breath of cold air without causing pain ; or men
and women recovering from severe illnesses, when
their weakness is both a cause of sensitiveness, and
a reason why they cannot endure thoroughness of
treatment. In these cases, if we can, without
attempting to remove all, or even any of the newly
decalcified dentine, so shape the space between
two decaying teeth that gutta-percha can be re-
tained in contact with both surfaces, we shall have
gained a step. Even an operation so slight as this
may give comfort to a sufferer, as well as check the
ravages of decay, while an attempt at thorough ex-
cavation would probably drive the patient out of the
chair, or cause a sacrifice of valuable teeth. Protec-
tion of carious surfaces, no more thorough than
that just indicated, will in a short time make it
possible to excavate more thoroughly, and so, in
time, a proper filling may be possible. But it must
not be supposed, because a man tries to make an
operation bearable to his patient, and attain perfec-
tion of work by stages that are easy, not so much
for himself as for those who seek relief at his
hands, that he will be content with the result before



144 DENTAL PEACTICE.

perfection is attained. Perhaps it is too much to
expect of human nature that a man will try to put
himself in the place of his rival, as Charles Eeade's
Dr. Amboyne might suggest ; but if we could,
when we see a patient who has had this kind of
treatment at the hands of our neighbour, try to
realise the circumstances under which the opera-
tions were performed, and not say, with an expres-
sion of wonder at the incapacity of the operator,
and of pity for the victim, that we cannot see why
the work was not more thoroughly done, it might
help us to a better position, as professional men,
in the estimation of the public, and certainly it
would give us more self-respect.

We may put a young man's teeth in order, and,
if he is vigorous and strong, it may be quite pos-
sible that he will not need the services of a dentist
again until he is past the prime of life ; but a young
woman, with equally good work in her mouth, has
not the same chance of reaching middle age without
requiring more or less of the dentist's aid; for
although good work may make the teeth as safe
from new decay as if they had never decayed at all,
it cannot make them better than this. The young
woman gets married, and has a family of children.
During pregnancy she suffers from acidity, which
attacks her teeth to such an extent that she often
despairs of saving any of them. Perhaps in her
despair she relaxes her efforts to neutralise the
acids and keep her teeth clean, when at such time
she should redouble, and if necessary, quadruple,



TREATMENT OF ADULT TEETH. 145

her exertions. Of course we can do but little if
she will not try to help herself; but to those who do
try, are we to give no help at all, because the teeth
are too sensitive to bear the excavating for gold, or
because, when the teeth are filled with gold to the
best of our ability, the fillings fail ? I do not think
it would be dentistry in the highest sense, if we
could not do something for her. It is possible to
keep the teeth for ten, or twenty years, if necessary,
with gutta-percha fillings, renewing them as often
as may be needful ; and|then, when this temporary
work is no longer requisite, we may do as much
gold work as may be necessary. But to put it on
the low ground of policy alone, without reference
to the patient's ability to bear pain, I doubt if it is
best to attemj)t to do the permanent work until we
see the last of the babies.

The cervical edge of a filling that extends
under the gum, is^always a weak spot ; and I have
very little confidence in the safety of gold in that
position. I therefore generally commence a filling
in that position with gutta-percha, if much of the
cavity is under the gum, or with tin, if it is only
slightly so. Tin never loses its compressibility,
until it is hard and dense throughout ; gold, on the
contrary, may become hard on the surface from
packing, and perfectly soft beneath. Therefore, in
packing a filling into a position that we cannot see
all the time the instrument is at work, it is possible
to leave a corner loosely packed ; but with a few folds
of tin foil beneath the gold this is not so likely to

E



146 DENTAL PRACTICE.

occur, as the tin will still be condensed, while the
gold is being packed down upon it. In these
positions, where the slightest deviation of the instru-
ment from its proper direction may flood the cavity
with blood, it is a help to leave the tin projecting so
as to overlie the gum, and we can condense this por-
tion of the filling more thoroughly when the gold is
completely packed, and thus make a tight joint after
the risk of flooding is past. I have had, in the
course of my professional experience, the opportunity
of examining a great many fillings in which gold and
tin were used in combination, — the work of a man
long since dead, — and there was certainly no ill result
in any one instance from the contact of the two metals
in the same cavity. If any failure of the fillings
occurred, it was more frequently the gold that failed
than the tin, because the gold had to stand the wear
of mastication, and the cohesive quality of this metal
had never been utilized to give a harder surface to
any of the fillings. Tin makes an extremely good
filling. It appears to have a better preservative
effect upon the surface of dentine with which it is
in contact than gold, but it can never be hard
enough to wear as gold does if properly packed.
This is, however, an objection which only applies
in cavities which are actually exposed to the attrition
of mastication. When tin is placed against the
cervical wall in approximal cavities, and the bulk of
the cavity filled with gold, all its best qualities are
available without its disadvantages. But care must
be taken that it is not packed in contact with the



TREATMENT OF ADULT TEETH. 147

labial wall of a frout tooth, as it will show dis-
colouration, which, however, the thinnest fold of
gold in that corner of the cavity will prevent.
Before the tin is quite fully condensed, a twist of
gold should be packed into it, and then packed
down with it, so as to leave a surface of gold, and
then the filling may be proceeded with exactly as in
the case of soft and cohesive gold fillings previously
described. When gutta-percha is used for that por-
tion of the cavity which is under the gum, it is, of
course, still soft enough to be compressed by the
packing of the gold, and it makes as tight a joint as
can perhaps be made, and as it is perfectly pro-
tected from attrition, it is practically indestructible.
For approximal cavities in bicuspids and molars,
which, as every dentist knows, are extremely liable
to fail at the cervical edge, if they are to the slightest
extent under the gum, the use of tin, or gutta-
percha, as a foundation, makes safer work than
can be made by trusting to gold alone.

A case came into my hands about three or four
years ago, where the palatine cusp of an upper
second bicuspid had been broken away, the fracture
extending under the gum. It had been restored
with gold, making a very nice looking operation,
but the patient told me it was a very laborious one,
as the operator had spent about six hours in
packing and finishing the filling. A few months
after I first saw the case, and admired its appear-
ance — much to the patient's satisfaction, as he
thought it a very good piece of work — he called to



148 DENTAL PRACTICE.

ask me to look at his big filling, which he fancied
was becoming loose. An examination showed that
he was quite correct, as the whole mass of gold
came away without the application of any force.
The failure was due to some slight decay — very
slight it was — at the point where the anchorage for
the gold had been made under the gum. The
question then arose, How could the mischief be
remedied so as to make the tooth safe and useful ?
My own preference would have been to make a new
cusp of porcelain, and fill in the space between that
and the natural cusp with amalgam, a process
which I will explain later on, but the patient was
desirous that gold should be tried once more.
Being satisfied that it would not be safe to make
another filling like that which had failed, I deter-
mined to build down the cusp around a gold pin
fixed in the root, and on a foundation of gutta-
percha. I therefore proceeded to drill the root ;
that is, to enlarge the pulp canal, so that it would
take the gold wire which is used for the English
tube teeth, and this enlargement of the canal I
carried as deeply as I dared go without perforation
of the side of the root, feeling my way carefully by
using drills that were each a trifle larger than the
preceding one, and watching for any indication of
sensibility to show that I was getting too near the
peridental membrane. Then fitting my wire, I cut it
to the exact length that would allow it to touch and
take the bite of the lower tooth, when the mouth was
closed with the wire in position. I then fitted a sort



TKEATMENT OF ADULT TEETH. 149

of half-hoop of eighteen carat gold to the broken
edge of the root that was beneath the gum, making
it wide enough to extend slightly beyond the margin
of the gum. This I soldered by a connecting stud
on either side to the wire. All this work was done
upon a plaster model in the workroom. Finding
that this gold work fitted properly, when tried in
the mouth, the next step was to fix the wire in the
root, which was done by barbing it on four sides
with a strong knife, and then pressing it up into the
root with a little stiff sandarac varnish to act as a
cement. I then packed the half-hoop nearly full of
gutta-percha, taking care to make a tight joint
where the hoop fitted the surface of the root. On
this foundation I built down the gold cusp, my
retaining points being the half-hoop, the wire, and
the remaining natural cusp. The fixing of the wire
and half-hoop, the packing of the gutta-percha, and
finally, the packing of the gold, took altogether less
than an hour of my time. The gold was packed by
hand-pressure. The rubber dam was not used, and
a napkin sufficed to keep the work dry. The patient
sat low and comfortably in the chair, not as though
lying on a surgeon's operating table, and the work
was wholly done by reflection from my little mirror,
without stooping or discomfort on my own part ;
and it is standing perfectly well at the present time,
as I recently had an opportunity of seeing, three
years after the operation was completed.

Cavities in the grinding surfaces of molars, and
in the sulci between the cusps of bicuspids, are



150 DENTAL PRACTICE.

simple enough, unless, from neglect, their walls are
allowed to become too weak to stand the packing of
gold fillings. It is a common practice, however, to
prepare all such cavities by simply driving a rose
drill into them, and then inserting the filling. This
is a rough and ready way of preparing for a failure,
unless the drill is unnecessarily large, for such
cavities are never cylindrical in shape, and a drill
will either not cut out enough to make the filling
safe, or it will cut away too much sound dentine.
It is perhaps well enough to open a cavity of this
description with a drill, but it should never be
considered ready for a filling until all the fissures
radiating from it are cut out, which may be done
with fissure drills, or with a narrow enamel chisel.
My own practice is to open all these cavities with a
chisel, feeling the depth and extent of the decay,
and noting the course of the fissures which are to be
cut out after I have ascertained the nature of the
cavity, when the fissure drills may be very useful.
I find this a safer course, as one will sometimes
meet with a case where, after cutting away a com-
paratively strong substance of enamel, the drill will
plunge suddenly into a soft and sensitive dentine, to
the great discomfort and alarm of the patient ; and
all this is better to be avoided if possible. Not
infrequently there will be two or three of these
cavities in a grinding surface, and they may be
connected by narrow fissures, or possibly, but more
rarely, they may be separated by perfectly sound,
well calcified enamel. There cannot, however, be



TREATMENT OF ADULT TEETH. 151

any doubt on this point in the mind of a careful and
observant operator. The fissures can be seen, if
they exist to endanger the fillings, and they must
be cut out as far as they can be seen to extend. It
is quite unnecessary to make under cuttings, or
retaining points, in cavities of this nature. The
walls may be parallel, or even in parts slightly
sloping outwards, and well-packed gold fillings will
never move. Cavities of this class are, I consider,
the only ones where the use of the mallet is justi-
fiable. If the walls are strong, that is, if there is a
good substance of dentine, as well as of enamel, and
there is no irritation in the socket, either from
diseased pulp or unnatural pressure, the mallet may
be very useful in attaining that degree of hardness
and density which is most desirable in fillings that
wiU be subjected to the direct wear of mastication,
and which, as all operators are not equally endowed
with a good physique, may not be attainable by
mere wrist strength. If, however, any one of the
walls is weak, if it is of enamel unsupported by
dentine, the mallet should never be allowed to touch
a plugger in that locality, as the suddenly -applied
force will crack the enamel in every direction, and
leave it liable to crumble and break down after the
filling is completed. I prefer to fill all such cavities
two -thirds or three-quarters full with soft gold,
and then finish with cohesive gold, as this gives
greater hardness of surface than is possible with
soft gold alone. If the cavities are deep and
dangerously near the pulp at any point, it is a safe



152 DENTAL PEACTICE.

precaution to pack a lining of gutta-percha in that
portion of the cavity (taking care that the pressure
shall not be directly towards the pulp) and, when
this is hard, complete with gold. The gutta-percha
will save the pulp from the shock which it might
be subjected to from hot or cold drinks, or food, if
the gold, with its quick conducting nature, were in
close proximity to it.

In the description of the process of making and
fitting gold cups and gutta-percha fillings, quoted
from Dr. Essig, on page 30, that author mentions
a case which had come under his observation,
where a gutta-percha filling had lasted fifteen years
in a position not exposed to much attrition. It is
not by any means an exceptional case, but I wonder
how many of our experienced operators (I use the
word "experienced" because those who are not
so qualified to form an opinion are usually too
sanguine to put any limit to the durability of their
work) would not be glad to be assured that the
gold fillings they make in positions which are not
exposed to much wear from mastication, would last
as long. It is in such situations that gutta-percha
makes a safer, and certainly a more comfortable
filling than can be made with gold, however well
the work may be done. I do not by any means
advocate the use of gutta-percha as an unprotected
permanent filling in situations where a soft material
must of necessity be worn away rapidly. Gold
fiUings very rarely fail in the grinding surfaces of
molars and bicuspids, or in the lingual surfaces of



TREATMENT OF ADULT TEETH. 153

canines and incisors, where they are always exposed
to attrition in some form. It is in the nooks and
corners, which are not exposed to natural friction,
that we are to look for failure, and it is in these
places that we shall often find gutta-percha more
valuable than gold as a barrier to the ravages of
decay. Constant attrition is a great safeguard to
the teeth in preventing decay, and, if all their
surfaces were alike exposed to it, the work of the
dentist would be greatly simplified, if not rendered
altogether unnecessary.

Another class of cavities are those which are
found at the necks of the teeth, on the labial
and buccal surfaces. Caries of this description
may affect any or all of the teeth, upper and
lower, but it is rarely seen in youth, while
the gums retain their natural position and adhe-
sion to the teeth in a line exactly corresponding
to the cervical termination of the enamel. But
when, from neglect, a formation of calculus has
been allowed to accumulate at the neck of the
tooth, forcing the gum back, and destroying the
thin edge of alveolus which gives the gum its
form ; or when, on the other hand, the efforts at
cleanliness have been too severe, and hard brushing
that would have been more suitable for fire-irons
and fenders than for flesh and blood structures, has
worn away the delicate covering of the dentine in
this locality, and the tooth is left without its
natural protection, it is only too well prepared to
suffer from any abnormal condition of the mucous



154 DENTAL PRACTICE.

secretion which, from a variety of constitutional
causes, may become so acidulated as to overpower
the neutraHzing effect of the sahva. This condition
of the mucous secretion may arise from indigestion,
from hepatic derangements, from uterine affections
of every nature, or from any protracted disturbance
of the mucous membrane and the sympathetic
nervous system. We have, however, more to do
with the effect than with the cause. When we have
a condition of this nature to deal with, we may find
decay progressing so rapidly, that deep cavities
with well-defined walls are developed in a few
months, or the progress may be slow, and, as the
dentine is softened, the brush will wear it away,
and the lesion will gradually assume an appearance
as if a round file had been used to cut a groove
across the necks of the teeth, and the surfaces had
then been carefully polished. In the latter case
there is little need for anxiety, for the causes which
have operated so slowly may cease to act, and the
teeth, though disfigured, be safe for years ; but, if
the disease is making sufficiently rapid progress to
form a definite cavity, it must be checked as quickly
as possible. Like all other cases of dental caries,
but, perhaps, to a more marked degree in these, the
rapidity with which the disease progresses regulates
the sensibility ; and in many such cases it is not so
much a question what is best to be used for fillings,
as what is possible. When the cavities are so
sensitive that it seems to be absolute cruelty to be
thorough, I have always found that such slight



TREATMENT OF ADULT TEETH. 155

excavation, as can be done in a few seconds with a
sharp excavator, will enable me to put in a gutta-
percha filling which will so effectually check the
disease, that in a few months it may be quite
possible, if it is desirable, to fill them with gold
without any unbearable pain. Or if, as will often
be the case, the dentine is still too sensitive to bear
gold with comfort, such a gutta-percha filling may
be made that it will last five or six years, and give
more comfort, and, I think, more security too, than
gold will ever give on a very sensitive surface. It
is an error to suppose that any rough work is good
enough for gutta-percha. A filling may certainly be
made with this material in a few minutes, and yet
be sufficient to check the rapid progress of decay so
as to allay an intolerable sensibility of a decaying
surface ; but quick work does not necessarily mean
rough, or bad work. A few quick strokes with
well -selected instruments, and a firm hand, guided
by a sure knowledge of how and where to cut, may
shape a cavity that will retain for months a gutta-
percha stopping sufficiently impermeable for this
purpose. When, however, it is possible to do so,
careful excavation and careful packing, with fine
points, is as necessary to ensure durability with this
material as with gold.

When the rapid progress of decay has been
stopped, and when the surface of the dentine has
regained its normal state of comparative insensi-
bility, there can be no doubt that it is best to fill all
cavities of the class under discussion, as far back



156 DENTAL PRACTICE.

at least as the second bicuspid, with gold. For
molars, however, when we consider the difficulty of
keeping such cavities dry long enough to pack a
good gold filling, even with the rubber dam, and
the difficulty of applying the rubber dam to be
useful in such a locality, without " dissecting away
the gum " — as a dentist once coolly told me he
did in such cases, without any idea that he was
talking of such a dreadful thing as vivisection — I
doubt whether it is not best to be content with the
degree of permanency that can be got from gutta-
percha, more especially if the lesion is extensive.
These cavities usually extend under the margin of
the gum, and, if gold is to be used, it is of the
utmost importance to make sure of clean excava-
tion there. If the operator is not confident of his
ability to excavate without touching the gum with
his instruments, he must cut the gum away, and
after placing a proper clamp or clamps, apply the
rubber dam, but as all this adds immensely to the
formidable nature of the operation, it is better, if
one can, to train the eye and hand to work without
these appliances. This certainly can be done, for I
have never cut away the gum to fill a cavity of this
nature. I have often found the gum growing over
the edge of such a cavity, perhaps filling it, so that
it required to be pressed back ; but these were dead
teeth almost invariably, and the necessary course of
dressings has always enabled me to get the gum
out of the way without cutting. If the cavity
extended far under the margin of the gum, I have



TREATMENT OF ADULT TEETH. 157

used gutta-percha instead of gold for the filHng,
whether it was a front or a back tooth, and the
patient has generally been glad enough to be so
mercifully treated. I can point to cases where,
side by side, some such cavities are filled with gold
and some with gutta-percha — the worst, of course,
being treated with the latter material — and both I
and the patient must live some more years before I
can say which lasts the longer.

In filling these cavities it is a very good pre-
caution to pack against the cervical wall, leaving a
good mass of gold there to be condensed after the
rest of the cavity is quite full. This will serve as a
breakwater, and the completion of the packing at the
point, where there is the greatest risk of wounding
the gum, makes this risk of less importance, since
the flooding with blood cannot be so serious a
matter when the packing is practically finished.
But there is really very little danger of even this, if
the packing is done with a firm steady hand, the
third and fourth fingers resting on the edges of the
tooth, if the operation is on an upper tooth, and on
the chin if it is on one in the lower jaw, to prevent
a slip, while the second finger guides the instru-
ment, held between the thumb and first finger.
This resting of the fingers to guard against slipping
soon becomes purely instinctive, though doubtless
it seems to the student as if he should always have
a distinct thought for every thumb and finger;
but it is like a practised performer on a musical
instrument whose fingers find the note correspond-



158 DENTAL PRACTICE.

ing to the melody in the mind, without conscious
effort.

The effect of acidity in the mucous secretion is
not always confined to exposed dentine, or to cracked
and abraded, or imperfectly calcified enamel. You
may find the whole labial surface of the incisors
and canines wasting away, but so generally and
uniformly that, if it were ground away with car-
undum wheels, and the surfaces carefully polished,
the result could not be a smoother surface. One of
the most remarkable features of this peculiar form
of erosion is that, while the destructive process is
going on, the enamel, and then the dentine of one
portion or surface of the tooth may be affected to
a serious degree, and other adjoining surfaces be
absolutely untouched. We may find the dentine of
the labial surface of a central incisor laid bare, and
the full thickness of the enamel of the mesial and
distal surfaces of the same tooth, with the lingual
surface, remain unaffected, the edges of enamel
being as sharply defined as though the work had
been done with a file. It may attack the tooth in