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How Should the General Practitioner Equip Himself for the Practice of Periodontia?*
H O W SHOULD T H E GENERAL PR A C TITIO N ER EQ U IP HIM SELF FOR T H E PRA CTICE OF PERIODONTIA?* By CLYDE C. SHERWOOD, D.D.S., Toledo, Ohio
B
E F O R E entering into the discussion as to how the general practitioner should equip himself, o r herself, for the treatm ent of periodontoclasia, I find it necessary to consider several points that have a vital bearing on the subject. M y first impression, when assigned this subject, was that it should have been given to one engaged in teaching den tistry ; at least, to one more familiar with the art of teaching or having some connection w ith university work. But, having accepted the assignment, I began to diagnose my own feelings in the case. W h a t I found was quite insufficient, and w hat ideas I did possess I wished to have verified. A questionnaire suggested itself as a means of getting a widespread ex pression on this most im portant subject. T h e response given me by dentists from all over the U nited States and Canada was indeed most beneficial, and I wish to express my gratitude to everyone who so promptly answered my questionnaire. Question 1: Should the dentist in gen eral practice treat periodontal disease? T h e reason for asking this question was that, to my mind, the future of perio dontia depends on the answer. Shall the dentist in general practice treat periodon tal disease or shall it be left to the spe cialists? W ith but few exceptions, the *Read before the Section on P e riodontia a t the S eventy-F irst A nnual Session of the A m er ican D ental A ssociation, W ash in g to n , D . C., Oct. 9, 1929. Jo u r. A . D . A ., Ju ly ,
1930
answers favored the general practitioner, many believing that a practical knowl edge of periodontia would raise the standard of his general dentistry, and that all cases in their incipiency should certainly be taken care of by him. A rth u r H . M e rritt answers this ques tion thus: “Yes, because it is the most fundamental thing in dental practice, be cause such diseases are easily prevented and are not difficult to treat if taken in their incipiency, and because a handful of specialists cannot hope to meet the re quirements of the public.” “T h e dentist in general practice,” says Paul R. Stillman, “should by all means treat periodontal disease. If not the den tist in general practice, how then can the relatively few periodontists and compe tent dentists hope to cope w ith it as a profession ?” T h e few who are opposed took the attitude th at the dentist in general practice lacked interest and sufficient un derstanding, and so could not give intelli gent treatm ent, believing that he should by all means practice prevention and prophylaxis. Frederick A. Bricker be lieves th at the general practitioner can not develop the sense of touch necessary for delicate scaling and does not have the opportunity for observing the changes continually taking place during treatm ent as does the person who limits his practice.
1241
1242
T he Journal o f the American D ental Association
These are certainly sane and sound answers to this question. Question 2: W h at, briefly, is your method of procedure in treating perio dontoclasia ? I t was not my purpose to find any special or definite answer to this ques tion, but merely to find, if possible, just how far apart, or how close together, the profession really were on the ques tion of procedure in treatm ent. T o give the answer from every dentist w ould be quite impossible. Benjam in T ishler believes in the use of full mouth roentgenograms and good models of teeth when necessary; removal of hopelessly diseased teeth and replace ment w ith good substitutes; occlusal grinding; removal of root deposits, and careful instruction to the patient regard ing gingival massage w ith the tooth brush. Julian Smith lists: “ 1. G eneral pro phylaxis. 2. Correcting occlusion. 3. Toothbrush instruction. 4. Rest for ob servation. 5. Root surgery. 6. F inal pro phylaxis and examination as to results.” James Gregory O ’N eill: “F our major steps: 1. Occlusal equilibration. 2. Su perficial scaling. 3. Surgery of pocket. 4. Instructions in proper care of the m outh.” O lin K irkland : “A conservative sur gical operation under block anesthesia.” A ustin F. Jam es: “ 1. Diagnosis. 2. Instruction as to diet. 3. Home care. 4. Instrum entation. 5. Balancing occlu sion. 6. Thorough and continual prophy lactic treatm ents.” John Oppie M cC all: “ 1. Equilibra tion of occlusion ; relieving excessive oc clusal stress. 2. Giving stim ulation to the blood supply of the m arginal gingi vae, preferably w ith the toothbrush. 3. Apoxesis. 4. Use of epithelial solvent (sodium sulphid).”
E. J . W eaver : “O u r treatm ent is sur gical, radical or otherwise, as the case seems to indicate. In my opinion, 80 per cent of the periodontoclasia presented is simply a local manifestation of a physi cal condition. T h e general set-up must^ be looked into and the general diagnos tician must work hand-in-hand w ith the dental specialist in treating these cases. O f course, the specialist must take into consideration traum atic conditions and all other contributing causes which may be classed as contributory factors. A lim ited number of cases, of course, owe their inception purely to traum atic con ditions.” Question 3 : W h at, in your opinion, is the one most im portant procedure in treatm ent which might be applied to the general practitioner? M . H . G arvin : “ Regular prophylaxis and examination every three months, and instruction in home care.” Frederick A. Bricker: “ Preparing himself (the dentist) to teach the pa tient intelligent care of the oral cavity.” T h e answers to this question were unanimous as to the use of prophylaxis and teaching effective mouth hygiene. Question 4. (T h e subject for real dis cussion) : H ow should the general prac titioner equip himself for the practice of periodontia? Paul R. Stillman : “ Study and w ork.” Austin F. Jam es: “By making use of the things he need know if he is a grad uate of any dental college.” C. W . H offer: “ By visiting the of fices and w atching the procedure of the periodontist.” A. W . Bryan : “T he training that he receives in school, if a relatively recent graduate, should be sufficient. T h e older practitioner could brush up by studying published articles and books on the sub ject.”
Sherwood— Practice of Periodontia
12+3
Leslie W ad d ill: “ By spending a few erature on the subject and observe clin weeks w ith a reliable periodontist. Learn ics. Lastly, he should avoid all ‘special a sane technic and get proper instru aids’ such as medicaments, vaccines and ments. Read all articles on the subject radical operations, until he has grounded himself thoroughly in the fundamentals. and use common sense.” Russell W . B unting: “ By spending as If he can do this, the probabilities are much time and effort in m aintaining the that he w ill not have to resort to the health of the supporting tissues as he former except out of mere curiosity.” H . J . L eo n ard : “A t present, there does in the making of inlays and fillings are not available very good places for for the teeth.” D. P. M o w ry : “ Study the histology schooling in this subject. Several schools of the dental tissues, the physics of oc have well-developed courses for under clusion, the phenomena of inflammation, graduates, but these are not available to the relationship of morphology to func practitioners.” D r. Leonard advises get tion. T h e technic and the type of instru ting m aterial from articles and then ments are easily found when the working it out oneself. H e does not approve of high priced courses in private foregoing knowledge is obtained.” G race Rogers Spalding: “ 1. T rain in g offices. “T h e best periodontists,” he the eyes to recognize the slightest devia states, “have ‘dug it out’ for themselves tion from normal gum tissue in color, by practice, trial and error, w ith such form and tone. 2. Study. 3. Consulta help as they could get from articles and tion at frequent intervals w ith a reliable clinics.” Sidney S o rrin : “ H e must study and and successful periodontist who could advise him concerning equipment and learn how to master the knowledge that demonstrate a simple technic. 4. A good is essential to cure any case of periodon course of instruction. T his is invaluable tal disease, which includes (1 ) study when practical, but not essential. 5. A t of the tissue involved in treatm ent; (2 ) tendance at the meetings of the A m er removal of all etiologic factors, espe ican Academy of Periodontology and the cially traum atic occlusion; (3 ) the sci Section on Periodontia of the American entific method of instrum entation; (4 ) proper instruction in gingival stimula D ental Association.” George W ood Clapp : “T h e general tion by use of a toothbrush. O ther practitioner might be better prepared for agencies employed may be of assistance the practice of preventive dentistry by a in the procurement of health, but they course of training that would first of w ill not prove successful unless the den all give him a better conception of w hat tist understands the principles upon the practice of dentistry ought to mean which the treatm ent of periodontal dis than is general at present.” ease is based. T his education may be pro cured by postgraduate study and the Isador H irshfeld : “By taking one or more postgraduate courses as an intro practical experience obtained in dental duction ; by studying clinically the nor clinics.” mal periodontium and observing closely T h e increasing interest in periodon the pathologic; by treating as many tia leads one to believe that the dentist, cases as he can procure, graduating to the physician and public are beginning to more difficult ones. H e should cultivate realize fully the significance of perio an active interest in reading special lit dontia as related to health. D entistry
1244
T he Journal of the American D ental Association
has taken its rightful place along w ith medicine as a real division of health service. People are being restored to health by the proper adm inistration of dental service. T h e dentist of today must be recognized as a diagnostician, for he certainly is justly entitled to this recognition. D entistry has passed just its mechanical stage. Never in the his tory of dentistry has art and technic been so highly developed. N ow , let us develop the medical side of our profes sion, stressing the relation of dentistry to our bodily health. W hile the dentist is in need of knowledge related to condi tions in medical practice, ju st so is the physician in need of knowledge relating to clinical dentistry and its relationship to human welfare. Periodontia is the meeting ground of the dentist and the physician. I t is here that the dentist must begin to get his real professional contact w ith the phy sician. If for no other reason than just this one, the dentist in general practice should know periodontia: at least, he should be thoroughly familiar w ith its true relationship to health. I t has long been my opinion that the dentist in general practice should not only treat incipient cases of periodonto clasia, but should also be equipped in every way to practice prevention and treat the more advanced cases. T h e sup porting structures of the teeth are the real foundation of all dentistry: why should they be so sadly neglected or be eliminated from the general practice of dentistry ? T im e w ill not perm it the discussion of procedure in the treatm ent of perio dontoclasia. T o me, the most im portant and the one most sadly neglected is the teaching of effective mouth hygiene. Some of our most successful periodon tists have been preaching it for years.
In the past, the patient has been merely told to brush his teeth, w ith no thought of stim ulating the gums. If we are to attain any success in the treatm ent of periodontal disease, we must teach effec tive m outh hygiene. T h e patient should be told the cause of periodontal disease. W e should explain just w hat part the blood supply plays in the control of in fection and should emphasize the im portance of cooperation of the patient as related to success or failure. Ju st how the general practitioner is to best equip himself for the practice of periodontia has been so thoroughly out lined by my friends from all parts of this country and Canada that I feel it un necessary to make any further sugges tions. I commend for your study the out lines that have been given previously in this paper, also suggesting a compilation of all the current literature, reprints and everything available that you can get possession of. Place them under one cover, with proper index and classifica tion. You will then have at your finger tips the most recent m aterial published on the subject. I urge the general practitioner to be come interested in periodontia, believing that he will get a new viewpoint in den tistry. A new interest in the profession w ill be thus created and the patient will receive the added value in service to his health. 1304 Second N a tio n a l B ank B uilding.
C.
DISCUSSION
B. Vaughan, Boston, M ass.:
T hese fo u r questions are v ita l to every m an interested in the treatm en t of periodontal disease. T h e re is no question th a t every dentist should be able to recognize a n d tre a t incipient perio dontia cases, and in so doing dim inish the num ber of a dvanced cases as tim e goes on. B ut how m any dentists in general practice today find that, in spite of th eir best efforts,
Sherwood— Practice of Periodontia m any cases seem to re tro g ra d e . Such cases are fo r the specialist, a n d w hen w e realize th at, even u n d e r his tra in e d care, the re sults are not alw ay s all th a t could be hoped for, how can w e expect the busy general p ractitioner, who is occupied w ith countless o perations of every sort and only able to give an occasional h our o r so to a w ell-developed case, to get results. T h e m an w ho has had no special tra in in g such as the trea tm e n t of p e riodontal disease requires is doing a g re at injustice to his p a tie n t and to him self w hen he takes the responsibility of th is p a rtic u la r type of case. H e is equally u n fo rtu n ate w hen he neglects the m ore sim ple c a s e ; so th a t periodontal disease should be tre a te d by both the g e n era l p ra c titio n e r and the spe cialist, each tak in g those p a rtic u la r cases w hich his know ledge a n d skill fit him for treatin g . A gain, the question of tim e has m uch to do w ith the an sw er to this question. N atu rally , the longer a m an is in practice, the g re a te r the dem ands th a t w ill be m ade on his tim e ; and, fo r th a t reason, it is im possible to c a rry on a larg e g e n era l practice and a larg e practice of p erio d o n tia a t the sam e tim e a n d do justice to e ith e r one. Q ues tion 2, as to m ethods of tre a tin g periodonto clasia, does not ad m it of m uch discussion as n early all periodontists a g re e th a t there a re th ree im p o rtan t steps, nam ely, su r gical curetm ent of all root surfaces, b a l ancing occlusion and stim ulation of the gums by m assage. A s fo r Q uestion 3 (W h a t in y our opinion is the one most im p o rta n t p ro cedure in trea tm e n t w hich m ig h t be applied to the general p ra c titio n e r? ), it seems to me there is no one most im p o rta n t procedure. Each of the th ree m entioned procedures are equally im portant. E ach is so dovetailed into the o ther th a t no definite o r lastin g re sult can be expected if any one of the three a re left out. Surgical cu retm en t of the roots alone, lea v in g ap u n balanced exces sive stress on the teeth, w ill not be p e r m anently successful. N eith er w ill b alancing the occlusion, leav in g rough ro o t surfaces, w ith consequent irrita tio n to the su rro u n d ing tissues, be successful. W h en h ealth has been restored, by both su rg ical curetm ent of all root surfaces and balan cin g of the oc clusion, health w ill not be m ain tain ed w ith
1245
out p ain stak in g follow -up w ork by both the dentist and his p a tie n t in the w ay of gingival m assage. So it w ould seem th a t th ere m ust be three definite procedures to provide one im p o rta n t cure. Q uestion 4 (H ow should the g e n era l d entist equip him self fo r the p ra c tice of p e rio d o n tia ? ), h a d it been asked ten o r fifteen y e a rs ago, w ould h a v e been m ost difficult to answ er. H a d it been asked a t th a t tim e, I doubt th a t the a n sw e r w ould have been forthcom ing. I t seems to m e th a t the ease w ith w hich it can now be answ ered is a g re a t trib u te to the periodontists w ho h av e m ade it possible to an sw er it. F ifteen years ago, the teaching of the tre a tm e n t for periodontal disease in the dental schools w as p ractically nonexistent. T oday, in one of our univ ersity dental schools, th ere is one departm ent, w ith a full-tim e m an a n d a corps of instructors, in w hich a complete course of study a n d clinical instruction is given. T h is d e p artm e n t is o p e ratin g d u rin g the entire school session. H undreds of cases, including every stage of periodontal disease, a re treated by students. Anyone g ra d u a tin g from a school g iving such a course w ill be equipped to begin w ork in th is specialty. T h e sam e school la st y e a r g a v e a postg rad u ate course of ten days of intensive instruction under u niversity supervision. It w as largely attended. I am sure th ere a re other schools g iv in g sim ila r courses. T h e re is no better w ay th an this fo r the general p ractitio n er to equip him self. T h e entire subject is cov ered in such a course in a short period. T h e sacrifice of tim e is sm all and the educational v alu e g re at. In such a course as this, the student derives the benefit of instruction from a group of men. T h is is better th an tak in g instruction from one in d iv id u a l. It has been custom ary in the p ast to procure instruction in p riv a te offices. T h is is very satisfactory, pro v id ed the rig h t office is se lected. I believe such an introduction to p eriodontia d e sira b le ; but a t best is only a beginning, a n d p riv a te instruction is not calculated to tr a in men as specialists, but sim ply to give the g en eral p ra ctitio n er a fo u n dation, and a stim ulation to re n d er better service in this field. T h e p ro p e r source of all dental tea ch in g is the accredited u n iv e r sity school.
B
E F O R E entering into the discussion as to how the general practitioner should equip himself, o r herself, for the treatm ent of periodontoclasia, I find it necessary to consider several points that have a vital bearing on the subject. M y first impression, when assigned this subject, was that it should have been given to one engaged in teaching den tistry ; at least, to one more familiar with the art of teaching or having some connection w ith university work. But, having accepted the assignment, I began to diagnose my own feelings in the case. W h a t I found was quite insufficient, and w hat ideas I did possess I wished to have verified. A questionnaire suggested itself as a means of getting a widespread ex pression on this most im portant subject. T h e response given me by dentists from all over the U nited States and Canada was indeed most beneficial, and I wish to express my gratitude to everyone who so promptly answered my questionnaire. Question 1: Should the dentist in gen eral practice treat periodontal disease? T h e reason for asking this question was that, to my mind, the future of perio dontia depends on the answer. Shall the dentist in general practice treat periodon tal disease or shall it be left to the spe cialists? W ith but few exceptions, the *Read before the Section on P e riodontia a t the S eventy-F irst A nnual Session of the A m er ican D ental A ssociation, W ash in g to n , D . C., Oct. 9, 1929. Jo u r. A . D . A ., Ju ly ,
1930
answers favored the general practitioner, many believing that a practical knowl edge of periodontia would raise the standard of his general dentistry, and that all cases in their incipiency should certainly be taken care of by him. A rth u r H . M e rritt answers this ques tion thus: “Yes, because it is the most fundamental thing in dental practice, be cause such diseases are easily prevented and are not difficult to treat if taken in their incipiency, and because a handful of specialists cannot hope to meet the re quirements of the public.” “T h e dentist in general practice,” says Paul R. Stillman, “should by all means treat periodontal disease. If not the den tist in general practice, how then can the relatively few periodontists and compe tent dentists hope to cope w ith it as a profession ?” T h e few who are opposed took the attitude th at the dentist in general practice lacked interest and sufficient un derstanding, and so could not give intelli gent treatm ent, believing that he should by all means practice prevention and prophylaxis. Frederick A. Bricker be lieves th at the general practitioner can not develop the sense of touch necessary for delicate scaling and does not have the opportunity for observing the changes continually taking place during treatm ent as does the person who limits his practice.
1241
1242
T he Journal o f the American D ental Association
These are certainly sane and sound answers to this question. Question 2: W h at, briefly, is your method of procedure in treating perio dontoclasia ? I t was not my purpose to find any special or definite answer to this ques tion, but merely to find, if possible, just how far apart, or how close together, the profession really were on the ques tion of procedure in treatm ent. T o give the answer from every dentist w ould be quite impossible. Benjam in T ishler believes in the use of full mouth roentgenograms and good models of teeth when necessary; removal of hopelessly diseased teeth and replace ment w ith good substitutes; occlusal grinding; removal of root deposits, and careful instruction to the patient regard ing gingival massage w ith the tooth brush. Julian Smith lists: “ 1. G eneral pro phylaxis. 2. Correcting occlusion. 3. Toothbrush instruction. 4. Rest for ob servation. 5. Root surgery. 6. F inal pro phylaxis and examination as to results.” James Gregory O ’N eill: “F our major steps: 1. Occlusal equilibration. 2. Su perficial scaling. 3. Surgery of pocket. 4. Instructions in proper care of the m outh.” O lin K irkland : “A conservative sur gical operation under block anesthesia.” A ustin F. Jam es: “ 1. Diagnosis. 2. Instruction as to diet. 3. Home care. 4. Instrum entation. 5. Balancing occlu sion. 6. Thorough and continual prophy lactic treatm ents.” John Oppie M cC all: “ 1. Equilibra tion of occlusion ; relieving excessive oc clusal stress. 2. Giving stim ulation to the blood supply of the m arginal gingi vae, preferably w ith the toothbrush. 3. Apoxesis. 4. Use of epithelial solvent (sodium sulphid).”
E. J . W eaver : “O u r treatm ent is sur gical, radical or otherwise, as the case seems to indicate. In my opinion, 80 per cent of the periodontoclasia presented is simply a local manifestation of a physi cal condition. T h e general set-up must^ be looked into and the general diagnos tician must work hand-in-hand w ith the dental specialist in treating these cases. O f course, the specialist must take into consideration traum atic conditions and all other contributing causes which may be classed as contributory factors. A lim ited number of cases, of course, owe their inception purely to traum atic con ditions.” Question 3 : W h at, in your opinion, is the one most im portant procedure in treatm ent which might be applied to the general practitioner? M . H . G arvin : “ Regular prophylaxis and examination every three months, and instruction in home care.” Frederick A. Bricker: “ Preparing himself (the dentist) to teach the pa tient intelligent care of the oral cavity.” T h e answers to this question were unanimous as to the use of prophylaxis and teaching effective mouth hygiene. Question 4. (T h e subject for real dis cussion) : H ow should the general prac titioner equip himself for the practice of periodontia? Paul R. Stillman : “ Study and w ork.” Austin F. Jam es: “By making use of the things he need know if he is a grad uate of any dental college.” C. W . H offer: “ By visiting the of fices and w atching the procedure of the periodontist.” A. W . Bryan : “T he training that he receives in school, if a relatively recent graduate, should be sufficient. T h e older practitioner could brush up by studying published articles and books on the sub ject.”
Sherwood— Practice of Periodontia
12+3
Leslie W ad d ill: “ By spending a few erature on the subject and observe clin weeks w ith a reliable periodontist. Learn ics. Lastly, he should avoid all ‘special a sane technic and get proper instru aids’ such as medicaments, vaccines and ments. Read all articles on the subject radical operations, until he has grounded himself thoroughly in the fundamentals. and use common sense.” Russell W . B unting: “ By spending as If he can do this, the probabilities are much time and effort in m aintaining the that he w ill not have to resort to the health of the supporting tissues as he former except out of mere curiosity.” H . J . L eo n ard : “A t present, there does in the making of inlays and fillings are not available very good places for for the teeth.” D. P. M o w ry : “ Study the histology schooling in this subject. Several schools of the dental tissues, the physics of oc have well-developed courses for under clusion, the phenomena of inflammation, graduates, but these are not available to the relationship of morphology to func practitioners.” D r. Leonard advises get tion. T h e technic and the type of instru ting m aterial from articles and then ments are easily found when the working it out oneself. H e does not approve of high priced courses in private foregoing knowledge is obtained.” G race Rogers Spalding: “ 1. T rain in g offices. “T h e best periodontists,” he the eyes to recognize the slightest devia states, “have ‘dug it out’ for themselves tion from normal gum tissue in color, by practice, trial and error, w ith such form and tone. 2. Study. 3. Consulta help as they could get from articles and tion at frequent intervals w ith a reliable clinics.” Sidney S o rrin : “ H e must study and and successful periodontist who could advise him concerning equipment and learn how to master the knowledge that demonstrate a simple technic. 4. A good is essential to cure any case of periodon course of instruction. T his is invaluable tal disease, which includes (1 ) study when practical, but not essential. 5. A t of the tissue involved in treatm ent; (2 ) tendance at the meetings of the A m er removal of all etiologic factors, espe ican Academy of Periodontology and the cially traum atic occlusion; (3 ) the sci Section on Periodontia of the American entific method of instrum entation; (4 ) proper instruction in gingival stimula D ental Association.” George W ood Clapp : “T h e general tion by use of a toothbrush. O ther practitioner might be better prepared for agencies employed may be of assistance the practice of preventive dentistry by a in the procurement of health, but they course of training that would first of w ill not prove successful unless the den all give him a better conception of w hat tist understands the principles upon the practice of dentistry ought to mean which the treatm ent of periodontal dis than is general at present.” ease is based. T his education may be pro cured by postgraduate study and the Isador H irshfeld : “By taking one or more postgraduate courses as an intro practical experience obtained in dental duction ; by studying clinically the nor clinics.” mal periodontium and observing closely T h e increasing interest in periodon the pathologic; by treating as many tia leads one to believe that the dentist, cases as he can procure, graduating to the physician and public are beginning to more difficult ones. H e should cultivate realize fully the significance of perio an active interest in reading special lit dontia as related to health. D entistry
1244
T he Journal of the American D ental Association
has taken its rightful place along w ith medicine as a real division of health service. People are being restored to health by the proper adm inistration of dental service. T h e dentist of today must be recognized as a diagnostician, for he certainly is justly entitled to this recognition. D entistry has passed just its mechanical stage. Never in the his tory of dentistry has art and technic been so highly developed. N ow , let us develop the medical side of our profes sion, stressing the relation of dentistry to our bodily health. W hile the dentist is in need of knowledge related to condi tions in medical practice, ju st so is the physician in need of knowledge relating to clinical dentistry and its relationship to human welfare. Periodontia is the meeting ground of the dentist and the physician. I t is here that the dentist must begin to get his real professional contact w ith the phy sician. If for no other reason than just this one, the dentist in general practice should know periodontia: at least, he should be thoroughly familiar w ith its true relationship to health. I t has long been my opinion that the dentist in general practice should not only treat incipient cases of periodonto clasia, but should also be equipped in every way to practice prevention and treat the more advanced cases. T h e sup porting structures of the teeth are the real foundation of all dentistry: why should they be so sadly neglected or be eliminated from the general practice of dentistry ? T im e w ill not perm it the discussion of procedure in the treatm ent of perio dontoclasia. T o me, the most im portant and the one most sadly neglected is the teaching of effective mouth hygiene. Some of our most successful periodon tists have been preaching it for years.
In the past, the patient has been merely told to brush his teeth, w ith no thought of stim ulating the gums. If we are to attain any success in the treatm ent of periodontal disease, we must teach effec tive m outh hygiene. T h e patient should be told the cause of periodontal disease. W e should explain just w hat part the blood supply plays in the control of in fection and should emphasize the im portance of cooperation of the patient as related to success or failure. Ju st how the general practitioner is to best equip himself for the practice of periodontia has been so thoroughly out lined by my friends from all parts of this country and Canada that I feel it un necessary to make any further sugges tions. I commend for your study the out lines that have been given previously in this paper, also suggesting a compilation of all the current literature, reprints and everything available that you can get possession of. Place them under one cover, with proper index and classifica tion. You will then have at your finger tips the most recent m aterial published on the subject. I urge the general practitioner to be come interested in periodontia, believing that he will get a new viewpoint in den tistry. A new interest in the profession w ill be thus created and the patient will receive the added value in service to his health. 1304 Second N a tio n a l B ank B uilding.
C.
DISCUSSION
B. Vaughan, Boston, M ass.:
T hese fo u r questions are v ita l to every m an interested in the treatm en t of periodontal disease. T h e re is no question th a t every dentist should be able to recognize a n d tre a t incipient perio dontia cases, and in so doing dim inish the num ber of a dvanced cases as tim e goes on. B ut how m any dentists in general practice today find that, in spite of th eir best efforts,
Sherwood— Practice of Periodontia m any cases seem to re tro g ra d e . Such cases are fo r the specialist, a n d w hen w e realize th at, even u n d e r his tra in e d care, the re sults are not alw ay s all th a t could be hoped for, how can w e expect the busy general p ractitioner, who is occupied w ith countless o perations of every sort and only able to give an occasional h our o r so to a w ell-developed case, to get results. T h e m an w ho has had no special tra in in g such as the trea tm e n t of p e riodontal disease requires is doing a g re at injustice to his p a tie n t and to him self w hen he takes the responsibility of th is p a rtic u la r type of case. H e is equally u n fo rtu n ate w hen he neglects the m ore sim ple c a s e ; so th a t periodontal disease should be tre a te d by both the g e n era l p ra c titio n e r and the spe cialist, each tak in g those p a rtic u la r cases w hich his know ledge a n d skill fit him for treatin g . A gain, the question of tim e has m uch to do w ith the an sw er to this question. N atu rally , the longer a m an is in practice, the g re a te r the dem ands th a t w ill be m ade on his tim e ; and, fo r th a t reason, it is im possible to c a rry on a larg e g e n era l practice and a larg e practice of p erio d o n tia a t the sam e tim e a n d do justice to e ith e r one. Q ues tion 2, as to m ethods of tre a tin g periodonto clasia, does not ad m it of m uch discussion as n early all periodontists a g re e th a t there a re th ree im p o rtan t steps, nam ely, su r gical curetm ent of all root surfaces, b a l ancing occlusion and stim ulation of the gums by m assage. A s fo r Q uestion 3 (W h a t in y our opinion is the one most im p o rta n t p ro cedure in trea tm e n t w hich m ig h t be applied to the general p ra c titio n e r? ), it seems to me there is no one most im p o rta n t procedure. Each of the th ree m entioned procedures are equally im portant. E ach is so dovetailed into the o ther th a t no definite o r lastin g re sult can be expected if any one of the three a re left out. Surgical cu retm en t of the roots alone, lea v in g ap u n balanced exces sive stress on the teeth, w ill not be p e r m anently successful. N eith er w ill b alancing the occlusion, leav in g rough ro o t surfaces, w ith consequent irrita tio n to the su rro u n d ing tissues, be successful. W h en h ealth has been restored, by both su rg ical curetm ent of all root surfaces and balan cin g of the oc clusion, health w ill not be m ain tain ed w ith
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out p ain stak in g follow -up w ork by both the dentist and his p a tie n t in the w ay of gingival m assage. So it w ould seem th a t th ere m ust be three definite procedures to provide one im p o rta n t cure. Q uestion 4 (H ow should the g e n era l d entist equip him self fo r the p ra c tice of p e rio d o n tia ? ), h a d it been asked ten o r fifteen y e a rs ago, w ould h a v e been m ost difficult to answ er. H a d it been asked a t th a t tim e, I doubt th a t the a n sw e r w ould have been forthcom ing. I t seems to m e th a t the ease w ith w hich it can now be answ ered is a g re a t trib u te to the periodontists w ho h av e m ade it possible to an sw er it. F ifteen years ago, the teaching of the tre a tm e n t for periodontal disease in the dental schools w as p ractically nonexistent. T oday, in one of our univ ersity dental schools, th ere is one departm ent, w ith a full-tim e m an a n d a corps of instructors, in w hich a complete course of study a n d clinical instruction is given. T h is d e p artm e n t is o p e ratin g d u rin g the entire school session. H undreds of cases, including every stage of periodontal disease, a re treated by students. Anyone g ra d u a tin g from a school g iving such a course w ill be equipped to begin w ork in th is specialty. T h e sam e school la st y e a r g a v e a postg rad u ate course of ten days of intensive instruction under u niversity supervision. It w as largely attended. I am sure th ere a re other schools g iv in g sim ila r courses. T h e re is no better w ay th an this fo r the general p ractitio n er to equip him self. T h e entire subject is cov ered in such a course in a short period. T h e sacrifice of tim e is sm all and the educational v alu e g re at. In such a course as this, the student derives the benefit of instruction from a group of men. T h is is better th an tak in g instruction from one in d iv id u a l. It has been custom ary in the p ast to procure instruction in p riv a te offices. T h is is very satisfactory, pro v id ed the rig h t office is se lected. I believe such an introduction to p eriodontia d e sira b le ; but a t best is only a beginning, a n d p riv a te instruction is not calculated to tr a in men as specialists, but sim ply to give the g en eral p ra ctitio n er a fo u n dation, and a stim ulation to re n d er better service in this field. T h e p ro p e r source of all dental tea ch in g is the accredited u n iv e r sity school.