound- 
 ness much more readily than when by an application 
 of arsenious acid, and less topical treatment will ordi- 
 narily be required; indeed, in many such cases there 
 will be nothing else required, than to keep the canal 
 well cleansed, so as to obviate any irritation that other- 
 wise might be'induced by decomposition. When the 
 pulp has been destroyed by arsenious acid, more en- 
 ergetic treatment is usually demanded; for then there 
 is always a greater or less disposition to slough or dis- 
 charge through the tooth; which must of course be 
 entirely abated, before the operation of rilling is at 
 all admissible. In the treatment of this condition, 
 the canal should be kept perfectly clean by frequent 
 syringing; floss silk, moistened with creosote and tan- 
 nin, should be introduced to the extreme part of the 
 cavity or canal, and should be changed every twenty- 
 four hours, the cavity being thoroughly washed each 
 time. It will be necessary, in many cases, to continue 
 this treatment for several days. In order to determine 
 whether the condition is such as to admit of the fill- 
 ing, the floss silk should be removed after a sufficient 
 time is supposed to have elapsed, the cavity thoroughly 
 
EXPOSED PULPS. 275 
 
 cleansed and dried, and a portion of dry floss silk or 
 cotton introduced loosely into the canal. Then close up 
 the decayed cavity with adhesive wax, gutta-percha, or 
 some other substance that will effectually exclude the 
 moisture ; let it remain thus from twelve to twenty- 
 four hours; then open the cavity, and withdraw the 
 silk or cotton, and if this is found free from moisture 
 and odor, the tooth is ready to be filled. 
 
 The treatment just described will be sufficient for 
 all cases in which the pulp has been destroyed by the 
 operator. But teeth whose pulps are already dead, 
 would seem to be less difficult of treatment and fill- 
 ing; yet such is not the case; — indeed, the therapeutic 
 treatment of these is usually more protracted, and 
 their diseased condition less easily controlled ; and 
 this because of the fact that the decaying pulp, re- 
 maining in the canal, becomes very offensive and 
 irritating to the living parts adjacent, in which it 
 induces a chronic diseased condition, frequently in- 
 volving the dentine along the walls of the canal in 
 decomposition. 
 
 A classification of these teeth, based on their con- 
 ditions, might be somewhat auxiliary to a further 
 examination of this subject; and the following will 
 probably embrace them all : — 
 
 1st. Those whose pulps are dead, but their attach- 
 ment and adjacent parts alive and healthy. 
 
EXPOSED PULPS. 
 
 2d. Those predisposed to disease. 
 
 3d. Those already diseased, either discharging 
 acrid matter through the root, or exhibiting inflam- 
 mation of the periosteum. 
 
 4th. Those having alveolar abscess. 
 
 Sound or slightly decayed teeth are sometimes 
 found with dead pulps. This condition may be pro- 
 duced in various ways : by blows, or by any force 
 that will partially loosen the tooth; by undue press- 
 ure in rilling; by excessive sensitiveness of the den- 
 tine, even where the decay is not extensive; and, 
 sometimes, by a filling of the tooth when it is in an 
 unfit state for the operation. Ordinarily, in cases in 
 which the pulp is dead before its exposure, and there 
 is no abscess from the root or periosteum, the pulp- 
 chamber may be opened, and the remains of the pulp 
 removed. The canal should then be cleansed out, 
 and floss silk moistened with creosote, introduced and 
 permitted to remain from one to six hours; when it 
 should be withdrawn, the pulp-cavity and the canal 
 again thoroughly cleansed, when, if there is no dis- 
 charge of pus through the root, it may be filled. 
 The fact that the dead pulp is inclosed in its chamber 
 without producing irritation is evidence that there is 
 no secretion of pus. Occasionally, where the pulp 
 has died from exposure, the living part immediately 
 adjacent will present a healthy condition, and there 
 
EXPOSED PULPS. 277 
 
 will be no discharge; such cases should be treated in 
 the manner just described. In operating on teeth 
 already dead, more delicate manipulation is requisite 
 to prevent irritation, than on those in which the pulp 
 is destroyed by the operator. In very many cases of 
 dead teeth, where there is not a state of actual dis- 
 ease, there is a strong predisposition to it; and in 
 these cases, the preparation of a cavity, or the intro- 
 ducing and condensing of a filling, may produce in- 
 flammation of the periosteum. When such a condition 
 is recognized, several sittings may be required to 
 complete the operation. But it is not always easy to 
 recognize such a predisposition; yet, whenever it is 
 suspected, it is well to press the investigation, which 
 may be. guided by the following rules: ascertain 
 whether the tooth experiences a different sensation or 
 any pain, under percussion in any direction; whether 
 periostitis has ever existed in that or in a contiguous 
 tooth; whether the parts adjacent to the tooth are in 
 a healthy state; whether there is a general inflamma- 
 tory diathesis, or an enfeebled condition. These are 
 the prominent points in an examination of this kind. 
 
 Where this predisposition exists, it may be coun- 
 teracted by general or local treatment, according as 
 it depends on general or local causes; but in even- 
 case, this treatment should be very careful, and it 
 will, in some instances, have to be protracted. Iu 
 
278 EXPOSED PULPS. 
 
 those eases, where there is a discharge through the 
 root of the tooth, such treatment should be adopted, 
 as will most speedily and effectually suppress it; and 
 if it proceeds from a remaining portion of the pulp-tis- 
 sue near the point of the root, this should he removed, 
 and such application made as will prevent a recur- 
 rence of the discharge, and assist the part to recover 
 its health. The discharging surface may be broken 
 up by cutting it away with an instrument, or be 
 destroyed with an escharotic — either nitrate of silver, 
 creosote, or chlorid of zinc, in the use of which, seve- 
 ral applications will, in many cases, be necessary. 
 From their action, the secreting surface is destroyed, 
 healthy granulations spring up, and a healthy condi- 
 tion is established. 
 
 The discharge should be wholly suppressed before 
 the tooth is filled ; otherwise, alveolar abscess would 
 be speedily formed. In cases where there is periosti- 
 tis, it must be subdued before the tooth will tolerate 
 the operation of filling. To attain this end, the treat- 
 ment to be adopted will be dictated by the nature of 
 the causes which operate to induce the disease. 
 General treatment will be indicated where there is a 
 constitutional condition favorable to the local affection ; 
 but where there is no such general predisposition, the 
 treatment should be chiefly local, and may consist of 
 the following or similar appliances : depletion, either 
 
EXPOSED PULPS. 279 
 
 by leeching, cupping, or scarifying the gums; or 
 counter-irritation, either by scarifying, or by the ap- 
 plication of highly stimulating lotions. Counter- 
 irritation may be produced, also, by making a deep 
 incision in the gum opposite the tooth affected, and 
 introducing a little flock of floss or cotton, saturated 
 with creosote, which is to be kept in place till the 
 inflammation of the periosteum is allayed; which will 
 be effected in from one to five days. The silk or 
 cotton should be changed every day, till the restora- 
 tion of the tooth to health is affected, when it is to be 
 removed, and the wound permitted to heal. Mild 
 stimulating applications to the gums in the immediate 
 vicinity, to increase the circulation, will, in some 
 cases, be all that is required. A vapor bath, or warm 
 water applied to the part, is often beneficial; and, in 
 some cases, a continued application of cold, by means 
 of ice-water, will subdue inflammation of the perios- 
 teum. Indeed, any antiphlogistic treatment that can 
 be adopted advantageously, may be employed in 
 periostitis. 
 
 The periostitis of teeth whose pulps are dead, 
 commonly has its origin at the point of the root, from 
 irritation induced in the beginning by the dead and 
 decomposing pulp and other matter at that point. In 
 many instances, the inflammation is not confined to 
 the root of the tooth on which it began; but it will 
 
2S0 EXPOSED PULPS. 
 
 extend to the alveolus, the gums, and the periosteum 
 of the neighboring teeth. Whenever the existence 
 of this disease is suspected, and yet not very appa- 
 rent, as is often the case, the examination should be 
 very thorough. In some instances, percussion of the 
 tooth at one particular point and at a certain angle, 
 will produce pain; whereas, striking on any other 
 part of the tooth, or at any other angle, will cause 
 none at all. By an exercise of care and discrimina- 
 tion, the exact point of disease, even if confined to 
 a small space, may be ascertained. For instance, if 
 striking on the labial surface of a central incisor 
 near the point, produces pain in the socket, while on 
 any other point it does not, the place of the inflam- 
 mation is the anterior portion of the root, at or near 
 its point. By such means, the skillful and discern- 
 ing will be enabled to form a tolerably accurate 
 opinion as to the extent and location of periostitis 
 in all cases ; and this is an important consideration ; 
 for, if inflammation is found confined to a small por- 
 tion of a root, the treatment, if local, should be as 
 near that point as possible. 
 
 Inflammation of the periosteum may sometimes be 
 induced by the presence of foreign substances forced 
 down between the free margin of the gum and the 
 neck of the tooth, which have remained there till 
 they have become vitiated,- so as injuriously to affect 
 
FILLING ROOTS. 281 
 
 the gums and periosteum. A deposit of salivary cal- 
 culus sometimes produces inflammation of the gums 
 and periosteum. Teeth otherwise healthy are, in 
 some instances; thus affected ; though those which 
 have lost their internal vitality, are much more liable 
 to such disease. 
 
 Preparing the Teeth and Roots for Filling. — After the 
 tooth has been brought to a healthy condition, the de- 
 cayed cavity is first to be excavated and made of pro- 
 per form, the pulp-chamber to be shaped, and then the 
 canals and the roots to be prepared for filling. For 
 the preparation of decayed cavities here, the directions 
 given on that subject hitherto, will be quite sufficient. 
 In the formation of the pu]p- chamber, the abrupt 
 projecting portions of dentine should be cut down ; 
 and if there is any decomposition of this, it should 
 be removed. The pulp-chamber may be, when it is 
 excavated, of a general retaining form, or there may 
 be retaining points made within it at proper situa- 
 tions. In the preparation of the canals in the roots, 
 some operators do nothing more than cleanse them 
 out thoroughly. Another method is, to pass fine 
 bur-drills into them as far as practicable, thus making 
 the opening of the same size all the way ; or to scrape 
 out the canal with a fine No. 10 excavator. Very 
 fine, delicate instruments are' required for cleansing 
 out and forming the canals'; and they should be quite 
 
282 
 
 FILLING ROOTS. 
 
 elastic and of low temper. A set of instruments for 
 forming the canals in the roots of the teeth have been 
 devised and made by Dr. C. Palmer. These are of 
 such forms and sizes as to be suitable for every 
 case. They are represented in Fig. 54. Before 
 
 Fie. 54. 
 
 the introduction of these instruments, the method of 
 forming these canals was by the use of a three or 
 four-sided broach, tapering to a sharp point, and in 
 inclination corresponding as far as possible to that of 
 the canal. This instrument was employed to enlarge 
 the canal, and give it a regular shape ; a variety 
 should be at hand, so that one of the proper size and 
 taper can be selected. In cleansing and forming the 
 canal, care is necessary to prevent the instrument 
 from passing entirely through the point of the root. 
 
FILLING ROOTS. 283 
 
 Such an accident is not very liable to occur with the 
 tapered broach ; but with the miniature excavator or 
 barbed wire, it is, — especially in the teeth of the 
 young, where the foramina through the roots are 
 large ; and it is especially liable to happen to the 
 incisors, the canine, and the palatine roots of the 
 superior molars. But, after the complete develop- 
 ment of the teeth, there is no excuse for an accident 
 of this kind ; for then there is an abrupt contraction 
 of the canal near the point of the root, which may 
 always be detected by a careful introduction of the 
 instrument. 
 
 The decayed and pulp-cavities and the canal all 
 being thus prepared, are now ready to receive the 
 rilling. For filling the root, there are several 
 methods; one of which is, to prepare small strips of 
 gold, of two or four thicknesses of foil, take these on 
 the point of an instrument, and pack them into the 
 root, in successive folds, till the canal is full. Another 
 method is, to take small portions of gold, and pack 
 them in, one on another, till the canal is full. 
 Another is, to take strips of from two to four thick- 
 nesses, and from one to two lines wide, and roll them 
 on a fine broach in such a manner as to make a cone- 
 shaped block, a little longer than the depth of the 
 canal to be filled, and of the same taper ; quite a 
 number of these blocks will be required for any given 
 
284 FILLING ROOTS. 
 
 case, of various sizes, lengths, and densities ; the 
 longest, largest, and least dense should be first used, 
 the last requiring to be of less size and greater density. 
 These cones may be made as dense as desirable by 
 rolling them firmly between the thumb and fingers, 
 after having taken them off the broach. They are 
 then introduced with the plugging pliers, and passed 
 up as near to the point of the root as is consistent with 
 safety. In some instances, there is danger of thrust- 
 ing them through the point ; and, in order to prevent 
 this, the end of the first block introduced may be 
 made so large that it will not pass through, even 
 when forced up ; or, what is probably better, a very 
 small round pellet of gold may be forced up the canal, 
 as near to the point of the root as admissible, and 
 this serves as a foundation for the subsequent portions 
 of gold, and prevents them from passing too far up. 
 The cone-shaped blocks may be introduced and con- 
 solidated with an instrument of the same general form 
 as the canal, but much smaller. This kind of instru- 
 ment should be made of untempered steel; though 
 some operators make them of whalebone, to prevent 
 breaking off in the canal, — an unnecessary precaution, 
 since no skillful operator would ever break off a low- 
 tempered, well-polished, properly-formed instrument 
 of this kind. After a block is placed in the cavity, 
 the instrument is thrust in by its side, thus consoli- 
 
FILLING ROOTS. 
 
 285 
 
 dating the gold to the side of the cavity. Thus, the 
 blocks are successively introduced and consolidated, 
 till the canal is filled. It is better so to arrange as to 
 introduce the last portion of gold near the center of 
 the canal, rather than at the side. ' The last blocks 
 introduced should be stiff and dense, that they may 
 be thrust in with considerable force. The method of 
 filling canals at present employed by many, is in the 
 use of the filling instruments invented by Dr. C. 
 Palmer, represented in Fig. 55. There is a variety 
 
 Fig. 55. 
 
 in size and somewhat in form, so that in all positions 
 they will readily enter the canals and effectually con- 
 solidate the gold, which is introduced in small cone- 
 shaped pellets, loosely rolled, so that they may be 
 thoroughly consolidated. * 
 
 Another method of preparing gold for filling roots 
 is, to take the pure metal, and roll it down, on a 
 
286 FILLING ROOTS. 
 
 good rolling-mill, as thin as possible, keeping it well 
 annealed ; and of this, form the cones, and introduce 
 them as already directed. Made in this way, they 
 are stiffer, and fill up much more rapidly, than when 
 made of foil. They are to be condensed in the same 
 manner. Where the canal has been formed with a 
 tapered broach, it may be filled with a gold wire, 
 made of the same size and taper of the broach ; this 
 wire may be cut off at the orifice of the canal, or left 
 protruding more or less into the decayed cavity, and 
 be covered up with the filling. When a lost por- 
 tion of the form of a tooth is to be restored, such 
 projecting wires may be made very valuable as 
 anchorages. 
 
 Some other substances have been thought quite as 
 suitable for filling the roots of teeth as gold. Lead 
 has been employed for this purpose; but the principal 
 difficulty with this is, to get it into such a condition 
 as to be used with facility; but, if as completely 
 introduced, it would probably answer the purpose 
 quite as well as gold. Tin foil is also used, and, 
 under favorable circumstances, with success. Some 
 experiments, too, have been made with plaster of 
 Paris and similar substances, for filling roots and pulp 
 cavities'; but with what success, it is not ascertained 
 — some claiming instances of success, and others re- 
 porting, in every instance, failure ; so that there are 
 
FILLING ROOTS. 287 
 
 not sufficient data to warrant the adoption of plaster 
 or any* similar substance in practice. 
 
 In cases in which there is liability to irritation, 
 the operation of filling a root is quite enough' for one 
 sitting; and in any case, not more than three roots 
 should be filled at one time. The filling of a large 
 pulp-cavity will occupy one sitting, and that of the 
 decayed cavity, another. When a respite is thus 
 had between the filling of the pulp-cavity, and that 
 of the decayed cavity, the former should be dressed 
 down perfectly solid and smooth, so that no moisture 
 may penetrate it; and then, when the latter is to be 
 introduced, the surface of the former should be rough- 
 ened by being cut up with a sharp instrument, or by 
 being indented with small retaining pits, so as to lay 
 hold of and fasten the last filling. From one to four 
 days should intervene between the different divisions 
 of the operation. The filling of the decayed cavity 
 is to be performed according to the directions already 
 given. When inflammation ensues on an operation 
 of this kind, recourse is had to the treatment already 
 described for preventing, counteracting, or reducing 
 inflammation. 
 
 Some experiments have been made to test the 
 effect of restoring the parts to health, forming a cica- 
 trice at the point of the root, cleansing this out, fill- 
 ing the pulp-cavity and the cavity of decay, and 
 
288 FILLING ROOTS. 
 
 leaving the canal unfilled ; and it is maintained that 
 this method will, in favorable cases, answer the pur. 
 pose quite as well as that of filling the root, and 
 incur less risk. The treatment will be such as 
 already described for the restoration of diseased 
 roots ; all discharge through it must be suppressed, 
 and all foreign substances liable to decomposition, 
 removed from the canal, so that there may be a 
 complete restoration before it is closed. 
 
 Oftentimes, when a tooth has been filled without 
 filling the roots and pulp-chamber, if the pulp be 
 dead, or if the pulp afterward dies, the chamber 
 becomes the receptacle of a very vitiated and acrid 
 material, the retention of which will almost invariably 
 produce irritation. In all such cases, an opening 
 should be made for the escape of the offensive matter. 
 This is clone, if the filling is not to be removed, by 
 passing a small drill into the pulp-chamber or canal, 
 just above the filling, as close as possible. The handle 
 of the drill should be depressed, so as to give the 
 opening a downward inclination from within outward, 
 and thus favor the escape of any secretion. 
 
 In the superior molars, this opening may be made 
 through the masticatory surface; it may, sometimes, 
 be in the depressions on the crown surface, even 
 though there be no filling. In incisors, it is made 
 through the palatine portion of the crown. It is bet- 
 
FILLING ROOTS. 289 
 
 ter, however, in all cases, to make an opening of this 
 kind through the neck of the tooth, just under the 
 free margin of the gum, since here foreign substances 
 are not so liable to be crowded into it, as where it is 
 through the masticatory surface. In cases in which 
 it is obvious at the time of filling the tooth, that such 
 an opening will be required, it is better to make it 
 before the filling is introduced, as follows : first, pre- 
 pare the decayed and pulp-cavities for filling; then 
 drill through the neck of the tooth, into the canal, to 
 the extreme part of the pulp-chamber; and finally, 
 introduce into this' hole, its entire depth, a piece of 
 smooth steel wire, such as will closely fit, leaving it 
 exposed through the decayed cavity — and if it is not 
 enough exposed when introduced, the tooth-bone may 
 be cut away about it, till it is fully exposed; when 
 the decayed and pulp-cavities are filled in the usual 
 manner, and condensed solidly against the wire. 
 After the filling is finished, the wire is withdrawn, 
 leaving a smooth, continuous opening for the escape 
 of any secretion that may collect within. When the 
 opening into the canal is not made till after the tooth 
 is filled, there is liable to be a space between it and 
 the filling that will receive and retain fetid matter, 
 which may become very offensive. This method of 
 treatment is, however, always to be deprecated, and 
 should never be employed except as a last resort, or 
 
 T 
 
290 DENTAL PERIOSTITIS. 
 
 in cases where it is impossible to command the time 
 and opportunity for the proper treatment ; and even 
 then it is better to make the opening and entrance 
 into the chamber and canal just as though it were to 
 receive immediate treatment; for in a great many 
 instances, the opportunity for that may soon occur. 
 
 DENTAL PERIOSTITIS. 
 
 This affection of the investing membrane of the 
 roots of the teeth, is of frequent occurrence after the 
 death of the pulp ; but rarely if ever before. In- 
 flammation of this tissue in its manifestation, is modi- 
 fied by the anatomical structure of the parts. 
 
 "Whether there be two membranes in the alveolar 
 sockets, the one lining the walls of these, and the 
 other investing the roots of the teeth, is not a matter 
 of importance, so far as the nature and treatment of 
 this affection is concerned. This condition of the den- 
 tal periosteum, is induced by such irritating causes 
 as would produce inflammation in other tissues. 
 
 The first indication of approaching difficulty in this 
 tissue, is a sense of slight fullness, which invites con- 
 tact, and even pressure from the opposing teeth; 
 such pressure affording a rather pleasurable sensation, 
 and seeming relief. 
 
 This condition is brought about by determination 
 
DENTAL PERIOSTITIS. 291 
 
 of blood to the part, and the surroundings being such 
 as to prevent free expansion of the capillaries, and 
 other small vessels, ramifying this membrane, these 
 walls are pressed upon in proportion to the force of 
 this determination. 
 
 This effort at expansion will occasion, especially in 
 those teeth having very conical roots, quite a per- 
 ceptible elongation, and this more particularly occurs 
 when active inflammation supervenes, which is the 
 sequence of the state of irritation, to which reference 
 has just been made. 
 
 After active inflammation has occurred, pressure or 
 percussion upon the affected tooth, usually causes 
 great pain; to such an extent, that sometimes the 
 slightest contact even by the tongue is intolerable. 
 
 This condition varies much in degree, in different 
 cases, dependent largely upon the predisposition, and 
 susceptibility to exciting causes of irritation and 
 inflammation, together with the character of these 
 exciting causes, whether concentrated in action to a 
 mere point, or more extensive in their sphere of 
 operation. 
 
 Oftentimes only a very small portion of the peri- 
 osteum of a tooth will be affected ; it may be confined 
 to the immediate vicinity of the point of the root, or 
 to one side, or to the periosteum near the margin of 
 the alveolus and the border of the gum. 
 
292 DENTAL PERIOSTITIS. 
 
 Indeed, so circumscribed is this affection often 
 found, that the periosteum on one side of a root, will 
 pass through all the successive stages of inflammation 
 to suppuration and destruction, without that upon the 
 opposite side having undergone anything more than a 
 slight irritation, if even that. In such cases the 
 vitality has sufficient power to hold the disease at 
 bay, and confine it to the immediate point of attack. 
 
 When there is a systemic predisposition, the local 
 exciting causes will sooner and more vigorously at- 
 tack. Always when the pulp of a tooth is devitalized, 
 the periosteum is more liable to disease, and perhaps 
 for several reasons. In almost all cases there are 
 irritants at hand, that did not exist before ; and the 
 periosteum is either enfeebled, and consequently less 
 resistant, or the demand upon its function greater 
 than before, in view of its being the medium of 
 connection, between the normally vital tissue and 
 that which is devitalized, or at best, its life very 
 much impaired, and when the latter condition exists, 
 the nourishment received by the cementum and den- 
 tine is wholly through the periosteum. In these facts 
 doubtless are to be found the cause of the greater 
 susceptibility of the dental periosteum to disease, after, 
 than before the death of the pulp. 
 
 The exciting causes of this affection are to be found 
 in the acrid debris of the dead and decaying pulps of 
 
DENTAL PERIOSTITIS. 293 
 
 the teeth, passing either in a fluid or gaseous state, 
 through the foramen at the point of the root, and 
 there coming in contact with the periosteum, and in 
 various deposits, calcarious and others, insinuated 
 beneath the margin of the gum, encroaching upon 
 and irritating the periosteum. 
 
 It is also sometimes occasioned by an extension of 
 disease from some other point. As an illustration of 
 this, in susceptible cases, the periosteum of one tooth 
 may become affected, by the action of some local 
 irritant, and two or more of its neighbors become 
 affected by extension of the inflammation. 
 
 Some medicinal agents act specifically upon the 
 dental periosteum, inducing a very painful condition, 
 thickening of the tissue, and elongation of the teeth. 
 
 Mercurials present an illustration of this class of 
 agents. The precise condition produced in the dental 
 periosteum in mercurial ptyalism is perhaps not clearly 
 comprehended. It is more than simple inflammation. 
 It is not modified or controlled by the same remedial 
 treatment. It attacks the periosteum of living teeth, 
 as readily and with quite as much violence as of those 
 which are devitalized. Alveolar abscess is not a 
 common result of this affection of the periosteum. 
 
 Treatment. — The treatment of dental periostitis, in 
 its details, will be governed by the attendant con- 
 ditions, such as systemic predispositions, the vital 
 force, and the local causes, and their peculiarities. 
 
294 DENTAL PERIOSTITIS. 
 
 Systemic treatment should have for its object, the 
 removal or counteracting of predispositions, and the 
 abatement of the determination of blood to the part 
 in question, by inviting it to other parts, by their 
 stimulation, and by introducing into the system such 
 agents as will tend to allay excitement in the affected 
 part, and induce, so far as possible, an equilibrium of 
 circulation throughout the system. 
 
 The local treatment must also be wisely and faith- 
 fully attended to. The principle applicable to the 
 treatment of inflammation in any tissue is that to be 
 employed here. It will be remembered, however, 
 that there are many medicinal agents which possess 
 very desirable properties, that are still totally inef- 
 ficient, because of a want of adaptation. We have, 
 however, at our command some very efficient reme- 
 dial agents, for the treatment of this affection, and 
 the list is being constantly enlarged. 
 
 We propose here to consider rather the principles 
 involved in the treatment, than details for special 
 cases. 
 
 The causes producing and influencing the disease, 
 should always be fully apprehended, immediately after 
 which, the following points should receive attention : 
 First, remove all irritants ; this will embrace the re- 
 moval of the dead pulp, and all the debris from its 
 chamber, and from the canal in the root, or roots, and 
 rendering them perfectly free from all offensive ma- 
 
DENTAL PERIOSTITIS. 295 
 
 terial, and keeping them so ; and the removal of all 
 deposits that may be upon the teeth, and especially 
 those that may encroach upon the gum, or the alveolus 
 and periosteum at or beyond the neck of the tooth ; 
 and the removal of all injurious and useless teeth and 
 roots in the vicinity. 
 
 And, secondly, relieve the congestion of the affected 
 part, in some or all of the following ways : either by 
 systemic influence as already suggested, or by coun- 
 ter-irritation, producing determination to a neighbor- 
 ing part, and thus relieving the affected part, or by 
 depletion from the gum immediately opposite the seat 
 of the affection. 
 
 Counter-irritation may be effected by scarifying the 
 gum, or by the application of some irritating agent, 
 such as tincture of capsicum, tincture of iodine, and 
 cantharides. An excellent preparation of the latter, 
 denominated cantharidal collodion, has recently been 
 prepared, and introduced to the medical profession. 
 This preparation when applied to the gum acts 
 promptly and efficiently in almost every case of acute 
 dental periostitis ; it produces desquamation upon 
 the surface of the mucous membrane where it is 
 applied. 
 
 Depletion, with many, is a favorite method of treat- 
 ment, and often productive of very good effects. Two 
 or three methods of accomplishing this are employed. 
 
296 DENTAL PERIOSTITIS. 
 
 Simple scarification of the gum, cutting it more or less 
 deeply, will secure sufficient hemorrhage, especially 
 if the gums are quite vascular ; when this fails, cup- 
 ping, or the artificial leech, may be employed ; but 
 the natural leech is the most efficient means of local 
 depletion, in this treatment; and every dentist should 
 always have these at command, and be familiar with 
 their use. The application of a leech in very many 
 cases will, in a very short time, subdue the most 
 violent attack of acute periostitis. 
 
 In the treatment of this affection, hyperdermic 
 injections give promise of most desirable results; for 
 this purpose, the solution of morphine, or tincture of 
 opium from ten to twenty drops, may be injected, 
 with a proper syringe, beneath the mucous membrane, 
 when the pain would be found to subside in a few 
 moments, and the severest symptoms be abated in a 
 few hours. 
 
 In all cases of periostitis, the sooner it can be 
 brought under proper treatment after the attack, the 
 more easily will it be subdued. 
 
 In cases of longer standing where the affection has 
 assumed a chronic form, the membrane more or less 
 thickened and indurated, and a persistent soreness of 
 the tooth affected, heroic and persevering treatment 
 will be required to overcome the difficulty; in the 
 great majority of cases, however, the result is the 
 
ALVEOLAR ABSCESS. 297 
 
 formation of alveolar abscess, rather than the con- 
 dition just referred to; a description and treatment 
 of which will next receive consideration. 
 
 ALVEOLAR ABSCESS. 
 
 Alveolar abscess is a result or consequence of per- 
 iostitis, and consists of a pus secreting sac, on the 
 root, usually at or near the point, but sometimes upon 
 one side. The secretions of these sacs differ in 
 character, according to the different conditions of the 
 parts together with systemic influences. Sometimes, 
 the discharge from these sacs is through the root ; 
 sometimes from between the tooth and alveolus ; and 
 sometimes, directly through the alveolus and gums. 
 There are occasional cases in which the discharge 
 will be at a very considerable distance from the 
 point of secretion ; but, in such cases, the secretion 
 always follows some natural avenue that affords a 
 facility for its passage — as, for instance, along a 
 suture. There are cases recorded where the issue 
 from an abscess of the central incisor was near the 
 posterior portion of the hard palate ; and, in these, 
 the channel of the pus lay along the suture of the 
 palate bones. Sometimes, the opening from an ab- 
 scess of the first or second molar will be opposite the 
 bicuspids on the buccal portion of the gum. Alveolar 
 
298 ALVEOLAR ABSCESS. 
 
 abscess is exceedingly variable in character, according 
 to the constitutional peculiarities and susceptibilities 
 of the patient, the condition of the parts immediately 
 adjacent, and, to some extent, the cause which has 
 produced it. In a good constitution, after an abscess 
 is formed, it will discharge healthy pus. Occasion- 
 ally, yet very seldom, does nature alone effect a per- 
 manent cure. In constitutions of a cachectic dia- 
 thesis, alveolar abscess is liable to constant discharge 
 of an unhealthy pus, or purulent acrid matter; and 
 the parts about it are usually in a diseased condition. 
 
 The cases in which alveolar abscess is most likely 
 to occur are those of a manifest inflammatory diath- 
 esis, or those in which there is considerable local 
 inflammation, from some local exciting cause. In 
 the cases of constitutional predisposition, the abscess 
 after a time assumes a chronic character, constantly 
 secreting and discharging pus, but does not usually 
 cause much pain, though the tooth from which it 
 proceeds will experience some soreness and an uneasy 
 sensation. In the acute forms of it, however, there 
 will be intense pain. In some cases, the sac will be 
 formed without much irritation of the surrounding 
 parts ; while in others, irritation and inflammation will 
 extend to parts more remote, especially if there are 
 any irritating agents at work. 
 
 Usually, the sac is found at the point of the root ; 
 
ALVEOLAR ABSCESS. 
 
 299 
 
 but, sometimes, it is located on the side, the point 
 remaining comparatively free. In the molars, par- 
 ticularly the superior ones, the sac will frequently be 
 found in the bifurcation, often occupying the entire 
 space between the roots. When it is on the point of 
 
 Fig'. 56. 
 
 one of the roots, this is usually the palatine. Fig. 56 
 represents the position of the sacs on the roots of the 
 different teeth. 
 
 Treatment. — The treatment of alveolar abscess will 
 be governed by the constitution of the patient and 
 the condition of the part affected ; a case of recent 
 origin will yield much more readily than one of long 
 standing. When a case has assumed the chronic 
 form, and the surrounding parts have become impli- 
 cated in the diseased condition, a restoration to 
 health is often very difficult. Indeed, till within a 
 few years, the removal of alveolar abscess was 
 thought to be, as a general thing, wholly impracti- 
 cable. But, by the treatment now employed, this 
 affection is readily eradicated, unless the parts in the 
 
300 ALVEOLAR ABSCESS. 
 
 immediate vicinity are very much involved. In 
 some cases, the sac on the point of the root is verv 
 large, and absorption has taken place, to accommo- 
 date it ; in such instances, the sac being destroyed, 
 the space occupied by it will be filled up with a 
 healthy tissue. In young persons, when an abscess is 
 formed on the point of a root, especially in the single- 
 root teeth of the superior maxilla, the discharge is 
 frequently through the tooth, in consequence of the 
 large size of the foramen at the point of the root; 
 and generally, in such cases, the local treatment may 
 be made through the canal. Sometimes the dis- 
 charge is between the root and the wall of the alveolus. 
 More often, however, especially in persons over 
 twenty-five years of age, the discharge is through 
 the alveolus and the soft parts to the surface, by the 
 shortest course. 
 
 When an alveolar abscess is influenced by any 
 constitutional derangement, general treatment must 
 be resorted to, such as the condition indicates. The 
 local treatment always demanded, is such as will 
 break up and destroy the secreting sac. This is 
 effected either by surgical or by therapeutic treatment, 
 and frequently in chronic cases, by both together; 
 but, in the great majority of acute cases, therapeutic 
 treatment alone will be sufficient. In order to break 
 up an abscess by an operation, it must be easy of 
 
ALVEOLAR ABSCESS. 301 
 
 access ; and it is very seldom that an operation of 
 this kind can be performed tnrough the root of a 
 tooth ; but, fortunately, in almost all those cases 
 where the discharge is through the root, therapeutic 
 treatment alone will answer the purpose. When the 
 point of discharge is on the gum opposite the secret- 
 ing sac, a sharp-pointed bistoury should be used, and 
 the canal of discharge sufficiently opened to admit 
 the free use of the instrument at the seat of the 
 disease. Then the secreting sac should be dissected 
 from the point of the root, and its connection with the 
 circulation severed as completely as possible, thus 
 cutting off its supply. After this, if the case is a 
 favorable one, nature may be left to accomplish the 
 work ; in which case, the broken up sac will be thrown 
 off, healthy granulations developed, and the parts 
 restored to complete health. In other cases, how- 
 ever, after an operation, nature unaided will not 
 complete the cure; but such therapeutic treatment 
 must be resorted to, as the circumstances seem to 
 require. In some cases, the opening through the 
 alveolus will require to be enlarged ; and this part of 
 the operation requires great care. All detached 
 particles of bone should be removed from the opening, 
 since, if permitted to remain, they would produce 
 irritation and tend to increase the difficulty. 
 
 When the therapeutic treatment is applied through 
 
302 ALVEOLAR ABSCESS. 
 
 the root, the canal is to be cleansed of all foreign and 
 detached matter, and opened freely through to the 
 point; and, if the discharge is very fetid, some dis- 
 infectant should be used, than which perhaps nothing 
 is better than diluted creosote, since a fetid condition 
 keeps up irritation. The cleansing of the root may 
 be accomplished by injection of chlorid of sodium; 
 after which, the agent to act on the disease at its 
 seat, is to be introduced. Of this agent, there are 
 various kinds employed, the chief of which are 
 chlorid of zinc, nitrate of silver, and creosote, the first 
 being applied in the solid, and the latter two in the 
 liquid state — though the nitrate may be employed in 
 the solid form. The method of using the chlorid of 
 zinc is, to pass it in small portions up the canal, on a 
 piece of silk; with a fine probe, entirely through the 
 point of the root ; which process should be repeated 
 every twenty-four to forty-eight hours, as the case 
 may indicate. After this, during two or three days, 
 floss silk, moistened with a mild solution of creosote 
 and tannin in alcohol, should be applied daily; and 
 then clean silk or cotton may be worn in the canal, 
 changed every day, for three or four days, or till it 
 is manifest that there is no longer any discharge, and 
 that the parts are in a healthy condition. If nitrate 
 of silver, in solution, or creosote is used, it should be 
 absorbed into a piece of floss silk, and passed through 
 
ALVEOLAR ABSCESS. 6\J6 
 
 the root in the manner already described. The nitrate 
 is more prompt of action than creosote, and will ac- 
 complish a specific object in a shorter time. Either 
 of these solutions may. by the use of the syringe, 
 be very effectively thrown through a root in the 
 following manner : fill the orifice of the canal with 
 gutta-percha ; drill through it a hole large enough to 
 receive tightly the point of the syringe ; and then, 
 charging with the solution, inject it through the root ; 
 and, in cases where there is an opening through the 
 gum, the injection may be forced round through this. 
 The condition of the parts will indicate how long this 
 kind of treatment should continue. Ordinarily, when 
 the discharge is entirely through the gum, the bistoury 
 should be used to enlarge the opening. In many 
 cases, therapeutic treatment alone will accomplish the 
 object; and, when the opening to the sac is large and 
 direct, the therapeutic agents may be introduced 
 through it directly to the seat of disease. If nitrate 
 of silver, in solution, or creosote is used, it should be 
 introduced to the point of affection on a pledget of 
 cotton or floss silk, as heretofore directed ; or if, as is 
 preferable, chlofid of zinc or nitrate of silver in solid, 
 it should be passed through the opening into contact 
 with the sac. This treatment should be kept up till 
 the indications are fulfilled. 
 
 In the treatment of abscess of the inferior maxilla, 
 
301 ALVEOLAR ABSCESS. 
 
 much difficulty is often experienced from a want of 
 free egress for the secretion : while, in the superior 
 teeth, the pus may frequently escape through the 
 tooth by gravitation ; this force, in the inferior jaw. 
 increases the difficulty. The sac being usually 
 formed on the point of a root, the secretion then 
 rests at the bottom of the socket, and is frequently 
 pent up there till it finds an outlet through the gum. 
 somewhere between the point of the root and the 
 neck of the tooth. It is, in many instances, very 
 difficult to get an ope nng as low down as the point 
 of the root, since the buccal attachment to the gum 
 is usually quite above that point, particularly in the 
 case of the molars and second bicuspids. Very sel- 
 dom, if ever, can a secreting sac on the root of an 
 inferior tooth be destroyed by treatment applied 
 through the canal of the root. Some are accustomed 
 to make a vertical incision of the sum, as low as the 
 point of the root, and perforate the alveolus, and 
 treat through this channel, as already described. 
 Owing to the disadvantage above mentioned, much 
 more energetic treatment is necessary to attain suc- 
 cess with an abscess of the inferior than with that 
 of the superior teeth. 
 
 In the great majority of cases, where one half or 
 more of the periosteum of a root is involved in 
 abscess, the indications certainly point to the re- 
 
ALVEOLAR ABSCESS. 305 
 
 moval of the tooth. In the lower teeth, a very 
 serious difficulty occasionally occurs from abscess, 
 namely, an external opening and discharge ; and in all 
 cases where this condition has already been reached, 
 the offending tooth should be removed. But, when 
 such a result is only anticipated, and is yet contin- 
 gent, treatment may be employed to avert it; and, 
 in order to do this, a deep and free incision should be 
 made in the gum, opposite the affected tooth, and 
 poultices applied within ; and, where there is ex- 
 ternal swelling, pressure is recommended, as follows : 
 adjust a piece of thick sheet-lead to the part, and 
 make the pressure on this by means of a bandage 
 comprising it and passing round the head. It is 
 supposed that this application counteracts the gravi- 
 tation of the secretion, pressing it upwards, and thus 
 inducing it to seek an outlet at some more desirable 
 point. If it is a worthless tooth that is producing a 
 difficulty of this kind, it should be removed at once. 
 
 In regard to the treatment of alveolar abscess, 
 much yet remains to be learned. With the attain- 
 ments thus far made in this direction, no aspiring 
 dentist will rest satisfied ; though in the hands of a 
 few it has made great progress within a very recent 
 period. 
 
 In a treatise of this character it is impracticable to 
 
306 ALVEOLAR ABSCESS. 
 
 enter into the details of the pathology of this affection, 
 or very minutely into the rationale of its treatment. 
 A thorough knowledge of these involves a wide 
 range of pathological knowledge. 
 
CHAPTER X. 
 
 PIVOT TEETH. 
 
 Whenever the crowns of the anterior teeth have 
 become so much decayed that they can not by fill- 
 ing, be rendered useful, they may, under favorable 
 circumstances, be supplied by artificial crowns con- 
 structed on the roots. For the successful accom- 
 plishment of this work, the following conditions are 
 important: 1. The constitution of the patient should 
 be good. 2. The mouth should be in a healthy con- 
 dition, and without diseased teeth or roots. 3. The 
 teeth should be free from calcareous deposits and 
 from all foreign substances liable to induce irritation 
 or inflammation. 4. The attachment of the teeth 
 should be perfect and healthy. 5. It is desirable 
 that the root have a living, healthy pulp remaining. 
 6. The root above the neck should be sound. 7. 
 The root should occupy a correct position in the 
 arch. Prior constitutional treatment will often be 
 required where there are unfavorable conditions. 
 
 The roots of the six superior anterior teeth are 
 better adapted for the reception of artificial crowns, 
 
308 PIVOT TEETH. 
 
 than those of any other in the mouth. The roots of 
 the first bicuspids frequently terminate in two points, 
 and are always more or less compressed, so that they 
 will not receive a pivot large enough to sustain a 
 crown; besides, these teeth are masticatory, and 
 crowns pivoted to them very soon become loose and 
 useless. The roots of the inferior incisors are also 
 compressed, and thus subject to the same disability. 
 Occasionally, however, pivot crowns are attached to 
 the roots of the superior bicuspids, and the inferior 
 incisors, cuspids, and bicuspids. But in order that 
 such an operation shall be of any utility, the condi- 
 tions must be favorable, the roots with as little lateral 
 compression as possible, in a very sound and healthy 
 state, and without any tendency to inflammation. 
 
 The preparation of the root for the reception of an 
 artificial crown, is a very simple process. It will, 
 however, be somewhat modified by the kind of crown 
 used, and the method of attaching it. Ordinarily, 
 the first step is, to remove the natural crown, or any 
 remaining portion of it, with a fine saw or excising 
 forceps. Of this latter instrument, there are various 
 forms, that in most common use having narrow, 
 transverse edges, closing squarely together, as repre- 
 sented in Fig. 57. With these forceps, any broken 
 fragments of the crown can be removed with great 
 facility. Many operators, placing their edge on the 
 
PIVOT TEETH. 309 
 
 neck of the tooth, are accustomed to excise with 
 them the principal part of the crown at a single cut. 
 This method, however, is objectionable, since it 
 
 Fig. 57. 
 
 always gives too great a jar to the root, and is liable 
 to loosen, and, in many instances, to fracture it so as 
 to unfit it for the reception of the crown. But, in 
 every case in which an artificial crown is required, 
 the natural crown is very much decayed ; and, in this 
 condition, is very readily removed with excising for- 
 ceps, nipping it off in fragments, beginning where it 
 is weakest and thinnest, and encroaching on it till it 
 is all cut down — at least, as far as the forceps are 
 available. Yet care is necessary even in this man- 
 ner of using the forceps, lest the root be fractured or 
 too much jarred. 
 
 After such excision with the forceps, the root is to 
 be dressed down for the reception of the crown, with 
 a round, or, better, an elliptical file. But, for this 
 
310 PIVOT TEETH. 
 
 operation of removing a crown, a very fine, smooth, 
 narrow saw, set in a frame (Fig. 58), is, in some 
 respects, preferable to the forceps, it being less liable 
 to injure the root, than the latter. With this, the 
 
 Fig. 58. 
 
 crown is sawed off at the margin of the gum, leaving 
 the end of the root about the form required for the 
 reception of the artificial crown. In the process, the 
 crown being sustained by the fingers, the saw, kept 
 constantly wet, is applied to the tooth, and passed 
 along its proximal side to the margin of the gum, 
 and then along this through it, cutting it off at right 
 angles with its axis. After the crown has been thus 
 sawed off, the root is fitted, with a fine, round file, 
 for the artificial crown; and, ordinarily, it should be 
 dressed at right angles with its axis. 
 
 At this stage of the work, if the pulp remains 
 alive, it should be removed ; and the preferable 
 method is by direct operation, in the manner already 
 described (p. 263). It is better, in all such cases, to 
 avoid the use of arsenic for destruction of the pulp. 
 It will often be necessary to destroy the pulp before 
 the crown is removed. For a successful operation, it 
 is always preferable that the root have the pulp 
 
FITTING THE CROWN. 311 
 
 living. After it is removed, the canal is to be 
 enlarged to a suitable size, with the appropriate 
 drill. If there is any remaining sensitiveness of the 
 dentine, as is very seldom the case, the bur drill may 
 be used for this purpose ; but if not, then the com- 
 mon spear-pointed drill will be best. Where, how- 
 ever, the canal takes the form of a mere fissure, 
 either the bur drill or the four-sided broach may be 
 employed. The depth to which the canal should be 
 enlarged, will be determined by the length of the 
 root ; but it should, in all cases, be sufficient, firmly 
 to retain a pivot — which is from one to two lines ; 
 and the diameter of the hole will be determined by the 
 size of the root. The drills should be frequently 
 moistened with water, to prevent their clogging. 
 The shaft of the instrument, in the operation, should 
 be in a line with the cutting edges of the two adjoin- 
 ing teeth, and midway between them ; and the drill 
 itself should follow the natural canal as nearly as 
 possible. 
 
 FITTING THE CROWN. 
 
 The tooth selected should be of a size, shape, and 
 color to correspond with the natural crown which it 
 is to represent. It should not be ground on the 
 sides or point 3 and according to general opinion, 
 ought not to be touched with the emery-wheel at all. 
 
312 PIVOT TEETH. 
 
 However a different opinion is entertained by Dr. C. 
 Palmer, in which he suggests the grinding of the 
 entire anterior surface of the artificial crown, thus 
 removing the vitrified surface of the enamel; by 
 which it is claimed that the appearance corresponds 
 much better with that of the natural teeth ; which, 
 in many cases, at least, is correct. The diameter of 
 the neck of the crown should correspond with that of 
 the articulating surface of the root to which it is to be 
 attached. In fitting the crown to the root, the joint 
 should be made as nearly perfect as possible ; for the 
 tooth is thus more permanent and comfortable; an 
 open joint offers a receptacle for the lodgment of 
 food and other foreign substances, where they 
 become vitiated, and produce unpleasant, if not inju- 
 rious effects. The crown may be principally fitted to 
 the root without a pivot, by dressing the latter with a 
 round or elliptical file, and frequently trying the 
 crown on in its proper position. After having been 
 thus pretty accurately fitted, a trying pivot of soft 
 wood should be introduced, by means of which, 
 grinding it to its exact position, the crown may be 
 fitted to the root in its proper position. 
 
 For fitting pivot teeth, Dr. E. Townsend invented 
 a round file, with a counterpart, into which the file 
 exactly fits ; with the former of which the root is 
 dressed, and with the latter, the articulating surface 
 
FITTING THE CROWN. 313 
 
 of the crown. This apparatus would be good, were it 
 not for the great difficulty of dressing porcelain teeth 
 with a file. By care, a very complete fit can be 
 made with a round file alone. Some coloring material, 
 as rose pink, for instance, may be put on the base of 
 the crown, and then the tooth, with the pivot inserted, 
 set in its place — when the root will be marked where 
 the crown has touched it, and this can be dressed at 
 the point of contact. This operation is repeated till a 
 perfect fit is attained. This method is to be recom- 
 mended to those who have had but little experience 
 in adjusting pivot teeth. 
 
 Another method of making the articulation is, to 
 dress the end of the root square, and then counter- 
 sink it about half a line deep with a square-ended 
 bur, about three fourths the diameter of the root. 
 The base of the crown is then ground down, by the 
 measure of the bur, perfectly round, so as exactly to 
 fit into the depression in the root. The bur used for 
 counter-sinking the root should have a center-point to 
 fit into the hole in the root, and thus guide the instru- 
 ment. This method of fitting on crowns is objection- 
 
 Fio;. 59. 
 
 able, by reason of its too great exposure of the root 
 of the tooth. Fig. 59 represents the bur used for 
 
314 PIVOT TEETH. 
 
 this purpose. It is a method now very seldom em- 
 ployed. 
 
 Still another method of making an articulation is. 
 to dress up the root as first described ; then take an 
 impression of the part in plaster of Paris ; and from 
 this, get a model, to which to fit the crown. This 
 method, however, is advisable only in cases where it 
 is desirable to avoid annoyance to the patient by a 
 tedious fitting process. 
 
 ATTACHMENT OF THE CBOWN. 
 
 The means of attachment in most common use is 
 that of wood pivots; for which, wood in the natural 
 condition is ordinarily employed, though it is much 
 improved by compression. The kind best adapted 
 for pivots is the fine-grain, tough, slow-growth hick- 
 ory, of straight, uniform fiber, which should be 
 thoroughly seasoned. For its preparation, take 
 blocks, six or eight inches long, and split them into 
 rods, about one fourth of an inch square ; then, with 
 a knife and file, dress them down to a size one third 
 greater than that of the intended pivots ; afterward, 
 pass them through three or four holes of the ordinary 
 drawplate inverted, thus making them of uniform 
 thickness throughout : and finally, turning the draw- 
 plate, pass them through it in the same manner as 
 
ATTACHMENT OF THE CROWN. 315 
 
 wire, continuing till the rods are of proper size, and 
 all the pores of the wood are closed by compression. 
 They should be slightly oiled before being drawn 
 through the plate. They may be drawn so as just 
 to fit the holes of the artificial crowns, being, of 
 course, of different sizes. Pivots thus compressed are 
 stiffer, stronger, and far more durable ; and, there 
 being greater density of fiber, there is less absorp- 
 tion of moisture, less expansion, and less liability to 
 decay, than in wood in the natural condition. 
 
 In arranging the crown in position, care is necess- 
 ary to prevent it from being struck by the teeth of 
 the opposing jaw, — especially since it often happens, 
 where the natural crown has been absent for some time, 
 that the corresponding tooth of the lower jaw becomes 
 somewhat elongated, and strikes forcibly against a 
 properly adjusted pivot tooth. Such a difficulty is 
 met either by filing off the elongated tooth, or by 
 grinding out the palatal portion of the artificial 
 crown sufficiently to accommodate the elongation. 
 The former is the better method, and should always 
 be adopted when inflammation of the dentine, exposure 
 of the pulp, or an irascible condition of the surrounding 
 parts, do not forbid it : though, in many instances 
 both methods may be advantageously employed. 
 But, by whatever means, the antagonizing tooth 
 should always be prevented from coming in contact 
 
316 PIVOT TEETH. 
 
 with the artificial crown ; and this latter should 
 never press against the tooth, on either side of it; — 
 indeed, it is better that there be a small interval on 
 each side. 
 
 When the crown is in its proper position, the hole 
 in the root and that in the crown do not always have 
 precisely the same direction ; in which case, a pivot 
 will be required, having a curvature according to the 
 variation ; and the extent and direction of such in- 
 flection, should be carefully observed while adjusting 
 the crown with the trying pivot. The pivot is to be 
 neatly and accurately fitted into the crown first, and 
 then the length of it required for the root, ascertained 
 with the gauge represented in Fig. 60. This gauge 
 
 Fig. 60. 
 
 consists of a wire of a size freely to enter the pivot-hole, 
 having a little slide with a flange attached. By in- 
 troducing this wire into the pivot-hole, the slide is 
 pressed back, and the depth of the hole indicated at 
 once. The pivot is then cut off accordingly, and 
 dressed to the proper size and inclination, and gently 
 pressed to its place with the thumb and fingers. 
 Before being introduced, however, it may be wrapped 
 with gold foil, which will serve to protect the dentine 
 
ATTACHMENT OF THE CROWN. 317 
 
 of the root from decay, and also to preserve the pivot. 
 Two or three thicknesses of gold foil, too, may be 
 placed between the crown and the root, so as to make 
 a more perfect joint and exclude the moisture. There 
 is, however, not much advantage in an arrangement 
 of this kind ; a thin sheet of Hill's stopping placed 
 in the joint, makes a better adaptation than the gold, 
 and os artificial may be used for the same purpose, 
 and in many instances is far better than either Hill's 
 stopping or gold. The canal in the root above the 
 pivot should be filled with gold ; though, in cases 
 where there is a discharge through the root, this 
 would not be admissible. 
 
 The canal at the orifice is sometimes considerably 
 enlarged by decay, so that when the crown is fitted, 
 and the canal sufficiently opened for the reception of 
 the pivot, there will be a cone-shaped space which 
 the ordinary pivot will not fill. There are several 
 methods of obviating this difficulty ; one of which is, 
 completely to fill the enlargement with gold, and then 
 perforate this filling with the proper-sized drill for the 
 reception of the pivot; or, which is better, to intro- 
 duce into the canal a polished steel wire of the size 
 of the intended pivot; round this consolidate a 
 filling of gold, having first made retaining points at 
 the proper places in the dentine ; finish perfectly 
 flush with the end of the root; and then withdraw 
 
318 PIVOT TEETH. 
 
 the wire from the canal, and it is ready to receive the 
 pivot with the crown attached. Some operators form 
 the wood pivot of such a shape as to fit into and fill 
 the enlarged cavity. Another method is, after the 
 pivot is fastened into the crown, to build round it, on 
 the base of this, a portion of Hill's stopping, of about 
 the size and form of the enlargement in the canal; 
 and then, the tooth being ready to insert, soften the 
 stopping by heat, and introduce carefully into place. 
 The os artificial in such cases is still better. 
 
 It frequently happens, in c::ses where the pulp 
 has been dead for a considerable time, that there is 
 more or less discharge through the canal of the root, 
 and a tooth is required immediately, or at least 
 before there is time for treatment to abate the dis- 
 charge. To such a condition some arrangement 
 must be adapted, so as not entirely to close up the 
 canal, and preclude the escape of pus. For this pur- 
 pose, a groove may be cut down the wall of the canal, 
 or, perhaps better, on the side of the pivot through- 
 out its length, for the discharge of the secretion. 
 Where there is irritation or liability to inflammation, 
 a temporary pivot of soft wood, or of hard wood 
 loosely fitted, should be worn ; for thus the root is 
 less jarred by percussion on the crown, and, if need 
 be, the crown and pivot can be removed. 
 
METALLIC PIVOTS. 319 
 
 METALLIC PIVOTS. 
 
 The liability of a pivot of wood to wear off at the 
 point between the crown and the root, as well as to 
 become offensive, and the difficulty of removing the 
 tooth, have led dentists to seek some less objection- 
 able material; and metals have been experimented 
 upon, and found in some respects preferable. Gold 
 has been employed for this purpose more than any 
 other metal. Pivots made of this do not become 
 offensive, do not wear off; and admit of any desired 
 curve, and of an easy removal of the crown. There 
 are several methods of attaching this kind of pivot 
 to a tooth; and a very common one is, to fit into the 
 hole in the crown a piece of pivot wood— cut it off 
 even with the base of the crown, and perforate it 
 with the proper-sized drill for the reception of the 
 metal pivot, which may be roughened, or barbed on 
 its sides, and then forced into the place prepared for 
 it. Another method is, to drill into a block of wood ; 
 insert the pivot, prepared as above, then dress down 
 the wood round it till this will fit closely into the 
 crown; and, after it is pressed in, cut off the pro- 
 truding portion of wood. In either of these methods, 
 when the wood becomes moist, the metal pivot will 
 be very firmly retained. This pivot may also be at- 
 tached to the crown by soldering : place the edge of 
 
320 PIVOT TEETH. 
 
 the tooth in plaster of Paris; set the pivot in its 
 proper position in it ; fill round this with fragments 
 of gold plate, and put on solder and borax ; heat up 
 with a blow-pipe, and draw the solder to the bottom 
 of the cavity. Another method, sufficient for all 
 practical purposes, is 5 to set the pivot in place, and 
 pack round it a stiff amalgam of gold and mercury, 
 evaporate the mercury by heat. A better method 
 than any of these is, to have teeth manufactured with 
 a platinum tube inserted, into which the pivot can be 
 soldered. Pivots may also be attached to the ordi- 
 nary plate teeth. 
 
 For attaching the metal pivot to the root, it is 
 sometimes fitted tightly to the canal, and introduced 
 into it without any other substance. This is object- 
 ionable, on account of the wearing of the root, certain 
 to take place, if there is the least jarring or moving 
 of the crown. To obviate this, various methods 
 have been devised; one of which is, to wind floss 
 silk about the pivot before introducing it; but this 
 soon becomes offensive, and requires frequent re- 
 newal. Another method is, to introduce a piece of 
 wood into the root, and drill through it for the re- 
 ception of the pivot, which is squared and roughened 
 — squared to prevent it from turning round, and 
 roughened to secure it from drawing out. But if it 
 is desirable to remove the tooth occasionally, the 
 pivot should not be barbed. 
 
METALLIC PIVOTS. 321 
 
 Metal tubes may be introduced into the roots for 
 the reception of the pivots. These tubes are made of 
 hollow gold wire of proper size ; the method of pre- 
 paring which, is, to take a piece of No.-30 gold plate, 
 from four to six inches long, and from a third to a 
 half an inch wide, and bend it round a piece of smooth 
 polished steel wire of the size of the intended pivot; 
 draw both together through a drawplate, down to one 
 size larger than the hole in the root ; then take out the 
 wire, and solder up the tube ; on it cut a fine thread 
 with a screwplate ; from it cut off from a half to three 
 fourths of an inch in length, and insert into this a 
 piece of the wire it was drawn upon ; grasping this 
 section with a small vice or pair of nippers, screw it 
 carefully into the root; and having introduced it 
 far enough, withdraw the piece of wire, cut off the 
 protruding piece of tube with a fine saw, and file and 
 neatly polish. The root is thus ready for the recep- 
 tion of the crown, the pivot of which should fit very 
 accurately into the tube. A very slight curvature of 
 the pivot will enable it to retain a very firm hold in 
 the tube. The tube's inner end may be soldered up 
 if desirable ; and, if there is decay at the orifice of 
 the canal, a flange may be soldered on to its outer end, 
 flush with the end of the root, and the decayed 
 cavity filled beneath it, the flange serving to retain 
 the filling perfectly in place. These tubes can be 
 
 v 
 
322 PIVOT TEETH. 
 
 best fitted in with the screw, though they are some- 
 times placed in without this, aud gold foil packed about 
 them to retain them. They may be made to receive 
 a square pivot, by being drawn, in their manufacture, 
 on a square wire, instead of a round one. For the 
 escape of pus, as already referred to, the pivot may 
 be made of hollow wire, with a hole through the 
 crown of the tooth. 
 
 A plate tooth, with a metallic pivot attached, may 
 be used instead of the ordinary pivot tooth ; and it 
 is in some cases required, on account of the manner 
 in which the teeth antagonize. But in all cases 
 where a plate tooth is used, it should have a metallic 
 base to rest on, and cover the end of the root. Pro- 
 perly to construct this, an impression must be ob- 
 tained, and models and countermodels made, and 
 the base swaged ; and then to this the pivot and 
 tooth are attached. Irregularity of the teeth, and 
 especially of the root on which the crown is to rest, 
 may require a peculiar adjustment of the pivot, which 
 may be very happily effected by the method just re- 
 ferred to. 
 
 Occasionally, bad consequences follow the opera- 
 tion of inserting a pivot tooth, the most frequent of 
 which is, inflammation of the periosteum. Rough 
 manipulation is very liable to induce this condition, 
 where there is an inflammatory diathesis ; in which 
 
METALLIC PIVOTS. 323 
 
 case, too great care can not be recommended ; and 
 prior treatment will sometimes be advantageous. 
 After periostitis has supervened, either constitutional 
 or local treatment, or both, may be employed ; con- 
 stitutional, by emetics and saline cathartics, and, 
 indeed, any agent that will equalize the circulation 
 and counteract the inflammation ; and local, by the 
 same means as already prescribed for periostitis else- 
 where — in addition to which, it may sometimes be 
 necessary to remove the crown and pivot from the 
 root. It is always important to commence the treat- 
 ment of such cases at the first indications of the 
 disease. 
 
 Sometimes, even with considerable care, a crown 
 will be split by the introduction or the expansion of 
 the pivot ; in which case, of course, another tooth 
 must be selected. When a pivot breaks off, and a 
 portion adheres in the root, this may be drawn out 
 with pliers or a pivot-extractor, or, if it does not pro- 
 trude enough for this, it may be drilled out. A root 
 is sometimes split by the expansion of a tightly-fitting 
 pivot, or by a blow on the crown of the tooth ; and 
 when this happens, it must be removed, since it can 
 not be made any longer to retain a tooth. Pivot 
 teeth should seldom, if ever, be worn in a mouth in 
 which teeth on plate are worn. They are now far 
 less frequently worn than formerly, because, perhaps, 
 
324 PIVOT TEETH. 
 
 of the improved methods of inserting teeth on plate. 
 Under favorable circumstances, however, they may 
 be worn with great comfort and usefulness, from five 
 to fifteen years. 
 
CHAPTER XI. 
 
 EXTRACTION OF TEETH, 
 GENERAL REMARKS. 
 
 The extraction of teeth is an important operation, 
 requiring, for its proper performance, skill, judgment, 
 and experience, as well as an accurate knowledge of 
 the parts involved. Success in the operation formerly 
 was very uncertain; but now, from an increase of 
 knowledge in the art of dental surgery, and from 
 great improvements in the instruments employed, the 
 operation is generally attended with success. The 
 ancients were not strangers to this operation, as is 
 evidenced by relics found in ancient tombs, with 
 teeth absent, under such circumstances as to warrant 
 the conclusion that they were removed by the sur- 
 geon. Extracting instruments of very ancient date 
 have also been found ; and ancient writers, too, refer 
 to the operation as one not much more pleasant then 
 than now. The demand for this operation rises not 
 from fancy, fashion, or caprice, but from dire necess- 
 ity — a necessit}^, too, of great frequency. Very few 
 individuals in this country arrive at mature ago with- 
 
326 EXTRACTION OF TEETH. 
 
 out being required to submit to it ; and, indeed, the 
 majority, before middle age, lose in this manner from 
 four to ten teeth, and many, all. The following are 
 some of the objects for which a resort is had to this 
 operation : — 
 
 1. To obtain relief from pain, caused either by 
 disease of the pulp, by inflammation of the perios- 
 teum, or by any other affection involving the teeth, 
 that can not be readily controlled without their 
 removal. 
 
 2. To prevent pain in future. This, of course, has 
 reference only to those teeth which are very much 
 decayed, or rendered useless by any cause, and which 
 are liable at any time to occasion disease in the parts 
 about them. 
 
 3. To save sound teeth from the attack and ravage 
 of decay. This implies those teeth which, by their 
 offensive condition, would prove injurious to healthy 
 teeth. 
 
 4. To relieve a diseased condition of the contigu- 
 ous parts, such as alveolar abscess, neuralgia excited 
 by dental irritation, diseased antrum — and sometimes, 
 indeed, remote parts, which are in many instances 
 affected by diseased teeth. 
 
 5. To anticipate and obviate irregularity. Of this 
 there are many cases, in which all the teeth can not 
 be accommodated with a proper position in the arch, 
 
GENERAL REMARKS. 327 
 
 and in which the removal of one or more of them, for 
 this purpose, becomes a necessity if regularity and 
 symmetry are to be secured. 
 
 6. To prepare the mouth for a proper reception of 
 artificial teeth on plates. Though plates are some- 
 times inserted, with the roots of teeth remaining, 
 which is admissible only when the roots and the parts 
 about them are healthy; otherwise they should be 
 removed. 
 
 Before anything else is done, every case presented 
 should be carefully examined, in order to ascertain 
 all the circumstances and conditions that might in 
 any way affect the operation. It is important to 
 arrive at a correct conclusion in regard to the tooth 
 or teeth to be removed ; the number of roots, their 
 inclination, and the character of their attachment; 
 in what manner, and to what extent the surround- 
 ing parts will be affected by their removal ; and the 
 probable amount of force necessary for this purpose. 
 The operator will, in many instances, be referred to 
 the wrong tooth ; for a sound and healthy one is 
 sometimes painful from sympathy, and, standing in 
 contact with a decayed and painful tooth, makes it 
 many times difficult for the patient to determine in 
 which the pain exists ; and sometimes difficult for the 
 operator, too, especially where the decay is on a 
 proximal portion of the tooth, and not easy of 
 
328 " EXTRACTION OF TEETH. 
 
 approach. In all such cases, great care should be 
 exercised, and a thorough examination made. There 
 is often extensive decay on the proximal portion of 
 the tooth, that is not apparent at first view. 
 
 The constitution is also to be noted — its peculiar- 
 ities, tendencies, and susceptibilities ; as these will 
 often modify the operation. A highly nervous tem- 
 perament will not endure an operation that one of 
 a different character will undergo with impunity. 
 There may also be idiosyncrasies and conditions that 
 will forbid the extraction of a tooth. One of these, 
 and not the least formidable, is a hemorrhagic dia- 
 thesis. 
 
 The manner of performing the operation is an im- 
 portant consideration : it should not be precipitate 
 or hurried. A very good criterion is, that the eye 
 should critically follow, and the mind attentively 
 comprehend every movement of the hand and instru- 
 ment. It is a very common method, to seize the 
 tooth, turn away or shut the eyes, and make the 
 most rapid motions possible, regardless of conse- 
 quences. Accidents, such as breaking the tooth, 
 fracturing the alveolus, laceration of the soft parts, 
 and rupture of the blood-vessels, are very liable to 
 follow a hurried execution; and there are many 
 cases on record, in which injury has resulted from a 
 rapid application of force in the extraction of teeth. 
 
GENERAL REMARKS. 329 
 
 The ancients were cautious in this particular : it is 
 recorded of them, that they made extracting instru- 
 ments of lead, to prevent injury from the employ- 
 ment of too great force. It is difficult, indeed, 
 always to determine what amount of force may be 
 necessary for the removal of a tooth in any given 
 case ; though by long and close observation, it may 
 be pretty accurately calculated ; and it is important 
 for the operator to know it, so as to prepare for the 
 emergency, and to select the instrument appropriate 
 to the occasion. In order to be successful, an ope- 
 rator must be confident of his ability, and, to be so, 
 must be possessed of it. He should be familiar with 
 the anatomical structure of the parts to be operated 
 upon; should understand the physiological and the 
 pathological conditions of the parts adjacent; and 
 should properly appreciate their influence on, and 
 their connection with, the teeth. 
 
 There is a great difference in teeth with regard to 
 their facility of removal. Those most difficult to ex- 
 tract, possess the following peculiarities : shortness 
 and thickness of crown ; in the incisors, thickness — 
 the edges of the superior and the inferior meeting 
 squarely on, or deviating but little from their points ; 
 freedom from prominences on the crowns of the mo- 
 lars and bicuspids, their masticating surfaces being 
 smooth; regularity in arrangement, all being in cor- 
 
330 EXTRACTION OF TEETH. 
 
 rect position and in contact with one another ; color 
 slightly yellow ; denseness and thickness of alveolus ; 
 unyielding firmness of the soft tissues ; lack of promi- 
 nences on the gums to indicate the size and position 
 of the roots. Another class of teeth, differing in 
 characteristics from those of the above, are also very 
 difficult of extraction, namely : those having crowns 
 of medium length and of a diameter at the neck much 
 less than at the masticating surface ; roots long and 
 divergent, and in some cases considerably curved ; 
 and often a very firm union with the alveolus, so that 
 a portion remains adhering to the tooth when it is 
 extracted; which occurs more frequently with the 
 superior cuspid teeth than with any others ; and often 
 the septum between the roots is so firmly embraced 
 by them, especially when they converge, that it is 
 brought away with the tooth on its extraction. Bony 
 uniou of the teeth has been enumerated as one of the 
 occasional obstacles in extraction of the teeth ; but 
 this rarely if ever occurs — the mode of development 
 almost precluding the possibility of its existence — so 
 that it need scarcely be reckoned. Exostosis of the 
 root sometimes renders extraction very difficult, 
 especially when the enlargement attaches to the point 
 of the root, and forms a bulb larger than the diame- 
 ter of the root elsewhere. It is then like a ball in a 
 socket, and, if the walls of the alveolus are thick and 
 
GENERAL REMARKS. 331 
 
 firm and closely embrace the root, the tooth is very 
 securely retained. Exostosis of the same extent in 
 the inferior as in the superior teeth, will reader the 
 latter the more difficult to remove, because of the 
 greater density of the inferior maxilla; and it has 
 been maintained that this cause would produce a 
 like difference even in the normal condition of the 
 organs ; but experience does not warrant the opinion. 
 The superior molars have more numerous and more 
 divergent roots than the inferior ; and the roots of the 
 anterior superior teeth are much larger, and conse- 
 quently have a greater amount of attachment, than 
 the anterior inferior ones. In a healthy condition, 
 the periosteum of the root has comparatively little 
 sensibility ; but in proportion as it is subjected to 
 acute disease, is the sensibility, and thus the pain 
 consequent on the removal of the tooth, augmented. 
 
 Instruments adapted to all the different forms and 
 locations of the teeth, are requisite in the various 
 operations of extraction. It is impossible to remove 
 all teeth in a proper manner with but three or four 
 instruments, as recommended by some. 
 
 For any kind of successful manipulation in the 
 mouth, and especially that involved in the extraction 
 of teeth, the patient should be placed in such a posi- 
 tion as to make him the most comfortable, and to 
 secure to the operator the greatest facility of execu- 
 
332 EXTRACTION OF TEETH. 
 
 tion. But different positions, of course, will be re- 
 quired for the removal of different teeth. Finally, 
 there should be as little show of preparation, and as 
 little display of instruments as possible — thus to 
 avoid exciting the nervous apprehensions of the 
 patient ; and the operator should at all times exhibit 
 a gentle and encouraging deportment, yet work 
 promptly and surely. 
 
 INDICATIONS FOR EXTRACTION. 
 
 The most common and imperative indication is, 
 continued and violent toothache. In all cases where 
 the teeth are diseased and painful, and can not be re- 
 stored to health, the}^ should be removed. There 
 are, however, few cases of diseased teeth, that cannot 
 be relieved by the present methods of treatment, so 
 as to remain in the mouth with some degree of com- 
 fort and usefulness. Alveolar abscess terminating on 
 the outside of the face, or tending to it, always indi- 
 cates the removal of the offending tooth. Chronic 
 inflammation of the investing membrane used to be 
 considered an indication for extraction; but it is 
 found that many cases thus affected, may, by judi- 
 cious treatment, be restored to comparative health. 
 Ulceration of the investing membrane clearly points 
 to extraction as the remedy. Teeth that have no 
 
INDICATIONS FOR EXTRACTION. 666 
 
 antagonists, and that, on this account, keep up an ir- 
 ritable condition in the contiguous parts, should be 
 removed ; and so, as a general rule, should super- 
 numerary teeth. In order to relieve a crowded con- 
 dition of the teeth, it is sometimes necessary to remove 
 one or more, even though they may be healthy. 
 
 Till within the last few years, the existence of an 
 alveolar abscess was considered an indication for the 
 removal of the tooth from which it proceeded ; but, 
 under the present mode of treatment, except in very 
 aggravated cases, a simple abscess is not reckoned a 
 sufficient cause for extraction. 
 
 The posterior teeth may be removed for causes 
 that would not warrant the removal of the anterior. 
 All dead teeth and roots that produce or keep up irri- 
 tation, should be removed, especially if the tendency 
 is persistent. 
 
 The temporary teeth that are not cast at or hear 
 the time their respective permanent teeth should ap- 
 pear through the gum, ought to be removed; but 
 caution must always be exercised, lest they be re- 
 moved too soon. Painful and uncontrollable disease 
 may indicate their removal long before the period just 
 mentioned; yet they should not be removed on ac- 
 count of diseased condition, unless the rudiments of 
 the permanent teeth are likely to suffer thereby. A 
 crowded condition of the permanent with the tempo- 
 
334 EXTRACTION OF TEETH. 
 
 rary teeth, may indicate the removal of one or more 
 of the latter. It is important to understand the true 
 indications for the removal of temporary teeth ; in 
 these, as in the permanent teeth, apparent indications 
 are liable to be mistaken for real ones. Teeth may 
 sometimes, even though undecayed, produce nervous 
 affections, and in such a manner as to render their 
 removal necessary. This indication is most frequent 
 with teeth affected by exostosis. 
 
 A high state of inflammation in the contiguous 
 parts, is regarded by some as a counter indication ; 
 but it can be such only in cases in which the inflam- 
 mation would be increased by the operation ; and this 
 would happen only where there is a decided inflam- 
 matory diathesis; which peculiarity can be readily 
 detected by careful observation. 
 
 EXTRACTING INSTRUMENTS. 
 
 Numerous and various instruments have been em- 
 ployed for extracting teeth ; and each of these has 
 passed through various modifications. Imperfection 
 and inadaptation have, till within a few years, char- 
 acterized them all in a marked degree, as indicated 
 by the numerous changes they have undergone. Two 
 general classes comprehend them all — represented by 
 the key and the forceps. The former makes its 
 
EXTRACTING INSTRUMENTS. 335 
 
 attachment on one side of the tooth, coming in con- 
 tact with but a small portion of it, and has a resting 
 point for a fulcrum on the adjacent parts, the gum 
 and the alveolus. The latter embraces the tooth on 
 both sides, and has no fulcrum resting on the adjacent 
 parts. There are other instruments somewhat differ- 
 ent from these in their application ; but the principle 
 on which they operate, is the same. For instance, 
 the elevator has a point of embrace or contact with 
 the teeth, and a fulcrum or resting point on the ad- 
 jacent parts, the power being applied to the handle, 
 as to a lever. The screw makes its attachment inside 
 of the tooth, instead of outside, like the forceps, and 
 does not touch any other part. 
 
 There should always be at hand a sufficient 
 number and variety of instruments to meet every 
 case, however rare its occurrence. Desirabode re- 
 commends the employment of but four instruments 
 for the removal of all the teeth : the first is a forceps, 
 and the other three are nothing more than so many 
 different forms of the elevator. He was not familiar 
 with the present improvements in extracting instru- 
 ments, or he could not have made such a recommen- 
 dation. 
 
336 EXTRACTION OF TEETH. 
 
 THE KEY. 
 
 The principle of this instrument was, at a very 
 early period, brought into requisition for the extrac- 
 tion of teeth ; it is, emphatically, an old instrument. 
 It consists of a shaft six inches long, with a handle 
 four inches, attached at right angles, while the hook 
 is attached laterally at the other end of the shaft, 
 and the bolster, either movable or fixed, to the side 
 of it, immediately below the articulation of the hook. 
 This instrument has passed through a great variety of 
 forms and modifications ; having the shaft straight, 
 curved, or double-curved ; the fulcrum large, small, 
 flat, round, long, short, fixed, movable, and anterior, 
 posterior, or opposite to the point of the hook. There 
 has also been a great variety of forms of the hook ; 
 and it has been made with machinery attached, to 
 control its grasp, the object of which is, to prevent 
 the instrument from slipping off the tooth, and skill 
 in the use of which would doubtless add to the effi- 
 ciency of the instrument. The principle of the forceps, 
 too, has been combined with the key, and probably 
 with very decided advantage. 
 
 The modus operandi of the key is worthy of some 
 consideration. The hook is attached to the shaft 
 directly above the bolster, and starts off at right 
 
THE KEY. 337 
 
 angles with its vertical axis, but curves down to the 
 point, almost or quite as low as the base of the bolster. 
 When properly constructed, the hook embraces the 
 tooth at the neck on one side, and the bolster rests a 
 little below this on the other. When the instrument 
 is applied to a tooth, the center of the shaft is the 
 axis of motion ; but, as force is applied to the instru- 
 ment, this axis is transferred from the shaft to the 
 base of the bolster, which is the center of motion the 
 moment it is fixed on the gum and alveolus, and the 
 shaft describes an arc about it. Now, as a result of 
 this motion and arrangement, the line of force is at 
 an angle of from forty to sixty degrees with the axis 
 of the tooth ; and hence it is at this angle that the 
 tooth must be extracted, if at all. The axis of power 
 exerted on the tooth by the instrument, is in a line 
 from the point of the hook to its attachment to the 
 shaft; and the line of this force has its termination 
 below the neck of the tooth on one side, and just 
 above the crown on the opposite side. The angle 
 formed by the line of power with the axis of the 
 tooth, is different in the different relative positions of 
 the key to the tooth. If the instrument is applied to 
 an inferior molar, with the bolster on the inside, the 
 angle of the line of force with the axis of the tooth is 
 about forty degrees; but, if placed on the outside of 
 the jaw, as recommended by some, the angle con- 
 
338 EXTRACTION OF TEETH. 
 
 rained by the line of power and the axis of the tooth, 
 is sixty degrees or more. The line of force is not 
 changed by any form the hook may assume ; — it may 
 be regularly cr irregularly curved, or be turned at 
 right angles, and yet the line of force is not changed. 
 Indeed, this line can not be changed, except by 
 changing the relative position of the hook and its at- 
 tachment. This application of the power constitutes 
 one of the prominent objections to the use of the in- 
 strument : the force is applied at too great an angle 
 with the axis of the tooth, and her.ce, in numerous 
 instances, it is broken off. The bolster of the key 
 rests, in the operation, on the gum, on which it 
 exerts great pressure, and which it always bruises, 
 and frequently lacerates in a cruel manner ; the press- 
 ure exerted by the bolsters of the variously con- 
 structed keys differs but little ; though, perhaps, the 
 bolster which has a broad base, and attached to 
 the shaft by a joint, would cause less pain to the 
 patient by its pressure, and be much less liable to 
 lacerate or cut the gum, than the small and perma- 
 nent one. The pressure of the bolster on the gum 
 and process is always greater than the power required 
 to extract a tooth ; and this extreme pressure and its 
 consequences constitute another strong objection to 
 the use of the key. The power being applied at a 
 disadvantage, much more is required than when 
 economically applied. 
 
THE KEY. 339 
 
 This instrument is so seldom employed for the 
 extraction of teeth, that any very special directions 
 as to its use will scarcely be required ; yet a few gen- 
 eral suggestions may not be out of place. Whether 
 a tooth should be drawn inward or outward depends 
 on its position and inclination. As a general rule for 
 the removal of the molars, the bolster should be 
 placed on the inside of the inferior teeth, and on the 
 outside of the superior. For removing the lower teeth 
 of the left side, the operator should stand at the right 
 of the patient ; and for the teeth of the right side, in 
 front or at the right. For the inferior teeth of the 
 right side, he should stand at the right of the patient ; 
 and for the left superior, in front of him. There have 
 been a great many different opinions as to the manner 
 of applying and using the instrument. One recom- 
 mends that " the teeth should be always turned 
 towards the tongue." Another, "that the fulcrum 
 should be so placed that it w T ould not come in contact 
 with the tooth." Another directs : " Place the ful- 
 crum on the margin of the gum." Another : " Place 
 the fulcrum on the gum below its margin." Another 
 suggests, " that the fulcrum be placed on the side of 
 the tooth opposite the point of the hook." Again. 
 we are directed "that the tooth should be drawn 
 from the higher alveolus." This great diversity of 
 opinion as to the manner of using the key, as well as 
 
340 EXTRACTION OF TEETH. 
 
 the great variety of changes in its form, is evidence 
 that it is, at best, a very imperfect instrument. It is 
 impossible to embrace a tooth as deep with it as with 
 well constructed forceps ; and with it, the liability to 
 accident in the extraction of teeth, is much greater 
 than with any other instrument. A strong advocate 
 of this instrument says that " the key always produces 
 injury; but the greatest skill exhibits the least 
 injury." 
 
 FORCEPS. 
 
 The forceps are the most efficient extracting instru- 
 ments in use ; and the improvements made in them 
 during the last few years have been very great; 
 indeed, twenty years ago, they were not made with 
 any special adaptation whatever, and were totally 
 unfit to be used for the extraction of teeth ; but now, 
 they are constructed with such various shapes and 
 curves as to facilitate their approach to the teeth, 
 whatever thefr position in the mouth may be, and to 
 fit all the various forms, and make the most perfect 
 embrace of the teeth possible. Forceps, with the pre- 
 sent improvements, take a deeper and more thorough 
 hold on the teeth than any other instrument. The 
 beaks may be made so thin that they will penetrate 
 between the roots and alveolus, and the adaptation so 
 
FORCEPS. 341 
 
 complete that the instrument will not slip or move from 
 its position when placed. The form of the beaks 
 should be such as to fit the crown without pressing on 
 it, and yet perfectly embrace the neck of the tooth ; 
 and the entire instrument of such form and curve as 
 to give to the hand, arm, and body of the operator the 
 best position for ease and facility of execution. 
 
 There are various opinions as to the position rela- 
 tive to the patient which the operator should occupy 
 while extracting teeth with the forceps. Some re- 
 commend different positions for the removal of differ- 
 ent teeth ; but it is preferable, on many accounts, to 
 occupy as nearly as possible the same position in the 
 removal of all ; and this is at the right and a little 
 back of the patient. 
 
 The forceps for removing the superior incisors are 
 straight, and have thin beaks, which are sufficiently 
 broad to embrace the anterior and the posterior sur- 
 faces of the teeth entire (Fig. 61) ; and they should 
 
 Fig. 61. 
 
 be much broader for the centrals than for the laterals. 
 The points should not be so broad, however, as to 
 
342 EXTRACTION OF TEETH. 
 
 corne in contact with the contiguous teeth, in the 
 rotary motion made to break up the attachment. 
 The same principle in regard to the width of the for- 
 ceps is to be observed for the lateral incisors and 
 cuspids. The ordinary straight, root forceps, may be 
 employed for the extraction of the lateral incisors ; 
 though, for this purpose, it is desirable that their 
 beaks be somewhat thinner than usual. For the 
 superior cuspid teeth, the ordinary bicuspid forceps 
 are frequently used ; but their beaks are commonly 
 too narrow, and those of the central incisor forceps 
 too thin. The cuspid forceps should be about as 
 wide as those for the central incisors, with the thick- 
 ness of the bicuspid forceps (Fig. 62), and with a 
 
 Fig. 62. 
 
 greater concavity, so as to fit the neck of the tooth. 
 The superior bicuspid forceps have narrow, thick, and 
 quite concave beaks, and the instrument is straight, 
 or nearly so ; though for the second bicuspids, 
 especially in a small mouth, it should have some 
 anterior curvature. (Fig. 63.) One pair of forceps 
 will serve for both sides, though it is desirable to 
 
FORCEPS. 343 
 
 have one for the first, and another for the second 
 bicuspid. For the removal of the bicuspids, there is 
 
 Fie. 63. 
 
 a form of forceps with thick, smooth beaks, and of 
 such a form as, by pressure, to force the tooth from 
 its socket, taking advantage, for this purpose, of the 
 conical form of the root. The superior molar for- 
 ceps, a pair for each side, have one of the beaks a 
 single concave, to embrace the palatine root, and the 
 other a double concave, with a projecting point from 
 the center of the beak, to pass into the bifurcation, 
 and with the edge of the beak so formed as to em- 
 brace the two palatine roots. The concavity and 
 curvature of the beaks should be first just sufficient 
 to accommodate the crown of the tooth. These for- 
 ceps should have a double curve, to facilitate their 
 approach to the teeth — an anterior curve just above 
 the joint, and a downward curve just below it ; 
 sometimes, also, a lateral curve above the joint, 
 throwing the instrument more toward the angle of 
 the mouth. (Fig. 64.) 
 
 For the second molars, the forceps should have a 
 little more curve above the joint, than for the first. 
 
344 
 
 EXTRACTION OF TEETH. 
 
 A third pair of forceps for these teeth, and especially 
 for the roots before they are separated, have the inner 
 
 Fig. 64. 
 
 beak similar to the one above, and the outer a 
 curved, attenuated, sharp point, to pass between the 
 
 Fig. 65. 
 
 buccal roots (Fig. 65.) The forceps for the superior 
 dens sapientice have two single-concave beaks, made 
 
FORCEPS. 
 
 345 
 
 to embrace the tooth, as though it were cylindrical, 
 or nearly so, at its neck. The instrument has two 
 curves, or rather angles, the one forward, and the 
 other downward, so that its handle is somewhat an- 
 terior to, but almost parallel with, the axis of the 
 tooth. (Fig. 66.) It is a principle that should be 
 
 Fig. G6. 
 
 observed in all forceps, that the handle of the instru- 
 ment when placed upon the tooth be as nearly par- 
 allel with the axis of the latter as possible, and as 
 
 Fig. 67. 
 
 nearly in a line with it as the location of the tooth, 
 the size of the mouth, and other circumstances will 
 admit. 
 
 The forceps for the inferior incisors may have 
 
346 
 
 EXTRACTION OF TEETH. 
 
 either a lateral or a transverse curve — almost to a 
 right angle, if transverse, but if lateral, not more 
 than half that inclination. (Fig. 67.) The ordi- 
 nary, slightly curved root forceps may be used for 
 the extraction of these teeth. (Fig. 68.) The 
 
 Fig. G8. 
 
 beaks should be very narrow and thin ; for a great 
 amount of force is not required for the extraction of 
 these teeth. The beaks of the inferior incisor for- 
 
 Fig. 69. 
 
 ceps should be relatively broader than those of the 
 forceps for the superior incisors. Rotary motion in 
 the extraction of inferior incisors, is not admissible 
 unless the roots be cylindrical or nearly so. The in- 
 
FORCEPS. 
 
 347 
 
 ferior bicuspid forceps are well adapted to the removal 
 of the inferior cuspids also. These forceps, two in 
 number, one for each side, are of different forms. 
 (Fig. 69.) The beaks are narrow, thick, and quite 
 concave. The instrument for the right side has a 
 lateral curvature, which brings the handle out at the 
 angle of the mouth, and is necessary in order to ob- 
 viate a contact with the superior teeth. The forceps 
 for the left side have beaks of the same form. They 
 are bent to almost a right angle above the joint, 
 while below it the handle is thrown upward ; and 
 
 Fig. 70. 
 
 their inner beak is longer than the outer. The inferior 
 molar forceps (Fig. 70) are two in number, that for the 
 right side being curved outward and forward, and 
 that for the left forward and upward, the beak making 
 almost a right angle w r ith the body of the instru- 
 
348 EXTRACTION OF TEETH. 
 
 merit, and the inner beak of each being longer than 
 the outer. The beak should be of sufficient breadth 
 to embrace the entire side of the tooth, of double- 
 concave form, with a ridge and a long point in the 
 center of the beak, to pass into the bifurcation of the 
 roots. The inner beak of these forceps should be 
 longer than the outer 5 for the teeth on which they are 
 designed to operate, have an inward inclination, and 
 the outer alveolus is higher than the inner. 
 
 A pair of forceps for the left side, similar in form 
 to those for the right, would be preferable to the 
 ordinary left forceps, when the mouth can be opened 
 wide ; and the curvature of the handle of this instru- 
 
 Fie. 71. 
 
 ment would be toward the center of the mouth, in- 
 stead of outward, as that of the right forceps. With 
 this form of forceps, more power can be exerted than 
 with the ordinary left inferior forceps. 
 
 Forceps for the removal of the inferior dens sapi- 
 entice have large single-concave beaks, to make a 
 general embrace of the tooth, and have but one 
 curve, which is between the joint and the point, and is 
 almost a right angle. (Fig. 71.) One pair of forceps of 
 this kind is quite sufficient for both the right and the 
 
FORCEPS. 349 
 
 left side. The forceps denominated Physics forceps, 
 are also sometimes employed for the removal of the 
 wisdom-teeth. These are constructed with thick, 
 sharp blades, the edges of which come squarely 
 together, and the points sometimes have an enlarge- 
 ment on them. They are curved almost to a right 
 angle, to facilitate their adaptation. (Fig. 72.) 
 There are two or three different forms of Physic's 
 forceps. 
 
 Fig. 72. 
 
 Of the variety of root forceps now used, those for 
 the removal of the anterior teeth, are straight, or but 
 slightly curved, with long, thin, sharp-edged beaks, 
 and of a width regulated by the diameter of the roots. 
 Those for the removal of the roots of the superior 
 molars, when these are separated, have the same form 
 of beaks as those for the front teeth, but more curved, 
 to facilitate their approach to the roots. For the re- 
 moval of these roots, it is well to have several pairs 
 of forceps with different degrees of curvature, using, 
 in any given case, those with the least admissible 
 curve — which, in a small mouth, will be considerable, 
 while in a large one, it will be very slight. The same 
 
350 
 
 EXTRACTION OF TEETH. 
 
 forceps that are used for the removal of the front 
 inferior teeth, are applicable to the removal of their 
 roots. 
 
 Of the different forms of forceps for the removal of 
 the roots of inferior molars, those for the extraction 
 of the roots before they are separated, and while they 
 are firmly attached,, have two long, slender, round, 
 curved beaks, designed to pass down deep between 
 and embrace the roots in the bifurcation ; their curva- 
 ture should be almost a right angle, and their handles 
 
 Fig. 73. 
 
 assume the form of the ordinary right and left inferior 
 molar forceps, already described (Fig. 73) ; or, if but 
 one is used, the handle should be straight. The for- 
 ceps for the removal of these roots after they are 
 separated, should have the beaks of the same form as 
 those of the superior root forceps ; but the beaks 
 
ELEVATORS. 
 
 351 
 
 should be curved to a right angle with the handle, and 
 the handle be straight. (Fig. 74.) 
 
 Fig;. 74. 
 
 ELEVATORS. 
 
 There are in use variously formed instruments 
 constructed on the principle of the elevator. They 
 are made with such points as to take the most tho- 
 rough hold on the teeth or roots on which they are 
 to be used, and with such curvature of shaft as to 
 enable them to pass most readily to the desired posi- 
 ng. 75. 
 
 tion. Some Jare so formed at the points as to em- 
 brace the root at the border of the alveolus, using 
 
 the latter as a fulcrum (Fig. 75) ; others, to pass 
 between the alveolus and the root (Fig. 7C) ; others, 
 to cut through the alveolus, and thus approach the 
 
352 
 
 EXTRACTION OF TEETH. 
 
 root. All the ordinary elevators make a fulcrum of 
 the alveolus or of an adjoining tooth; but some ope- 
 rators, in using this instrument, contrive to make a 
 fulcrum of the thumb or one of the fingers ; which is 
 the preferable way. 
 
 HOOKS. 
 
 These are formed so that the point shall embrace 
 the root and remove it, without resting on the sur- 
 rounding parts. The root is removed simply by 
 
 Fig. 77. 
 
 pressure, applied in the proper direction. Of the 
 various forms of this instrument, there are the for- 
 ward hook, the backward (Fig. 77), and the com- 
 pound (Fig. 78), which last includes the former two. 
 
 These are valuable instruments, but require care in 
 order to avoid injuring the surrounding parts. 
 
SCREW. 
 
 353 
 
 SCREW. 
 
 This is a cone-shaped instrument, with a very 
 definite, sharp screw-thread; the manner of using 
 it in the operation of extraction is, to screw it into 
 the root. It will be required of various sizes to 
 correspond with those of the different roots to be 
 extracted. It is commonly attached to the handle 
 by a permanent shaft (Fig. 79) ; but, sometimes, it is 
 
 Fig. 79. 
 
 made with a square shaft fitted into a socket handle 
 (Fig. 80), by which arrangement the handle is used 
 only to introduce the screw ; and this serves only as 
 a support to a frail root, the forceps being then brought 
 
 Fig. 80. 
 
 e{&&* 
 
 to bear in connection with it, for the removal of the 
 root. A screw-tap, of the same form as the screw, 
 should accompany it. 
 
 When the screw is combined with the forceps, for 
 the purpose of supporting the root and preventing 
 it from crushing while it is removed with the forceps. 
 
354 EXTRACTION OF TEETH. 
 
 the latter is of the same form as that of the ordinary 
 straight root forceps, with the shaft of the screw at- 
 tached in the joint. In some, the screw is attached 
 with a spring and ratchet, so that it can be drawn 
 out, seized between the beaks, and introduced into 
 
 Fig. 81. 
 
 the root; and then these are slipped on the root, 
 which they embrace and remove. In others, the 
 screw is fixed ; but the movable screw is to be pre- 
 ferred. (Fig. 81.) An arm attached by a joint, and 
 bearing a pad, to rest as a fulcrum on the other teeth, 
 is sometimes attached to the shaft of the screw ; but 
 this is objectionable because of its liability to impede 
 the action of the instrument, and also to injure the 
 adjoining teeth. 
 
 GUM-LANCET. 
 
 Of the various forms of the gum-lancet, the most 
 common is that with the round point, and with the 
 blade from two to four lines wide, and from half an 
 inch to an inch long, attached to a shaft and handle ; 
 the whole being about six inches in length. The in- 
 strument should have a keen edge on the sides, two 
 
GUM-LANCET. 
 
 355 
 
 or three lines from the extreme point. It is some- 
 times made with the edge square ; but the round 
 edge is the better form. The edge is parallel with 
 the handle in the ordinary lancet. (Fig. 82.) This 
 
 Fig. 82. 
 
 form is used for separating the gum from the buccal 
 and palatal surfaces of the tooth. A lancet with the 
 edge transverse to the shaft is required for separating 
 the gum from the proximal portions of the teeth. 
 The blade of this should be of the same general 
 form as that already described, except that it should 
 be quite narrow — in no case more than two lines 
 wide. (Fig. 83.) Gum-lancets are made with the 
 
 Fig. 83. 
 
 blade set in a socket on the end of the shaft, so that 
 it can be rotated and set to any angle, to meet every 
 case. 
 
 A very ingenious instrument, invented by Dr. 
 Merry, and denominated " Merry's Revolving Gum- 
 lancet," has recently been brought to the notice of 
 the profession. This is a very excellent instrument — 
 
356 EXTRACTION OF TEETH. 
 
 superior, indeed, to any thing else of the kind. (Fig. 
 84.) The following is a description of it: "It 
 consists mainly of two shafts : one is round and 
 small ; the other is larger, and part round, and part 
 octagon. Just back of the spiral spring which curves 
 down at the lancet end, is seen a piece connecting 
 the two shafts. This piece is soldered fast to the 
 round shaft, while the upper end of it forms a collar, 
 in which the round part of the larger shaft slides 
 
 Fig. 84. 
 
 back and forth, and revolves. On the other end of 
 the large shaft is seen a screw, made by winding a 
 wire spirally round it. From the small shaft arises 
 another, but shorter spiral wire, which, it will be 
 seen, fits into that upon the larger shaft. The short 
 one may be considered the nut, in which the other 
 revolves. The ends of the short spiral are soldered 
 fast to the small shaft. If, then, the large shaft is 
 revolved, the screw on it playing in the nut, is 
 made to slide back and forth, accordingly as it may 
 be revolved. This motion, then, changes the direc- 
 tion of the point of the lancet to the plane of the 
 shafts, any degree from a right angle to a parallel. 
 Having thus got the inclination which is desired, the 
 
METHOD OP LANOING THE GUMS. 35T 
 
 blade is inserted into the gum at the point at which 
 the incision is to begin ; and as the instrument cuts, 
 rotate the larger shaft slightly, and the blade will 
 follow the outline of the tooth as it cuts round it." 
 
 THE METHOD OF LANCING THE GUMS. 
 
 In all cases, the gum should be separated from the 
 tooth as far as the embrace of the forceps is to ex- 
 tend ; the lancet should pass close to the tooth, so as 
 to make the separation clean about its neck; — in 
 order to do which, the lancet must be kept in good con- 
 dition; — and it should also be passed freely between 
 the teeth. A complete separation of the gum is 
 essential to a good hold of the forceps on the tooth. 
 Some operators, however, do not use the lancet for 
 this purpose, but tear the gum away by forcing the 
 forceps to its position on the tooth. This method is 
 objectionable on several accounts : it causes the patieDt 
 much more pain than with a sharp lancet ; the for- 
 ceps can not thus be adjusted to the tooth with so 
 much facility ; there is far more danger of lacerating 
 the soft parts, and, because of an imperfect adapta- 
 tion of the forceps to the tooth, more danger of 
 fracturing it ; and the operation is always more diffi- 
 cult of accomplishment. In those cases in which the 
 
358 EXTRACTION OF TEETH. 
 
 gum is firm and dense, and would obstruct the free 
 passage of the forceps to the proper position on the 
 tooth, it is sometimes necessary to make a vertical in- 
 cision of the gum, even after it has been separated, 
 directly opposite the root. But it is in many instances 
 better to cut away a portion of the free margin of 
 the gum, in the extraction of roots that are partially 
 covered by it; and there is no objection to this 
 method in any case where it may at all facilitate the 
 operation ; for this portion of the gum, if let remain, 
 is always absorbed or sloughed away after the ex- 
 traction of teeth. It is also sometimes necessary 
 to dissect the gum somewhat from the alveolus, in 
 those cases in which a deep hold on the tooth or root 
 is required, and in which the alveolus is either cut 
 away or embraced by the forceps. The character and 
 condition of the tooth will somewhat modify the extent 
 to which the gum-lancet should be used. 
 
 EXTRACTION OF THE TEETH. 
 
 In the following remarks it is the design to con- 
 sider only those principles obviously involved in the 
 extraction of the teeth with forceps, and in the ex- 
 traction of roots with forceps, elevators, and screws. 
 
 Superior Incisors. — After an examination, the gum, 
 as in all cases, should be perfectly separated from the 
 
EXTRACTION OF TEETH. 359 
 
 neck of the tooth, up to the border of the alveolus : 
 this is quite sufficient, if the tooth is not too much 
 decayed. With the forceps already described (see 
 Fig. 61), grasp the tooth firmly at the border of the 
 alveolus ; introduce the instrument slowly, adjusting 
 it carefully, as it passes up to the proper position : 
 then, by a gradual movement, rotate the tooth in the 
 socket, thus breaking up the attachment. All the 
 cylindrical, single-root teeth may be luxated by a 
 rotary motion. There are occasional circumstances, 
 however, that render this somewhat difficult, — as, for 
 instance, any considerable curvature of the root; or, 
 sometimes, the attachment to the outer plate of the 
 alveolus is so firm that it can not be broken up by 
 rotary motion. Neither of these difficulties is usual 
 with the lateral incisors ; but, with the centrals, one 
 or other of them is not unfrequent. When either of 
 them does occur, the attachment must be broken up 
 by an inward and outward movement, which, on 
 account of the pressure made on the parts, is at- 
 tended with much more pain, and far greater danger 
 to the contiguous parts, than the loosening by rotary 
 motion. 
 
 The roots of the incisors are not difficult to remove, 
 unless, being very much decayed, they will not sus- 
 tain the embrace of the forceps below the border of 
 the alveolus ; and when they are thus decayed, one 
 
360 EXTRACTION OF TEETH. 
 
 of the following methods may be adopted : the gum 
 may be dissected from the alveolus, and the latter 
 cut away with the thick cutting instrument, so as to 
 expose the root sufficiently for extraction with the 
 root forceps ; or, after the gum is dissected up, the 
 alveolus and the root may be together embraced, and 
 the former broken and removed with the latter. This 
 is a rather rough method of operation, though it is 
 often adopted. Or, an elevator of the proper form may 
 be introduced between the root and the alveolus, and 
 the root thus dislodged. 
 
 The screw, either simple or compound, is a valuable 
 instrument for the removal of these roots. But the 
 gum should be separated even when the extraction 
 is to be accomplished with this. The canal in the 
 root should first be enlarged with a taper drill, of the 
 same shape as the screw, till all the softened dentine 
 is removed. Then the screw, selected of proper 
 size, having a very sharp thread, is introduced till 
 it takes a strong hold in the solid dentine, espe- 
 cially if it is the simple screw. In some instances, 
 while it is being introduced, the root will be loosened. 
 In using the screw in connection with the forceps, it 
 is not necessary to introduce it with the same firm- 
 ness as when the screw alone is employed. In the 
 use of the screw-forceps, the screw is embraced in 
 the beaks, and introduced; then, the forceps are passed 
 
EXTRACTION OF TEETH. 361 
 
 up on the root, or between it and the alveolus, if need 
 be, the screw serving to sustain the root under the 
 pressure of the forceps. The attachment of the root 
 is broken by a rotary, or an inward and outward move- 
 ment, as the case may require. 
 
 Superior Cuspids. — For the removal of these teeth, 
 the central incisor or the bicuspid forceps may be 
 used ; though usually, the beaks of the former are too 
 thin, and those of the latter, too narrow. The for- 
 ceps appropriate for the removal of these teeth, have 
 broad, deep, concave beaks, so as to embrace the tooth 
 as completely as possible ; and they are thick, so as 
 to possess sufficient strength. The gum being sepa- 
 rated, and the forceps adjusted on the tooth, the at- 
 tachment is broken up, either by an inward and out- 
 ward, or by a rotary movement ; the former will be 
 far more frequently brought into requisition, since 
 these teeth are generally so firmly attached that 
 they can not be loosened by the latter ; but the skill- 
 ful and experienced operator will often combine the 
 two, with the happiest effect. These teeth have 
 larger roots than any others in the mouth, and the 
 alveolar process, especially the outer plate, closely in- 
 vests them ; and thus they are very firmly fixed in 
 the sockets, and are also more frequently found curved 
 than the roots of the incisors. Often, in extraction 
 of the cuspids, a portion of the outer wall of the aire- 
 
362 EXTRACTION OF TEETH. 
 
 olus is broken off, and comes away with the tooth. 
 But this accident is not attended with any serious 
 results ; indeed, in the preparation of the mouth for 
 artificial teeth, it is desirable that it be broken away 
 somewhat. 
 
 The movement in the extraction of a tooth should 
 always be very deliberate — never sudden and violent. 
 A very good criterion in regard to the rapidity of 
 movement, is, that the eye should follow and dis- 
 tinctly recognize every motion of the forceps, the 
 tooth, and the contiguous parts. 
 
 The removal of the roots of these teeth is far more 
 difficult than that of the incisors. Frequently the 
 gum has to be separated up two or three lines on the 
 alveolus, and the latter broken in with the forceps, 
 before the root is removed. The compound screw is 
 often very valuable in the removal of these roots — 
 the simple screw not commonly being of much avail, 
 since the force necessary to extract the root, is gene- 
 rally so great that the screw alone will not take a 
 sufficiently firm hold to accomplish it. The elevator 
 is not a very efficient instrument in the removal of 
 these roots. 
 
 Superior Bicuspids. — For the removal of the bicus- 
 pid teeth of both sides, one pair of forceps is quite 
 sufficient (see Fig. 63). These forceps are without 
 any curve ; though, in a small mouth, for the second 
 
EXTRACTION OF TEETH. 363 
 
 bicuspids, a slight anterior curve would be desirable, 
 since it would admit the instrument to a better position 
 on the tooth. These forceps properly adjusted on the 
 tooth, according to the directions already given, the 
 attachment is broken up by an inward' and outward 
 movement, carried just to the extent necessary to 
 accomplish the object; and then, traction is applied 
 to remove the tooth from the socket. This applica- 
 tion of the force is specially adapted to the first 
 bicuspids. Rotary motion should be very seldom 
 applied to these teeth, because their points generally 
 terminate in a bifurcation, and it is impracticable 
 thus to detach them without breaking off, at least, 
 one of the roots ; and, where they do not bifurcate, 
 they are so much compressed as generally to forbid 
 such a force. Occasionally, however, there is but 
 one root, and this is nearly cylindrical, as will be 
 indicated by the cylindrical form of the crown and 
 neck of the tooth ; and, in such cases, the rotary may 
 be combined with the inward and outward motion. 
 The root of the second bicuspid commonly has no 
 bifurcation, is usually somewhat compressed; and, in 
 general, the rotary motion may be combined with 
 the inward and outward in its extraction. There is 
 occasionally, however, some curvature to the roots of 
 these teeth ; but very seldom is it sufficient to cause 
 any difficulty in their removal. The skillful and 
 
364 EXTRACTION OF TEETH. 
 
 experienced operator will, in most cases, determine 
 very accurately the size, shape, and position of the 
 roots by the peculiarities of the crown ; and the at- 
 tention of the young practitioner should be directed 
 very closely to this point, till he is able to arrive at 
 accurate conclusions. For the removal of these teeth, 
 there are forceps with thick, peculiarly-formed beaks, 
 constructed to take advantage of the conical shape of 
 the roots. The instrument is placed on the tooth at 
 the border of the alveolus, or, if need be, a little be- 
 yond it ; and then, the process having been first cut 
 away, firm compression is made on the handle of the 
 instrument, and thus great pressure on two sides of the 
 root, — which are relatively as two inclined planes, — 
 by which the tooth is forced directly from its socket, 
 without either the oscillating or the rotary motion. 
 This instrument is rarely ever applicable to the re- 
 moval of any other teeth than the second bicuspids, 
 and occasionally the central incisors, and then only 
 when the roots are very tapering. The roots of the 
 bicuspids, especially the second, are usually not diffi- 
 cult to remove. Sometimes, however, the first bicus- 
 pids have two well-formed roots, somewhat divergent, 
 that are difficult to remove, especially if the decay 
 has eaten away till there is little of the tooth left for 
 the instrument to take hold upon. But, frequently, 
 if one of the contiguous teeth is absent, a lateral 
 seizure will remove the root at once. 
 
EXTRACTION OF TEETH. 365 
 
 Root forceps with narrow, thin beaks, which may 
 be readily forced between the root and the alveolus, 
 are very valuable for the extraction of all small 
 roots. 
 
 The screw, whether simple or compound, is not ap- 
 plicable to the extraction of the roots of the bicus- 
 pids. 
 
 A bicuspid will sometimes stand somewhat out of 
 the true circle, and the contiguous teeth approximate 
 so that it will not pass between them. In such a 
 case, the principal part of the movement for its de- 
 tachment should be in the direction of its inclination. 
 The cuspid teeth are sometimes found in the same 
 condition, and a similar applicatian of force for their 
 removal is to be made ; indeed, this method is appro- 
 priate to all cases where the teeth stand out of a 
 proper position and the contiguous teeth impinge on 
 the space. 
 
 Superior Molars.- — The first and the second superior 
 molars have each three roots, one palatal, and two 
 buccal ; the palatal being the largest and longest, 
 and the anterior buccal larger than the posterior. 
 The palatal root diverges very considerably from the 
 axis of the tooth ; while the buccal are often parallel 
 with it and with each other; but they sometimes 
 diverge in both directions. Occasionally, the diver- 
 gence of some or all of these roots, is so great that 
 
366 EXTRACTION OF TEETH. 
 
 they can not pass out of the socket without either 
 fracturing the alveolus or breaking off one or more 
 of the roots. On the contrary, there is sometimes 
 such a convergence of the buccal roots, that the inter- 
 vening portion of bone is necessarily brought away 
 with the tooth. Indeed, the three roots are some- 
 times found all in contact, forming an irregular conical 
 root; but this is a condition of unnatural develop- 
 ment. 
 
 The appropriate forceps being firmly fixed on the 
 tooth, an outward and inward movement is applied, 
 and traction at the same time. In the examination 
 of these teeth, to ascertain the force necessary for 
 their removal, two particulars have to be considered ; 
 the firmness of the attachment, and the position and 
 inclination of the roots. When these teeth, as they 
 occasionally do, stand somewhat outside of the cor- 
 rect position, great care must be exercised in their 
 removal, especially if the contiguous teeth impinge. 
 In small mouths, the contiguous impinging tooth is 
 liable to be injured by the pressure in extraction ; but 
 this injury may be avoided by directing the pressure 
 backward. Commonly, the first effort made to break 
 up the attachment, should be outward ; except where 
 the tooth stands inside of the circle, or where it is 
 decayed very much on its inner side, while its outer 
 remains firm. In those cases in which the roots 
 
EXTRACTION OF TEETH. obi 
 
 diverge so much that they will not pass out of the 
 socket, without tearing away some of the wall of the 
 alveolus, it would be impossible to break up the'.-at- 
 tachment by an inward movement; for the palatal 
 roots brace the tooth, and the inner process is very 
 strong and unyielding. Where a molar is decayed 
 on its proximal sides, and the contiguous teeth en- 
 croach on it, so that it can not pass out directly be- 
 tween them, it must either be cut away with the 
 chisel or file till it is small enough to pass out or 
 be drawn from between them. 
 
 The decay on the buccal or palatal sides often ex- 
 tends below the gum, and even below the border of 
 the alveolus ; or there may be extensive softening of 
 the dentine of the crown; and in either case, the gum 
 and process must be cut away sufficiently to admit a 
 firm hold on the root where it is strong enough to sus- 
 tain the embrace of the forceps. 
 
 Extraction of Roots. — The extraction of the roots 
 of the superior molars is not attended with much 
 difficulty when they are separated by decay, or are 
 easily broken apart ; the method then is the same as 
 for single roots. They should be deeply embraced 
 with the curved, sharp-pointed root forceps (see Fig. 
 68), and rotated to break up the attachment, trac- 
 tion being applied at the same time. It is very 
 rarely necessary to resort either to the elevator or to 
 
368 EXTRACTION OF TEETH. 
 
 the screw for the removal of these roots. The 
 greatest difficulty is experienced when the bifurca- 
 tion is deep, and the roots all adhere firmly together. 
 In such case, the same force is required for their 
 removal as before the crown was decayed off. The 
 root forceps, shown in Fig. 65, can be very effect- 
 ively used in the extraction of these roots. The 
 round, sharp beak is passed between the buccal roots, 
 the other beak embracing the palatal ; and with this 
 hold, by an inward and outward movement, the root 
 is removed. These forceps are not applicable where 
 there is but one large conical root. For the removal 
 of roots of this form, the wisdom-tooth forceps, or 
 those with similar beaks, are required. When it is 
 necessary to dissect off the gum, and cut away the 
 process, in order to obtain a firm hold of the root, this 
 should be done in preference to crushing in the pro- 
 cess with forceps — except, indeed, it may be the case 
 of a very irritable patient, who will not tolerate a pro- 
 tracted operation ; in which case, it is better to com- 
 plete the operation at a single effort. 
 
 REMOVAL OF THE SUPERIOR DENTES SAPIENTLE. 
 
 There is not usually much difficulty attending the 
 extraction of these teeth. The appropriate forceps 
 for this purpose (see Figs. 66 and 71) have two large 
 
REMOVAL OF THE DENTES SAPIENTLE. 369 
 
 single-concave beaks, so formed as to embrace the 
 neck of the tooth, without any reference to the bifur- 
 cation or the number and position of the roots. 
 Ordinarily, the attachment of these teeth is broken 
 up by the inward and outward movement ; but where 
 a single, round, conical root is clearly indicated, the 
 rotary movement would be preferable, or the rotary 
 in conjunction with the inward and outward. These 
 teeth sometimes stand out of the true position, more 
 frequently inclining outward, as already suggested in 
 another place ; and the direction of the force for 
 their extraction will correspond with this inclination. 
 Sometimes these teeth are very difficult to extract; 
 and this difficulty is dependent on the following cir- 
 cumstances : first, an anterior inclination of the tooth, 
 so that it stands at a considerable angle with the 
 adjoining tooth, and in contact with its posterior 
 proximal surface, the posterior border of the process 
 being thick and firm, and extending down full on 
 the crown of the tooth ; and second, the existence of 
 several roots, with great divergence, irregularity, 
 and curvature. The removal of a tooth in the first 
 of these conditions is often a very protracted opera- 
 tion, fraught with much pain to the patient and con- 
 siderable labor to the operator. Such preparation 
 must be made, as will permit a free egress of the 
 tooth from the socket, before an effort is made, lor its 
 
370 EXTRACTION OF TEETH. 
 
 extraction. This is effected either by cutting away 
 the portion of ]Drocess behind the tooth, so that it 
 may be forced backward sufficiently to let it pass out 
 of the socket, or by cutting away enough from the 
 anterior portion of the tooth ; or, if the posterior 
 proximal surface of the second molar is decayed, it 
 may be quite as well, and more convenient, to cut this 
 down so as to permit the ready removal of the tooth. 
 Physic's forceps can be used very effectively for 
 the extraction of these teeth, when they occupy such 
 a position, provided the root is straight, or has a pos- 
 terior curvature ; but if there is an anterior curvature, 
 the tooth is most difficult to extract, and Physic's 
 forceps would be wholly inefficient — except to break 
 off the tooth. In such case, the posterior portion of 
 the process should be cut away as much as possible. 
 Physic's forceps are frequently employed for the 
 removal of these teeth, when they occupy a correct 
 position; but their use is somewhat objectionable, 
 especially in the following respects : the instrument 
 acts first on the principle of a wedge, being forced 
 between the teeth ; and then on that of a lever, the 
 second molar being the fulcrum ; and hence, when it 
 is employed, the second molar must always be pre- 
 sent, and it is liable to injury from the pressure which 
 may do violence to the periosteum, or fracture and 
 scale off portions of the enamel. But if the first 
 
INFERIOR INCISORS. 371 
 
 molar is absent, there is almost as much liability, 
 with the Physic's forceps, of loosening the second as 
 of extracting the third. Indeed, it is always objec- 
 tionable to use a sound tooth, under any circum- 
 stances, as a fulcrum for an extracting instrument. 
 
 A wisdom tooth the roots of which are irregular in 
 number, inclination, and curvature, should be grasped 
 firmly, and an oscillating force applied, sufficient to 
 remove it from its socket. There is nothing per- 
 taining to the removal of the roots of these teeth that 
 involves any different principle or application of in- 
 struments from that given for the removal of the teeth 
 themselves. The anterior inclination which so often 
 renders the whole tooth difficult of extraction, very 
 seldom affects the removal of the roots. These are, 
 in general, easily extracted with the common curved 
 root-forceps. 
 
 EXTRACTION OF THE INFERIOR INCISORS. 
 
 In the extraction of these teeth, either of the for- 
 ceps described for the purpose, may be employed. 
 The beaks should be quite narrow and thin (see Fig. 
 67). The instrument well fixed on the tooth, the 
 attachment is broken up by an inward and outward 
 movement, the rotary being seldom applicable, since. 
 in general, the roots are flattened, and in many cases 
 
372 EXTRACTION OF TEETH. 
 
 quite thin, so as to be incapable of turning in the 
 socket. Care must be exercised in the oscillating 
 movement, and especially where the tooth to be ex- 
 tracted stands out of the proper position, and the con- 
 tiguous teeth incline together; though this is of little 
 consequence where the teeth are all to be removed. 
 "When the crowns of these teeth are short and thick, 
 the roots are shorter, thicker, more conical, and more 
 nearly cylindrical; and. in the extraction of such, the 
 rotary may be combined with the oscillating move- 
 ment, 
 
 There is seldom any superadded difficulty in the 
 
 removal of the roots of these teeth, the same instru- 
 ments and movements being applicable as for the 
 removal of the teeth themselves. The only dif- 
 ference in any respect is, that where the teeth are 
 decayed off far down, the forceps should be forced 
 down on the process, in order to obtain a firm hold 
 on the root. Xeither the elevator nor the screw is 
 ever required for the removal of these roots. 
 
 INFERIOR CUSPIDS. 
 
 These teeth may be removed with the inferior bicus- 
 pid forceps of the right side ; though an instrument 
 of the same general form, but of less curvature would 
 be preferable, since with such, the required movement 
 
INFERIOR CUSPIDS. 373 
 
 for breaking up the attachment could be more easily 
 given. They commonly have long, round, conical 
 roots, not so large as those of the superior cuspids, 
 nor so difficult to extract — seldom having any curva- 
 ture, and thus being susceptible of detachment by the 
 rotary motion. They often stand so much anterior 
 to the true circle, that an attempt to thrust them 
 inward, would be liable to break or loosen the lateral 
 incisors. Their situation, as indeed that of all teeth, 
 should be strictly attended to before any attempt is 
 made to remove them. 
 
 The crowns of these teeth decay off, and leave the 
 roots standing, far more frequently than do those of 
 the superior bicuspids. But there is no difficulty in 
 the removal of their roots ; and the only indication is, 
 when they are deeply decayed, to pass the forceps far 
 down on them, either first cutting away the process 
 or embracing it,' as the circumstances may warrant; 
 the former method being preferable. After the root 
 is extracted, the fractured pieces of process, if any, 
 should be removed. 
 
 A long, tapering screw may sometimes be advan- 
 tageously used for the extraction of these roots, when 
 they are decayed so deeply that an extensive break- 
 ing away of the process would be incident to their 
 removal with the forceps. The elevator, however, is 
 rarely ever called in requisition here. 
 
374 EXTRACTION OF TEETH. 
 
 INFERIOR BICUSPIDS. 
 
 These teeth, two in number on each side, have but 
 one root each, and that generally round, or nearly so, 
 and not so long as that. of the cuspids; and have less 
 diameter at the neck than they. They require, in 
 extraction, forceps for each side, as already described 
 (see Fig. 69). They may be removed either by the 
 rotary, or by the inward and outward movement, or 
 both combined. With the handle of the forceps 
 thrown very far out of a line with the axis of the 
 tooth, it is always more difficult to be rotated 
 accurately in its socket; a straight instrument is best 
 for the rotary motion. In the removal of these teeth 
 from the right side, when the mouth is small, care 
 should be taken that too much pressure is not made 
 against the anterior tooth. This accident is more 
 liable to happen in the removal of the second bicus- 
 pid, than in that of the first, and especially if the 
 mouth can not be opened wide. As the tooth comes 
 out, the forceps are liable, without some attention, to 
 strike the superior teeth, and in this way fracture 
 them or scale off their enamel. In many cases, for- 
 ceps with a forward and an outward curvature com- 
 bined, would be very desirable, for facility of ap- 
 proaching the tooth; but with such a complication 
 of curves, the operator loses control of the instru- 
 ment. 
 
INFERIOR MOLARS. 375 
 
 Iii the removal of the bicuspids of the left side, 
 there is little or no liability to undue pressure against 
 the anterior teeth ; and in their extraction, the move- 
 ment should be mainly inward and outward, since 
 the great curvature of the forceps renders a rotary 
 motion very difficult and uncertain. There is also 
 danger of striking the upper teeth, especially if 
 the tooth to be extracted comes out with less effort 
 than the operator anticipated ; an accident that some- 
 times befals the most skillful and discriminating. The 
 first and the second inferior bicuspids are removed 
 with about equal facility. 
 
 Occasionally, though seldom, these teeth have two 
 distinct, well denned roots ; a condition that can not 
 be determined by the form of the crown or by any 
 other visible indication; and one tooth alone will 
 sometimes be found w T ith this peculiarity. The re- 
 moval of the roots of these teeth is not attended with 
 much difficulty ; the main consideration being, to 
 obtain a deep, strong hold on them, and then apply a 
 firm, steady movement. 
 
 INFERIOR MOLARS. 
 
 These teeth commonly have two roots, a posterior 
 and an anterior ; the latter being the largest, and fre- 
 quently the longest. The roots have different incli- 
 
376 EXTRACTION OF TEETH. 
 
 nations to the axis of the tooth, being in some cases 
 divergent from, and in others parallel with it, and in 
 others convergent, or curved together so that their 
 points almost meet. The forms of the crowns will 
 give some indication of the inclinations of the roots : 
 if the former are short, the latter are so, and vice versa; 
 if the diameter of the crown is about the same at the 
 masticatory surface and the neck, the roots do not 
 diverge ; if the crown is long and of uniform diam- 
 eter, the roots will be either parallel or convergent; 
 and if the angles on the crown are not sharp and well 
 defined, the roots most probably curve together at 
 the points. If, however, the angles formed by the 
 masticatory and lateral surfaces of the teeth are sharp 
 and well defined, the roots generally diverge. 
 
 Forceps adapted to each side are required for the 
 removal of these teeth. These forceps have a promi- 
 nence, or point, in the center of the beaks, to pass 
 into the bifurcation; and, in separating the gum, it is 
 important to dissect it away, and, if need be, even 
 cut away the margin of the process, so that the bifur- 
 cation may be well exposed, to admit the forceps to 
 a proper position on the tooth, without obstruction. 
 The tooth being firmly grasped in the proper manner 
 by the forceps, is moved gradually, but steadily, 
 inward and outward, to break up the attachment, 
 and then drawn from its socket. In the removal of 
 
INFERIOR MOLARS. 377 
 
 these teeth from the right side with the ordinary for- 
 ceps, there is great clanger of undue pressure on the 
 anterior contiguous teeth ; which is to be avoided by 
 directing the pressure backward in the operation. 
 And there is also danger of injuring the upper teeth 
 with the forceps ; which may be obviated by wrap- 
 ping the point of the instrument with a small napkin. 
 
 In the removal of the inferior molars of the left 
 side, the application of force is the same — an inward 
 and outward movement — but the handles of the for- 
 ceps occupy different relative positions to the teeth 
 to be extracted ; passing directly out at the front of 
 the mouth, instead of at one side. In consequence 
 of this arrangement, the operator can not exert the 
 same force on them, as, with the proper forceps, on 
 those of the right side. Yery little traction can be 
 employed in connection with the oscillating move- 
 ment, but the attachment must be almost wholly 
 broken up before beginning to lift the tooth from the 
 socket. But in extracting the teeth on the right 
 side, with the proper forceps, traction is always com- 
 bined with the inward and outward movement. 
 
 In the extraction of the roots of these teeth, little 
 difficulty is experienced after the decay has pro- 
 ceeded so far as to effect their separation. They are 
 then embraced with the appropriate forceps, and 
 removed as single roots are elsewhere. These for- 
 
378 EXTRACTION OF TEETH. 
 
 ceps have narrow, thin, sharp beaks, turned to almost 
 a right angle. With them, the root is embraced, and 
 moved inward and outward till loosened, and then 
 removed. When the mouth is large, and can be 
 opened wide, the slightly curved root forceps are 
 convenient, and the rotary movement may be em- 
 ployed with them, if the roots are not very much 
 curved, flattened, or firmly set The removal of 
 these roots is more difficult when the bifurcation is 
 low down, and the roots remain firmly attached 
 together, and especially when they diverge. If the 
 bifurcation is not too low, and the attachment not too 
 firm, the roots may be separated with the separating 
 forceps (Fig. 85), and then removed singly, as in 
 other cases. This is the preferable method, when 
 
 Fig. 85. 
 
 there is much divergence ; but if the fangs can not 
 be separated, they may be extracted with the forceps 
 shown in Fig. 74. The round, curved, sharp beaks 
 are passed down between the roots, and the whole is 
 removed at once ; the attachment being broken up on 
 the principle already described. 
 
 These teeth sometimes have but one, large, round, 
 
INFERIOR DENTES SAPIENTIiE. 379 
 
 conical root; and there is seldom, if ever, enough 
 curvature of the roots to render extraction difficult. 
 The ordinary inferior-molar forceps arc not well 
 adapted to the purpose : for the central points of 
 their beaks will prevent a perfect adaptation. The 
 broad, single-concave beaked forceps are best adapted; 
 the curves and general forms of which, except the 
 beaks, are the same as those represented in Fig. 71. 
 The removal of teeth having this kind of roots is 
 easily accomplished. Rotary movement would be 
 applicable here, if the exact form of the root could be 
 ascertained before extraction; but it is, in general, 
 the safest course to employ the inward and outward 
 movement. 
 
 INFERIOR DENTES SAPIENTLE. 
 
 These teeth require, for their removal, the broad, 
 single-concave beaked forceps, the beaks curved at a 
 right angle with the handle, and the handle straight. 
 This instrument fixed deeply and firmly on the tooth, 
 the attachment is to be broken up by the inward and 
 outward movement. These, more frequently than 
 the superior dentes sapienticv, stand out of the proper 
 position ; their variations and the manner of obviating 
 the attendant difficulties, however, being about the 
 same — at least, so far as deviation is concerned. 
 
380 EXTRACTION OF TEETH. 
 
 Physic's forceps may be used here with greater 
 facility than on the upper teeth. 
 
 These teeth frequently exhibit but a very small 
 portion of the crown through the gum. Being 
 erupted with an anterior inclination, the tooth comes 
 in contact with the posterior portion of the second 
 molar, and is thus checked in its external develop- 
 ment. Thus the crown is left partially covered with 
 the gum, which frequently inflames, and even sup- 
 purates, remaining in that condition for a consider- 
 able time, to the great annoyance of the patient. 
 Such teeth are difficult to remove ; first, because of 
 their inclination and contact with the second molar ; 
 and secondly, because the crown is more than half 
 below the borders of the thick, firm alveolus, render- 
 ing it impossible to obtain a firm hold of the tooth, 
 without cutting away a portion of the alveolus. In 
 such cases, it is generally best to make a free excision 
 of the alveolus all round the tooth, sufficient to per- 
 mit its easy removal. 
 
 EXTRACTION PREPARATORY TO THE INSERTION OF 
 ARTIFICIAL DENTURES. 
 
 Whenever there is a number of teeth to be re- 
 moved, the method and the duration of the operation 
 will depend on the following circumstances: first, the 
 
EXTRACTION PREPARATORY TO INSERTION. 381 
 
 number to be removed ; second, the firmness of their 
 attachment; third, the patient's power of endurance ; 
 and fourth, the manner in which the immediate parts 
 are affected. Where the number to be removed is 
 considerable, and the attachment feeble, or not very 
 firm, and the patient's power of endurance good, 
 the extraction may be as rapid as is consistent with 
 efficiency. In many such cases, from three to six 
 teeth may be removed, without any relaxation, by 
 the operator, of his hold on the parts with the left 
 hand. This is generally practicable with the front 
 teeth of the lower, and frequently with those of the 
 upper jaw ; but it is not proper to remove more than 
 three or four of the molar teeth, without respite, even 
 when they are quite loose, or have but a feeble 
 attachment in the socket. The gum should, of 
 course, be well separated previously to the operation. 
 Only so many teeth should be removed at one sitting 
 as the nervous system will allow without too great a 
 shock. In many instances, however, it is practicable 
 so far as this is concerned, to remove at once all the 
 teeth in the mouth. In the extraction of a large 
 number those most easily removed should be first 
 taken, so as by degrees to bring the patient to the more 
 severe operations. If there is a manifest hemorrhagic 
 diathesis — a disposition to bleed freely from the capil- 
 laries, as well as from the larger vessels — but two or 
 
882 EXTRACTION OF TEETH. 
 
 three teeth should be removed at a sitting, lest uncon- 
 trollable hemorrhage ensue. 
 
 After all the teeth are removed from one or both 
 of the jaws, the gums and alveolus should undergo a 
 trimming process : all detached, flabby, or prominent 
 portions of the gums should be dissected off; the 
 whole ridge made uniform ; all loose portions of the 
 alveolus removed ; all the prominent points and sharp 
 edges cut down; and the whole border of the process 
 rendered as smooth and even as possible. By this 
 means, the healing of the parts is facilitated, and they 
 assume the desired condition and form in much less 
 time, and with far less soreness and inconvenience. 
 
 CONDITIONS TO BE OBSERVED IN EXTRACTION. 
 
 Such conditions are often found to exist in the 
 system, as indicate the necessity of great care in the 
 operation, or of prior treatment, or forbid the extrac- 
 tion of the teeth altogether. Of these conditions, the 
 following are some of the more obvious : 
 
 Extreme debility. 
 
 Great nervous irritability. 
 
 Excessive local inflammation, especially where it 
 tends to the other parts. 
 
 Much irritability of the parts intimately connected 
 with the teeth. 
 
CONDITIONS TO BE OBSERVED IN EXTRACTION. 383 
 
 Pregnancy, and all uterine irritations. 
 
 A tendency to epilepsy. 
 
 In many cases, where there is great debility, so 
 painful an operation as the extraction of a tooth, will 
 cause extreme, and sometimes alarming prostration. 
 This, however, may be anticipated, by prior invigo- 
 rating treatment, continued till strength and tone are 
 obtained sufficient to endure the operation. This 
 treatment may occupy considerable time ; while an 
 urgent case may arise, in which the removal of the 
 offending tooth is immediately demanded ; in which 
 case, it is proper to administer stimulants — -brandy or 
 wine, or such as the case may seem to require. By 
 such means the system may be so invigorated as to 
 withstand the shock of the operation with compara- 
 tive fortitude. 
 
 There is in some cases a highly irritable condition 
 of the nervous system, that almost absolutely forbids 
 the extraction of teeth, convulsions being sometimes 
 produced, in such cases, by a simple operation. This 
 remark does not of course apply to facial neuralgia 
 that may be either partially or wholly produced and 
 kept up by diseased teeth ; neither general nor local 
 neuralgia would be aggravated by an operation of 
 this kind. Accompanying general nervous irrita- 
 bility, there is usually excessive dread of an opera- 
 tion, such as to occasion rapid prostration — even 
 
384 EXTRACTION OF TEETH. 
 
 greater and more rapid than that caused by the ope- 
 ration itself. In such cases, if the extraction is 
 effected immediately, it will give relief; but where 
 the excitement has been very high, and the tension 
 for some time great, the depression after the opera- 
 tion will be correspondingly great, and considerable 
 time be required for complete recovery ; indeed, the 
 shock is sometimes so severe as to occasion confine- 
 ment for several days. Treatment for quieting the 
 nervous system, consisting in agents of a sedative 
 character, may be employed previously to the opera- 
 tion : stimulants, as a general rule, should be avoided. 
 
 Where there is a high state of inflammation in the 
 immediate parts, especially if there is a general in- 
 flammatory diathesis, the propriety of extracting the 
 teeth is questionable. Under such circumstances, 
 there is probably less danger in the extraction of the 
 inferior teeth, than of the superior. Where the in- 
 flammation has a disposition to extend, it is liable to 
 go to the head from the superior maxilla, and to the 
 fauces and throat from the inferior. In cases, then, 
 where there is excessive inflammation in the imme- 
 diate parts, accompanied by a general inflammatory 
 condition, both local and general antiphlogistic treat- 
 ment should be adopted. 
 
 Extreme irritability, or a diseased condition of 
 parts having an intimate connection with the teeth, 
 
CONDITIONS TO BE OBSERVED IN EXTRACTION. 385 
 
 as the immediate surrounding tissues, the salivary 
 glands, and the throat, is a circumstance admonishing 
 to great caution in the extraction of teeth, especially 
 when such condition does not depend on the teeth 
 for its exciting cause or modifying influence. It is, 
 however, very generally the case, when any of the 
 parts having an intimate relation with the teeth, 
 become in any way affected, diseased teeth will exer- 
 cise an injurious influence on them. If the necessity 
 for the removal of the offending tooth is not too urgent, 
 the parts that may be diseased about it, should be 
 brought to as good a condition as possible. 
 
 Pregnancy and uterine irritation frequently pro- 
 duce strong sympathetic influences on the teeth, and 
 especially on those which are in an irritable condi- 
 tion : even sound teeth may be thus affected, so as to 
 occasion great annoyance. Such teeth are frequently 
 presented for extraction; but these cases should 
 always be thoroughly examined before deciding as to 
 the propriety of an operation. As a consequence of 
 this sympathetic connection between the teeth and 
 the uterus, the latter, when in an irritable condition, 
 is very liable to be affected by any special violence 
 to the former. In many cases, under such circum- 
 stances, the extraction of a tooth is attended with 
 pain in the uterus; and in cases of pregnancy, whore 
 there is debility of the parts involved, abortion is 
 
386 EXTRACTION OF TEETH. 
 
 liable to follow the operation. It is the duty of the 
 patient, under such circumstances, to notify the ope- 
 rator of the condition; or, if the latter has any know- 
 ledge of it, it is his duty to become fully acquainted 
 with the circumstances, and then to conform to the 
 indications. In such case, treatment will avail but 
 little to prepare the system for the operation. The 
 better method is to adopt palliative treatment; which, 
 if the affection is wholly sympathetic, must be 
 directed to the organ producing the difficulty. But 
 if the affection is in part local, then topical treatment 
 is also indicated. When there is a suppression of 
 menstruation, there will be an increased disposition 
 to hemorrhage ; and in the extraction of the teeth of 
 a patient of hemorrhagic diathesis, this is a point to 
 which observation should be very specially directed : 
 here, of course, a remedy for the obstruction would 
 meet the difficulty. 
 
 Persons subject to epilepsy should be very cau- 
 tiously treated in all operations on the teeth, and 
 most especially in their extraction. It is not pro- 
 bable, however, that an operation of this character 
 would increase the tendency to epilepsy ; but any 
 undue excitement is liable to produce a paroxysm of 
 the disease ; and hence the operator should proceed 
 to his work with as little parade as possible; yet, not 
 stealthily ; the patient should be thoroughly aware of 
 
CONDITIONS TO BE OBSERVED IN EXTRACTION. 387 
 
 what is to be done ; for, of all patients, such a one is 
 the last that should be deceived. Of course, in a case 
 of this kind, there can be no prior treatment that will 
 avail anything; the most that can be done is, to await 
 the fittest opportunity in respect to the paroxysms. 
 There is no more liability to fatal results with such 
 patients than with others. 
 
CHAPTER XII. 
 
 ACCIDENTS IN THE EXTRACTION OF TEETH. 
 
 The accidents liable to occur to the teeth and the 
 contiguous parts in the operation of extraction, were 
 formerly far more frequent than at present. This 
 results from the existence of more perfect instru- 
 ments and of more accurate and extensive knowledge. 
 Formerly, very few studied the peculiarities of the 
 teeth, either in their physical or anatomical struc- 
 ture ; their peculiar forms, as indicated by their 
 crowns ; their anatomical and physiological relations 
 to the contiguous parts and to one another ; and their 
 attachment as affected by the character and structure 
 of the tissues about them. The instruments em- 
 ployed, too, were, till within a few years past, very 
 crude in their forms, very inapplicable in that part 
 which embraces the tooth, inappropriate in their 
 shapes, and defective in their manner of applying the 
 force in the operation. But these causes of accidents, 
 so far as the better part of the dental profession is 
 concerned, have been in a very marked degree dimin- 
 ished. 
 
HEMORRHAGE. 389 
 
 Some of the accidents attendant or consequent on 
 the extraction of teeth, are of a grave character. 
 Permanent deformity has sometimes been occasioned 
 by extensive laceration of the soft parts, or by frac- 
 ture of the alveolus and of the maxilla. Intense 
 and protracted suffering frequently, and death some- 
 times, follows such accidents. 
 
 HEMORRHAGE. 
 
 Excessive and obstinate hemorrhage in some cases 
 follows the extraction of teeth, occasionally resulting 
 seriously and even fatally. There is in some con- 
 stitutions a hemorrhagic diathesis, so that from a 
 small wound, or even a scratch, there will ensue per- 
 sistent bleeding. This condition is dependent, first, 
 on a lack of tone in the bloodvessels, so that they 
 fail to contract at an injured or ruptured point ; and 
 secondly, on a peculiar condition of the blood, such 
 as to prevent ready coagulation, as, when there is a 
 relative deficiency of albumin and fibrin. It is one 
 of the most important duties that ever devolve on the 
 dentist, to make a correct diagnosis in cases where 
 there is a tendency to hemorrhage. Close attention 
 to the following points, will assist much in arriving 
 at a just conclusion. In persons of a hemorrhagic 
 tendency, there is a lymphatic, serous temperament ; 
 
390 ACCIDENTS IN THE EXTRACTION OF TEETH. 
 
 a lack of tone in the soft parts — a soft, flabby condi- 
 tion ; the skin pale, and devoid of the bright, vital 
 appearance; the eyes and hair of light color; and the 
 flow of saliva and mucus abundant. Besides these 
 indications, much may be learned sometimes by pro- 
 perly directed inquiries of the patient in regard to a 
 disposition to hemorrhage on being wounded, either 
 in his own case, or in that of his relatives ; if in the 
 former, under what circumstances ; whether from an 
 extensive or slight wound ; from large or small ves- 
 sels — from arteries or veins ; or, whether it occurred 
 immediately, or after the lapse of some time. If the 
 patient has never met with an accident sufficient 
 to occasion excessive hemorrhage, and any of his 
 relatives have, and a tendency to bleeding is sus- 
 pected in the case, the operator should ascertain 
 whether there is a similarity of temperament and 
 constitutional tendencies between the patient and 
 such relative. 
 
 There are certain conditions in which excessive 
 hemorrhage would be more likely to occur than in 
 others ; as, for instance, when there is an accidental 
 relaxation, or deficient tone, in the system, especially 
 the vascular; and also, when there is a suppres- 
 sion of any periodical discharges. There may be 
 excessive hemorrhage from a ruptured vessel when 
 there is no constitutional hemorrhagic tendency. 
 
HEMORRHAGE — TREATMENT. 391 
 
 There is sometimes a local difficulty with the vessels 
 — a lack of tone in the part — or an aneurismal con- 
 dition — on account of which obstinate hemorrhage 
 will occur. A peculiarity of this kind is not very 
 readily recognized. 
 
 Violent passion, and, indeed, any strong agitation 
 of the mind, will aggravate hemorrhage. Improper 
 medication, as well as highly stimulating food, will 
 have the same tendency. Anything that will in- 
 crease the circulation, or reduce the tone of the ves- 
 sels, or change the condition of the blood, will 
 increase the liability to hemorrhage. Simple deter- 
 mination of blood to a part, however, would not 
 indicate such a liability. When there is a special 
 hemorrhagic diathesis, the blood will flow from all 
 the wounded surface, will be thrown out from all the 
 ruptured capillaries. The most difficult cases are 
 those in which there is a defect both in the vessels 
 and in the blood. If the latter is in a good condition, 
 it will coagulate in ruptured capillaries, though they 
 might be deficient in tone ; but in larger vessels, 
 though coagulum might be formed, it would not be 
 retained. 
 
 TREATMENT. 
 
 In cases where there is manifest hemorrhagic dia- 
 thesis, prior treatment is indicated, if the necessity o( 
 
392 ACCIDENTS IN THE EXTRACTION OF. TEETH. 
 
 extraction is not urgent ; and that treatment will be 
 determined by the peculiar condition of the case. If 
 there is a lack of tone in the vessels — an inability to 
 contract — then the treatment should be of a tonic 
 character ; and, if the blood is in good condition, this 
 is the only treatment necessary ; but, if in a vitiated 
 state, other treatment will be demanded ; the object 
 of which is to produce an increase of red corpuscles, 
 albumin and fibrin. It is always better to postpone 
 an operation, if at all practicable, till such treatment 
 can be had as will bring the system to the best pos- 
 sible condition. 
 
 Of the several methods of arresting hemorrhage, 
 the proper one in a given case will be determined by 
 the circumstances. Styptics, or astringents, applied 
 directly to the ruptured surface, will often be found 
 to produce coagulation of the blood, and thus stop its 
 flow, without anything else. This kind of remedy 
 will be efficient in those cases in which the applica- 
 tion will produce contraction of the bleeding vessels, 
 as well as coagulation of the blood. Sometimes this 
 class of agents will fail to accomplish the object; in 
 which case, in addition to them, compression should 
 be made upon the part. Indeed, in many cases, the 
 compress will effect all that is desired, without any 
 other application. 
 
 There are several methods of applying the com- 
 
HEMORRHAGE — TREATMENT. 393 
 
 press ; but the one best adapted to any given case, 
 will be determined by circumstances; such as the 
 extent of the wound, the character of the hemor- 
 rhage, the location of the injury, and the size of the 
 mouth. 
 
 A very common method of making compression in 
 the socket from which a tooth has been drawn, is, to 
 force into the cavity pledgets of cotton, or small 
 strips of linen, tightly, till it is full. It is well to 
 saturate these with a solution of tannin, or some 
 astringent preparation, applying it, too, in connection 
 with the compression. In some cases, a simple pack- 
 ing of the cavity in this manner, is quite sufficient ; 
 but, in others, it is necessary to retain the pledgets 
 in the socket by means of further compression. This 
 is effected by placing a roll of linen, or perhaps bet- 
 ter, a properly formed piece of cork on the packing, 
 and then closing the jaws tightly upon this, and, if 
 need be, placing a bandage under the chin, and tying 
 it firmly over the head. The length of time during 
 which it will be necessary to keep the jaws thus 
 together, will, depending on the nature of the case, be 
 from one to six hours. After the hemorrhage has 
 entirely ceased, the bandage is to be removed care- 
 fully, and the patient instructed to hold the jaws 
 together on the compress for a time, and then gradu- 
 ally to open the mouth, and remove the cork with 
 
394 ACCIDENTS IN THE EXTRACTION OF TEETH. 
 
 much caution. After this, the packing should re- 
 main in the socket from one to three days, and then 
 be removed very carefully, one piece at a time, lest 
 the ruptured vessels be opened and the hemorrhage 
 caused to recur. 
 
 The object in applying a compress is to bring it to 
 bear upon the aperture of the wounded vessel, and in 
 this way to prevent the escape of blood, till coagulum 
 is formed and the opening permanently closed. The 
 operator should ascertain the precise point from which 
 the blood flows, and form the compress so as to bear 
 full upon it. If the flow is from all the wounded 
 surface, then the compress must be made to conform 
 exactly to that throughout. 
 
 Another method of making the compression, is to 
 force softened wax into the socket, so as to fit it per- 
 fectly ; remove it and chill it in cold water; and then 
 introduce and make compression upon it in the man- 
 ner already described, following, throughout, the 
 general directions. Another, and probably better 
 method, is, to form cones of wax cloth, as near the 
 shape and size of the root removed from the socket 
 as possible. This material is prepared by dipping 
 thin linen into melted beeswax, withdrawing it and 
 letting it cool, and then cutting off strips of from a 
 fourth to a half an inch wide, and rolling them to the 
 proper size and shape. Having softened this material 
 
HEMORRHAGE — TREATMENT. 395 
 
 by heat, and freed the socket of coagulum, introduce 
 and press it firmly into place, making the compression 
 on it as already directed. This makes a very efficient 
 compress for many cases. 
 
 Plaster of Paris is sometimes used on the principle 
 of a compress. Having the plaster mixed of the 
 proper consistence, and the cavity clear, fill com- 
 pletely with it, let it set, and then make compression 
 on it in the usual manner. 
 
 The root of the tooth is sometimes returned to the 
 socket to serve as a compress. It possesses the 
 advantage of having a perfect adaptation. This 
 method of compression may be made more thorough 
 by immersing the root in melted wax, and then, before 
 this becomes too hard, introducing it into its original 
 position. This makes a very perfect and efficient 
 compress. If the crown is still remaining, when the 
 jaws are closed it will come in contact with the oppo- 
 sing teeth, and thus be kept firmly in place, without 
 anything further. It may be removed carefully after 
 from one to three days. In cases where there is 
 hemorrhage from the entire wounded surface, there 
 will be a considerable flow of blood from the margin 
 of the gum, even after plugging up the socket, and 
 making compression by either of the methods de- 
 scribed. In such case, after the socket is plugged up 
 as already described, a plate is so formed as to tit 
 
396 ACCIDENTS IN THE EXTRACTION OE TEETH. 
 
 tightly over the gum, and draw its margin down 
 closely upon the compress. This pressure on the 
 bleeding edges of the gum, checks the flow of blood 
 there. The plate must be held down by the means 
 already described. It is sometimes difficult to obtain 
 an accurate fit for the plate, so as entirely to prevent 
 the blood from continuing to ooze out. In such 
 cases, make the plate to conform as nearly as conve- 
 nient to the part; then fill up its concavity with 
 plaster of Paris, mixed to a proper consistence ; and 
 then place the whole upon the part, till the plaster 
 conforms exactly to it, and retain it there till the 
 plaster sets. This is then used for the compress. 
 Or the inside of the plate may be thickly coated with 
 softened gutta-percha, instead of plaster, and .pressed 
 upon the part in the manner already described, and 
 employed in the same way. 
 
 It will often require considerable discrimination to 
 determine the best method of obtaining compression. 
 Very great difficulty is occasionally experienced when 
 a portion of the process has been broken away, or the 
 soft parts have been lacerated. 
 
 Various preparations are used as hemostatics. 
 These agents serve to check hemorrhage in two 
 ways: first, by facilitating a coagulation of the blood; 
 and secondly, by producing a contraction of the ori- 
 fice of the ruptured vessels. It is proper in all cases 
 
HEMORRHAGE — TREATMENT. 397 
 
 to use styptics in connection with the compress. The 
 following agents have been used as styptics : tannic 
 acid, creosote, nitrate of silver, chlorid of zinc, sul- 
 phate of zinc, oil of turpentine, muriate of iron. The 
 methods of applying these different preparations are 
 the same. The agent is simply to be retained in 
 contact with the part till it has exerted its influence. 
 A solution of tannin in alcohol with creosote, equal 
 parts, makes a very powerful styptic ; or tannin and 
 creosote alone is perhaps equally efficient. 
 
 The actual cautery is sometimes used to arrest 
 hemorrhage ; but the propriety of using it in cases 
 where there is a manifest hemorrhagic diathesis, is 
 exceedingly doubtful. When the cauterized surface 
 is sloughed off, the hemorrhage is liable to recur with 
 increased vigor, indeed, is certain to do so in almost 
 every case when there is a strong predisposition. 
 Constitutional treatment may be employed to antici- 
 pate hemorrhage; and it should have in view an 
 increase of the relative amount of red corpuscles, 
 albumen and fibrin, in the blood ; and also the pro- 
 duction of a normal tone of the system. Saline purga- 
 tives may be used with very decided advantage, 
 followed with acetate of lead, in connection with 
 opium ; the effect of the lead being to increase the 
 coagulability of the albumen and fibrin. Care should 
 be exercised, however, in its administration. 
 
 
398 ACCIDENTS IN THE EXTRACTION OF TEETH. 
 
 Excessive hemorrhage will sometimes occur from 
 very slight wounds ; death has been known to ensue 
 from simply scarifying the gums. Mr. C. desired 
 the removal of the first superior molar. The gum 
 was separated from the neck of the tooth with the 
 lancet, in the usual manner, when he refused to have 
 anything further done, and left the office, there being 
 a slight discharge of blood from the gum. After a 
 few hours, the hemorrhage increased so as to cause 
 alarm to the friends. The patient was some eight 
 miles from a dentist, and a physician of rather mode- 
 rate skill was called to the case. He probably acted 
 according to his best knowledge, but failed to arrest 
 the hemorrhage, and succeeded in convincing the 
 friends that no one else could do better. The flow 
 of blood continued three to four days, proving well- 
 nigh fatal, but at last abated, and the patient recov- 
 ered. In this case, a properly directed compress would 
 have checked the bleeding in a few minutes. 
 
 Another case : Mrs. T. had nine teeth removed. 
 The operation was not followed immediately by un- 
 usual hemorrhage ; but, within two or three hours, 
 the flow of blood had increased to an alarming extent, 
 so as to run from the mouth in a continuous stream. 
 The indications were that the patient w 7 ould soon die. 
 She had become very weak. On examination, the 
 blood was found issuing only from the socket of one 
 
HEMORRHAGE — TREATMENT. 399 
 
 root of an inferior molar. The mouth and socket 
 being cleansed of blood and coagulum, it was perceived 
 that the hemorrhage was from a small artery at the 
 bottom of the socket, spouting out in jets with the 
 pulsations. The treatment consisted in rolling up 
 pledgets of cotton very tightly, saturating them with 
 creosote and tannin, and forcing them in on the bot- 
 tom of the socket, so as to make compression upon 
 the bleeding vessel. The socket was then filled up, 
 compression made, and the head bandaged in the 
 manner already described. Thus the hemorrhage 
 was immediately checked, and did not return. The 
 constitution of this patient was of a scorbutic dia- 
 thesis. 
 
 Excessive bleeding often does not occur till con- 
 siderable time after an operation ; and it may come 
 on without any exciting cause, or be induced by 
 vigorous muscular exercise, or by any intense mental 
 excitement. Everything of this kind should be 
 avoided, where there is a predisposition to hemor- 
 rhage, and everything invited, that would tend to 
 maintain the equilibrium of the circulation and the 
 utmost quiet. 
 
400 ACCIDENTS IN THE EXTRACTION OF TEETH. 
 FRACTURE OF THE ALVEOLUS. 
 
 The ordinary fracture of the alveolus is a matter 
 of no considerable consequence, if it receives proper 
 attention. This fracture occurs to a greater or less 
 extent under the following circumstances: first, when 
 there is great divergence of the roots, so that the 
 tooth can not pass from its socket, unless one or more 
 of them are broken off, or the alveolus fractured ; 
 second, where the tooth is forced out of the socket at 
 a very considerable angle with its axis ; third, where 
 the alveolus is very firmly attached to the roots, and 
 is very thin toward the points of these. Usually, the 
 fracture is of that part which forms the socket of the 
 tooth removed ; and when this is the case, it is of 
 but small moment. It sometimes, however, extends 
 far beyond this, involving the alveolus of from one to 
 four of the adjacent teeth, and causing very serious 
 injury, even the loss of the teeth themselves. Ex- 
 tensive fracture, however, is far less liable to occur 
 now, than when less perfect instruments were em- 
 ployed. When the key was in general use, extensive 
 fracture of the alveolus was frequent; but with the 
 forceps, it is comparatively rare. 
 
 When an accident of this kind does occur, all of 
 the detached portion, whether large or small, should 
 be removed. A pair of bone nippers, or enucleating 
 
FRACTURE OF THE ALVEOLUS. 401 
 
 forceps will answer for this purpose. If there is much 
 attachment to the soft parts, it should be dissected 
 off, and then removed. If such fractured portions 
 are permitted to remain, inflammation, and oftentimes 
 sloughing of the gums, will ensue; necrosis of the 
 bone is also sometimes produced by detached bone 
 remaining in contact with the living. 
 
 Sometimes extensive fracture occurs, involving the 
 adjacent bony structure. In the case of Mr. W., in 
 an effort to remove the first superior molar, the outer 
 wall of the alveolus was separated from the other 
 teeth. The fracture extended almost to the zygo- 
 matic process, and detached a portion of the floor of 
 the antrum, as well as a part of its outer wall. After 
 the removal of this detached portion, there was a 
 considerable external depression, that very much 
 marred the form and symmetry of the face. 
 
 Fracture of the alveolus should always be guarded 
 against as carefully as possible. It always makes an 
 unfavorable impression, on the mind of the patient, 
 which in many cases no explanation can obliterate. 
 Whenever the accident does occur, the disagreeable 
 knowledge of it may, if practicable, remain a secret 
 with the operator. 
 
402 ACCIDENTS IN THE EXTRACTION OF TEETH. 
 
 LACERATION OF THE GTJMS. 
 
 The gums are often bruised and lacerated with the 
 key in the extraction of teeth. But this accident 
 seldom happens with the forceps; indeed, never, un- 
 less the gum is very firmly attached to the neck of 
 the tooth, and has not been separated with the lan- 
 cet. The gum will sometimes be lacerated by adher- 
 ing to a piece of the process, while the tooth is drawn 
 from its socket, with the process and gum attached. 
 With the various hooks and punches, the gums^ lips, 
 and cheeks are sometimes wounded. Accidents of 
 this kind are to be prevented by placing a ringer of 
 the left hand, or a guard made of a roll of linen, in 
 front of the instrument. When any considerable 
 portion of the gum is lacerated, the detached portion 
 should be cut off. The worst consequences from 
 laceration of the soft parts occur where there is a 
 hemorrhagic diathesis. The most effectual means 
 «of preventing accidents of this kind is to separate the 
 gum perfectly, and guard well the points of the 
 instrument. 
 
 BREAKING THE TEETH. 
 
 This is an accident of no small consequence, and is 
 liable frequently to occur in the use of imperfect, ill 
 
BREAKING THE TEETH. 403 
 
 adapted instruments, or in the unskillful use of good 
 ones. It is of very common occurrence when the key 
 is employed for extracting, even in the hands of those 
 who claim to be skilled in its use. And with forceps, 
 too, of the primitive form, the teeth were so fre- 
 quently broken, as almost to preclude their use as 
 extracting instruments. This accident usually occa- 
 sions great pain to the patient, as well as protracts 
 the operation, and diminishes his confidence in the 
 ability of the operator. One s*uch accident will 
 create more prejudice than fifty skillful operations 
 can obliterate. 
 
 In all cases where a tooth is broken, the root, if 
 possible should be removed; for, if it be not, con- 
 tinuous or periodical pain, inflammation, alveolar 
 abscess, and like affections, are liable to ensue. 
 The remark is often made, when teeth are broken, 
 that the gums will close over the roots and thus 
 effectually protect them, and no disagreeable conse- 
 quences will follow. In no ordinary case will the 
 gums unite over even the smallest portion of root 
 that may have been left in the socket. 
 
 REMOVAL OF A WRONG TOOTH. 
 
 There is very rarely any excuse for the removal of 
 a sound, healthy tooth in the immediate vicinity of a 
 
404 ACCIDENTS IX THE EXTRACTION OF TEETH. 
 
 diseased one, unless it be in a case of those deep- 
 seated, hidden affections which are difficult to diag- 
 nose. It sometimes happens, however, that a sound 
 tooth is removed; and when a mistake of this kind 
 is made, the diseased tooth should also he at once 
 removed, and then, if the conditions are favorable, 
 the healthy one should be immediately replaced. 
 The circumstances most favorable for such replace- 
 ment, are, a good constitution in a state of health, 
 and a normal condition of the mouth, especially of 
 the gums and mucous membrane, so that the attach- 
 ment would take place with as little inflammation 
 and soreness as possible. If the tooth is necessarily 
 kept out of the mouth many minutes, it should be 
 placed in water at about blood heat: and before the 
 replacement, the socket should be thoroughly cleansed 
 of coagulum. The tooth is then introduced, pressed 
 firmly to place, and allowed to remain without dis- 
 turbance or irritation, till the attachment has become 
 complete. During the time it is reuniting, treatment 
 may be required to counteract inflammation. Meager 
 diet, abstinence from stimulants, and quiet, should 
 always be recommended in the case. 
 
 This operation has been wholly condemned by some 
 very g:od dentists. Dr. Koecker declares that it 
 should never be attempted. But numerous success- 
 ful cases, well attested, give assurance that it may 
 
REMOVAL OF A WRONG TOOTH. 405 
 
 very frequently be accomplished with the most satis- 
 factory results. Mr. T., aged 15 years, of.good consti- 
 tution, and in good health, and with the mouth princi- 
 pally in a normal condition, had the second inferior 
 bicuspid of the left side removed by mistake, the first 
 molar being the offending tooth. The former was at 
 once put into cold water, and the latter forthwith 
 extracted. The socket of the bicuspid was then 
 cleansed, and the tooth replaced. There was slight 
 soreness for a few days, after which the tooth was 
 found to have made a firm and permanent reattach- 
 ment; and from that time to this — twenty-five 
 years — it has remained perfect, and is now as healthy, 
 lifelike, and valuable as any other tooth in the mouth. 
 
 Since the issue of the first edition of this work* 
 many cases have come under the observation of the 
 writer, in which detached teeth have been replaced, 
 and become as firmly fixed in the sockets as before re- 
 moval, and remained in apparently a healthy condition 
 so far as the attachment is concerned. In some of 
 these cases very unfavorable conditions were present. 
 
 So numerous and successful have these cases been, 
 that the feasibility of replacing teeth that have been 
 improperly removed, is a matter no longer to be con- 
 troverted, and especially when favorable conditions 
 exist — good health and tone, both general and local. 
 and the parts involved not too much fractured and 
 lacerated. 
 
406 ACCIDENTS IN THE EXTRACTION OF TEETH. 
 
 DISLOCATION OF THE INFERIOR MAXILLA. 
 
 The dislocation of the inferior maxilla is an acci- 
 dent of not very frequent occurrence. In persons of 
 lax muscles and with large mouths, the operation of 
 extracting teeth is liable to produce it; sometimes 
 when the operation is on the upper jaw, but more 
 frequently when it is on the lower. In the former 
 case, it is an effect of the patient's effort to open the 
 mouth; but in the latter, generally that of the move- 
 ment of the jaw by the instrument. The dislocation 
 consists in a downward and forward movement of 
 one or both of the condyles, so that they are thrown 
 out of their sockets, and rest in front of the anterior 
 rim. In such case, the mouth is distended to its 
 utmost, the chin thrown down on the breast, and 
 deglutition and speech rendered impossible. Some- 
 times but one condyle will be thrown out; in which 
 case the jaw is thrown downward and to one side. 
 
 This accident seldom or never occurs with patients 
 who have small mouths or firm muscles. When it 
 does happen, however, the dislocation should be 
 promptly reduced. Of the various methods of accom- 
 plishing this reduction, the one most commonly em- 
 ployed, which is very efficient, is as follows: if both 
 condyles are dislocated, place corks, or some similar 
 

 DISLOCATION OF THE INFERIOR MAXILLA. 407 
 
 substance, between the superior and the inferior molar 
 teeth of both sides; and then, with the fingers of 
 both hands, make firm, steady pressure on the chin 
 upward and backward, thus forcing the condyles 
 downward and backward into their proper places. 
 If but one condyle is out, the cork should be ap- 
 plied only on that side, and in the manner already 
 directed. Another method is, to substitute the 
 thumbs of the operator for the corks, placing them 
 in the same position between the teeth, and manipu- 
 lating with the fingers on the chin, as before. The 
 patient should be placed in a recumbent position for 
 the operation. Another method is, to make down- 
 ward and backward pressure on the coronoid process, 
 and in this manner cause the condyles to glide into 
 their places. This accomplishes the reduction with- 
 out taking hold of the jaws, or placing a fulcrum 
 between them. 
 
 This accident is far more liable to occur the second 
 time in the same case. In extracting the lower molar 
 teeth for one who has suffered a dislocation, or is pre- 
 disposed to it, the lower jaw should be very firmly 
 supported with the left hand; or, the accident may 
 be prevented by placing a bandage under the chin, 
 and over the head, so that the mouth can not be 
 opened to its furthest extent; and this is the surest 
 method. In all cases after an accident of this kind. 
 
408 ACCIDENTS IN THE EXTRACTION OF TEETH. 
 
 the patient should abstain from solid food for a few 
 
 days, or at least till the soreness is abated, and avoid 
 everything promotive of inflammation. 
 
 SYNCOPE. 
 
 * 
 
 Syncope, or minting, is frequently brought on by 
 extraction of the teeth, and even by other operations 
 upon them; indeed, it is sometimes produced simply 
 by cutting the gums, or by the sight of blood, or, in 
 some instances, by dread of an operation. It con- 
 sists in an intermission of the heart's action, and 
 consequently irregularity of the circulation of the 
 blood, accompanied with a temporary suspension of 
 the functions of the brain and a loss of consciousness. 
 Difficult or suspended respiration, lividness of the 
 skin, and inability to move, are the external indica- 
 tions of the condition. There are no constitutional 
 appearances known, by which a predisposition to 
 syncope can be determined : persons of all apparent 
 conditions and peculiarities are subject to it. The 
 most strong, robust, and healthy sometimes faint 
 under the most trivial influences; while others, of 
 the weakest and feeblest constitutions, can not be 
 brought into this condition by any ordinary means ; 
 so that nothing can be predicated of appearances as 
 to such predisposition. The fainting may occur- once 
 or twice in the same case, even under the most sim- 
 
SYNCOPE. 409 
 
 pie operation, owing to some temporary condition of 
 the system, and never happen again under any cir- 
 cumstances whatever. 
 
 It sometimes comes on before, sometimes after, and 
 sometimes during, the operation. There is greater 
 liability to it after a recent meal than after digestion 
 is completed, since the nervous energy, during diges- 
 tion, is directed to the stomach and its appendages, and 
 thus the circulating apparatus has less of nervous force. 
 The frequent occurrence of syncope indicates a 
 constitutional predisposition to it, and may enable 
 the operator to anticipate it to some extent, by the 
 aid of stimulants, such as brandy, or, what is in 
 some respects preferable, a galvanic current. The 
 patient subject to such affection, should be placed, 
 for an operation, as nearly as practicable in a recum- 
 bent position— especially for the extraction of teeth — 
 and his mind kept as tranquil as possible. 
 
 To restore the patient from syncope, place him in 
 a horizontal position, the head quite as low as the 
 body, and apply volatile stimulants to the nostrils. 
 and dash water on the face and chest. All compres- 
 sion should be removed from the body, especially 
 from the chest, as it would constrain the action of 
 the respiratory muscles. This remark is peculiarly 
 applicable to female patients. This treatment will 
 usually be quite sufficient to effect a rapid reaction 
 and resuscitation. 
 
CHAPTER XIII. 
 
 ANESTHETICS. 
 ETHER CHLOROFORM NITROUS OX IDE . 
 
 Sulphuric ether was the first agent successfully 
 employed for producing insensibility to pain during 
 surgical operations. It was brought to the notice of 
 the profession in 1846 by the late Dr. Horace Wells, 
 of Hartford, Conn. 
 
 The mode of administering it is, by inhalation of 
 the vapor; and it produces its effects in a short time, 
 depending on the quality of the ether, the amount of 
 air introduced with it, and the susceptibility of the 
 patient. A complicated instrument, denominated an 
 inhaler, was first employed for its administration; but 
 it soon became apparent that this was not at all 
 necessary, and that simpler methods were preferable, 
 because more easily regulated and adapted to varying 
 circumstances. The best method is, to inhale it from 
 a sponge or napkin, since, in this way, the admission 
 of the air can be controlled entirely by the will of the 
 
ETHER — CHLOROFORM. 411 
 
 operator, graduating it to the requirements of the 
 case. 
 
 During the administration, the patient should be in 
 a reclining posture; though it is held, by much good 
 authority, that a horizontal position is the safest, 
 because, in that, the force of the circulation is most 
 nearly equalized. In the administration of general 
 anaesthetics, the circulation is always more or less 
 affected. It is an opinion very generally received, 
 and probably correct, that, where there is functional 
 derangement of the heart, lungs, or brain, general 
 anaesthesia should not be employed. This opinion, 
 however, is perhaps derived more from analogy than 
 from actual observation. It is true that, other things 
 being equal, the liability to injury in such case would 
 be greater; but the danger with both ether and chlo- 
 roform is, that there are cases in which there is an 
 undefinable and undetectable idiosyncracy, or malsus- 
 ceptibility of its influence, to a great extent indepen- 
 dent of pathological conditions. 
 
 The patient having been placed in a comfortable 
 position, and his mind freed as far as possible from 
 apprehension, he should be directed to breathe tran- 
 quilly by full inspirations, carefully guarding against 
 any compression of the chest, so as to allow the re- 
 spiratory muscles free play. During the administra- 
 tion of the anesthetic, a strict watch must be main- 
 
412 ANESTHETICS. 
 
 tained over the patient, having reference to the fol- 
 lowing points : the breathing should be free and easy, 
 without irritation of the throat or bronchia; the skin 
 should not become blanched, but should retain a 
 florid, lively color; but the great criterion is the 
 pulse, and the indications given here should be strictly 
 observed and obeyed. In order that the operator 
 may follow every indication, he should be familiar 
 with the manifestations of the pulse in different con- 
 stitutions, and under different circumstances. During 
 the administration of ether or chloroform, the pulse 
 usually becomes more frequent ; but it should not be 
 much accelerated, nor its strength and fullness be 
 much diminished. Enfeebled or irregular pulse should 
 in all cases be regarded as a warning; and if the 
 feebleness and irregularity be very marked, the ope- 
 rator should desist. In some instances, death has 
 occurred after a few inhalations ; but perhaps only in 
 the use of chloroform. This fact indicates that the 
 first effects of the administration should be very closely 
 noted. 
 
 The degree to which the anaesthesia should be car- 
 ried, is a matter about which there is much diversity 
 of opinion. Every condition of it, from that of simple 
 allayed irritability to that of complete insensibility 
 and unconsciousness, has its advocates. But the 
 extent to which the administration may be carried, 
 
ETHER — CHLOROFORM. 413 
 
 will be suggested by the indications already referred 
 to, and, if these are unfavorable, should be determined 
 at once. Mere nausea, however, without any other 
 unfavorable symptom, is not a counter-indication in 
 the use of ether or chloroform. 
 
 The method of administering chloroform is the 
 same as that for ether, except that, in the use of the 
 former, more care and closer observation are required. 
 Chloroform is more rapid and powerful in its action 
 than ether, and hence more liable to do injury ; but, 
 independently of this fact, it is generally believed 
 that the former is less safe than the latter, when 
 taken into the system, especially by inhalation. A 
 mixture of ether and chloroform, or chloric ether — 
 usually equal parts of chloroform and ether, but the 
 proportions are sometimes varied — -is used by some ; 
 the object being to secure greater promptness than 
 with ether alone, and incur less danger than with 
 chloroform ; and it is probable that a mutual compen- 
 sation in these respects is thus to be attained. 
 
 If either chloroform or ether has been administered 
 to entire unconsciousness, the patient should be per- 
 mitted to pass out of the condition spontaneously ; 
 for, after such a revival, there will be less liability to 
 unpleasant feelings, as headache, depression, and 
 nausea. The fingers of the person administering the 
 chloroform should be kept on the carotid, since the 
 
414 ANESTHETICS. 
 
 state of the circulation will be better recognized by 
 this than by the radial artery, and it is a more con- 
 venient point for observation. In favorable cases, it 
 is preferable to continue the inhalation till there is a 
 muscular relaxation. 
 
 When a condition arises in which respiration is 
 suspended, and the circulation partially or altogether 
 stopped — a condition of imminent peril — active mea- 
 sures must be resorted to for the patient's restoration. 
 Efforts must be directed to a recovery of the circula- 
 tion, by friction, motion, etc. ; but to restore the 
 respiration, is the first, immediate, imperative con- 
 sideration. Any or all of the ordinary methods of 
 re-establishing suspended respiration may be em- 
 ployed. Cold water should be dashed in the face, 
 and on the throat and chest, and volatile stimu- 
 lants applied to the nostrils ; the glottis should be 
 titillated with a feather, or some such implement, to 
 excite it to action ; and artificial respiration, by some 
 approved method, should be at once adopted. The 
 galvanic current, too, may be brought into requisition, 
 to excite the respiratory muscles to action, and to act 
 also upon the circulation. In all cases of accident of 
 this kind, prompt and efficient measures should be 
 immediately taken; for a delay of a few moments 
 may be attended with fatal results. 
 
NITROUS OXIDE. 415 
 
 NITROUS OXIDE. 
 
 This agent is now used as a general anaesthetic 
 quite extensively in dental practice. Such has not 
 been the case, however, till within the last three 
 years. This agent, when properly prepared, and 
 judiciously administered, is perhaps the safest general 
 anaesthetic in use ; it is very efficient for minor sur- 
 gical operations, and we believe will ere long be found 
 to be applicable to the more protracted and graver 
 operations. Its efficiency is very much modified by 
 its preparation and mode of administration. This gas 
 when pure is colorless, and of slightly sweetish taste 
 and odor ; it is usually prepared by decomposition of 
 nitrate of ammonia. 
 
 It is not the purpose here, to describe the method 
 of preparing this agent, that has been well done by 
 others ; yet it is proper to suggest here, that to a 
 large extent, the knowledge and opinions entertained 
 on this subject have been very circumscribed, and 
 exceedingly erroneous. In the administration of 
 nitrous oxide as an anaesthetic, great care should be 
 exercised to secure the best results. In order to 
 accomplish this, it should be inhaled, and in no case 
 but once, diluted as circumstances may indicate. 
 more or less with pure atmospheric air ; this is ordi- 
 narily necessary only at the beginning, for pure 
 
416 ANESTHETICS. 
 
 nitrous oxide will sustain respiration for an indefinite 
 time. 
 
 To a patient in an anaesthetic state, it is not so 
 readily administered as chloroform or ether ; but the 
 patient under its influence, is quite as manageable as 
 with any other agent, and the anaesthesia as perfect, 
 but not as prolonged without continued administration. 
 
 It is scarcely justifiable in ordinary dental practice 
 to use a more heroic general anaesthetic than the one 
 here referred to. 
 
 LOCAL ANESTHESIA. 
 
 Because of the frequently prejudicial and sometimes 
 fatal consequences to which systemic anaesthesia is 
 liable, local anaesthesia has been brought into requi- 
 sition ; the first method of accomplishing this was by 
 
 Congelation. — This was effected by the applica- 
 tion of two parts of pulverized ice and one of salt, 
 •applied by means of an instrument of the following 
 description : a vulcanized India-rubber tube, about 
 five inches long and one inch in diameter, closed at 
 its superior extremity by a screw-cap, and open at its 
 inferior, which latter is slightly enlarged and cut out, 
 so as to leave two lips to reach down on the sides of 
 the tooth ; within the tube, a follower and a spiral 
 spring, the latter forcing the former down to the open 
 
LOCAL ANESTHESIA. 417 
 
 end. When this instrument is to be used, tie a piece 
 of oiled silk or membrane loosely over its inferior 
 end, fill it expeditiously two-thirds full with the ice 
 and salt, prepared as above, adjust the follower and 
 spring in place, screw on the cap, and apply at once. 
 The sac of the instrument is to be pressed and worked 
 gradually down till it invests a portion of the gum on 
 each side of the tooth to be extracted. As the ice 
 melts in the sac, the follower forces the unmelted 
 portion down next to the tooth and gum. The appli- 
 cation should be continued from one to three minutes, 
 or till the margin of the gum is congealed — as will 
 be indicated by its hardness and whitened appear- 
 ance — and then the tooth should be extracted as 
 expeditiously as possible, though with all the ordinary 
 skill and care. 
 
 If the contiguous teeth are sound, and not to be 
 extracted, they must be protected as far as possible 
 from the influence of the application — as they may 
 be, by having their crowns enveloped in thin sheets 
 of wax, oiled silk, or any other substance that is a 
 non-conductor, and is not too bulky. Where some 
 such protection is not afforded, great injury is liable 
 to ensue. 
 
 If the tooth to be extracted is sensitive, the tem- 
 perature should be reduced by holding in the mouth 
 cold w T ater, and finally a piece of ice; and immediately 
 
 Bli 
 
418 ANESTHETICS. 
 
 after, the instrument should be applied. When the 
 pulp of the tooth is exposed, the application would 
 cause great pain. In such cases, it has been recom- 
 mended first to apply arsenic for twenty-four hours 
 to the exposed pulp. 
 
 Under the full influence of the freezing mixture, 
 the circulation in the part is wholly arrested, and the 
 sensibility entirely obtunded, so that the operation, 
 properly performed, produces no pain. In the ex- 
 traction, the gum, so far as congealed, may, if neces- 
 sary, be embraced by the forceps and broken away 
 without pain. After the operation, cold water or ice 
 should be applied to the part, to prevent a too rapid 
 re-action, which would be very painful, but which, 
 thus graduated, occasions but slight pain, and in some 
 cases none at all. 
 
 The aim in all cases should be to produce congela- 
 tion to the point of the root; for, without this, 
 the extraction will cause pain. And it is far more 
 difficult to effect this object where only the root is 
 remaining ; for the crown when present, serves as a 
 conductor. In the former case, however, a screw or 
 iron wire may be introduced into the root, and left 
 projecting, to serve as a conductor. But in some 
 cases, especially in those of roots, it is improper to 
 attempt the employment of congelation at all. The 
 practicability of a desirable result will depend much 
 
LOCAL ANESTHESIA. 
 
 419 
 
 upon the skill and tact of the operator, and the sus- 
 ceptibility of the parts. In patients of full habit and 
 active circulation, it is very difficult to produce insen- 
 sibility by congelation ; and in such cases great pain 
 usually attends its application. 
 
 Congelation is now far more easily, and efficiently 
 accomplished by the use of ether spray, than by the 
 process just described. So easy of application is it, 
 and so generally efficient, that it is in almost uni- 
 versal use. To Dr. Richardson, of London, is due 
 the credit of having brought this process to its pre- 
 sent state of perfection. 
 
 So accurately does the accompanying engraving 
 
 Fig. 86. 
 
 (Fig, 86) represent the apparatus used in this process, 
 that a minute description is unnecessary. The mode 
 of application and operation is apparent at once. 
 
 The instrument consists of the fluid holder — a four 
 ounce bottle, graduated — the bellows consisting of a 
 
420 ANESTHETICS. 
 
 rubber ball, with the proper valves, and the points 
 from which proceed the spray, and these all con- 
 nected by the proper sized flexible tube. 
 
 It will be observed that there are variously formed 
 points, single and double, straight and curved ; these 
 are required for the various purposes to which the 
 instrument is applied. 
 
 For the extraction of teeth, the double point is 
 applicable, throwing a jet upon the gum each side of 
 the tooth at the same time. The single points are 
 required where an incision or excision is to be made. 
 
 This is a very valuable instrument, and is exten- 
 sively used in minor surgical operations, and is espe- 
 cially adapted to the dentist's use. Ether is perhaps 
 as yet the best agent employed. Rhigolene, a far 
 more volatile fluid than ether, has been used to a 
 limited extent, but owing to its exceedingly rapid 
 evaporation, its action is too violent, and not so easily 
 controlled. 
 
 EXTRACTION BY ELECTRO-MAGNETISM. 
 
 The employment of electro-magnetism in the ex- 
 traction of teeth was introduced to the profession 
 some ten years ago ; and at one time was exten- 
 sively used. There is a great diversity of opinion as 
 to its efficiency for relieving pain ; for, while some 
 
EXTRACTION BY ELECTRO-MAGNETISM. 421 
 
 have been disposed to assume that, when properly 
 employed, it would, in the majority of cases, miti- 
 gate pain, and, in many, obviate it altogether ; 
 others, after having thoroughly tested it, as they 
 affirm, maintain that it does not produce insensibility 
 to any appreciable extent, and consequently does not 
 relieve the pain, but that, at most, it only complicates 
 the sensations, the pain of the tooth-drawing becom- 
 ing involved in the confusion of other feelings, so that 
 the patient can hardly decide whether he has been 
 definitely hurt or not ! 
 
 In using this agent for the process of extracting 
 teeth, the susceptibility of the patient to its influence 
 must be carefully regarded. Some persons are so 
 peculiarly constituted that an electric current is al- 
 most intolerable to them ; while others will receive a 
 strong current with pleasurable sensations. To the 
 former, the electricity would be as painful as the ex- 
 traction of the tooth; but to the latter, when properly 
 applied, it mitigates, and in many cases altogether 
 obviates, the pain. The reason of this difference in 
 its action is not very clearly understood. Several 
 theories in regard to it have been advanced, but 
 none of them sufficiently plausible to challenge con- 
 viction. 
 
 Again, the manner in which, and the condition of 
 the parts to which, this agency is applied, are to he 
 
422 ANESTHETICS. 
 
 closely observed. Where there is acute periostitis, 
 an electric current, even though feeble, would produce 
 intense pain, and should not be applied ; though, in 
 such cases, it has been suggested that an application 
 of the charged sponge to the gums will produce insen- 
 sibility. 
 
 APPLICATION. 
 
 The method of application is very simple. Any 
 ordinary battery, of convenient form, may be em- 
 ployed for this purpose. It should be uniform in its 
 action, and the vibration as short as possible. The 
 common zinc-and-copper battery, with the sulphate- 
 of-iron solution, is perhaps the most convenient and 
 safe. One pole of the battery — no matter which — is 
 attached to the forceps, and the other to a handle of 
 size and form convenient for the patient to grasp. -To 
 ascertain his susceptibility, the current should always 
 first be tested on the patient, by placing the handle 
 and the forceps one in each of his hands, and letting 
 it on first feebly, and then gradually increasing it till 
 he experiences the sensation just beyond the elbows; 
 when, finally, it is to be slightly weakened. The 
 gum having been separated, the forceps, with its ap- 
 pendages, is adjusted to the tooth, the connection 
 made by placing the handle in the patient's hand, and 
 the tooth at that moment removed. It has been re- 
 
APPLICATION. 423 
 
 commended by some to place the forceps on the tooth, 
 and complete the circuit, as above, with the current 
 very feeble, and then gradually increase it to the 
 proper force for the operation. In some instances, 
 perhaps, this would be the preferable mode. 
 
 Another method of producing insensibility by an 
 electric current is, to place two moistened sponges, 
 connected with the two poles of the battery, on the 
 gum, one on each side of the tooth, keep them there 
 a few moments, and then operate. This method ? 
 however, has not yet been sufficiently tested to ascer- 
 tain its merits. 
 
INDEX 
 
 Atrophy, 29. 
 
 cause of, 30. 
 Amalgam, 90. 
 Adhesive foil, 67. 
 Actual cautery, 65. 
 Arsenious acid, 45, 266. 
 
 application of, 68. 
 Alveolar abscess, 97. 
 
 treatment of, 99. 
 Attachment of an artificial crown, 314. 
 Accidents in the extraction of teeth, 388. 
 Anaesthetics, 410. 
 Application of electro-magnetism, 422. 
 
 Broaches, 101. 
 
 Bur drill, 96. 
 
 Breaking of the teeth, 402. 
 
 Chloroform, 410. 
 Chemical abrasion, 37. 
 
 cause of, 38, 
 Comparative liability of the teeth to decay, 63. 
 Caries of the teeth, 42. 
 
 causes of, 52. 
 
426 INDEX. 
 
 Caries, exciting causes of, 56, 
 
 consequences of, 65. 
 
 treatment of, 67. 
 Crystal or sponge gold, 88, 174, 198. 
 Classification of decayed cavities, 183. 
 Creosote or carbolic acid, 241. 
 Chloride of zinc, 243. 
 
 Conditions to be observed in extraction of the teeth, 342. 
 Cylinder or block filling, 159. 
 Cobalt, 271. 
 
 Deposits, 18. 
 
 points of, 20. 
 Denuding, 35. 
 Drills, 99. 
 Drill stocks, 103. 
 Drying cavities, 139. 
 Destruction of the pulp, 260. 
 Dislocation of the inferior maxilla, 406. 
 Dental periostitis, 290. 
 
 treatment of, 293. 
 
 Ether, 410. 
 
 Extraction preparatory to the insertion of artificial dentures, 380. 
 
 Exostosis, 32. 
 
 effects of, 34. 
 
 cause of, 34. 
 Examination of decays, 135. 
 Excavators, 105. 
 
 manufacture of, 109. 
 Exposed pulps, 249. 
 
 treatment of, 251. 
 
 destruction of, 260. 
 Extraction of teeth, 325, 358. 
 
INDEX. 427 
 
 Extracting instruments, 334. 
 Elevators, 351. 
 
 Extraction by electro-magnetism, 420. 
 Extraction of the inferior incisors, 371. 
 
 Filling teeth, 134. 
 
 examination of, 135. 
 
 opening cavities, 136. 
 
 drying cavities, 150. 
 
 removal of decay, 138. 
 Forming cavities, 142. 
 Forming blocks, 160. 
 Finishing fillings, 179. 
 Filling by classes and modifications, 185 . 
 Filling with foil, 195. • 
 Filling with adhesive foil, 196. 
 
 Filling large cavities on the labial surfaces of superior incisors, 231. 
 Filling pulp-cavities and canals, 273. 
 Forceps, 340. 
 Fracture of the alveolus, 400. 
 
 Green tartar, 24. 
 
 its origin, 25. 
 
 treatment of, 26. 
 General remarks on filling, 73. 
 Gold, 85. 
 
 General remarks on extraction, 325. 
 Gum Lancet, 354. 
 
 Hooks, 352. 
 
 Hemorrhage, 389. 
 
 Heavy cutting-instruments, 97. 
 
 Hill's stopping, 94. 
 
428 INDEX. 
 
 Inferior molars, extraction of, 375. 
 Inflamed dentine, 234. 
 
 treatment of, 237. 
 Inferior dens sapientise, extraction of, 37' 
 Inferior bicuspids, extraction of, 374. 
 Introduction, 17. 
 Instruments for filling, 97. 
 Introducing the filling, 154. 
 Introducing the blocks, 163. 
 Indications for extraction, 332. 
 Inferior cuspids, extraction of, 372. 
 Irregularity of the teeth, 27. 
 
 effects of, 28. 
 
 Lead for filling, 81. 
 Laceration of the gums, 402. 
 Local anaesthesia, 416. 
 
 Materials for filling, 77. 
 
 metallic, 77. 
 
 non-metallic, 93. 
 Manufacture of excavators, 109. 
 Mode of using the file, 123. 
 Metallic pivots, 319. 
 
 Necrosis of the teeth, 39. 
 
 causes of, 41. 
 Nitrate of silver, 241. 
 
 Opening cavities, 136. 
 Os artificial, 96. 
 
 Platinum, 84. 
 
 Plugging instruments, 111. 
 
INDEX. 429 
 
 Pathological conditions, 233. 
 
 Potential cautery, 266. 
 
 Preparing the teeth and roots for filling, 281. 
 
 Pivot teeth, 307. 
 
 fitting crowns of, 311. 
 
 attachment of, 314. 
 Pellets for filling, 166. 
 
 Removal of the dens sapientise, 368, 379. 
 Removal of decay, 138. 
 Removal of a wrong tooth 7 403. 
 
 Saliva pump y 190 o 
 
 Screw, 353. 
 
 Silver, 83. 
 
 Separation of the teeth, 127. 
 
 Special cases, 226. 
 
 Superior cuspids, extraction of, 361. 
 
 Superior bicuspids, extraction of, 362, 
 
 Syncope, 408. 
 
 Scranton's drill r 10L 
 
 Tartar, 18. 
 
 origin of, 19. 
 
 points of deposit, 20. 
 
 effects of, 21. 
 
 method of removing, 22. 
 Tin, 80. 
 
 The mallet, 171. 
 The file, 119. 
 
 use of, 122. 
 The palatal portion of the crown broken away, leaving the outer por- 
 tion standing — nerve not exposed, 227. 
 Treatment of inflamed dentine, 237. 
 
430 INDEX. 
 
 Tannin or tannic acid, 240. 
 Terchloride of gold, 244. 
 ' The key, 336. 
 
 The method of lancing the gums, 357. 
 Treatment of hemorrhage, 391. 
 
 Various preparations of gold, 87. 
 
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