ing the pledget to some of the powder, a sufficient
quantity will be taken up to serve the purpose ;
it should be placed directly on the nerve, and
covered up with a larger pledget of cotton, sufficient
to till the cavity, and some stiff sandarac varnish
mingled with the fibre. This will efi'ectually prevent
the escape of any of the arsenic, even if the dressing
is left for a week in the tooth ; but great care must
be taken in all cases, and especially in approximal or
buccal cavities near the gum, to avoid leaving even
the most minute quantity of the powder on the
14 DENTAL PEACTICE.
gum, and to prevent its escape from the cavity after
it is placed in position, as death, of the part and
sloughing- will inevitably result from such clumsy
manipulation. The use of such powerful drugs is
only safe when neatness and carefulness are instinc-
tive with the operator ; but clumsiness ought never
to be associated with the practice of dentistry. On
grinding surfaces, where the edges are broken down
so that there is very little depth of cavity, it is
sometimes better to cover the arsenical dressing
with plaster of paris, as this will adhere to the
dentine better than the sandarac. The plaster
should be mixed with hot water, and a few fibres of
cotton may be mingled with it to give it more
strength. If the dressing is quite secure in the
tooth, it cannot do any harm to let it remain for
a week ; but if it is not very^ secure, owing to the
form of the cavity, it may be removed in twelve or
twenty-four hours. In any case, however, the tooth
should be seen again in about a week or ten days,
and then the pulp cavity should be thoroughly laid
open, and all broken rough edges of the tooth cut
away in order to facilitate cleanliness, and prevent
as much as possible the lodgment of food, for the
tooth must be left without a stopping. It cannot be
treated as we should treat those of a later period,
by removing the pulp and filling the roots, unless
we are quite sure that there has not been any
absorption of the roots to widen the apical
foramina, and thus render a tight filling impos-
sible. Mr. Tomes tells us that the roots of some of
THE TEMPORARY TEETH. 15
these teeth are not fully developed until the child is
four and a half years of age ; we may therefore be
quite sure that the period of time t)etween perfect
formation and the commencement of absorption is
very limited, so that, practically, we may say it does
not exist for the success of this operation. It is
better, therefore, to leave the tooth without a filling,
but so shaped that lodgments of food may be easily
removed, and the neighbouring teeth suffer no
injury. What remains of the pulp will, of course,
pass through the stages of putrescence and slough-
ing, but if the gases have free escape into the oral
cavity, there will be very slight risk of their causing
what may be called secondary toothache, or inflam-
mation of the lining membrane of the socket, which
is simply the result of the poisonous action of the
gases, generated by decomposition of the pulp, in
a cavity which has no outlet, except the apical
foramen. We may be very sure that, if the pulp
cavity is well opened, and kej)t open, these gases
will escape harmlessly by the larger opening, rather
than by the smaller one at the end of the root.
I am perfectly well aware that, to some of the
members of our profession, who would probably call
themselves purists, if they could choose a distinc-
tive designation for themselves, this treatment of
pulps may seem dreadfully heterodox, but I should
be glad to hear of one well- authenticated case where
the pulp of a temporary tooth in the mouth of a
child under six years of age has been capped and
preserved alive, or where the nerve has been
16 DENTAL PRACTICE. ^
removed and the roots filled, so as to prevent
alveolar abscess. And if abscess does occur, what
is to be done ? It is absurd to talk of taking root
fillings out of a tooth that is painful from this cause,
when the patient is not old enough to fully appre-
ciate the advantage of retaining a valuable tooth,
knowing, as we all probably do, how extremely difii-
cult it is to remove root fillings, under similar cir-
cumstances, from adult teeth. It is quite as much
as we can do to persuade a child suffering from
abscess to allow us to open the pulp cavity and
syringe it out, although we know that, in such
cases, relief from pain follows so quickly that we can
be quite sure of sending the little patient away
happy and comfortable ; but if the roots were filled,
there would be very little chance of relief to the
sufferer until the abscess had run its course, or the
tooth had been removed. It is a choice of evils, but
I maintain that less harm will be done by leaving
such a tooth in the mouth, and, of course, keeping
it clean, than will be done by extracting it, although
I have very little doubt in my own mind that the
death of the pulp very greatly interferes with, if it
does not altogether put a stop to, the natural
absorption of the roots. This is a point which I do
not think has been noticed hitherto by any author,
but if it is not so, why do we always find the roots
of dead temporary molars pushed aside by the
advancing bicuspids, so that we often have to ex-
tract long thin splinters of roots from around the
new tooth ? These roots may certainly be said to
THE TEMPORARY TEETH. 17
have served to guide the new tooth into its proper
position, but they never show any traces of recent
absorption. There is no appearance resembling the
absorbent organ — nothing different from what we
should see if the dead root of a permanent tooth
were left in the mouth. On the other hand, if the
temporary tooth has remained perfectly healthy,
we shall almost always find the roots completely
absorbed, and the absorbent organ occupying the
place of what was the pulp. It may be argued that,
if this is the case, it must be better to extract than
to leave roots which will be obstructive in their
relation to the permanent tooth. But I contend
that we do not leave an obstruction in the way of
the permanent tooth. After the death of the pulp
and the opening of the pulp-cavity, the remainder
of the crown of the tooth will rapidly disappear,
and practically there will be nothing but the roots
left to be displaced by the advancing tooth. And
these do not prove to be an obstruction, for they are
simply pushed aside, and the new tooth comes into
its right position almost, if not quite, as quickly as
it would have done if its predecessor had been
perfectly healthy ; but if the temporary tooth is
extracted, we know that the permanent one is often
very much delayed and misplaced.
It will often happen that a child will not be
taken to the dentist, although really suffering from
primary toothache, because the parents are not
aware of the cause of the pain. The child does not
feel the pain in a tooth, but rather in the temple, or
B
18 DENTAL PRACTICE.
in the ear. It is well enough all day, perhaps, and
takes its food as usual, but cries with pain all night
from genuine toothache, although, perhaps, there
may be no disagreeable sensation in the tooth
which causes the pain.
The pulp will not, however, long survive a con-
dition of acute inflammation, and with its death the
pain disappears and is forgotten. But there is left
in the tooth a fleshy substance, which was lately
nerve and blood-vessels, and this having died a
natural death, will in time become putrid. It is not
necessary here to attempt to explain the nature of
putrescence, for it is well known in the profession,
that one of our most scientific men, Mr. Charles
Tomes, with his able associates in physiological
research, is at the present time investigating the
subject of the agency of bacteria in the develop-
ment of alveolar abscess, and we may be quite sure
that the work will be well done. But we know that
the pulp of a tooth, which is so shut up in the tooth
that the gases generated by decomposition have no
vent except through the apical foramina, so that it
would appear as though putrescence could not be
the effect of external causes, may and does become
putrid, and generates poisonous gases which, having
no direct means of escape into the oral cavity
through the partially only disintegrated dentine,
that is yet sufficiently decayed to have affected
and caused the death of the pulp, will find their way
through the foramen by which, while the vessels
were in health, the blood found access to the tooth,
THE TEMPORARY TEETH. 19
and will so poison the surrounding tissues that
inflammation, and perhaps abscess, will result. This
is what I have called secondary toothache, and it is
what the sufferer never mistakes for anything but
toothache, and can always localise without any
hesitation, because the pain is directly intensified
by pressure on the tooth, so that, in these cases,
the patient's judgment is of great use in helping the
dentist to decide where his skill is needed to relieve
pain.
The treatment of this form of toothache may
have been sufficiently indicated in the previous
pages, but it deserves special and definite men-
tion. It is simply the free opening of the pulp
c^ity, the removal of all putrescent matter,
for which purpose fine barbed instruments, that
will reach well into the roots, will be required ;
syringing with warm water to which a five per
cent, proportion of carbolic acid may be added ;
and, when it can be done without risk to the
adjacent parts, a drop of the acid of full officinal
strength may be left in the tooth. But this is only
possible in lower teeth, because there must not be
any stopping inserted, not even of cotton, at this
stage of the treatment, to prevent the free escape of
gases or pus through the pulp canals. The relipf
from pain will be almost instantaneous. A certain
amount of soreness will remain, but the intensity of
the suffering will be gone, as if by magic, and the
soreness will disappear as surely, though more
gradually ; and we may with confidence make an
20 DENTAL PRACTICE.
appointment for the child to be brought back to us
in three or four days, when the tooth will bear
pressure without giving pain. We should then so
shape what remains of the tooth, that it can be
easily kept clean, and we should endeavour to
impress upon the minds of those in charge of the
child the necessity of cleanliness, if they would
avoid a repetition of the suffering.
Irregularity in the position or occlusion of the
temporary teeth is not of sufficient importance to
justify interference, unless it is caused by the
infantile habit of sucking the thumb, the fingers,
the lip, or the tongue — practices which, if per-
severed in, as they undoubtedly are by some
children, even after the tempora-ry teeth have all
disappeared, may be the cause of serious displace-
ment of the permanent teeth, with malformation of
the jaws. Some of the most troublesome irregu-
larities we have to treat are traceable to this habit
of sucking, and the dentist should, in all cases that
come under his observation, see how the teeth
close, and, if there is any fault in this respect, it
should be pointed out to the parents, and the
necessity for breaking up a habit so liable to cause
disfigurement should be strongly urged.
It will be seen at once that the weight of the
hand, when the thumb is constantly in the child's
mouth, will have the effect of shortening the lower
jaw and elongating the upper. The lower front
teeth will have an inward inclination, showing a
straight or even concave line from one canine to the
THE TEMPORARY TEETH.
other, while the upper teeth will project over the
lower Hp.
Figure 6. — Showing bow thumb sucking may effect the arrangement of the
front teeth.
Fig. 6 is a remarkably good illustration of the
effect of this habit, which, in this case, was con-
tinued until the child was twelve years of age. Two
of the lower bicuspids, as will be seen, have been
extracted by some one who probably thought he
had a reason for such treatment; but I cannot
believe that they were so much out of place that
they could not have been pressed into position,
which would certainly have been better than remov-
ing them, as the effect of forcing them into their
proper place must, of necessity, lengthen the lower
jaw to something nearer what it should be. Like
many other cases, this is one where more thought
for the future of the mouth, and a little more
trouble in regulating the teeth, instead of extracting
those that may be out of place, would be much
more creditable to us as professional men.
Sucking the fingers will have a different effect
upon the development of the mouth. There is no
leverage upon the upper teeth, but the weight of the
22 DENTAL PRACTICE.
hand acts directly to elongate the lower maxillary,
causing what is usually described as an '' under-
hung jaw." Fig. 7 is an example of this.
Figure 7. — Showing the effect that may be produced upon the lower jaw by
sucking the fingers.
Sucking the lower lip produces a result some-
what similar to that caused by thumb-sucking, and
sucking the tongue may seriously displace the
canine and bicuspids of one side of the mouth, as
the child will usually turn the tongue to one side or
the other, and always to the same side. Fig. 8
represents the worst case I have ever seen of the
effect of sucking the tongue. The boy was eight
years of age when I first saw him. His intellectual
development was below the average, but he was
very teachable, and seemed quite to understand the
remarks I made about the condition of his mouth.
The habit of sucking his tongue had been observed,
but no one ever thought that any ill effects would
result from it ; and no one had noticed that he
could not make his front teeth meet until I
pointed it out to the parents. The lower teeth on
the right side were completely hidden by a mass of
tartar, but there was no dribbling of saliva, and the
lips met without much effort.
THE TEMPOEARY TEETH. 28
An attempt was made to correct the deformity
by the use of a strong elastic strap on each side of
the face, attached to a well-fitting chin-piece and to
a sort of skull-cap, consisting of a fillet, with bands
over the top of the head, from front to back and
from side to side, an arrangement much better than
a close cap. The apparatus was working well, and
the upper and lower front teeth were nearly meeting,
when a severe illness put a stop to the treatment,
and, as the boy had to be sent to a milder climate
when he was well enough to be moved, the treat-
ment was necessarily abandoned.
Figure 8. — Showing the effect of sucking the tongue.
Nurses will sometimes teach children to suck
the thumb to keep them quiet. Of course it is done
in ignorance of the possible effect, which they are
generally very unwilling to believe in, even after the
malformation has become apparent to every one,
preferring to assign any other reason than the real
one for the disfigurement of the child's mouth, and,
perhaps, never suspecting the true cause, as the
change in the form of the jaw is gradual, and it may
24 DENTAL PRACTICE.
be three or four years before it becomes so serious
as I have described. It is another point on which
the public need more information, although, doubt-
less, many a lip will curl in derision at the sugges-
tion that any more knowledge is requisite on the
subject of the management of babies. Sucking the
thumb or the fingers may be easily cured by put-
ting the hand into a thumbless mitten, which
should be sewed into the sleeve of the frock and the
night-gown, so that the thumb and fingers will be
inseparable and sucking impossible. Half measures
will be of no use ; it must be made literally impos-
sible until the habit is forgotten. Sucking the lip
or tongue is much more difficult to cure, and pos-
sibly the treatment may have to be deferred until
the child is old enough to wear a plate that is made
to cover the whole of the lower teeth, and keep the
mouth so much open as to make sucking an
impossibility.
Beyond the curing of the habit, I do not think it
is well to attempt any treatment of these cases until
the child is older, and has parted with all or
nearly all of the temporary teeth.
25
CHAPTER II.
The Permanent Teeth.
When the child is about six years of age, if a boy,
or five and a half, if a girl, we may begin to look for
the first permanent molars ; and these must be
watched most carefully, for there are no other teeth
in the mouth so liable to be defective. Probably
the period of their formation, beginning in the first
month of infancy, and extending through all the
trials and illnesses of first dentition, has much to
do with the defective structure of these teeth ; but
whether this is so or not, the fact remains that not
ten per cent, of them, in the mouths of the middle
and upper classes, are perfectly formed teeth. The
chief defects are in the sulci, between the cusps.
All the other teeth that have a grinding surface of
cusps and sulci are later in development, and they
certainly average better than the first molars, which
is a fairly good reason for thinking that their
defective nature is partly owing to the period of
formation. There is often a want of perfect union
in the formation of enamel in the sulci, and as
every fissure that will admit the secretions to con-
tact with the dentine will prove to be a weak spot
and probable starting-point for caries, it is evident
that these weak spots should be sought for as soon
26 DENTAL PRACTICE.
as the grinding surface of the tooth has emerged
from the gum, and a very little care in filling the
fissures at this early period may save a great deal of
pain and trouble later on.
Few parents are aware of the nature of these
teeth, and it is therefore the duty of the dentist to
instruct them when to look for these pioneers of the
permanent denture, and of the importance also of
looking after their condition. Popular information
on these subjects is greatly needed, and should
have a much larger space in the public papers than
is conceded to it at present.
Every practitioner is aware of the frequency with
which children suffering from pain in their molars
are brought to us, and of the frightfully broken
down and hopeless state in which we find them on
such occasions ; and surely it is not charlatanism to
try to increase the knowledge of those who have the
care of children, in order to prevent such a con-
dition of things. If one wrote so that it was
evidently his object to direct attention to himself as
the fountain of knowledge, an accusation of that
nature might well be laid at his door ; but there is
no doubt that a sensitive shrinking from this charge
is the chief cause of the want of popular literature
on this subject, and of the absurd nonsense that we
sometimes see in the public prints from lay sources.
If, however, the parents err from ignorance, they
are not so much to blame ; but if the dentist, who
has knowledge at his command, if not in his posses^
sion, commits the. I am sorry to say, common error
THE PERMANENT TEETH. 27
of extracting these teeth, merely to reheve pain,
without a thought of the future of the mouth, what
can be said of him ? If it was important to retain
the temporary molars in order to insure the pro-
per lengthening of the jaw to make room for the
permanent molars, there is still greater necessity
for the preservation of the latter, inasmuch as they
in their turn are necessary for the proper growth of
the jaw to make room for the second permanent, or
twelve-year molars. They also serve an important
function in lengthening the rami, for as they are
in every respect larger and longer teeth than the
temporary molars, they must have more room for
this additional length. Therefore the ramus must
lengthen out to give the required space, and it is
certain that this growth only keeps pace with the
growth of the roots of the six-year molar, which is
rarely complete before the ninth or tenth year. It
is therefore very desirable not only to keep these
teeth, but also to keep them healthy, to keep their
pulps alive ; and as such young teeth go very rapidly
when they begin to decay, they should be examined
often, every three or four months, and every cavity
filled, if possible, before it becomes a source of
danger to the vitality of the tooth.
The material best suited for filling these and
any other permanent teeth that may decay previous
to, or during the constitutional changes at puberty,
is, without doubt, a preparation of gutta-percha. I
am quite sure that whatever may be said of gold as
a material for filling teeth after the sixteenth year —
28 DENTAL PRACTICE.
and I will say here that I believe there is no other
material to be compared to it for the teeth that are
old enough and dense enough to stand it — it is not
fit to be used in a tenth part of the teeth that
one has to treat for patients who have not attained
that number of years. Gutta-percha will preserve
the teeth at this early age, and gold may do so, but
I believe that more harm than good is generally
done by using the latter too early. It is better in
the grinding surface of molar teeth, such as we are
now treating of, than in any other cavities at this
time of life ; but I say it does harm, because it sub-
jects the patient to a needless amount of suffering
in preparing the cavities and inserting the filling,
and thus keeps alive the dread of the dentist's
chair, and prevents the frequent examinations that
are so necessary ; and again, because in using a
material of this nature we convey an impression
that we expect it to be a perfect safeguard against
further decay. Every man of experience in our
profession may judge for himself whether this
impression will be justified by the result. I do not,
by any means, intend to imply that all gold filling
will fail. I have some in my own mouth that have
protected the teeth for thirty-five years ; but I was
past the age of sixteen when the first filling was
made. NVhat I do mean to say is, that a large per-
centage of gold fillings, made in the teeth of patients
under sixteen years of age, do and will constantly
fail, and will have to be renewed, and that it would
be better to tell the parents plainly that the work is
THE PERMANENT TEETH. 29
only meant to save the teeth from further decay
until the child is old enough to have them properly
filled. If the cavities are large, the gutta-percha
should be protected on a grinding surface, as it is
liable to be rapidly worn away. This may be done
by using the porcelain caps prepared for this pur-
pose, or by making a cap of thin gold-plate, swaged
to correspond to the surface it is to replace, and a
loop or stud soldered to the under side to retain it
in position. A quantity of these may be prepared
of different sizes and shapes, but if one is not
readily found to fit the cavity, it may easily be cut
and trimmed to the required form. Some gutta-
percha should be pressed into the loop, or around
the stud, and then when the tooth is filled, and
before the filling gets hard, the cap may be well
warmed over the lamp and carefully pressed into
its place. A filling of this character is a perfect
protection to the tooth, and the tooth is very com-
fortable at once, which is not always the case when
the filling is wholly metallic, for metal is a quick
conductor, and in contact with the sensitive surface
of a tooth it may for weeks make the patient pain-
fully conscious of thermal changes.
I have been using these gold caps for years,
and have even described them in a paper read before
the Odontological Society of New York, in 1881, as
an idea of my own, and it was a surprise to me, on
looking over an old report of a meeting of the
Pennsylvania Association of Dental Surgeons, in
March, 1877, to find a full description, with illus-
30 DENTAL PRACTICE.
trations, of the same thing, by Dr. Charles Essig, of
Philadelphia. I can only say that I did not intend
to claim another man's ideas as my own, and as
Dr. Essig carries out the idea more perfectly than
I have done, I will take the liberty of copying the
illustrations, with his remarks, as reported in the
Dental Cosmos, vol. 19, p. 314.
"Professor Chas. Essig presented some models
of very badly decayed teeth, which, he said, he had
treated according to the plan, or idea, proposed by
Dr. Bing, of Paris, France. Instead, however, of
using a simple plate, or disk, with loops soldered to