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Endodontics: Then and now
Endodontics: Then and now Louis I. Grossmm, D.I).Y., Yhiladelphic~, Pa. SCHOOL
OF DENTAL
RIEDICINE,
TJNIVERSITY
OF PENNSYI,VANI.\
Edgar Coolidge played an important, role in the founding of the American Asso&tion of Endodontists and the American Board of Endodontics. His research and clinical contrilmtions in endodontics, his high standing in the dental profession, and his influence with the lcadcrs of dcwtistty on behalf of endodontics helped considerably in gaining recognition for the sl~ecialty. His was a lifetime of selflessness dedicated to the common good.
I
appreciate t,he honor ac~cordctl mc of giving the Etlgar I). Coolidge Memorial Ilecture. I proposc to delineate the tlcvelopmcnt of e&loclontics as it unfolded during Dr. Coolidge’s lifetinic. Edgar Coolidge was b01~~ in 188 1 and, by his precept ant1 personality, became an inspiration I o me and to thousands of others in dentistry. His was a lifetime of dedication to i~warch and teaching in endodontics. 111 addition, our closely related specialty. ~wrioclontics, (lit1 Ilot suff’er for want of his contributions. 1 first met T)r. Coolidge in 1931 ilt a m&in, 0’ of the Chicago Dental Societ! ai~cl was instant,ly inil~rcwtvl by his friendly, courteous manner. In later years, as I came to know him bet,tcr, T realized even more how much compassion and empatlly hc had for others. \Ve often speak in cliches of a “gentleman and a scholar.” Edgar was a grtltlcman alltl iL scholar in the t,rur sense of the wortl. ITe was born in (~Ialesbnrg, Illinois, of’ parents who had migrat,ed from Yen England. His father pioneered in scientific farming. Edgar inherited his father’s love for the soil ;uicl thrc)ughout. his liCetime lived on il farm, although his profession brought him into the city. Edgar attained a college education at. a time when predentul education was nut a requirement for admission to dental school. IIe received his clcntal tlegwe. in 1906 and began teaching soon afterward. A master of science degree was awarded him in 1930, an honorary doctor of laws in 1948, and a doctor of science degree in 1958. For 50 years he engaged in active practice and continued his interest in endodontics for a number of ywrs afterward. He was inst rluncntal in founding the American Association of Endodontists and t,lic Anlcrican IhillY of l3ntlodontics. The Edgar D. Coolidge Association of Endodontists,
254
Memorial Lecture delivered at the annual meeting Philndclphin, Pa., April 24, 1971.
of the American
Volume 32 Number 2
Endodontics:
Then and now
255
I will now review the development of endodontics in Dr. Coolidge’s lifetime (1881-1967). The progress made in this area of dental practice during this time, to which he contributed greatly, is truly astonishing. PULP EXTIRPATION
In the 1880’s pulp extirpation was a barbarous procedure. In 1883 Mills described a method for the painless removal of a pulp. This consisted of gaining access to the pulp chamber, applying a pointed hickory peg against the pulp, and giving it a sharp tap with a mallet. It is said that when the procedure was skillfully done, it was painless. This was apparently an accepted method of practice, since in the 1890’s B.Q. Stevens described boxwood points for the purpose. They were about 2 inches long and tapered to a fine point. Arsenic was also being used at the time to destroy the pulp. Its application to the pulp was painful, and arsenic also had an unfortuna,te tendency to leak out of the cavity, at times destroying the periodontal ligament and the adjacent bone. The anesthetic effect of cocaine was not discovered until 1884 and was not introduced into dentistry until 4 years later. In 1888 Burge suggested packing warm guttapercha around a hypodermic needle, inserting it into the cavity, and injecting cocaine into the pulp. The first method of anesthetizing the pulp was therefore the intrapulpal method. In the 1890’s Funk introduced pressure anesthesia for pulp removal. This consisted of applying crystals of cocaine to the exposed pulp and forcing them directly into the pulp tissue by inserting a piece of unvulcanized rubber in the cavity and exerting pressure with an instrument. After the initial “ouch,” all remained quiet in the dental office. Either the cocaine took effect or the patient fainted. In 1904 Myers developed a high-pressure syringe for injecting cocaine under considerable pressure directly into the pulp. This was more effective than the so-called “pressure” anesthesia method in cases where the pulp was accessible, but it never became a popular method. It might be mentioned here that, alt.hough Vaughan recommended infiltration anesthesia, as early as 1906, it was not commonly used for pulp extirpation until more than a decade later. and especially In 1905 Einhorn synthesized Novocain, which gave dentistry endodontic practice a more effective and less toxic anesthetic than cocaine. Infiltration anesthesia did not become a popular method until the introduction of the breech-loading syringe and Carpule in the early 1920%. Until that time the dentist boiled a Novocain tablet in a saline solution in a ceramic vessel over the Bunsen burner in full sight of the patient, then added an Adrenalin tablet when the solution became cool enough. This procedure was both inconvenient and time consuming. By comparison, pressure anesthesia was much simpler, even though it was not always so effective. DENTAL What
EDUCATION was the state
of dental
education
and of endodontic
time Dr. Coolidge received his dental degree in 19061
practice
at the
Volume 32 Number 2
Endodontics:
cement, and stuffed into the root canal. The extent often determined by the reaction of the patient. X-RAY
Then and now
257
of the canal filling
was
DIAGNOSIS
In 1895 an epoch-making event occurred which had a tremendous effect on the future of both medicine and dentistry. In that year Roentgen discovered x-rays. Two weeks after the announcement of Roentgen’s discovery, Prof. Walkhoff of Wurzburg, Germany, took the first dental x-ray picture. In those days there were no x-ray films; there were only sensitized glass plates. Walkhoff wrapped a sheet of rubber dam around a sensitized plate and lay quietly on the floor for almost half an hour to take a picture of his own teeth. Actually, it was a bitewing type of picture, since it showed only the crowns of the upper and lower posterior teeth. Processing of the x-ray plate in those days must have been quite a bore, as it took from half an hour to an hour to develop the plate. In the following year the Jouwal of the American Medical Association had this to say about the use of x-rays and x-ray equipment: “Case after case is reported where unsuspected formations were revealed by the x-ray photograph . . . . Half an hour is the shortest [x-ray] exposure possible, and most require an hour. The electric apparatus required is so expensive, $100 and upward, that few surgeons can use it yet in their private practice.” Roentgen’s discovery of x-rays lay fallow for a number of years as far as dentistry was concerned. The first dental x-ray machine did not make its appearance unt,il 1913, 18 years after Roentgen’s discovery, and this was only transformer.” a “semi-specialized dental unit . . . using an interrupterless The first dental x-ray unit as WC know it today was introduced to the profession in 1917. Some time in the early 1920’s dental x-ray studios began to spring up in the la.rger cities. These were offices, operated by technicians under the supervision of a dentist, where x-ray films were taken of pa.tients. The patients were referred to the studios by dentists who did not own x-ray machines. A survey made in I940 showed that only 75 per cent of all dentists owned x-ray machines. Today no dentist in his right mind would think of practicing without an x-ray machine; yet many teeth were still being treated endodontally without benefit of x-rays 30 years ago. FOCAL
INFECTION
In 1910 a veritable bomb exploded in the form of a severe castigation of the dental profession by Dr. William Hunter. His address at McGill University accused the dental profession of creating “gold traps of sepsis” which were responsible for many human ills. Hunter initiated the focal infection era which led to wholesale extraction of teeth. Let me quote from his address: “Gold fillings, gold caps, gold bridges, gold crowns, fixed dentures built in, on, and around diseased teeth, form a veritable mausoleum of gold over a mass of sepsis to which there is no parallel in the whole realm of medicine or surgery. The whole constitutes a perfect gold trap of sepsis.” He went on to say: “The
258
Oral .4ugust,
Grossman
ENDODONTIC
PRACTICE
Surg. 1971
TODAY
Enclodontics has advanced along a broad front in recent years. Endodontic practice, as we know it today-, is no longer limited to simple root canal treatmcnt. The scope: of endodontics has been broadened to include such diverse opclrations as hemisection, radisectomy, treatment of the combined periodontalentlodontal lesion. intentional replantation, and endodontic implants. 1Ccxcarc.hin t,ndodontics has kept pace with advances in endodontic practice. Of sixty papers publishetl in 1970 that were chosen for review for our graduate students, forty-six (76 pc’r cent) were either clinical or laboratory research
Volume 32
Number 2
Endodontics: Then and now 259
papers.We can evaluateresearchin endodonticsin anotherway. Of the fortyone paperspublishedlast year in ORAL SURGERY, ORAL MEDICINE AND ORAL PATHOLOGY under the heading of Endodontics, thirty-two (78 per cent) were based on research studies. This is truly a remarkable record for a relatively young specialty. The American Association of Endodontists must be given recognition for the role it has played in advancing the practice of endodontics. The Association was organized in 1943 with the following objectives in mind, as stated in the constitution : ” (a) to p romote interchange of ideas on methods of pulp conservation and root canal t.reatment: (b) to stimulate research studies, both clinical and laboratory, among its members; (c) to assist in establishing local root canal study clubs; (d) to help maintain a high standard of root canal practice within the profession by disseminating information through lectures, clinics, publications, etc.” It has achieved these objectives in the intervening years. From a small band of organizers, it soon grew to about 200 members in this country during the first year. Today it numbers more than 1,300 members from every cont,inent on the globe. I shall not count for you the yea.rs that were imposed by a moratorium which prevented consideration of endodontics as a specialty of dental practice or the disappointments of those who strove to gain recognition of an endodontic board. Finally, in 1963, endodontics was declared an area of special dental practice by the American Dental Association, and the American Board of Endodontics gave its first examination in May, 1965. In the founding of the American Association of Endodontists and the American Board of Endodontics, Edgar Coolidge played an important role. His research and clinical contributions in endodontics, his high standing in the dentad profession, and his influence with the leaders of dentistry on behalf of endodontics helped considerably in gaining recognition for the specialty. His was a lifetime of selflessness dedicated to the common good. Reprint requests to : Dr. Louis I. Grossman Hchool of Dental Medicine University of Pennsylvania Philadelphia, Pa. 19104
OF DENTAL
RIEDICINE,
TJNIVERSITY
OF PENNSYI,VANI.\
Edgar Coolidge played an important, role in the founding of the American Asso&tion of Endodontists and the American Board of Endodontics. His research and clinical contrilmtions in endodontics, his high standing in the dental profession, and his influence with the lcadcrs of dcwtistty on behalf of endodontics helped considerably in gaining recognition for the sl~ecialty. His was a lifetime of selflessness dedicated to the common good.
I
appreciate t,he honor ac~cordctl mc of giving the Etlgar I). Coolidge Memorial Ilecture. I proposc to delineate the tlcvelopmcnt of e&loclontics as it unfolded during Dr. Coolidge’s lifetinic. Edgar Coolidge was b01~~ in 188 1 and, by his precept ant1 personality, became an inspiration I o me and to thousands of others in dentistry. His was a lifetime of dedication to i~warch and teaching in endodontics. 111 addition, our closely related specialty. ~wrioclontics, (lit1 Ilot suff’er for want of his contributions. 1 first met T)r. Coolidge in 1931 ilt a m&in, 0’ of the Chicago Dental Societ! ai~cl was instant,ly inil~rcwtvl by his friendly, courteous manner. In later years, as I came to know him bet,tcr, T realized even more how much compassion and empatlly hc had for others. \Ve often speak in cliches of a “gentleman and a scholar.” Edgar was a grtltlcman alltl iL scholar in the t,rur sense of the wortl. ITe was born in (~Ialesbnrg, Illinois, of’ parents who had migrat,ed from Yen England. His father pioneered in scientific farming. Edgar inherited his father’s love for the soil ;uicl thrc)ughout. his liCetime lived on il farm, although his profession brought him into the city. Edgar attained a college education at. a time when predentul education was nut a requirement for admission to dental school. IIe received his clcntal tlegwe. in 1906 and began teaching soon afterward. A master of science degree was awarded him in 1930, an honorary doctor of laws in 1948, and a doctor of science degree in 1958. For 50 years he engaged in active practice and continued his interest in endodontics for a number of ywrs afterward. He was inst rluncntal in founding the American Association of Endodontists and t,lic Anlcrican IhillY of l3ntlodontics. The Edgar D. Coolidge Association of Endodontists,
254
Memorial Lecture delivered at the annual meeting Philndclphin, Pa., April 24, 1971.
of the American
Volume 32 Number 2
Endodontics:
Then and now
255
I will now review the development of endodontics in Dr. Coolidge’s lifetime (1881-1967). The progress made in this area of dental practice during this time, to which he contributed greatly, is truly astonishing. PULP EXTIRPATION
In the 1880’s pulp extirpation was a barbarous procedure. In 1883 Mills described a method for the painless removal of a pulp. This consisted of gaining access to the pulp chamber, applying a pointed hickory peg against the pulp, and giving it a sharp tap with a mallet. It is said that when the procedure was skillfully done, it was painless. This was apparently an accepted method of practice, since in the 1890’s B.Q. Stevens described boxwood points for the purpose. They were about 2 inches long and tapered to a fine point. Arsenic was also being used at the time to destroy the pulp. Its application to the pulp was painful, and arsenic also had an unfortuna,te tendency to leak out of the cavity, at times destroying the periodontal ligament and the adjacent bone. The anesthetic effect of cocaine was not discovered until 1884 and was not introduced into dentistry until 4 years later. In 1888 Burge suggested packing warm guttapercha around a hypodermic needle, inserting it into the cavity, and injecting cocaine into the pulp. The first method of anesthetizing the pulp was therefore the intrapulpal method. In the 1890’s Funk introduced pressure anesthesia for pulp removal. This consisted of applying crystals of cocaine to the exposed pulp and forcing them directly into the pulp tissue by inserting a piece of unvulcanized rubber in the cavity and exerting pressure with an instrument. After the initial “ouch,” all remained quiet in the dental office. Either the cocaine took effect or the patient fainted. In 1904 Myers developed a high-pressure syringe for injecting cocaine under considerable pressure directly into the pulp. This was more effective than the so-called “pressure” anesthesia method in cases where the pulp was accessible, but it never became a popular method. It might be mentioned here that, alt.hough Vaughan recommended infiltration anesthesia, as early as 1906, it was not commonly used for pulp extirpation until more than a decade later. and especially In 1905 Einhorn synthesized Novocain, which gave dentistry endodontic practice a more effective and less toxic anesthetic than cocaine. Infiltration anesthesia did not become a popular method until the introduction of the breech-loading syringe and Carpule in the early 1920%. Until that time the dentist boiled a Novocain tablet in a saline solution in a ceramic vessel over the Bunsen burner in full sight of the patient, then added an Adrenalin tablet when the solution became cool enough. This procedure was both inconvenient and time consuming. By comparison, pressure anesthesia was much simpler, even though it was not always so effective. DENTAL What
EDUCATION was the state
of dental
education
and of endodontic
time Dr. Coolidge received his dental degree in 19061
practice
at the
Volume 32 Number 2
Endodontics:
cement, and stuffed into the root canal. The extent often determined by the reaction of the patient. X-RAY
Then and now
257
of the canal filling
was
DIAGNOSIS
In 1895 an epoch-making event occurred which had a tremendous effect on the future of both medicine and dentistry. In that year Roentgen discovered x-rays. Two weeks after the announcement of Roentgen’s discovery, Prof. Walkhoff of Wurzburg, Germany, took the first dental x-ray picture. In those days there were no x-ray films; there were only sensitized glass plates. Walkhoff wrapped a sheet of rubber dam around a sensitized plate and lay quietly on the floor for almost half an hour to take a picture of his own teeth. Actually, it was a bitewing type of picture, since it showed only the crowns of the upper and lower posterior teeth. Processing of the x-ray plate in those days must have been quite a bore, as it took from half an hour to an hour to develop the plate. In the following year the Jouwal of the American Medical Association had this to say about the use of x-rays and x-ray equipment: “Case after case is reported where unsuspected formations were revealed by the x-ray photograph . . . . Half an hour is the shortest [x-ray] exposure possible, and most require an hour. The electric apparatus required is so expensive, $100 and upward, that few surgeons can use it yet in their private practice.” Roentgen’s discovery of x-rays lay fallow for a number of years as far as dentistry was concerned. The first dental x-ray machine did not make its appearance unt,il 1913, 18 years after Roentgen’s discovery, and this was only transformer.” a “semi-specialized dental unit . . . using an interrupterless The first dental x-ray unit as WC know it today was introduced to the profession in 1917. Some time in the early 1920’s dental x-ray studios began to spring up in the la.rger cities. These were offices, operated by technicians under the supervision of a dentist, where x-ray films were taken of pa.tients. The patients were referred to the studios by dentists who did not own x-ray machines. A survey made in I940 showed that only 75 per cent of all dentists owned x-ray machines. Today no dentist in his right mind would think of practicing without an x-ray machine; yet many teeth were still being treated endodontally without benefit of x-rays 30 years ago. FOCAL
INFECTION
In 1910 a veritable bomb exploded in the form of a severe castigation of the dental profession by Dr. William Hunter. His address at McGill University accused the dental profession of creating “gold traps of sepsis” which were responsible for many human ills. Hunter initiated the focal infection era which led to wholesale extraction of teeth. Let me quote from his address: “Gold fillings, gold caps, gold bridges, gold crowns, fixed dentures built in, on, and around diseased teeth, form a veritable mausoleum of gold over a mass of sepsis to which there is no parallel in the whole realm of medicine or surgery. The whole constitutes a perfect gold trap of sepsis.” He went on to say: “The
258
Oral .4ugust,
Grossman
ENDODONTIC
PRACTICE
Surg. 1971
TODAY
Enclodontics has advanced along a broad front in recent years. Endodontic practice, as we know it today-, is no longer limited to simple root canal treatmcnt. The scope: of endodontics has been broadened to include such diverse opclrations as hemisection, radisectomy, treatment of the combined periodontalentlodontal lesion. intentional replantation, and endodontic implants. 1Ccxcarc.hin t,ndodontics has kept pace with advances in endodontic practice. Of sixty papers publishetl in 1970 that were chosen for review for our graduate students, forty-six (76 pc’r cent) were either clinical or laboratory research
Volume 32
Number 2
Endodontics: Then and now 259
papers.We can evaluateresearchin endodonticsin anotherway. Of the fortyone paperspublishedlast year in ORAL SURGERY, ORAL MEDICINE AND ORAL PATHOLOGY under the heading of Endodontics, thirty-two (78 per cent) were based on research studies. This is truly a remarkable record for a relatively young specialty. The American Association of Endodontists must be given recognition for the role it has played in advancing the practice of endodontics. The Association was organized in 1943 with the following objectives in mind, as stated in the constitution : ” (a) to p romote interchange of ideas on methods of pulp conservation and root canal t.reatment: (b) to stimulate research studies, both clinical and laboratory, among its members; (c) to assist in establishing local root canal study clubs; (d) to help maintain a high standard of root canal practice within the profession by disseminating information through lectures, clinics, publications, etc.” It has achieved these objectives in the intervening years. From a small band of organizers, it soon grew to about 200 members in this country during the first year. Today it numbers more than 1,300 members from every cont,inent on the globe. I shall not count for you the yea.rs that were imposed by a moratorium which prevented consideration of endodontics as a specialty of dental practice or the disappointments of those who strove to gain recognition of an endodontic board. Finally, in 1963, endodontics was declared an area of special dental practice by the American Dental Association, and the American Board of Endodontics gave its first examination in May, 1965. In the founding of the American Association of Endodontists and the American Board of Endodontics, Edgar Coolidge played an important role. His research and clinical contributions in endodontics, his high standing in the dentad profession, and his influence with the leaders of dentistry on behalf of endodontics helped considerably in gaining recognition for the specialty. His was a lifetime of selflessness dedicated to the common good. Reprint requests to : Dr. Louis I. Grossman Hchool of Dental Medicine University of Pennsylvania Philadelphia, Pa. 19104