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The Problem of Root Canal Treatment
1384
T h e Journal of the American D ental Association'
justifiable seems to be the old Scottish verdict, “not proven” ; a verdict not very complimentary to the character of the defendant. I know of no method of me dicinally treating a pulpless tooth which can be routinely relied on to reduce to a negligible minimum the hazard which the retention of such a tooth offers to the general health of the patient. Before we can be satisfied that we have such a method in our grasp, its clinical results must be weighed in the balance and not found wanting. T h e methodologic needs which have been emphasized by this review follow : 1. T h e technic followed must be ex plicitly set forth in the minutest detail. 2. W e should never draw on an as sumption when it is possible to appeal directly to the facts. 3. Carefully taken case histories, re cording the findings and exactly w hat was done, are indispensable.
4. Numerically adequate control and comparative series of cases must be had. 5. Results must be checked up clin ically (local and general), roentgenographically, histologically and bacteriologically. T h e report must be docu mented adequately w ith the results of this checking up. CONCLUSION
I am perfectly willing for the moment to admit that any or all methods of man aging the pulpless tooth leave nothing to be desired; that they accomplish all they are intended to accomplish. But we do not know w hether this goal has been reached. W e may be on the right track or we may have arrived, but we do not know, and we cannot know, unless and until the principles outlined in this re view (and possibly other principles) have been applied. 4001 Spruce Street.
T H E PROBLEM OF ROOT C A N A L T R E A T M E N T /
a
By BALINT ORBAN, M.D., Vienna, Austria
T was a great pleasure to read in the M ay issue of T h e J o u r n a l the sym posium on root canal work by Skillen, Rickert, H atton, Coolidge, W alker, Adams and Blayney, presenting the opin ion of some of the leaders in root canal work in the U nited States, as well as some of the most widely known research men. W e can see in these papers the honest and consistent effort of these men to find the best w ay to combat this problem. T h e Federation D entaire Internation ale, recognizing the fact that dentistry, as a p art of the profession of medicine, is in an untenable position owing to its fail ure to solve the problem of root canal treatm ent, determined some time ago to
I
Jour. A . D .A .,A u gu st, 1932
make an effort to clear up this question. Assuredly, not all of the 100 or 1,000 procedures described in the dental litera ture as the best methods of root canal treatm ent could be in fact the best, as we know very well that, in root canal work, we have failures enough. I t becomes the duty of the dental profession to solve this problem in order to relieve itself of a bur den of responsibility and thus strengthen its position of authority in the eyes of both the medical profession and the pub lic. Before this work could be undertaken, a number of preliminary problems had to be solved. H ow could a body like the F. D . I. initiate efforts at solution of this
Orbati— Problem of R oot Canal Treatm ent problem? As a rule, if a private indi vidual or a group wishes to launch a project, funds must be available; but this is not a ll: it is perhaps more important to know how to use the money. T h is was a m atter of discussion by the F. D . I. T h ere are two ways to make use of money in an effort at solution of a definite prob lem : ( 1 ) to finance the efforts of certain research men working independently or in a laboratory and wait to see whether they will be successful; or ( 2 ) to turn the funds over to a group like the F. D . I., which w ill judge the results obtained by various research workers or laboratories and make the aw ard accordingly. T h e men or laboratories solving the problem will thus receive the financial rew ard and the honor.- U nder the first plan, the lab oratories or individuals would receive the money and no one could foretell whether they would succeed. In a few years, it might become evident that the entire fund had been spent w ithout re sult. U nder the other plan, there is com petition and the award goes only to those who succeed. Appreciating that public funds should be used most carefully, the F. D . I. adopted the second plan, inviting compe tition. I t should be emphasized that this procedure is adapted only to the solution of a definite problem and not to the pro motion of research in general. T h e next step was to decide on a method by which the different modes of canal treatm ent could be evaluated. T his was the most difficult phase of the entire problem, requiring the time between the congress in Philadelphia and that in Paris for a decision. Therefore, it was not until the Paris meeting that the international commission, appointed for that purpose, determined on the procedure for con
1385
trolling methods of root canal treatm ent .1 T h e text of the plan adopted has been published .2 T h e conclusions of D r. Coolidge in the above-mentioned symposium may seem out of harmony w ith the premises on which experimentation in the F. D . I. contest is to be based. Coolidge found that after the use of neutral physiologic sodium chlorid, an inflammatory reaction occurred in the periodontal membrane of dogs’ teeth, and, after the use of more active drugs, the inflammatory reaction was more severe. He, as well as D r. Blayney, drew the conclusion that we cannot expect the same results in practical root canal treatm ent in human beings as in an experiment w ith dogs. T his is not a conclusion drawn from experiment, but is an opinion of these men not supported by actual observation. No one has up to date observed how sodium chlorid would act in a human tooth in twenty-one days, and therefore no one in entitled to draw from an experimental result in dogs the conclusion th at in human beings the result would be different. I t was clearly demonstrated and ac cepted in Paris that the periapical tissues of dogs’ teeth are very sensitive to any kind of injury. I t seems that they are in fact more sensitive than human tissues. I t was suggested at th at time that a part of this hypersensitiveness is due to the fact that there is greater permeability of the hard structures of the teeth, dentin and cementum than in human beings. These structures in dogs seem to permit the penetration of drugs more readily into the periapical tissues than is the case in 1. T h is commission consisted of J. L. T . Appleton, Jr., P. Bernard, E. D. Coolidge, Bernhard Gottlieb, O; Muller, Balint Orban, W . A. Price, U. G. Rickert and Georges Stein. 2. F. D. I. Competition in Root Canal W ork : Method for Verification of Root Canal T reat ment, J.A.D .A., 19:356 (Feb.) 1932.
1386
T h e Journal of the A?nerican D ental Association
human teeth. T h is difference in density of the structures could be observed in various experiments. Nevertheless, it has been shown that, in experimental root canal work, one can observe periapical tissue showing no inflammatory reaction, not only after extraction of an intact pulp, but also after treatm ent of an infected root canal w ith periapical inflammation.
cepted as constituting a fair and satisfac tory test. If treatm ent in the more sensi tive dog proves satisfactory, it can be ex pected to be still more acceptable in human beings. In Paris, we showed slides of periapical tissues after pulp extraction as well as pulp infection w ithout inflam m ation.3 A few additional apices present ing pathologic reactions are shown here ;
Fig. 1.—Apex of dog’s tooth, w ith pulp extirpated and root canal treated. T he apical periodontal tissues are entirely free from inflammatory reaction. T he dog was killed about eight months after filling of the root canal.
Evaluation of root canal treatm ent is difficult but is possible. T h e greater sensi tiveness of the dog’s tissues adds to the difficulty; but this is a welcomed fact, since if it can be shown that in dogs satis factory root canal treatm ent is possible, experiments on the dog have to be ac-
not to recommend a certain procedure in root canal surgery, but to show th at in experimental w ork the value of a method can be proved. (Figs. 1-4.) 3. Gottlieb, B ern h ard ; Orban, Bälint, and Stein, G eorges: Das Problem der W urzel handlung, Ztschr. f. Stomatol., 1932, No. 4.
O rbati— P r o b le m o f R o o t C a n al T r e a tm e n t
1387
Fig. 3.— Apex of dog’s tooth treated and filled. T h e periapical tissues are normal and there is no inflammatory reaction. T h e dog w as killed eight months after treatment.
1388
T h e Journal o f the American D ental Association
T h e profession seems to be tired of socalled satisfactory methods set forth w ith out proof. T h is reaction of the profes sion, which can be seen in the papers mak ing up the above-mentioned symposium, can be regarded as a forw ard step, prom ising much for the future. O f course, we do not expect from this
regarded today as the “best” shall be discarded. A great advantage w ill accrue to the profession if only about 10 per cent of the former methods are employed, and we can then go a step farther and try to so reduce these methods in number th at root canal surgery shall become standardized.
Fig. 4.— H igher magnification of the periapical tissue shown in Figure 3. T h ere is no inflammation of the tissues.
contest an immediate solution of the root canal problem, and we can hardly expect that one and only one method of root canal surgery w ill be found to be “the best.” I t w ill be a great achievement if we determine w hat has not to be done, and if about 90 per cent of all methods
T h e work that the F. D. I. has under taken suggests and bears a resemblance to the w ork that is being done by the Bureau of Standards. A ll who are interested in the solution of this problem should collaborate in and give this work their support.
T h e Journal of the American D ental Association'
justifiable seems to be the old Scottish verdict, “not proven” ; a verdict not very complimentary to the character of the defendant. I know of no method of me dicinally treating a pulpless tooth which can be routinely relied on to reduce to a negligible minimum the hazard which the retention of such a tooth offers to the general health of the patient. Before we can be satisfied that we have such a method in our grasp, its clinical results must be weighed in the balance and not found wanting. T h e methodologic needs which have been emphasized by this review follow : 1. T h e technic followed must be ex plicitly set forth in the minutest detail. 2. W e should never draw on an as sumption when it is possible to appeal directly to the facts. 3. Carefully taken case histories, re cording the findings and exactly w hat was done, are indispensable.
4. Numerically adequate control and comparative series of cases must be had. 5. Results must be checked up clin ically (local and general), roentgenographically, histologically and bacteriologically. T h e report must be docu mented adequately w ith the results of this checking up. CONCLUSION
I am perfectly willing for the moment to admit that any or all methods of man aging the pulpless tooth leave nothing to be desired; that they accomplish all they are intended to accomplish. But we do not know w hether this goal has been reached. W e may be on the right track or we may have arrived, but we do not know, and we cannot know, unless and until the principles outlined in this re view (and possibly other principles) have been applied. 4001 Spruce Street.
T H E PROBLEM OF ROOT C A N A L T R E A T M E N T /
a
By BALINT ORBAN, M.D., Vienna, Austria
T was a great pleasure to read in the M ay issue of T h e J o u r n a l the sym posium on root canal work by Skillen, Rickert, H atton, Coolidge, W alker, Adams and Blayney, presenting the opin ion of some of the leaders in root canal work in the U nited States, as well as some of the most widely known research men. W e can see in these papers the honest and consistent effort of these men to find the best w ay to combat this problem. T h e Federation D entaire Internation ale, recognizing the fact that dentistry, as a p art of the profession of medicine, is in an untenable position owing to its fail ure to solve the problem of root canal treatm ent, determined some time ago to
I
Jour. A . D .A .,A u gu st, 1932
make an effort to clear up this question. Assuredly, not all of the 100 or 1,000 procedures described in the dental litera ture as the best methods of root canal treatm ent could be in fact the best, as we know very well that, in root canal work, we have failures enough. I t becomes the duty of the dental profession to solve this problem in order to relieve itself of a bur den of responsibility and thus strengthen its position of authority in the eyes of both the medical profession and the pub lic. Before this work could be undertaken, a number of preliminary problems had to be solved. H ow could a body like the F. D . I. initiate efforts at solution of this
Orbati— Problem of R oot Canal Treatm ent problem? As a rule, if a private indi vidual or a group wishes to launch a project, funds must be available; but this is not a ll: it is perhaps more important to know how to use the money. T h is was a m atter of discussion by the F. D . I. T h ere are two ways to make use of money in an effort at solution of a definite prob lem : ( 1 ) to finance the efforts of certain research men working independently or in a laboratory and wait to see whether they will be successful; or ( 2 ) to turn the funds over to a group like the F. D . I., which w ill judge the results obtained by various research workers or laboratories and make the aw ard accordingly. T h e men or laboratories solving the problem will thus receive the financial rew ard and the honor.- U nder the first plan, the lab oratories or individuals would receive the money and no one could foretell whether they would succeed. In a few years, it might become evident that the entire fund had been spent w ithout re sult. U nder the other plan, there is com petition and the award goes only to those who succeed. Appreciating that public funds should be used most carefully, the F. D . I. adopted the second plan, inviting compe tition. I t should be emphasized that this procedure is adapted only to the solution of a definite problem and not to the pro motion of research in general. T h e next step was to decide on a method by which the different modes of canal treatm ent could be evaluated. T his was the most difficult phase of the entire problem, requiring the time between the congress in Philadelphia and that in Paris for a decision. Therefore, it was not until the Paris meeting that the international commission, appointed for that purpose, determined on the procedure for con
1385
trolling methods of root canal treatm ent .1 T h e text of the plan adopted has been published .2 T h e conclusions of D r. Coolidge in the above-mentioned symposium may seem out of harmony w ith the premises on which experimentation in the F. D . I. contest is to be based. Coolidge found that after the use of neutral physiologic sodium chlorid, an inflammatory reaction occurred in the periodontal membrane of dogs’ teeth, and, after the use of more active drugs, the inflammatory reaction was more severe. He, as well as D r. Blayney, drew the conclusion that we cannot expect the same results in practical root canal treatm ent in human beings as in an experiment w ith dogs. T his is not a conclusion drawn from experiment, but is an opinion of these men not supported by actual observation. No one has up to date observed how sodium chlorid would act in a human tooth in twenty-one days, and therefore no one in entitled to draw from an experimental result in dogs the conclusion th at in human beings the result would be different. I t was clearly demonstrated and ac cepted in Paris that the periapical tissues of dogs’ teeth are very sensitive to any kind of injury. I t seems that they are in fact more sensitive than human tissues. I t was suggested at th at time that a part of this hypersensitiveness is due to the fact that there is greater permeability of the hard structures of the teeth, dentin and cementum than in human beings. These structures in dogs seem to permit the penetration of drugs more readily into the periapical tissues than is the case in 1. T h is commission consisted of J. L. T . Appleton, Jr., P. Bernard, E. D. Coolidge, Bernhard Gottlieb, O; Muller, Balint Orban, W . A. Price, U. G. Rickert and Georges Stein. 2. F. D. I. Competition in Root Canal W ork : Method for Verification of Root Canal T reat ment, J.A.D .A., 19:356 (Feb.) 1932.
1386
T h e Journal of the A?nerican D ental Association
human teeth. T h is difference in density of the structures could be observed in various experiments. Nevertheless, it has been shown that, in experimental root canal work, one can observe periapical tissue showing no inflammatory reaction, not only after extraction of an intact pulp, but also after treatm ent of an infected root canal w ith periapical inflammation.
cepted as constituting a fair and satisfac tory test. If treatm ent in the more sensi tive dog proves satisfactory, it can be ex pected to be still more acceptable in human beings. In Paris, we showed slides of periapical tissues after pulp extraction as well as pulp infection w ithout inflam m ation.3 A few additional apices present ing pathologic reactions are shown here ;
Fig. 1.—Apex of dog’s tooth, w ith pulp extirpated and root canal treated. T he apical periodontal tissues are entirely free from inflammatory reaction. T he dog was killed about eight months after filling of the root canal.
Evaluation of root canal treatm ent is difficult but is possible. T h e greater sensi tiveness of the dog’s tissues adds to the difficulty; but this is a welcomed fact, since if it can be shown that in dogs satis factory root canal treatm ent is possible, experiments on the dog have to be ac-
not to recommend a certain procedure in root canal surgery, but to show th at in experimental w ork the value of a method can be proved. (Figs. 1-4.) 3. Gottlieb, B ern h ard ; Orban, Bälint, and Stein, G eorges: Das Problem der W urzel handlung, Ztschr. f. Stomatol., 1932, No. 4.
O rbati— P r o b le m o f R o o t C a n al T r e a tm e n t
1387
Fig. 3.— Apex of dog’s tooth treated and filled. T h e periapical tissues are normal and there is no inflammatory reaction. T h e dog w as killed eight months after treatment.
1388
T h e Journal o f the American D ental Association
T h e profession seems to be tired of socalled satisfactory methods set forth w ith out proof. T h is reaction of the profes sion, which can be seen in the papers mak ing up the above-mentioned symposium, can be regarded as a forw ard step, prom ising much for the future. O f course, we do not expect from this
regarded today as the “best” shall be discarded. A great advantage w ill accrue to the profession if only about 10 per cent of the former methods are employed, and we can then go a step farther and try to so reduce these methods in number th at root canal surgery shall become standardized.
Fig. 4.— H igher magnification of the periapical tissue shown in Figure 3. T h ere is no inflammation of the tissues.
contest an immediate solution of the root canal problem, and we can hardly expect that one and only one method of root canal surgery w ill be found to be “the best.” I t w ill be a great achievement if we determine w hat has not to be done, and if about 90 per cent of all methods
T h e work that the F. D. I. has under taken suggests and bears a resemblance to the w ork that is being done by the Bureau of Standards. A ll who are interested in the solution of this problem should collaborate in and give this work their support.