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DENTAL PKACTICB.
NOTES
ON
DENTAL PRACTICE.
BY
HENRY C. QUINBY,
LICENTIATE IN DENTAL SURGERY OF THE ROYAL COLLEGE OF SURIiBONS IN
IRELAND AND MEMBER OF THE ODONTOLOGICAL SOCIETIES
OF NEW YORK AND LONDON.
WITH ILLISTRATIONS.
PHILADELPHIA :
THE S. S. WHITK DENTAL MANUFACTURING CO.
1884.
PKEFACE.
It lias not been my purpose, in this work, to
attempt to wade in the deep waters of physio-
logical and pathological research. I am content
to leave the elaboration of theories, and the
search after causes, in the able hands that are
now, on both sides of the Atlantic, pursuing
these investigations with a trained skill which
cannot fail to give us much more light on the
now hidden, or only suspected, sources of dental
disease, and to confine myself, as strictly as a
clear explanation of my meaning will permit, to
the treatment of abnormal conditions of the
teeth.
Dentists may well be proud of the progress
that has been made in the last fifty years,
not only in the facilities for teaching, but in
the matter taught, in dental science. Even
twenty-five years ago the men of education and
social position in our profession were few in
number, while the rank and file were looked
VI PREFACE.
upon as mere petty tradesmen — deservedly so —
for they held their knowledge as a collection
of trade secrets, to be jealously guarded, and
handed down from father to son as so much
stock-in-trade ; and they scarcely dreamed of
the possibility of improving their position, and
increasing their professional knowledge by the
free interchange of thoughts and ideas with their
fellow-practitioners. The dealer in dental instru-
ments and materials looked upon the majority of
his customers as his inferiors in every respect, and
if he listened at all to any suggestions for im-
proving his wares, it was with the indulgence
and condescension of one who was quite sure he
knew, better than anybody could tell him, what
a dentist needed, and that what he considered
proper should be accepted with thankfulness.
To the general public the word dentistry meant
tooth pulling, and as in the last century the
barber practised blood-letting and called himself
a surgeon, so, within the memory of many
dentists, the chemist has considered himself a
dental practitioner because he possessed a key
for extracting teeth.
But a brighter prospect for dentistry began
to open in the second quarter of the nine-
PREFACE. Vll
teenth century. Societies were organised and
meetings held for the discussion of professional
subjects. A dental hospital was established in
London, and the example was soon followed in
some of the other large towns, and students
were admitted to see the operations. A College
of Dentistry followed naturally, and finally the
Dentists' Act of 1878 was obtained from Parlia-
ment by the sheer persistency of a few of our
leading men, against whom every possible form
of discouragement had been hurled. But this
Act gave us a position in the list of learned
professions, which we may reasonably hope will
continue to be, as it has been, attractive to
men of education and natural mechanical ability.
There is, however, much yet to be learned ;
and the teachings of experience, as well as the
researches of trained scientists, being valuable
to the student, it becomes the duty of those
who have seen much practice to make its lessons
known to the profession, and thus add as much
as possible to the available knowledge. This,
therefore, must be my excuse for publishing
these notes.
IX
CONTENTS.
CHAPTER I.
The Temporary Teeth ... ... ... ... 1
CHAPTER II.
The Permanent Teeth ... ... 25
CHAPTER III.
Extraction as a means of Preventing Decay... 59
CHAPTER IV.
Irregularities 87
CHAPTER V.
Treatment of Adult Teeth ... ... ... 114
CHAPTER VI.
Amalgam ... .. ... ... ... ... 169
CHAPTER VII.
Pivoting ... 180
CHAPTER VIII.
Gutta-Percha for Impressions ... ... ... 192
XI
LIST OF ILLUSTRATIONS.
Partially developed bicuspids between the roots of the
temporarj^ molars ... ... ... ... 6
Bicuspids in malpositions, which may be caused by pre-
mature extraction of the temporary molars; four illus-
trations ... ... ... ... ... 7
The effect upon the teeth of thumb-sucking . . ... 21
The effect upon the teeth of sucking the fingers ... 22
The eflfect upon the teeth of sucking the tongue ... 23
Gold caps for gutta-percha fillings ; three illustrations ... 32
Wide foramina in the imperfectly developed roots of molar
and bicuspid 37
Regulating-plate for moving a central incisor forward ... 42
Regulating-plate for turning a central, and moving a
lateral incisor forward .. ... ... ... ... .44
Retaining-plate for holding the same teeth in position
imtil the new alveoli are formed ... ... ... 45
A good mouth mirror; two illustrations 48
Manner of holding the mirror while operating ... ... 49
Imperfect and interrupted formation of enamel on front
teeth; four illustrations .. 54,55
Approximal surfaces of teeth cut away to prevent decay 57
Upper molar elongated so as to prevent the closing up
of gap where a lower molar has been extracted ... 61
Prominent upper canines 65
Second bicuspids extracted, and approximal surfaces of
other teeth cut away to prevent decay ... ... 66
Upper and lower teeth where the six year molars have
been extracted to prevent decay ... 67
Extracting instruments for six year molars ; seven illus-
trations ... ... ... ... ... ... 71, 72, 7;^
Position of twelve year molars and wisdom teeth at
different periods 80
Xll
PAGE
Upper and lower teeth of a boy at sixteen years of age,
the six year molars having been extracted at twelve
to prevent decay SI
Effect of extracting six year molars on one side and
neglecting to do so on the other side 84
Upper canine erupted in a wrong position at twenty-three
years of age, and moved to its proper place; three
illustrations 90, 91, 92
Canine and bicuspid out of position, and plate for correcting
the fault; two illustrations 93, 94
Upper front teeth projecting and lower teeth shutting
against the palate ... ... ... ... ... ... 94
Regulating-plate to cause elongation of back teeth ... 9.5
Treatment of projecting upper teeth with lower teeth
shutting against the palate; nine illustrations
96, 97, 98, 99, 100, 101, 102
Treatment of projecting upper teeth, with lower teeth
of normal length; six illustrations ... 102, 103, 104, 105, 106
Faulty articulation and treatment showing change in
form of upper jaw; four illustrations ... 107, 108, 109
Use of jack screws in regulating; four illustrations ...109, 110
Forms of regulating plates; five illustrations 112, 113
Use of the mouth mirror in operating ... 119
Various shapes of chisels and excavators ; two illustrations 122, 123
Loss of tooth substance from erosion ; three illustrations 158, 159, 160
Pivoting; five illustrations 181, 182, 185
Pivoting, retaining one cusp of a bicuspid and restoring
the other: four illustrations 190, 191
NOTES ON DENTAL PRACTICE.
CHAPTER I.
The Temporary Teeth.
Although the dentist may not often be called
upon to watch professionally the development and
eruption of the temporary teeth, or to treat the
constitutional disturbances so commonly prevalent
while this process is going on, he cannot fail to
take an interest in the progress of first dentition,
and his skill is, unfortunately, too often urgently
needed to alleviate pain in these temporary organs,
long before they are removed by the natural process
of absorption, to make room for their permanent
successors. It cannot be too strongly impressed
upon the mind of the student in dental surgery
that the preservation of the milk teeth, and their
retention in the mouth, in a healthy condition if
possible, are subjects worthy of his careful atten-
tion, and of the greatest importance to the proper
development and arrangement of the permanent
teeth. And when, as is too often the case through
neglect and inattention, or as the result of illness,
these teeth become a source of pain to the child,
the scientific dentist should be able to find some
]S DENTAL PEACTICE.
method to relieve the sufferer without resorting to
the only treatment which was possible when the
blacksmith and the barber were the usual operators.
At about three years of age the child should
have all the temporary teeth, ten in each jaw. Mr.
Tomes fixes the average age for the completion of
first dentition at forty months. And it is our duty,
as professional men, to teach those who have the
charge of children that the mere observation of
the fact that twenty teeth have appeared, is not
all that is needed. These teeth should be cared for
from the first moment of their eruption. The brush
must be used for the child until the little one is well
enough to be trusted to use it efficiently. The teeth
must be watched to see that they are not becoming
carious, and in order to give the child the benefit of
professional assistance as soon as possible, should
any disease appear, and before it should have time
to make serious progress. It is an advantage to the
child to become accustomed to having the mouth
examined ; to be made to feel that cleanliness
there is as essential as cleanliness of the skin ; to
establish a habit of attention to the teeth as early
as possible ; and to have the mind impressed with
the idea that such attention is of the greatest im-
portance to health and comfort. It cannot be
supposed that a child of two or three years of age
is conscious of the necessity of a daily bath and
frequent washing of the hands and face, but it
submits to such attentions as a matter of obedience
at first, and constant use creates the habit, and
THE TEMPORARY TEETH. 3
maintains the practice after mere unreasoning obedi-
ence has ceased to be a controlling power; thus
bridging over the period between the performance of
the act in obedience to authority, and the continu-
ance of the same from a sense of duty consequent
upon the development of the reasoning powers.
The daily use of the tooth-brush in the child's
mouth prevents decay, at least to a certain extent ;
but it does much more than this, — it creates a want,
a feeling that neglecting to brush the teeth is
neglect of personal cleanliness, which feeling, if it
is not developed in early childhood, will not be
developed at all, or, at any rate, not until it is too
late for the teeth to have the advantage of care
while they need it most.
If parents themselves are unable to make the
needful examination of the child's mouth, the
family doctor, or the dentist, should be asked to do
it ; though I am very decidedly of opinion that the
examinations should, at least, be commenced at
home, in order that no idea of fear should be asso-
ciated with the performance of this duty. Children
wdll learn, much more readily, to take the needful
care of their teeth, when the parents show a real
interest in teaching them to do so ; and the parents
themselves will learn, by experience, that it is best
to avoid the absurd practice of speaking and acting
as though the attentions of the dentist were some-
thing to be dreaded, and prepared for as if life itself
were at stake.
As the child is taught by the tone of home con-
4 DENTAL PRACTICE.
versation to expect something dreadful, the first
work of the dentist is to correct this erroneous
impression, and the task will sometimes tax his
patience to the utmost limit. Possibly two or three
persons will accompany the child on the first visit
to the dentist, and all will eagerly unite in well-
meant assurances of the harmless intentions of the
good man, who only wants to cure baby's pain,
mingled with expressions of pity, condolence, and
entreaties for brave endurance, the only effect of
which is to make the child feel instinctively that
some deception is intended, and naturally to in-
crease its terror.
The difficulty is the want of knowledge on the
part of the parents as to what their children's
teeth need. Most of them associate only one idea
with a visit to the dentist, and it is therefore the
duty of the latter to teach while he practices ; to
endeavour to the best of his ability to correct the
false ideas of the parent as well as of the child ;
and to learn gentleness and patience himself, in
order to make his teaching the more effective.
If the periodical examinations reveal the com-
mencement of decay in any of the child's teeth,
prompt measures must be taken to stop its progress.
Sometimes this can be done by cutting away the
decay with chisel and file, and sometimes by fillings.
A sensible discretion on the part of the dentist
will teach him what should be done, and what
should be left alone. The time the teeth are to
remain, and the extent and probable progress of
THE TEMPORARY TEETH.
the decay, will have to be considered; and, generally,
the operations should be attended with as little
pain to the youthful patient as the necessities of
the case will permit, and such as will save the
teeth as long as nature requires their presence in
the mouth.
Simple fillings of some of the preparations of
gutta-percha will be effective in all approximal
cavities that cannot be cut away with the chisel, and
amalgam will serve best in grinding surface cavities.
I have seen gold used for this purpose in tem-
porary teeth, but the practice seems to me some-
thing worse than an absurdity. There can be no
possible advantage in it. The difficulties in the way
of making good gold fillings in the teeth of a child
of such tender years must, indeed, render such
work less effective than the more simple fillings;
and the operation itself is far too trying for a child,
who is too young to see why its endurance should
be so exercised; nor should the operator ever forget
the danger of teaching the child to dread a visit to
his surgery.
Extraction is rarely necessary as a mere cure
for pain, and should never be resorted to when
this alone is the object. Probably no one would be
satisfied to say that contraction results from extrac-
tion of the first teeth, and that therefore extraction
is an unjustifiable interference with the advance-
ment of the second teeth, for to say this and no
more would be to form a very inaccurate idea of
what takes place. Nevertheless, there is coutrac-
6
DENTAL PRACTICE.
tion, for absorption of the alveolus follows the
extraction of the first, as surely as it does that of
the second teeth, and I have seen cases where the
premature loss of the temporary molars caused so
much shrinkage of the gum, that one would almost
feel inclined to doubt whether the bicuspids had
not also been removed. We know that in such
cases the eruption of the bicuspids is often very
much delayed, and there can be little doubt that
^/T
Figure 1. — Showing the partially developed bicuspids between the roots
of the temporary molars.
the partially developed crown of the bicuspid, lying,
as it does, in its crypt, between the spreading roots
of the temporary molar— -(^S^e Fig. 1) — may often be
so displaced or turned in its position in the dental
arch, by the wrenching out of the molar, as to cause
its final development in some of the malpositions
shown in Figs. 2, 3, 4 and 5.
THE TEMPORARY TEETH.
FigoreB 2, 3, 4 and 5. — Showing the bicuspids in malpositions which may
be caused by premature extraction of the temporary molars.
S DENTAL PRACTICE.
We know, too, that it takes but little pressure at
this early age to change the position of a tooth ;
that pressure will cause absorption of the alveolus
on the side of the tooth opposite to which it is
applied, and that the growth of the maxillary bones
is between the second temporary molar and the
tuberosity of the one, and the second temporary
molar and the ramus of the other. Therefore we
may infer that, as this growth is dependent upon the
formation of new teeth in this locality, it would not
take place if room were made for the teeth to de-
velop in space already provided. If we extract the
second temporary molar in either jaw before the
development of the permanent molar is complete,
there is nothing to prevent the permanent molar
from occupying that space, so far as mere space
is needed for the completion of its development.
The second bicuspid is still in an early stage of
formation, and is a much smaller tooth than its
predecessor, so that it cannot act as a barrier to
the molar moving forward. Thus we may regard
it as almost a certainty that, if one of the temporary
molars should be extracted before the permanent
ones were ready to be erupted, the growth of the
jaw would be interrupted, and a part of the space
reserved for the ten anterior permanent teeth would
be occupied by one that should have found space
by additional growth.
But there is still another, and, in some respects,
a worse result from the premature extraction of the
temporary molars. We have just seen that the
THE TEMPORARY TEETH. 9
roots of the temporary molars diverge very much to
make room for the development of the bicuspids,
therefore the extraction of a tooth so formed must
of necessity be a very painful operation. It is not
an uncommon thing for a bicuspid to be so much
smaller than the molar that it will not occupy all
the space between these wide- spreading roots, and
in such a case the roots of the molar may not be
equally affected by the process of absorption, so that
the bicuspid will be diverted from its position, and
we are obliged to extract the molar before one or
more of the roots are completely absorbed. We
can then judge how much more painful and diffi-
cult the extraction of such a tooth would be when
its roots are in perfect development, than the
extraction of a permanent molar. Yet a child of
tender years is to be subjected to this operation,
because it is the quickest way to cure a toothache.
The inevitable result must be to create, in the mind
of the child, that dread of the very name of a dentist
which is the greatest stumbling-block in the way of
what should be our chief work — the prevention of
pain by seasonable operations. Is it reasonable to
suppose that a child will come willingly to us, after
such an operation, to have something done to a
tooth which has been painless hitherto ? The
dentist cannot be too careful to avoid causing this
fear of his work, and although operations may be
needful, it is better sometimes to win the confidence
of the child on the occasion of a first visit by doing
nothing, or only some slight operation that will not
10 DENTAL PRACTICE.
give pain, than to terrify the young patient by pain-
ful work, and thus effectually banish it from the
consulting room, until dire extremity of suffering
shall force a visit.
One would scarcely say that premature extrac-
tion of the temporary teeth is never necessary ; but
in the course of an extensive practice for more than
a quarter of a century, I have never met with a case
where I considered it necessary. As I have before
remarked, it is far from being an uncommon
occurrence to have these small patients brought to
us with aching teeth, but I believe these cases may
always be treated without resort to extraction.
Toothache is a symptom, not a disease ; and it
may proceed from a variety of causes, which, how-
ever, rarely affect the temporary teeth ; so that it
will be sufficient for the present to confine our
attention to the two most easily recognised causes
of this pain, viz., inflammation of the pulp, and of
the lining membrane of the socket. When a child
is brought to us suffering from toothache, our first
enquiries should be to ascertain which of these two
causes is responsible for the pain. If it is due to
inflammation of the pulp, the pain may not be felt
at all in the tooth from which it actually proceeds,
but in any of the numerous branches of the fifth
nerve, or, even more remotely, through the connec-
tions of the fifth with the great sympathetic nerve.
More generally, however, the source of pain may be
localised to this extent, that if the pain is caused by
an inflamed pulp in an upper tooth, it will be felt in
THE TEMPORARY TEETH. 11
some of the branches of the superior maxillary
nerve ; while if it proceeds from a lower tooth, the
sensation is felt in some of the branches of the
inferior maxillary nerve. Though this is never
absolutely reliable, it is sufficiently so to be of great
use in determining the source of facial pain. If
the pain is caused by inflammation of the lining
membrane of the socket, there will be little, if any,
difficulty in the diagnosis. The tooth is sensitive
to pressure in the early stages, and this steadily
increases until an abscess is developed, when, of
course, there cannot be any doubt as to the source
of pain. Thus, if there are several decayed teeth
on the painful side, a few simple questions will be
of great service in helping us to decide which one is
the cause of pain. We must not trust too much to
the patient when we have reason to suspect an
inflamed nerve, for the sufferer is more likely to
point out the wrong tooth than the right one. We
must rather trust our own judgment in these cases,
and, when we are satisfied as to the cause of pain,
the treatment is easy.
If there be inflammation and congestion of the
socket, a free opening into the pulp cavity will
almost invariably give instant relief. Syringing
out the cavity with warm water, and, perhaps, if the
tooth is not too sore, cutting away the decayed
parts, so as to make the cavity self-cleansing, will
be all that can be done in a case of this nature. In
the majority of cases it is best to defer the cutting
and shaping of the cavity until the soreness sub-
12 DENTAL PRACTICE.
sides, which, we may be quite sure, will quickly
take place after the putrescent pulp has been
removed by the syringing.
When the pain is caused by an inflamed pulp,
the course of treatment is different, and we cannot
always expect such speedy relief from the suffering.
Having satisfied ourselves that inflammation of the
pulp is the cause of pain, we first gently remove,
with a sharp excavator, the carious bone that covers
the pulp, until we can see the nerve. Quite possibly
we may not be able to go so far as this without
causing a great deal of pain, but with a sharp
instrument it can usually be done, and it is better
to do it, if possible, because the patient is less
likely to suffer afterwards, if the nerve is fairly
uncovered and bleeding ; but this should not be
insisted on too strongly, as a little pain after
leaving the dentist's chair is not so likely to intimi-
date the patient for the future, as pain that, to the
child, seems needlessly inflicted by the operator.
If the nerve is wounded so as to cause a flow of
blood from the congested vessels, there will be pain
while the blood is flowing, but the nerve will be all
the more readily acted upon by the devitalizing
dressing which we are about to apply, and if it
is anything more than momentary pain, a little
carbolic acid on a pledget of cotton or a bit of
amadou, applied to the bleeding surface, will
quickly allay the pain. The dressing for destroying
the nerve should be a mixture of arsenious acid and
sulphate of morphia, in equal parts, and ground
THE TEMPORARY TEETH. 13
in a mortar until it is a perfectly impalpable
powder. Four hours' grinding for an ounce of the
mixture is not too much, as the action upon the
nerve being so much more certain when the mix-
ture is finely triturated, it will well repay the extra
trouble ; which, however, is not much when we
consider that an ounce ought to be sufficient to
destroy the nerves of ten thousand teeth ; quite as
many, probably, as will be presented for treatment
in a lifetime of active practice. Arsenic alone is
said to cause great pain, which morphia is used to
prevent. The latter certainly reduces the strength
of the arsenic by one-half, and as I have been
satisfied with the action of the mixture in this
form, I have never been tempted to try a change of
proportions. The best method of using it, accord-
ing to my experience, is to roll up tightly in the
fingers a pledget of cotton about the size of an
ordinary pin's head ; moisten this with carbolic
acid, but not to saturation, and then gently touch-