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A Further Consideration of the Pulpless Tooth
A FU R TH ER CO N SID ER A TIO N OF T H E PULPLESS TO O T H By HOWARD TEMPLE STEWART, D.D.S., New York City T h e aim o f m odern m edicine is not to m u tilate but to prese rv e the hum an body. O nly recently, d u rin g the short course o f one yea r, m ore than l,000j000 tonsil lectom ies w ere p erfo rm ed , seem ingly as a result o f a utosuggestive influences exerted on th e practitioners, w ho resorted to these radical m ethods ’w ithout proper scientific reasons. A n d n o w our present era is concerned w ith the general extraction o f the teeth. T h e term fo ca l d en ta l infection w a s fo rm u la te d a n d already influences every m edical thought and a c tiv ity. T h e -patient fea rs his ow n teeth, the physician points to the teeth, a n d condem ns them a n d the d entist extracts the teeth on the least in d i cation, all v isu a lizin g an im a g in a ry enemy. S ho u ld an enterologist today m aintain th a t all infections can be traced to the intestines, so ab u n d a n t w ith bacteria ( enterogenous focal in fe c tio n ), he w ould h a v e a fa r m ore plausible basis fo r discussion, a f a r m ore plausible w o rk in g hypothesis than he w ho constructs an erroneous a n d h a rm fu l theory based on the presence o f an a p p a ren tly norm al pulpless tooth. M e a n w h ile , no one w o u ld attem pt to elim inate the highly pathogenic bacteria w hich are ever present in the intestines. O ne pulpless tooth seem s to be fa r m ore dangerous E d w a r d L. M i l o s l a v i c h , M .D .
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M
Y earlier paper1 was necessarily so condensed th at much had to be omitted. Lucien H . A rnold shows how lightly some people, particularly physicians, re gard the loss of a tooth, under the assumption th at it can easily be replaced artificially. In this connection, D r. A rnold remarks that the artificial tooth is, on the average, only about 25 per cent efficient as compared w ith the nat ural tooth and th at the loss of teeth seri ously interferes w ith the oral starchdigesting mechanism. “ I t is entirely unw arranted,” he says, “to order the extraction of a tooth sus pected of metastatic infection unless a
complete physical examination excludes all other sources of infection and even then— should a tooth be p o s itiv e ly proved the cause— instead of immediately order ing an extraction, effort should be di rected to obliteration of the infection—which is quite as prompt and efficient and far less risky than extraction— in the hope of preserving the organs of diges tion as nearly intact as possible, ju st as would be done w ith an organ in any other part of the body.” V ilray P . Blair says, “ I think, w ithout question, one can agree in the premise th at the care of the devitalized tooth is the most serious and weighty problem that confronts the dentist today. I must confess to a very pessimistic view on my 1. Stewart, H. T .: Pulpless Tooth and Its p art as to the ultim ate results of the Treatment, J. A. D. A., 17:381 (March) ordinary treatm ent which these teeth are 1930.
Jour. A. D. A., October, 1930
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Stewart— A Further Consideration of the Pulpless Tooth receiving at the hands of the m ajority of the good dentists today.” “W ith o u t doubt,” Custer says, “the most vital question before the dental pro fession today is, W h at shall we do w ith the pulpless tooth ? T h e seat of the whole trouble lies at the apical foramen. T h e problem has been to sterilize and seal this opening in a manner acceptable to nature. Nowhere in the whole range of human endeavor has there been as much energy spent to patch up any part of a human being as at the tiny apical foramen. Is it not about time th at the dentist is able to seal w ith a foreign material so tiny an opening as the apical foramen in a man ner acceptable to nature?”
Fig. 1.— U pper cuspid w ith m uch a b sorption especially of the m esial su rface. T h e line of the absorption extends m esially from the apex dow n about one q u a rte r the length of the entire root. T h e case seem ed v e ry dis couraging. T h is figure also show s a larg e copper rod w hich w as kept in position about tw o m onths. I t w as rem oved about every tw o w eeks fo r d ra in a g e . T h e rough edges all aro u n d the end of the fo ram en al w a ll w ere sm oothed w ith a round b u r (com pare F igure 6 , T h e J o u r n a l , M arch, 1 9 3 0 , p . 3 8 7 ) , but the end of the root w as, in the beginning, p ractically the sam e shape as seen in the roentgenogram .
I believe this has been accomplished. As I have tried to show, “in a manner acceptable to nature,” means much, very much.
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Rosenow writes, “ I t is to be hoped that an efficient method may be found that will not only render pulpless teeth and periapical tissues sterile, th at have become infected, but that will also pre vent subsequent infection especially of the periapical tissues. T h e fulfilment of the latter requirements seems almost un attainable.” I believe these requirements have been met. T o quote H atton, Skillen and M oen: “O n the other hand, if a method could be devised of getting adequate surgical drainage, if the apex has been involved, and if a method could be found which would insure a higher percentage of successfully filled canals, there would be
Fig. 2.—Root filled. C onsiderable calcifica tion w ill be noted. T h is figure w a s taken im m ediately a fte r the filling and a denser calcification is expected to take place.
a much higher percentage of favorable results.” T aking the propositions in this para graph one by one, w hat I have presented shows that a method has been “ devised of getting adequate surgical drainage” ; that a method has been found which in sures “a higher percentage of successfully filled canals” and that there is “a much higher percentage of favorable results.” A clean record of more than 300 cases (everyone where the foramen could be successfully opened) extending over a period of more than four years, with
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most pleasing clinical results, speaks for itself. Hudson extracted pulps and filled roots “to the apex” w ith gold in 1809, 120 years ago. In 1888 (forty-tw o years ago), James T ru m an said, “W e are as far from a settled policy in the treatm ent of the pulpless tooth as we were forty years ago.” A t that time (eighty-two years ago), guttapercha was the chief m aterial used. I t was the chief material used when T ru m an spoke: it is the chief material used today, and so I think it could be said that we are no nearer a settled policy than the profession was eighty-two years ago. D r. Sudduth wrote, in 1888, “T h e
Fig. 3.— G lass tube th a t has been im m ersed in m ethylene blue fo r m ore th an tw o years. V arious sizes of tubes h ave been filled and tested in every conceivable w ay, even u n d e r pressure of a column of w ater, but th ere has n e v er been the slightest leakage. T h is test can be v e ry easily m ade by anyone who w ishes to satisfy him self. F illin g glass tubes is an excellent w a y to w atch the w ork in g of the filling w hile the m ate ria l is being placed in position. Sm all glass tubes of v a rio u s diam eters m ay be used to represent the canal of the tooth root.
main office of the pulp is formative, and all the ‘live’ portion of the dentine is a part of the pulp; the dentinal fibrils are prolongations of the pulp and when the latter is destroyed they die also. T here is no other tissue in the dentine to nour ish, hence no need of nourishment after
the death of the pulp. T he function of a tooth is to serve the purpose of mastica tion, and as after it is fully developed it w ill be retained in its place by the peri cementum and w ill serve the office of mastication quite as well as when its pulp was alive, provided the root-canal has been properly filled, therefore I see no harm in devitalizing the pulp if neces sary.” H ow like the discussions of forty years ago are those of today. In 1889, at the meeting of the American D ental Asso ciation, we find almost exactly repro duced the same thoughts and the same words in regard to the pulpless tooth. J . D . Patterson, of Kansas City, said, “ I think the subject of root canal filling the most im portant before the profession today.” James T ru m an said, “A great deal of talk on root canal filling seems to be based on guess work . . . no filling in a tooth root can be perfect because the largest part of the tooth is a tubulated s tru c tu re; these tubules hold organic ma terial and when the pulp dies, this or ganic structure dies and decomposition takes place at once, sulphuretted hy drogen being evolved to become a source of trouble; in filling a root an account must be taken of the contents of the tu b u li; chloride of zinc is the best agent to use to prevent decomposition because of its affinity for m oisture; it w ill follow to the extremities of the tubuli, change the character of their contents and pre vent their decomposition. A tooth treated w ith chloride of zinc w ill probably not discolor and at all events there will be no trouble in the roots. T h e use of chloride of zinc requires much care; if carried through the foramen it causes inflammation.” H e fills the upper end of the canal, then places cotton, satur ated w ith chloride of zinc, in the cavity for two or three days. H e believes oxy-
Stewart— A Further Consideration of the Pulpless Tooth chloride of zinc is the best m aterial with which to fill the remainder of the canal because it will keep up the effect th at he desires to secure. T o quote D r. M cKellops: “ N o man can go to the end of some roots w ith any security of following the canal . . . filled canals w ith chloropercha,” and so on. Jonathan T a ft, of Cincinnati, said, “T h e term ‘apical space’ is misleading, apical region or apical ter ritory is more applicable.” W . H . Dwinelle, of N ew York, said, “If the foramen is sealed, it makes little differ ence w hat m aterial is used for the rest
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W hen the pulp is removed, the principal source of nourishment of the tooth is taken away and the tubules are left filled w ith organic m atter to decompose and generate gas. You may fill the canal as perfectly as you please and these gases will percolate through the cementum and cause irritation of the pericementum. T o get rid of the contents of the tubuli, he uses hot air, following th at w ith an antiseptic and filling w ith oxychlorid of zinc, which, he says, “will prevent fu r ther decomposition.” “ M ore trouble comes from not clearing out the debris
Fig. 4.— C opper rods in position. Above, rig h t: C opper rod in a bicuspid w hich h a d been pulpless fo r m any years. T h e roots of the adjo in in g first m o la r h av e been filled about one year. T h is tooth also h a d been pulpless m any y ears. T h e bicuspid has ju st been opened and the rod inserted.
of the filling.” H e has seen teeth whose roots he filled nearly or quite fifty years before (ninety years back from the pres ent tim e). T h in k of it! H e used gold for the filling of the roots. H e said, “These teeth now verify my theory and justify my operations.” W . W . Allport, of Chicago, in root filling, w ants to know, not only how he does it, but why.
thoroughly and not filling perfectly than from any escharotic effects of materials forced through the foramen.” H e did not know th at there was any necessity for filling the canal perfectly if the canal was first thoroughly treated but th at it was safe to do so and might not be safe not to do so. D r. Dwinelle said fu rth e r: “ If the fibres of the tubuli are coagulated,
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they become inert and do not throw off gases.” A fter the age of 40 or 50, he does not consider the pulp essential to the tooth. Here, I quote from a w riter whose name I have lost. In speaking of the way that - these earlier practitioners treated pulpless teeth, he says, “ Such procedures have been the cause of saving thousands of teeth which, owing to the lack of den tal knowledge at the time these gentle men were trained, might otherwise have been lost.”
who assume a knowledge they do not pos sess, and sagely counsel w hat to do and w hat not to do w ith the pulpless tooth. In “Clinical Periodontia,” by Stillman and M cC all, we find the following ; “W hen shall a given pulpless tooth be extracted or when may it be safely treated and retained in the m outh?” F or the guidance of those wishing to know when to extract or retain, they say the condi tions required to be considered are as follows : T h is table means, if it means anything, W h en to
T re a t
E x tra ct
G e n era l health
G ood
Below norm al
H istory (personal and fam ily)
Freedom from debilitatin g disease
Susceptibility to disease
A ge
Below fifty
A bove fifty
Blood (facto rs concerned N orm al constituents a n d cell count in resistance)
A bnorm al constituents and cell count
Site of secondary in fection
T issu e of high re g en e rativ e pow er, as muscle
H isto ry of tooth
P e ria p ic a l disease absent o r of P rolonged p e ria p ic a l disturbance recent inception
R ad io g ra p h ic findings
L ittle or not periap ical o r p erio A ppreciable p e riap ical or dontal deran g em en t p a rie ta l bone alte ra tio n
Field of operation
Accessible.
I wish that I had the time and space to review dental literature in general and especially such literature as culminated in the paper of Lucas in the Dental Cosmos, June, 1928; literature th a t is the result of much labor and ability and that com pels us to think, even though we draw conclusions (which we do) absolutely opposite to those of these men. T hen, besides these experimenters and research workers who have really done something w orth while and who make us think, we have another class of w riters
T issu e of low reg en erativ e pow er, as eyes, ear, nervous system
Inaccessible
th at we are to follow the directions con tained therein before we decide to extract or treat a tooth. For instance, if the patient or the patient’s family show sus ceptibility to disease, we must extract. Ju st look those conditions over care fully and see how accurately the average reader could form an opinion on the question of treating or extracting teeth. If one wished to, there is an excellent opportunity to hold the entire statement up to ridicule, and that might be an excel lent way to dispose of it, but this would
Stew art— A Further Consideration of the Pulpless Tooth
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pulp canal treatm ent, if any, is the young patient of good health and good personal and family physical history.” And again “ . . . stim ulating a deposit of secondary cementum to close the apical foramina holds the only real promise which we can at present see for the continuation of root canal w ork.” A bright outlook for the pulpless to o th ! Again quoting from these authors in reference to the many diseases caused by the pulpless tooth: “These points have been arrived at through experience and study of many cases of metastatic disease and have been corroborated by careful investigators.” W e wish they had told w hat this “experience and study” was and w hat the “many cases of metastatic diseases” were that were caused by the teeth and how they knew the cause; and who the “careful investigators” were and how they corroborated “these points.” Such literature is very dangerous. M en generally reading statements, by supposed authorities, believe them, are discouraged and cease practical effort. “ Such labored nothings in so strange a style, amaze the unlearned— and make the learned smile” ; but the tragedy is th at so many are Fig. 5.— Film show ing shape of canal. amazed. R eferring to blood tests, H atton says, visibly ill or in apparent health.” T h e world is still w aiting to learn how this “A recent careful examination of more is done. Also, “W e now find that perio than a hundred individuals by M ueller dontal disease, both periapical and parie in our laboratory failed to prove the value tal, is the cause and not the result of the of this test. I t is true that there is an uric acid.” T h e Lancet must be rig h t: increase in the blood uric acid content T o quote from the authors of “ Clinical in a certain proportion of chronic infec Periodontia,” “T h e findings of blood tions, but it is uncertain, even more so chemistry make it possible to determine than the blood cell counts. An increase w hether we are justified in treating a seems to be much more significant of pulpless tooth. . . . I t also will cor lessened secretion because of some kidney roborate the evidence of the radiograph defect; in other words, retention is sug as to the existence of infection in the gestive of some degree of nephritis rather m axillary structures.” If you don’t than of focal infection.” M iller, a recognized authority on believe this, Alice, ju st shut your eyes and try hard. “ T h e best subject for blood chemistry, speaking of “the destruc
not be altogether consonant w ith a scien tific discussion. L et us see w hat the London Lancet says in reviewing “ Clinical Periodontia” : “ M any strange words indeed appear in this book . . . we deplore this invention of new and unnecessary words when others exist w ith the sanction of long usage— it darkens counsel and may, as Voltaire reminds us, conceal a poverty of thought.” And, to those who do take such writings seriously and who do not discern the “poverty of thought,” it does much harm. T h e same authors tell us, “ Fortunately we have at hand a means of determining w ith accuracy the presence of focal infec tion in the system, w hether the patient is
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tive effects that the so-called focal infec tion theory has left in its wake,” says, “ In an article in the Dental Cosmos in 1921, I called attention to some of the utterly absurd tests and ridiculous inter pretations thereof which over-zealous dentists are employing as the final criteria of the need, or otherwise, of extractions.” And yet, M cC all says, “ Blood chemistry w ill tell us w hether or not to extract a pulpless tooth.” T h e question has been raised as to whether I think that men generally can open the canals as shown in my illustra tions. I do think so. A little more than
thirty days and then go to work in the mouth to first test out the treatm ent of the pulpless tooth, before extracting, I believe this would constitute “the next great step in preventive medicine.” It would make a far more professional pro fession of dentistry, and be of immeasur able benefit to health and greatly increase longevity. I seem to have been under stood by some to imply that the old methods were failures. I meant to con vey no such impression, but I do believe that my method w ill free more teeth from infection (and keep them free) than the old methods. T h e old methods, if care-
Fig. 6.—M iscellaneous films w hich, if studied closely, show the usual shaping of canals.
four years ago, when I began this w ork in earnest, I could not open canals. It was only after conceiving the idea of drainage th at I began to open the fora men w ithout fear, and then I found how certainly and surely the average canal could be opened and so I know that men generally can open them. H ad I been asked, W i l l men generally do it? I would not know how to answer. T h a t is the question, but they can do it ju st as well as I, if they will. If dentists would open and fill fifty canals of extracted teeth during the next
fully, skilfully and thoroughly used, are usually successful, but usually they were not thus used, except by a very few men. H atton, Skillen and M oen say, “T he three most frequent failures in root canal filling are: 1. Failure to remove all of the pulp tissue. 2. Failure to fill the full length of the pulp canal. 3. Failure to fill the full diameter of the canal.” Grove gives us the situation in a nutshell: “T h e most im portant part of the root canal operation is hermetic sealing of the apical portion of the canal.” H atton, Skillen and M oen continue: “O n the whole, the
Stew art— A F urther Consideration of the Pulpless Tooth presence of these (sm all accessory) canals, especially in the apical third, does not interfere w ith regeneration. Infec tion in the small canals is extremely rare. W e do not remember any instance in our specimens. O n the contrary, it is the large canals that become infected, and it is through them that the apical space becomes involved. “O u r specimens all direct attention to another type of incomplete filling that is not revealed by the roentgenogram and which I believe is more im portant; namely, the incomplete occupation of the full diameter of the canal by the fill ing m aterial. W e have mentioned this type of incomplete filling repeatedly and stressed its importance in the production of failures in treatm ent.” A t this point, I wish especially to emphasize the ease and certainty w ith which “the incom plete filling of the full diameter of the canal” is overcome and how it is no longer a factor of "importance in the production of failures in treatm ent” when the canal is properly enlarged and filled w ith the gold-tin-mercury mix. T o test, simply fill a glass tube and im merse in dye. T h is type of incomplete filling, they say, is so common as to be present in more than three-fourths of the teeth that we have examined. Indeed, the examination of root-filled teeth breeds anything but respect for the aver age practitioner’s technic.” T h e forego ing is all very valuable inform ation and encouraging, but discouraging and almost hopeless is the following: “ Pulp canal treatm ent is at best a difficult operation, and if not to be w ell done, should not be attempted, but any reasonable modi fication of its technic in the direction of simplifying it should be welcome. “ In other words, while we do not desire to endorse pulpectomy or pulp am puta tion a t the level of the floor of the pulp
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chamber as a routine procedure, neither do we wish to condemn a method of fill ing root canals th at does not bring the apical end of the filling to the junction of the cementum and dentine at the apex. T h e selection of the level at which to end the filling is, we believe, a problem of accessibility.” T h in k of this for definite advice— it gets us nowhere— advises nothing— we know not a thing! See the u tter confusion into which this throws us, and yet my heart goes out to these men for the exceedingly careful and in telligent study they have given these things. T hey could draw no other rea sonable conclusion— they could give no other conscientious advice— after their numerous examinations of pulp canal work as usually done. T hey report that out of 500 treated extracted teeth exam ined, only one perfectly answered their requirements. '* O ne great advantage of my method is that it would be difficult to use it at all unless it were done thoroughly. If the canal is enlarged and the foramen opened, the canal is bound to be clean. T h e filling m aterial (gold, tin and mercury) is then so easily inserted th at it would be rather difficult not to fill “the full diameter of the canal” and to “seal the foramen.” Consequently, if this method were gen erally adopted, there could not possibly be the same conditions that now cause the treated pulpless tooth to be con demned. Kells said, “A perfect root fill ing is an accident.” W e can now, I be lieve, say that an imperfect root filling is an accident, provided the canal has been properly prepared. Another point that I wish to make c le a r: Even if the fora men is not enlarged for drainage, I believe that the gold and tin amalgam more certainly fills and seals the canal than any other m aterial that has been used; but remember th at the canal itself
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must be w ell enlarged to be perfectly filled w ith any m aterial. M offitt’s prep aration2 is w orthy the most careful study, enlightening and constructive. If you are skilful enough to abstract the contents of the canal in a favorable case w ithout carrying so much debris and infectious m atter through the foramen that N ature cannot take care of it, and object to going through the foramen, then by all means do this rather than extract the to o th ; and, if well done, favorable cases should be attended w ith success, but I believe it unwise not to give thorough drainage to a tooth where the apical tissues are clearly infected. T o quote H atton, Skillen and M oen ag ain : “ I t would seem that if the tissues at the apex are diseased to the extent that instrum entation or drugging w ith caustic substances w ithin the apical space seems necessary, such teeth should not be treated.” W h a t a commentary! T h a t w ould condemn by far the m ajority of the teeth I have treated, the results of which, I believe, reverse the statem ent that “ such teeth should not be treated.” T o open wide the foramen, to drain these “ diseased tissues at the apex,” thus get ting bone regeneration, and then to fill w ith a perfectly tolerated plastic m etal filling that does fill the full diameter of the canal, and that does permanently seal the foramen, and to obtain consist ently a satisfactory clinical result — all this entirely justifies us in rew riting their statem ent— such teeth should be treated. Remember, these men had in mind no surgical drainage of these tissues and no successful filling of a large open fora men. T h ey knew, of course, of no filling that could be used successfully in these cases. T h e m aterial that goes into the
apical space is extremely soft and plastic and remains so. T h e very movement of thè tooth in mastication would tend to make it even more so. T h e material in the apical space must be permanently plastic because the slight movement of the tooth in mastication would cause a hard or sharp edge or rough substance to irritate the tissue constantly and also because tissue changes should be able to displace the m aterial in the apical space. M ore than 300 roots (all those that I was able to open through the foramen) have been successfully filled clinically, and about 90 per cent were teeth long “dead” and, of course, infected, so that “the tissues at the apex were diseased to the extent that instrum entation or drug ging w ith caustic substances w ithin the apical space seemed necessary.” In other words, they come in th at class in which even the man advocating root canal treatm ent usually advised extraction. T eeth with freshly extracted pulps are a very small proportion of those seen by us. Few adult patients come to us who have no pulpless teeth, and very few, in comparison, w ith live pulps to be ex tracted ; and so the method that deals only w ith teeth having the pulp freshly extracted, renders a comparatively small service indeed. T h e point is this: If the source of in fection is entirely eradicated, the apical space w ill often recover from both the previous infection and the presence of the debris carried through by you. O f course, the freshly extracted pulp case is different; but Coolidge says, “ Records covering a period of more than twelve years reveal a larger percentage of suc cessful canal fillings of roots that were pulpless than of those from which vital pulps were removed.” Again : if you do 2. Moffitt, J. J .: R oot C anal T re a tm e n t not go to the end and do not force any P re p a ra to ry to C row n and B ridge A tta c h debris through, the tissues w ill often take m ent, J. A . D. A., 15:1480 (A u g .) 1928.
Stew art— A F urther Consideration of the Pulpless Tooth care of the small am ount of substance left in the end of the ro o t; in fact, sometimes N ature has already w alled it off. And again she does none of these things. And, if this is not enough, consider the possible accessory foram ina; then, too, the possible slight denudation of the apex. I t becomes kaleidoscopic— we are throw n into confu sion. And so, is it not the safest thing in all cases to open the canal thoroughly and establish drainage? M y advice to those really in earnest is to experiment w ith extracted teeth-— say, fifty teeth. Complete two a day— the fifty can be done w ithin a month. T h is w ill open the way for success in the mouth. Do not select the teeth— take them indiscriminately— single rooted and m ultirooted. You will probably be aston ished at how little you k n o w ; at least, I was. You w ill (as I did) probably find that it is not best to confine yourself to any one shape or kind of instrum ent, but to use anything the situation suggests, drills (hand and engine), broaches, files, picks, explorers— anything that w ill ex plore, penetrate, enlarge or clean. These w ill be suggested more readily by oper ating on extracted teeth than on teeth in the mouth. In your own office, treat yourself to a four weeks’ post-graduate course w ith fifty extracted teeth and a ll the instru ments (hand and engine) you know of for opening root canals. You w ill have a good time and it w ill cost very little. Do not try to economize on instruments — all you can think of w ill cost you only a few dollars. Each dentist should try out the instrum ents to see which ones can best be used by the individual. Barbed broaches, smooth broaches, root canal files, picks, drills, root canal reamers, and so on. Now, suppose we take an ordinary extracted pulpless tooth, pulpless from whatever cause and maybe for one year,
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maybe ten. You know how many of these “ flare up” on being opened. An entrance even into the pulp chamber with an ordinary bur may cause just enough pressure to force a little of the fluid m at ter in the canal through the foramen, so go carefully. Place equal parts of solu tion of formaldehyd (form alin) and a saturated solution of zinc chlorid in the pulp chamber. Even this pellet of cotton pressed in by pliers may force a little septic fluid through the foramen. I some times keep this in place only an hour or two, then open the canal freely, foramen and all. Usually, this is kept in place twenty-four hours. A fter the pulp chamber is cleaned, and the mouths of the canals are exposed, we first carry a small quantity of full strength hydrochloric acid (on any suit able instrum ent) into the mouth of the canal, and w ork this gently down with finest size barbed broach. N ot only does the acid help to open the canal, but also experience teaches me that it is the best surface sterilizer. Besides, it unites with and partially dissolves the minute shav ings of dentin as the broach or file cuts them off the wall. T hen, when some of this débris (as is inevitable if the canal is cleaned) is carried through the fora men, the acid renders it inert and fluid so it can readily be washed out of the periapical space. W hen at the one sitting the canal and foramen are thoroughly opened in this way for drainage, I have yet to have one of those cases of acute abscess swelling and all the unbear able symptoms with which we are so familiar. T ru e , there is sometimes pain (very seldom, how ever), but this pain is usually very slight as compared w ith the distressing agony of the usual acute abscess. T his is due, of course, to the free drainage.
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T he Journal of the American D ental Association
Lucien A rnold speaks of hydrochloric acid in the periapical space as being of benefit and no harm and states that it combines w ith sulphur, generating hydro gen sulphid, and the products left are chlorids which are norm al to the body. Sulphuric acid produces sulphates and these are taken care of w ith more diffi culty. M y own clinical results w ith hydrochloric acid coincide w ith A rnold’s. W hile using instruments in the canal, to open and enlarge it (in extracted teeth), we should watch carefully the débris that goes through the foramen. T h is w ill con vince one that the canal cannot be cleaned to the end w ithout carrying débris through it, and when it is through, even if the canal is filled perfectly to the end, septic m atter is simply sealed up in the periapical tissues. T ru e , this wonderful tissue often encysts or entirely digests such m atter, but w hat a chance to take! H ow much better it is to get it out as a surgeon would extraneous m atter before closing a wound. Remember th at a small canal and a small opening is no guarantee against m atter being carried through, but this m atter cannot possibly get out again. T h e foramen must be enlarged freely to perm it this. T hen, the cotton points, the spray, the syringe, can all be used w ith effect, but not so w ith the small foramen. Peroxid can be freely used with no fear of back-lash, and the excre tions readily exude into the canal and are harmless. I like to leave the canals free and open between sittings, stopping the pulp chambers only. T h is allows the accumulating secretions to overflow into the canal and prevents pressure. I t seems that we have been managing these cases as unlike surgery as it was pos sible to do. Drainage is the surgeon’s watchword, his first and greatest com mandment. If there is infection, he opens the tissue and keeps it open. Ochsner, in
“G eneral Surgery,” says: “ 1. Infected bone cavities should heal from the bot tom. 2. T h e soft tissues should be kept wide open. 3. No antiseptics should be used, only drainage, but w hatever may be used in this bone cavity should stimu late excretion from tissues, and do this only.” W h a t do we do? W e simply attem pt to clean out the drainage tube, and do not half do that. Besides, we care fully avoid cleaning it at the end that projects into the infected tissue for fear of wounding that tissue and then we place antiseptics in the drainage tube and w rite learnedly on the asepsis and bac teriology of our drainage tube. Could anything be more childish? Is it any wonder the surgeons had no confidence in anything we said about the pulpless tooth ? L et me not be misunderstood— thousands of cases have recovered (even when the periapical tissue was infected) simply by removal of the contents of the canal, and filling, this extraordinary tissue taking care of the infection as would not be done in any other bones in the body. And here we have the quarrel w ith the average “biologist” and “research w orker.” T heir efforts so often are bent to prove the con tra ry : that the tissue is low in recupera tive power when once wounded or in fected as is true of the dental pulp. Every organism they find is there to doom the tooth and produce all the dis eases in the category. And, much as I regret to say it, some otherwise honest w riters are presuming on the general lack of intimate histologic and bacteriologic knowledge to frighten dentists into extracting teeth. W e must remember too that these laboratory men are just as con versant w ith all the details of the clinical results in the mouth as we are conversant w ith their details in the laboratory; that they know just as much as to how our methods differ from each other as we
Stew art— A F urther Consideration of the Pulpless Tooth know how their methods differ from each other; and they know ju st as much as to how each operator can change and adapt his methods to produce a favorable and physiologic result as we know how each laboratory man can adapt and change his methods to produce an unfavorable result. W e have too long made our clinical judgm ent subservient to the expressed opinion of the laboratory man, while the laboratory man, on the whole, has done (largely unconsciously to himself) a most elaborate amount of w ork in order to draw the conclusion th at all clinical results have no w eight and are utterly worthless. O ne would think that the roentgen-ray was only a delusion and a snare; that the evidence of regeneration of bone around the apex of a tooth was an actual indication of disease and was different from regeneration of any other bone; that freedom from tenderness or inflammation or any unfavorable clinical results were only an indication of the utter depravity of these tissues, which are only lying in w ait and covertly hiding every symptom (unlike other tissues in the body) in order to produce every disease in the category for which no other cause can be found. L et me not be misunderstood. H is tologic and microscopic w ork are, of course, invaluable and w ill finally coin cide w ith and prove our clinical results just as much as it has proved the surgeons’ clinical results, w hile the average lab oratory w orker gives us the impression th at his mission in life is to disprove clin ical results. A fter the foramen is opened, it often clogs and needs to be cleared at each sit ting. T h is is usually done by cotton canal points carried up w ith the pliers. Some times, m etal rods are kept in place for this purpose. H ere, I shall refer briefly to the use of copper rods, which I often use,
1871
not only to keep the foramen open but also to stimulate drainage. I hesitate to refer to this now because my experiments have not extended over a sufficient time to give out definite information at pres ent, and I mention it only that others may experiment w ith them. O f course, it is too early to express a decided opinion, but copper seems to ( 1 ) stimulate secre tion; (2 ) cause a breaking down of dis eased tissue; (3 ) cause aseptic suppura tion; (4 ) stim ulate tissue regeneration, especially of bone, and (5 ) stimulate the flow of lymph. Figure 4 shows copper rods in place. Experiments of Lange of Germany and Zierold of M inneapolis show definite stimulation of bone production by copper. W hile causing aseptic suppuration of tissue immeditely adjacent, it causes a reproduction at a distance. Experiments w ith metals in culture mediums by Charles Leedham-Green (surgeon to the Q ueen’s and C hildren’s Hospitals, Birm ingham, E ngland) show th at “by far the most powerful of the metals bactericidally proved to be copper, and, in a less degree (according to the percentage of copper used in their composition), its alloys, bronze and brass.” As far as I know, no one has ever used the copper for the pur pose of producing suppuration or stimu lation of bone production. I t has been used only to ascertain its tolerance or intolerance (along w ith other metals) when implanted in normal healthy tissues. I t occurred to me that if it did produce the aseptic suppuration of the tissues w ith which it came into immediate contact; if it powerfully stimulated the reformation of tissue in the region ad jacent to the suppuration, and if, in addi tion, it was germicidal, it might be of use in breaking down granulation tissue and stim ulating regeneration about the root
1872
T h e Journal of the American D ental Association
in addition to keeping the entire field sterile. T o return to the canal opening: A fter removing as much of the canal contents as we can w ith barbed broaches, a No. 1 file is used. U sually, each file or broach should be used, not only until the entire canal is penetrated by it, but until it works loosely, although often we have to enlarge the first p art of the canal and later the apex. I t is w ell to curve the file slightly after it works loosely, as it w ill then bind and cut more. T h is better prepares the way for the next one. N early always, the entire six files are used. T h ere are few canals which I do not en large considerably w ith drills after the No. 6 file is used. I often begin w ith drills after the No. 4 file. Sometimes, it is argued th at such w ork can be done in a large city but not in small towns, th at people will not pay for the time. T h is is a mistaken argument. T h e city man is more pushed for time. H e has less time and inclination to ex plain details and carry his patient along w ith him. H e has greater expense and is tempted to be more commercial, and less human. I know a man in a big city who pays $300 a month for his office. H e paid $35 a month in the village before moving to the city. Is it not because he does not w ant to do this w ork that the average dentist reasons thus ? I am not censuring, just stating facts. Suppose we explain to the patient that if the tooth is extracted the two adjoining teeth w ill have to be m utilated, w ith almost certain discomfort and tenderness or grave danger of dying of pulps in the future, if replaced by the large inlay system of “movable-removable” bridges, and so forth. Suppose we explain further the danger of breakage and the annoy ance of having to remove and replace the bridge two or three times daily (imagine
four permanent molars so replaced), or the danger of deterioration from clasps (to say nothing of their looks) and the possible injury to the gums or peridental m em brane; the effect on facial expression from the loss of the roots of the teeth, besides the initial cost of making the im mediate bridge w ith a possible larger bridge sometime in the fu tu re; to say nothing of the pain and shock to the nervous system, and the m ental effect on the patient of the whole thing. H ow many right-minded, intelligent patients do you think, would agree to the extrac tion ? H ow many would refuse to pay as much for saving the tooth as for making the bridge? But, you say, suppose that, after you treat the root, you still have to extract it ? T h a t, of course, is well w orth considering and depends entirely on how you treat it. H ere, I w ill say, we are not developing finger skill, that great requisite of suc cessful dentistry, as we used to. , O ur fathers were much better prepared in this respect than we, and in some ways prac ticed much better dentistry. W hen my father began dentistry, we had few dental engines. W hen I began to work in his office as a boy, he compelled me to do all my first work w ith my fingers. Inciden tally, if the colleges do not get back to finger training, dentistry w ill still fu r ther deteriorate and we will have a con tinual flood of literature on becoming an M .D . instead of a dentist, and fu rth er more men w ill stay M .D .’s instead of becoming dentists. Here, I cannot for bear quoting from Sir John Tom es: “ It has been strongly urged that dental should become supplemental to medical knowl edge; th at the practitioner should be a doctor first, and a dentist afterwards. T h is opinion might perhaps be sustained if the position were reversed— a dentist first and a doctor afterwards, provided
Stew art— A F urther Consideration of the Pulpless Tooth all or even a m ajority of students were sufficiently rich in money and time to extend the educational period from four to six years.” A nd may I add, provided the 90 per cent of our population who are not receiving efficient dental service were so supplied. In my form er article, the preparation of the filling m aterial seems not to have been made clear to some. Simply mix gold foil and tin foil w ith mercury to a soft plastic mix. Glass tubes w ill demon strate the easy w orking qualities of the m aterial. A w riter in the Dental Digest says that no one can put in a perfect root filling, th at no one ever did or ever w ill fill and seal an apical foramen because, he says, it cannot be dried. “ If you doubt this,” he continues, “place a root end on wet cotton or spunk— the foramen w ill again fill as fast as you absorb the moisture.” If the w riter referred to w ill take the gold, tin and mercury mix and fill a glass tube (the tube standing on w et cotton— even first filling the tube w ith w a te r), he w ill see the metal gradually drive the w ater out of the tube. T his tube, afterw ards immersed in dye, w ill not leak. A nother thing th at I find was not clear to many readers is the use of the round bur. T h e picture of the two burs through the foramen of a m olar tooth, Figure 6, in a form er paper, gave the idea to some that I enlarged the canal w ith these burs. T h e canal is enlarged w ith ordinary nerve canal drills and the burs are used only to enlarge the foramen at the apex of the root, making it funnel-shaped. T his is done only in case of suspected denudation of the end of the root, and when the canal has been en larged, a round bur, the size of the canal, is then selected and passed through the foramen, then pressed to the side so as to hook the bur over the foramenal
1873
w all. T h e engine is not started until this bur is placed in position, then, by pulling downward, the end of the root can be entirely amputated, if desired. In this way, it is to be especially noted th at no dentin is left exposed as in the usual am putation of the apex. A ll of the dentin is left protected by the cementum so that when the canal is filled, no dentin is exposed to body fluids. T h is is a most im portant point. T his operation is much more conservative of root end structure than the usual amputation, and it is my opinion that it is usually necessary to sacrifice only a small proportion of the apex as compared to w hat is usually sacri ficed in apicoectomy. In other words, there is usually nothing like so much denudation of the end of the root as we have been led to believe. In most cases, even of long standing infection, the mere enlargement of the canal through the foramen is entirely sufficient to take care of the denuded area w ithout the use of the round bur at all. As was pointed out in my former paper, even if a slight denuded surface is left, the filling m a terial spreads over it and the tissues growing down against the material press it down from every side against this denuded surface. I t has been urged that the filling ma terial may discolor the crown of the tooth. T his is briefly answered by saying that it is not necessary to fill the entire canal. T h e apical one-half or one-quarter (if a crown post is to be used) may be filled w ith this material and the remain der w ith any suitable material. M y own preference is to fill down nearly to the pulp chambers w ith cotton saturated w ith zinc chlorid (saturated solution), and then to finish w ith oxychlorid of zinc. T h is small amount of oxychlorid is easily drilled through, in case the canal is to be reopened. In a nutshell: I t is
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T h e Journal of the American D ental Association
necessary only to definitely and safely seal the apical foramen. T h e question has been asked in many letters as to how long a dressing is to remain in the canal. T h is often depends on the secretion of the tissues. Usually, the second dressing is kept in from two to four days and the following ones governed by the indications, sometimes from two to four weeks. T h e time of filling is governed by the secretions and clinical indications much as in the closing of wounds in general surgery. I realize the lack of detail of consecu tive operative procedure in this and the preceding paper. I hope soon to give to the profession a paper dealing w ith this alone. CO N CLU SIO N
1. T his method accurately and easily fills the full length and full diameter of the canal. 2. It definitely and w ith certainty seals the foramen.
3. T h e surplus beyond the end of the canal is surprisingly mobile and plastic and remains so, and thus it is nonirritat ing to the tissues while the tooth is in the movement in mastication. T h is also allows the tissues to grow in over the end of the root or to press the material against a denuded area. 4. T h e material is impermeable to fluids, will displace moisture in the canal and will not leak. 5. A ctual and definite surgical drain age is obtained. 6. T h e tissue is given a chance to rid itself of infection and to heal as do other tissues in surgical operations. T his tissue has been the abused and despised step child of the human body. Let us give it a chance. 7. If the profession would earnestly and sincerely give this method the most thorough and exacting test, I should await the results w ith the utmost con fidence.
ODONTOM AS: CLASSIFICATION, DIAGNOSIS A N D TREATM ENT* By L. W. SCHULTZ, B.S., D.D.S., M.D., Chicago, 111. H E term “odontoma” was coined by Broca in 1869.1 And the anatomic society which met in Basle, Switzer land, in 1895, to devise a uniform scien tific medical nomenclature, accepted it. Hence, it should be a satisfactory term. It is of G reek derivation, from odous-odontos, meaning tooth, and oma-omatos, a tum or.
T
However, judging by the numerous classifications which have appeared in the literature, it would seem th at this expres sion is not sufficiently restricted. T he term permits inclusion of all new growths arising from the dental system, be they hard or soft. Among other authorities, M oorehead and Dewey2 restrict this term to hard tumors of the jaw composed of
*R ead before the O d o ntographic Society of 2. M oorehead, F. B., and D ewey, K aeth e Chicago, Oct. 21, 1929. 1. Broca, P .: T ra ité des tum eurs, P aris, W . : P athology of the M outh, P h ila d e lp h ia : W . B. Saunders Com pany, 1925, p. 483. 1869, Vol. 2, p. 275.
Jour, A, D. A., October, 1930
.—
M
Y earlier paper1 was necessarily so condensed th at much had to be omitted. Lucien H . A rnold shows how lightly some people, particularly physicians, re gard the loss of a tooth, under the assumption th at it can easily be replaced artificially. In this connection, D r. A rnold remarks that the artificial tooth is, on the average, only about 25 per cent efficient as compared w ith the nat ural tooth and th at the loss of teeth seri ously interferes w ith the oral starchdigesting mechanism. “ I t is entirely unw arranted,” he says, “to order the extraction of a tooth sus pected of metastatic infection unless a
complete physical examination excludes all other sources of infection and even then— should a tooth be p o s itiv e ly proved the cause— instead of immediately order ing an extraction, effort should be di rected to obliteration of the infection—which is quite as prompt and efficient and far less risky than extraction— in the hope of preserving the organs of diges tion as nearly intact as possible, ju st as would be done w ith an organ in any other part of the body.” V ilray P . Blair says, “ I think, w ithout question, one can agree in the premise th at the care of the devitalized tooth is the most serious and weighty problem that confronts the dentist today. I must confess to a very pessimistic view on my 1. Stewart, H. T .: Pulpless Tooth and Its p art as to the ultim ate results of the Treatment, J. A. D. A., 17:381 (March) ordinary treatm ent which these teeth are 1930.
Jour. A. D. A., October, 1930
1860
Stewart— A Further Consideration of the Pulpless Tooth receiving at the hands of the m ajority of the good dentists today.” “W ith o u t doubt,” Custer says, “the most vital question before the dental pro fession today is, W h at shall we do w ith the pulpless tooth ? T h e seat of the whole trouble lies at the apical foramen. T h e problem has been to sterilize and seal this opening in a manner acceptable to nature. Nowhere in the whole range of human endeavor has there been as much energy spent to patch up any part of a human being as at the tiny apical foramen. Is it not about time th at the dentist is able to seal w ith a foreign material so tiny an opening as the apical foramen in a man ner acceptable to nature?”
Fig. 1.— U pper cuspid w ith m uch a b sorption especially of the m esial su rface. T h e line of the absorption extends m esially from the apex dow n about one q u a rte r the length of the entire root. T h e case seem ed v e ry dis couraging. T h is figure also show s a larg e copper rod w hich w as kept in position about tw o m onths. I t w as rem oved about every tw o w eeks fo r d ra in a g e . T h e rough edges all aro u n d the end of the fo ram en al w a ll w ere sm oothed w ith a round b u r (com pare F igure 6 , T h e J o u r n a l , M arch, 1 9 3 0 , p . 3 8 7 ) , but the end of the root w as, in the beginning, p ractically the sam e shape as seen in the roentgenogram .
I believe this has been accomplished. As I have tried to show, “in a manner acceptable to nature,” means much, very much.
1861
Rosenow writes, “ I t is to be hoped that an efficient method may be found that will not only render pulpless teeth and periapical tissues sterile, th at have become infected, but that will also pre vent subsequent infection especially of the periapical tissues. T h e fulfilment of the latter requirements seems almost un attainable.” I believe these requirements have been met. T o quote H atton, Skillen and M oen: “O n the other hand, if a method could be devised of getting adequate surgical drainage, if the apex has been involved, and if a method could be found which would insure a higher percentage of successfully filled canals, there would be
Fig. 2.—Root filled. C onsiderable calcifica tion w ill be noted. T h is figure w a s taken im m ediately a fte r the filling and a denser calcification is expected to take place.
a much higher percentage of favorable results.” T aking the propositions in this para graph one by one, w hat I have presented shows that a method has been “ devised of getting adequate surgical drainage” ; that a method has been found which in sures “a higher percentage of successfully filled canals” and that there is “a much higher percentage of favorable results.” A clean record of more than 300 cases (everyone where the foramen could be successfully opened) extending over a period of more than four years, with
1862
The Journal of the American Dental Association
most pleasing clinical results, speaks for itself. Hudson extracted pulps and filled roots “to the apex” w ith gold in 1809, 120 years ago. In 1888 (forty-tw o years ago), James T ru m an said, “W e are as far from a settled policy in the treatm ent of the pulpless tooth as we were forty years ago.” A t that time (eighty-two years ago), guttapercha was the chief m aterial used. I t was the chief material used when T ru m an spoke: it is the chief material used today, and so I think it could be said that we are no nearer a settled policy than the profession was eighty-two years ago. D r. Sudduth wrote, in 1888, “T h e
Fig. 3.— G lass tube th a t has been im m ersed in m ethylene blue fo r m ore th an tw o years. V arious sizes of tubes h ave been filled and tested in every conceivable w ay, even u n d e r pressure of a column of w ater, but th ere has n e v er been the slightest leakage. T h is test can be v e ry easily m ade by anyone who w ishes to satisfy him self. F illin g glass tubes is an excellent w a y to w atch the w ork in g of the filling w hile the m ate ria l is being placed in position. Sm all glass tubes of v a rio u s diam eters m ay be used to represent the canal of the tooth root.
main office of the pulp is formative, and all the ‘live’ portion of the dentine is a part of the pulp; the dentinal fibrils are prolongations of the pulp and when the latter is destroyed they die also. T here is no other tissue in the dentine to nour ish, hence no need of nourishment after
the death of the pulp. T he function of a tooth is to serve the purpose of mastica tion, and as after it is fully developed it w ill be retained in its place by the peri cementum and w ill serve the office of mastication quite as well as when its pulp was alive, provided the root-canal has been properly filled, therefore I see no harm in devitalizing the pulp if neces sary.” H ow like the discussions of forty years ago are those of today. In 1889, at the meeting of the American D ental Asso ciation, we find almost exactly repro duced the same thoughts and the same words in regard to the pulpless tooth. J . D . Patterson, of Kansas City, said, “ I think the subject of root canal filling the most im portant before the profession today.” James T ru m an said, “A great deal of talk on root canal filling seems to be based on guess work . . . no filling in a tooth root can be perfect because the largest part of the tooth is a tubulated s tru c tu re; these tubules hold organic ma terial and when the pulp dies, this or ganic structure dies and decomposition takes place at once, sulphuretted hy drogen being evolved to become a source of trouble; in filling a root an account must be taken of the contents of the tu b u li; chloride of zinc is the best agent to use to prevent decomposition because of its affinity for m oisture; it w ill follow to the extremities of the tubuli, change the character of their contents and pre vent their decomposition. A tooth treated w ith chloride of zinc w ill probably not discolor and at all events there will be no trouble in the roots. T h e use of chloride of zinc requires much care; if carried through the foramen it causes inflammation.” H e fills the upper end of the canal, then places cotton, satur ated w ith chloride of zinc, in the cavity for two or three days. H e believes oxy-
Stewart— A Further Consideration of the Pulpless Tooth chloride of zinc is the best m aterial with which to fill the remainder of the canal because it will keep up the effect th at he desires to secure. T o quote D r. M cKellops: “ N o man can go to the end of some roots w ith any security of following the canal . . . filled canals w ith chloropercha,” and so on. Jonathan T a ft, of Cincinnati, said, “T h e term ‘apical space’ is misleading, apical region or apical ter ritory is more applicable.” W . H . Dwinelle, of N ew York, said, “If the foramen is sealed, it makes little differ ence w hat m aterial is used for the rest
1863
W hen the pulp is removed, the principal source of nourishment of the tooth is taken away and the tubules are left filled w ith organic m atter to decompose and generate gas. You may fill the canal as perfectly as you please and these gases will percolate through the cementum and cause irritation of the pericementum. T o get rid of the contents of the tubuli, he uses hot air, following th at w ith an antiseptic and filling w ith oxychlorid of zinc, which, he says, “will prevent fu r ther decomposition.” “ M ore trouble comes from not clearing out the debris
Fig. 4.— C opper rods in position. Above, rig h t: C opper rod in a bicuspid w hich h a d been pulpless fo r m any years. T h e roots of the adjo in in g first m o la r h av e been filled about one year. T h is tooth also h a d been pulpless m any y ears. T h e bicuspid has ju st been opened and the rod inserted.
of the filling.” H e has seen teeth whose roots he filled nearly or quite fifty years before (ninety years back from the pres ent tim e). T h in k of it! H e used gold for the filling of the roots. H e said, “These teeth now verify my theory and justify my operations.” W . W . Allport, of Chicago, in root filling, w ants to know, not only how he does it, but why.
thoroughly and not filling perfectly than from any escharotic effects of materials forced through the foramen.” H e did not know th at there was any necessity for filling the canal perfectly if the canal was first thoroughly treated but th at it was safe to do so and might not be safe not to do so. D r. Dwinelle said fu rth e r: “ If the fibres of the tubuli are coagulated,
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T h e Journal of the American D ental Association
they become inert and do not throw off gases.” A fter the age of 40 or 50, he does not consider the pulp essential to the tooth. Here, I quote from a w riter whose name I have lost. In speaking of the way that - these earlier practitioners treated pulpless teeth, he says, “ Such procedures have been the cause of saving thousands of teeth which, owing to the lack of den tal knowledge at the time these gentle men were trained, might otherwise have been lost.”
who assume a knowledge they do not pos sess, and sagely counsel w hat to do and w hat not to do w ith the pulpless tooth. In “Clinical Periodontia,” by Stillman and M cC all, we find the following ; “W hen shall a given pulpless tooth be extracted or when may it be safely treated and retained in the m outh?” F or the guidance of those wishing to know when to extract or retain, they say the condi tions required to be considered are as follows : T h is table means, if it means anything, W h en to
T re a t
E x tra ct
G e n era l health
G ood
Below norm al
H istory (personal and fam ily)
Freedom from debilitatin g disease
Susceptibility to disease
A ge
Below fifty
A bove fifty
Blood (facto rs concerned N orm al constituents a n d cell count in resistance)
A bnorm al constituents and cell count
Site of secondary in fection
T issu e of high re g en e rativ e pow er, as muscle
H isto ry of tooth
P e ria p ic a l disease absent o r of P rolonged p e ria p ic a l disturbance recent inception
R ad io g ra p h ic findings
L ittle or not periap ical o r p erio A ppreciable p e riap ical or dontal deran g em en t p a rie ta l bone alte ra tio n
Field of operation
Accessible.
I wish that I had the time and space to review dental literature in general and especially such literature as culminated in the paper of Lucas in the Dental Cosmos, June, 1928; literature th a t is the result of much labor and ability and that com pels us to think, even though we draw conclusions (which we do) absolutely opposite to those of these men. T hen, besides these experimenters and research workers who have really done something w orth while and who make us think, we have another class of w riters
T issu e of low reg en erativ e pow er, as eyes, ear, nervous system
Inaccessible
th at we are to follow the directions con tained therein before we decide to extract or treat a tooth. For instance, if the patient or the patient’s family show sus ceptibility to disease, we must extract. Ju st look those conditions over care fully and see how accurately the average reader could form an opinion on the question of treating or extracting teeth. If one wished to, there is an excellent opportunity to hold the entire statement up to ridicule, and that might be an excel lent way to dispose of it, but this would
Stew art— A Further Consideration of the Pulpless Tooth
1865
pulp canal treatm ent, if any, is the young patient of good health and good personal and family physical history.” And again “ . . . stim ulating a deposit of secondary cementum to close the apical foramina holds the only real promise which we can at present see for the continuation of root canal w ork.” A bright outlook for the pulpless to o th ! Again quoting from these authors in reference to the many diseases caused by the pulpless tooth: “These points have been arrived at through experience and study of many cases of metastatic disease and have been corroborated by careful investigators.” W e wish they had told w hat this “experience and study” was and w hat the “many cases of metastatic diseases” were that were caused by the teeth and how they knew the cause; and who the “careful investigators” were and how they corroborated “these points.” Such literature is very dangerous. M en generally reading statements, by supposed authorities, believe them, are discouraged and cease practical effort. “ Such labored nothings in so strange a style, amaze the unlearned— and make the learned smile” ; but the tragedy is th at so many are Fig. 5.— Film show ing shape of canal. amazed. R eferring to blood tests, H atton says, visibly ill or in apparent health.” T h e world is still w aiting to learn how this “A recent careful examination of more is done. Also, “W e now find that perio than a hundred individuals by M ueller dontal disease, both periapical and parie in our laboratory failed to prove the value tal, is the cause and not the result of the of this test. I t is true that there is an uric acid.” T h e Lancet must be rig h t: increase in the blood uric acid content T o quote from the authors of “ Clinical in a certain proportion of chronic infec Periodontia,” “T h e findings of blood tions, but it is uncertain, even more so chemistry make it possible to determine than the blood cell counts. An increase w hether we are justified in treating a seems to be much more significant of pulpless tooth. . . . I t also will cor lessened secretion because of some kidney roborate the evidence of the radiograph defect; in other words, retention is sug as to the existence of infection in the gestive of some degree of nephritis rather m axillary structures.” If you don’t than of focal infection.” M iller, a recognized authority on believe this, Alice, ju st shut your eyes and try hard. “ T h e best subject for blood chemistry, speaking of “the destruc
not be altogether consonant w ith a scien tific discussion. L et us see w hat the London Lancet says in reviewing “ Clinical Periodontia” : “ M any strange words indeed appear in this book . . . we deplore this invention of new and unnecessary words when others exist w ith the sanction of long usage— it darkens counsel and may, as Voltaire reminds us, conceal a poverty of thought.” And, to those who do take such writings seriously and who do not discern the “poverty of thought,” it does much harm. T h e same authors tell us, “ Fortunately we have at hand a means of determining w ith accuracy the presence of focal infec tion in the system, w hether the patient is
1866
The Journal of the American Dental Association
tive effects that the so-called focal infec tion theory has left in its wake,” says, “ In an article in the Dental Cosmos in 1921, I called attention to some of the utterly absurd tests and ridiculous inter pretations thereof which over-zealous dentists are employing as the final criteria of the need, or otherwise, of extractions.” And yet, M cC all says, “ Blood chemistry w ill tell us w hether or not to extract a pulpless tooth.” T h e question has been raised as to whether I think that men generally can open the canals as shown in my illustra tions. I do think so. A little more than
thirty days and then go to work in the mouth to first test out the treatm ent of the pulpless tooth, before extracting, I believe this would constitute “the next great step in preventive medicine.” It would make a far more professional pro fession of dentistry, and be of immeasur able benefit to health and greatly increase longevity. I seem to have been under stood by some to imply that the old methods were failures. I meant to con vey no such impression, but I do believe that my method w ill free more teeth from infection (and keep them free) than the old methods. T h e old methods, if care-
Fig. 6.—M iscellaneous films w hich, if studied closely, show the usual shaping of canals.
four years ago, when I began this w ork in earnest, I could not open canals. It was only after conceiving the idea of drainage th at I began to open the fora men w ithout fear, and then I found how certainly and surely the average canal could be opened and so I know that men generally can open them. H ad I been asked, W i l l men generally do it? I would not know how to answer. T h a t is the question, but they can do it ju st as well as I, if they will. If dentists would open and fill fifty canals of extracted teeth during the next
fully, skilfully and thoroughly used, are usually successful, but usually they were not thus used, except by a very few men. H atton, Skillen and M oen say, “T he three most frequent failures in root canal filling are: 1. Failure to remove all of the pulp tissue. 2. Failure to fill the full length of the pulp canal. 3. Failure to fill the full diameter of the canal.” Grove gives us the situation in a nutshell: “T h e most im portant part of the root canal operation is hermetic sealing of the apical portion of the canal.” H atton, Skillen and M oen continue: “O n the whole, the
Stew art— A F urther Consideration of the Pulpless Tooth presence of these (sm all accessory) canals, especially in the apical third, does not interfere w ith regeneration. Infec tion in the small canals is extremely rare. W e do not remember any instance in our specimens. O n the contrary, it is the large canals that become infected, and it is through them that the apical space becomes involved. “O u r specimens all direct attention to another type of incomplete filling that is not revealed by the roentgenogram and which I believe is more im portant; namely, the incomplete occupation of the full diameter of the canal by the fill ing m aterial. W e have mentioned this type of incomplete filling repeatedly and stressed its importance in the production of failures in treatm ent.” A t this point, I wish especially to emphasize the ease and certainty w ith which “the incom plete filling of the full diameter of the canal” is overcome and how it is no longer a factor of "importance in the production of failures in treatm ent” when the canal is properly enlarged and filled w ith the gold-tin-mercury mix. T o test, simply fill a glass tube and im merse in dye. T h is type of incomplete filling, they say, is so common as to be present in more than three-fourths of the teeth that we have examined. Indeed, the examination of root-filled teeth breeds anything but respect for the aver age practitioner’s technic.” T h e forego ing is all very valuable inform ation and encouraging, but discouraging and almost hopeless is the following: “ Pulp canal treatm ent is at best a difficult operation, and if not to be w ell done, should not be attempted, but any reasonable modi fication of its technic in the direction of simplifying it should be welcome. “ In other words, while we do not desire to endorse pulpectomy or pulp am puta tion a t the level of the floor of the pulp
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chamber as a routine procedure, neither do we wish to condemn a method of fill ing root canals th at does not bring the apical end of the filling to the junction of the cementum and dentine at the apex. T h e selection of the level at which to end the filling is, we believe, a problem of accessibility.” T h in k of this for definite advice— it gets us nowhere— advises nothing— we know not a thing! See the u tter confusion into which this throws us, and yet my heart goes out to these men for the exceedingly careful and in telligent study they have given these things. T hey could draw no other rea sonable conclusion— they could give no other conscientious advice— after their numerous examinations of pulp canal work as usually done. T hey report that out of 500 treated extracted teeth exam ined, only one perfectly answered their requirements. '* O ne great advantage of my method is that it would be difficult to use it at all unless it were done thoroughly. If the canal is enlarged and the foramen opened, the canal is bound to be clean. T h e filling m aterial (gold, tin and mercury) is then so easily inserted th at it would be rather difficult not to fill “the full diameter of the canal” and to “seal the foramen.” Consequently, if this method were gen erally adopted, there could not possibly be the same conditions that now cause the treated pulpless tooth to be con demned. Kells said, “A perfect root fill ing is an accident.” W e can now, I be lieve, say that an imperfect root filling is an accident, provided the canal has been properly prepared. Another point that I wish to make c le a r: Even if the fora men is not enlarged for drainage, I believe that the gold and tin amalgam more certainly fills and seals the canal than any other m aterial that has been used; but remember th at the canal itself
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T he Journal of the American D ental Association
must be w ell enlarged to be perfectly filled w ith any m aterial. M offitt’s prep aration2 is w orthy the most careful study, enlightening and constructive. If you are skilful enough to abstract the contents of the canal in a favorable case w ithout carrying so much debris and infectious m atter through the foramen that N ature cannot take care of it, and object to going through the foramen, then by all means do this rather than extract the to o th ; and, if well done, favorable cases should be attended w ith success, but I believe it unwise not to give thorough drainage to a tooth where the apical tissues are clearly infected. T o quote H atton, Skillen and M oen ag ain : “ I t would seem that if the tissues at the apex are diseased to the extent that instrum entation or drugging w ith caustic substances w ithin the apical space seems necessary, such teeth should not be treated.” W h a t a commentary! T h a t w ould condemn by far the m ajority of the teeth I have treated, the results of which, I believe, reverse the statem ent that “ such teeth should not be treated.” T o open wide the foramen, to drain these “ diseased tissues at the apex,” thus get ting bone regeneration, and then to fill w ith a perfectly tolerated plastic m etal filling that does fill the full diameter of the canal, and that does permanently seal the foramen, and to obtain consist ently a satisfactory clinical result — all this entirely justifies us in rew riting their statem ent— such teeth should be treated. Remember, these men had in mind no surgical drainage of these tissues and no successful filling of a large open fora men. T h ey knew, of course, of no filling that could be used successfully in these cases. T h e m aterial that goes into the
apical space is extremely soft and plastic and remains so. T h e very movement of thè tooth in mastication would tend to make it even more so. T h e material in the apical space must be permanently plastic because the slight movement of the tooth in mastication would cause a hard or sharp edge or rough substance to irritate the tissue constantly and also because tissue changes should be able to displace the m aterial in the apical space. M ore than 300 roots (all those that I was able to open through the foramen) have been successfully filled clinically, and about 90 per cent were teeth long “dead” and, of course, infected, so that “the tissues at the apex were diseased to the extent that instrum entation or drug ging w ith caustic substances w ithin the apical space seemed necessary.” In other words, they come in th at class in which even the man advocating root canal treatm ent usually advised extraction. T eeth with freshly extracted pulps are a very small proportion of those seen by us. Few adult patients come to us who have no pulpless teeth, and very few, in comparison, w ith live pulps to be ex tracted ; and so the method that deals only w ith teeth having the pulp freshly extracted, renders a comparatively small service indeed. T h e point is this: If the source of in fection is entirely eradicated, the apical space w ill often recover from both the previous infection and the presence of the debris carried through by you. O f course, the freshly extracted pulp case is different; but Coolidge says, “ Records covering a period of more than twelve years reveal a larger percentage of suc cessful canal fillings of roots that were pulpless than of those from which vital pulps were removed.” Again : if you do 2. Moffitt, J. J .: R oot C anal T re a tm e n t not go to the end and do not force any P re p a ra to ry to C row n and B ridge A tta c h debris through, the tissues w ill often take m ent, J. A . D. A., 15:1480 (A u g .) 1928.
Stew art— A F urther Consideration of the Pulpless Tooth care of the small am ount of substance left in the end of the ro o t; in fact, sometimes N ature has already w alled it off. And again she does none of these things. And, if this is not enough, consider the possible accessory foram ina; then, too, the possible slight denudation of the apex. I t becomes kaleidoscopic— we are throw n into confu sion. And so, is it not the safest thing in all cases to open the canal thoroughly and establish drainage? M y advice to those really in earnest is to experiment w ith extracted teeth-— say, fifty teeth. Complete two a day— the fifty can be done w ithin a month. T h is w ill open the way for success in the mouth. Do not select the teeth— take them indiscriminately— single rooted and m ultirooted. You will probably be aston ished at how little you k n o w ; at least, I was. You w ill (as I did) probably find that it is not best to confine yourself to any one shape or kind of instrum ent, but to use anything the situation suggests, drills (hand and engine), broaches, files, picks, explorers— anything that w ill ex plore, penetrate, enlarge or clean. These w ill be suggested more readily by oper ating on extracted teeth than on teeth in the mouth. In your own office, treat yourself to a four weeks’ post-graduate course w ith fifty extracted teeth and a ll the instru ments (hand and engine) you know of for opening root canals. You w ill have a good time and it w ill cost very little. Do not try to economize on instruments — all you can think of w ill cost you only a few dollars. Each dentist should try out the instrum ents to see which ones can best be used by the individual. Barbed broaches, smooth broaches, root canal files, picks, drills, root canal reamers, and so on. Now, suppose we take an ordinary extracted pulpless tooth, pulpless from whatever cause and maybe for one year,
1869
maybe ten. You know how many of these “ flare up” on being opened. An entrance even into the pulp chamber with an ordinary bur may cause just enough pressure to force a little of the fluid m at ter in the canal through the foramen, so go carefully. Place equal parts of solu tion of formaldehyd (form alin) and a saturated solution of zinc chlorid in the pulp chamber. Even this pellet of cotton pressed in by pliers may force a little septic fluid through the foramen. I some times keep this in place only an hour or two, then open the canal freely, foramen and all. Usually, this is kept in place twenty-four hours. A fter the pulp chamber is cleaned, and the mouths of the canals are exposed, we first carry a small quantity of full strength hydrochloric acid (on any suit able instrum ent) into the mouth of the canal, and w ork this gently down with finest size barbed broach. N ot only does the acid help to open the canal, but also experience teaches me that it is the best surface sterilizer. Besides, it unites with and partially dissolves the minute shav ings of dentin as the broach or file cuts them off the wall. T hen, when some of this débris (as is inevitable if the canal is cleaned) is carried through the fora men, the acid renders it inert and fluid so it can readily be washed out of the periapical space. W hen at the one sitting the canal and foramen are thoroughly opened in this way for drainage, I have yet to have one of those cases of acute abscess swelling and all the unbear able symptoms with which we are so familiar. T ru e , there is sometimes pain (very seldom, how ever), but this pain is usually very slight as compared w ith the distressing agony of the usual acute abscess. T his is due, of course, to the free drainage.
1870
T he Journal of the American D ental Association
Lucien A rnold speaks of hydrochloric acid in the periapical space as being of benefit and no harm and states that it combines w ith sulphur, generating hydro gen sulphid, and the products left are chlorids which are norm al to the body. Sulphuric acid produces sulphates and these are taken care of w ith more diffi culty. M y own clinical results w ith hydrochloric acid coincide w ith A rnold’s. W hile using instruments in the canal, to open and enlarge it (in extracted teeth), we should watch carefully the débris that goes through the foramen. T h is w ill con vince one that the canal cannot be cleaned to the end w ithout carrying débris through it, and when it is through, even if the canal is filled perfectly to the end, septic m atter is simply sealed up in the periapical tissues. T ru e , this wonderful tissue often encysts or entirely digests such m atter, but w hat a chance to take! H ow much better it is to get it out as a surgeon would extraneous m atter before closing a wound. Remember th at a small canal and a small opening is no guarantee against m atter being carried through, but this m atter cannot possibly get out again. T h e foramen must be enlarged freely to perm it this. T hen, the cotton points, the spray, the syringe, can all be used w ith effect, but not so w ith the small foramen. Peroxid can be freely used with no fear of back-lash, and the excre tions readily exude into the canal and are harmless. I like to leave the canals free and open between sittings, stopping the pulp chambers only. T h is allows the accumulating secretions to overflow into the canal and prevents pressure. I t seems that we have been managing these cases as unlike surgery as it was pos sible to do. Drainage is the surgeon’s watchword, his first and greatest com mandment. If there is infection, he opens the tissue and keeps it open. Ochsner, in
“G eneral Surgery,” says: “ 1. Infected bone cavities should heal from the bot tom. 2. T h e soft tissues should be kept wide open. 3. No antiseptics should be used, only drainage, but w hatever may be used in this bone cavity should stimu late excretion from tissues, and do this only.” W h a t do we do? W e simply attem pt to clean out the drainage tube, and do not half do that. Besides, we care fully avoid cleaning it at the end that projects into the infected tissue for fear of wounding that tissue and then we place antiseptics in the drainage tube and w rite learnedly on the asepsis and bac teriology of our drainage tube. Could anything be more childish? Is it any wonder the surgeons had no confidence in anything we said about the pulpless tooth ? L et me not be misunderstood— thousands of cases have recovered (even when the periapical tissue was infected) simply by removal of the contents of the canal, and filling, this extraordinary tissue taking care of the infection as would not be done in any other bones in the body. And here we have the quarrel w ith the average “biologist” and “research w orker.” T heir efforts so often are bent to prove the con tra ry : that the tissue is low in recupera tive power when once wounded or in fected as is true of the dental pulp. Every organism they find is there to doom the tooth and produce all the dis eases in the category. And, much as I regret to say it, some otherwise honest w riters are presuming on the general lack of intimate histologic and bacteriologic knowledge to frighten dentists into extracting teeth. W e must remember too that these laboratory men are just as con versant w ith all the details of the clinical results in the mouth as we are conversant w ith their details in the laboratory; that they know just as much as to how our methods differ from each other as we
Stew art— A F urther Consideration of the Pulpless Tooth know how their methods differ from each other; and they know ju st as much as to how each operator can change and adapt his methods to produce a favorable and physiologic result as we know how each laboratory man can adapt and change his methods to produce an unfavorable result. W e have too long made our clinical judgm ent subservient to the expressed opinion of the laboratory man, while the laboratory man, on the whole, has done (largely unconsciously to himself) a most elaborate amount of w ork in order to draw the conclusion th at all clinical results have no w eight and are utterly worthless. O ne would think that the roentgen-ray was only a delusion and a snare; that the evidence of regeneration of bone around the apex of a tooth was an actual indication of disease and was different from regeneration of any other bone; that freedom from tenderness or inflammation or any unfavorable clinical results were only an indication of the utter depravity of these tissues, which are only lying in w ait and covertly hiding every symptom (unlike other tissues in the body) in order to produce every disease in the category for which no other cause can be found. L et me not be misunderstood. H is tologic and microscopic w ork are, of course, invaluable and w ill finally coin cide w ith and prove our clinical results just as much as it has proved the surgeons’ clinical results, w hile the average lab oratory w orker gives us the impression th at his mission in life is to disprove clin ical results. A fter the foramen is opened, it often clogs and needs to be cleared at each sit ting. T h is is usually done by cotton canal points carried up w ith the pliers. Some times, m etal rods are kept in place for this purpose. H ere, I shall refer briefly to the use of copper rods, which I often use,
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not only to keep the foramen open but also to stimulate drainage. I hesitate to refer to this now because my experiments have not extended over a sufficient time to give out definite information at pres ent, and I mention it only that others may experiment w ith them. O f course, it is too early to express a decided opinion, but copper seems to ( 1 ) stimulate secre tion; (2 ) cause a breaking down of dis eased tissue; (3 ) cause aseptic suppura tion; (4 ) stim ulate tissue regeneration, especially of bone, and (5 ) stimulate the flow of lymph. Figure 4 shows copper rods in place. Experiments of Lange of Germany and Zierold of M inneapolis show definite stimulation of bone production by copper. W hile causing aseptic suppuration of tissue immeditely adjacent, it causes a reproduction at a distance. Experiments w ith metals in culture mediums by Charles Leedham-Green (surgeon to the Q ueen’s and C hildren’s Hospitals, Birm ingham, E ngland) show th at “by far the most powerful of the metals bactericidally proved to be copper, and, in a less degree (according to the percentage of copper used in their composition), its alloys, bronze and brass.” As far as I know, no one has ever used the copper for the pur pose of producing suppuration or stimu lation of bone production. I t has been used only to ascertain its tolerance or intolerance (along w ith other metals) when implanted in normal healthy tissues. I t occurred to me that if it did produce the aseptic suppuration of the tissues w ith which it came into immediate contact; if it powerfully stimulated the reformation of tissue in the region ad jacent to the suppuration, and if, in addi tion, it was germicidal, it might be of use in breaking down granulation tissue and stim ulating regeneration about the root
1872
T h e Journal of the American D ental Association
in addition to keeping the entire field sterile. T o return to the canal opening: A fter removing as much of the canal contents as we can w ith barbed broaches, a No. 1 file is used. U sually, each file or broach should be used, not only until the entire canal is penetrated by it, but until it works loosely, although often we have to enlarge the first p art of the canal and later the apex. I t is w ell to curve the file slightly after it works loosely, as it w ill then bind and cut more. T h is better prepares the way for the next one. N early always, the entire six files are used. T h ere are few canals which I do not en large considerably w ith drills after the No. 6 file is used. I often begin w ith drills after the No. 4 file. Sometimes, it is argued th at such w ork can be done in a large city but not in small towns, th at people will not pay for the time. T h is is a mistaken argument. T h e city man is more pushed for time. H e has less time and inclination to ex plain details and carry his patient along w ith him. H e has greater expense and is tempted to be more commercial, and less human. I know a man in a big city who pays $300 a month for his office. H e paid $35 a month in the village before moving to the city. Is it not because he does not w ant to do this w ork that the average dentist reasons thus ? I am not censuring, just stating facts. Suppose we explain to the patient that if the tooth is extracted the two adjoining teeth w ill have to be m utilated, w ith almost certain discomfort and tenderness or grave danger of dying of pulps in the future, if replaced by the large inlay system of “movable-removable” bridges, and so forth. Suppose we explain further the danger of breakage and the annoy ance of having to remove and replace the bridge two or three times daily (imagine
four permanent molars so replaced), or the danger of deterioration from clasps (to say nothing of their looks) and the possible injury to the gums or peridental m em brane; the effect on facial expression from the loss of the roots of the teeth, besides the initial cost of making the im mediate bridge w ith a possible larger bridge sometime in the fu tu re; to say nothing of the pain and shock to the nervous system, and the m ental effect on the patient of the whole thing. H ow many right-minded, intelligent patients do you think, would agree to the extrac tion ? H ow many would refuse to pay as much for saving the tooth as for making the bridge? But, you say, suppose that, after you treat the root, you still have to extract it ? T h a t, of course, is well w orth considering and depends entirely on how you treat it. H ere, I w ill say, we are not developing finger skill, that great requisite of suc cessful dentistry, as we used to. , O ur fathers were much better prepared in this respect than we, and in some ways prac ticed much better dentistry. W hen my father began dentistry, we had few dental engines. W hen I began to work in his office as a boy, he compelled me to do all my first work w ith my fingers. Inciden tally, if the colleges do not get back to finger training, dentistry w ill still fu r ther deteriorate and we will have a con tinual flood of literature on becoming an M .D . instead of a dentist, and fu rth er more men w ill stay M .D .’s instead of becoming dentists. Here, I cannot for bear quoting from Sir John Tom es: “ It has been strongly urged that dental should become supplemental to medical knowl edge; th at the practitioner should be a doctor first, and a dentist afterwards. T h is opinion might perhaps be sustained if the position were reversed— a dentist first and a doctor afterwards, provided
Stew art— A F urther Consideration of the Pulpless Tooth all or even a m ajority of students were sufficiently rich in money and time to extend the educational period from four to six years.” A nd may I add, provided the 90 per cent of our population who are not receiving efficient dental service were so supplied. In my form er article, the preparation of the filling m aterial seems not to have been made clear to some. Simply mix gold foil and tin foil w ith mercury to a soft plastic mix. Glass tubes w ill demon strate the easy w orking qualities of the m aterial. A w riter in the Dental Digest says that no one can put in a perfect root filling, th at no one ever did or ever w ill fill and seal an apical foramen because, he says, it cannot be dried. “ If you doubt this,” he continues, “place a root end on wet cotton or spunk— the foramen w ill again fill as fast as you absorb the moisture.” If the w riter referred to w ill take the gold, tin and mercury mix and fill a glass tube (the tube standing on w et cotton— even first filling the tube w ith w a te r), he w ill see the metal gradually drive the w ater out of the tube. T his tube, afterw ards immersed in dye, w ill not leak. A nother thing th at I find was not clear to many readers is the use of the round bur. T h e picture of the two burs through the foramen of a m olar tooth, Figure 6, in a form er paper, gave the idea to some that I enlarged the canal w ith these burs. T h e canal is enlarged w ith ordinary nerve canal drills and the burs are used only to enlarge the foramen at the apex of the root, making it funnel-shaped. T his is done only in case of suspected denudation of the end of the root, and when the canal has been en larged, a round bur, the size of the canal, is then selected and passed through the foramen, then pressed to the side so as to hook the bur over the foramenal
1873
w all. T h e engine is not started until this bur is placed in position, then, by pulling downward, the end of the root can be entirely amputated, if desired. In this way, it is to be especially noted th at no dentin is left exposed as in the usual am putation of the apex. A ll of the dentin is left protected by the cementum so that when the canal is filled, no dentin is exposed to body fluids. T h is is a most im portant point. T his operation is much more conservative of root end structure than the usual amputation, and it is my opinion that it is usually necessary to sacrifice only a small proportion of the apex as compared to w hat is usually sacri ficed in apicoectomy. In other words, there is usually nothing like so much denudation of the end of the root as we have been led to believe. In most cases, even of long standing infection, the mere enlargement of the canal through the foramen is entirely sufficient to take care of the denuded area w ithout the use of the round bur at all. As was pointed out in my former paper, even if a slight denuded surface is left, the filling m a terial spreads over it and the tissues growing down against the material press it down from every side against this denuded surface. I t has been urged that the filling ma terial may discolor the crown of the tooth. T his is briefly answered by saying that it is not necessary to fill the entire canal. T h e apical one-half or one-quarter (if a crown post is to be used) may be filled w ith this material and the remain der w ith any suitable material. M y own preference is to fill down nearly to the pulp chambers w ith cotton saturated w ith zinc chlorid (saturated solution), and then to finish w ith oxychlorid of zinc. T h is small amount of oxychlorid is easily drilled through, in case the canal is to be reopened. In a nutshell: I t is
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T h e Journal of the American D ental Association
necessary only to definitely and safely seal the apical foramen. T h e question has been asked in many letters as to how long a dressing is to remain in the canal. T h is often depends on the secretion of the tissues. Usually, the second dressing is kept in from two to four days and the following ones governed by the indications, sometimes from two to four weeks. T h e time of filling is governed by the secretions and clinical indications much as in the closing of wounds in general surgery. I realize the lack of detail of consecu tive operative procedure in this and the preceding paper. I hope soon to give to the profession a paper dealing w ith this alone. CO N CLU SIO N
1. T his method accurately and easily fills the full length and full diameter of the canal. 2. It definitely and w ith certainty seals the foramen.
3. T h e surplus beyond the end of the canal is surprisingly mobile and plastic and remains so, and thus it is nonirritat ing to the tissues while the tooth is in the movement in mastication. T h is also allows the tissues to grow in over the end of the root or to press the material against a denuded area. 4. T h e material is impermeable to fluids, will displace moisture in the canal and will not leak. 5. A ctual and definite surgical drain age is obtained. 6. T h e tissue is given a chance to rid itself of infection and to heal as do other tissues in surgical operations. T his tissue has been the abused and despised step child of the human body. Let us give it a chance. 7. If the profession would earnestly and sincerely give this method the most thorough and exacting test, I should await the results w ith the utmost con fidence.
ODONTOM AS: CLASSIFICATION, DIAGNOSIS A N D TREATM ENT* By L. W. SCHULTZ, B.S., D.D.S., M.D., Chicago, 111. H E term “odontoma” was coined by Broca in 1869.1 And the anatomic society which met in Basle, Switzer land, in 1895, to devise a uniform scien tific medical nomenclature, accepted it. Hence, it should be a satisfactory term. It is of G reek derivation, from odous-odontos, meaning tooth, and oma-omatos, a tum or.
T
However, judging by the numerous classifications which have appeared in the literature, it would seem th at this expres sion is not sufficiently restricted. T he term permits inclusion of all new growths arising from the dental system, be they hard or soft. Among other authorities, M oorehead and Dewey2 restrict this term to hard tumors of the jaw composed of
*R ead before the O d o ntographic Society of 2. M oorehead, F. B., and D ewey, K aeth e Chicago, Oct. 21, 1929. 1. Broca, P .: T ra ité des tum eurs, P aris, W . : P athology of the M outh, P h ila d e lp h ia : W . B. Saunders Com pany, 1925, p. 483. 1869, Vol. 2, p. 275.
Jour, A, D. A., October, 1930