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Extraction of the Pulpless Deciduous Tooth*
S w eet— E xtraction of Pulpless D eciduous T eeth come to the conclusion, after roentgenographically checking the postoperative re sults of many cases, th at the removal of the toot h intact is not always advisable for the reason that the amount of bone to be re moved can be greatly minimized in certain types of impacted teeth by splitting the tooth. It makes little difference whether the tooth is removed in its entirety or split with mal let and chisel in two or more segments, the real consideration is how little traum a has been created in the operative procedure. Dr. G ardner has given a definite and understandable description of the use of mallet and chisel. The use of disks, stones and burs is not conducive to the best results.
1037
For many years, my choice of anesthetic in removing impacted mandibular lower third molars was procaine. In recent years, I have been using nitrous oxide oxygen in quite a number of cases. T his has been made possible by using an aspirator with a suitable point and a tissue retractor with a light attached. Dr. G ardner mentioned the advantages of treating the soft tissues before operation. In many instances, it is impossible to treat patients for a week to ten days before operating, although one or two treatm ents with a Young rubber cup using 10 per cent chromic acid followed with tincture of metaphen will minimize post operative complications to a marked degree.
EXTRACTION OF THE PULPLESS DECIDUOUS TOOTH* B y C H A R LE S A. SW EET, D .D.S., F.A .C .D ., O ak lan d , Calif.
I N C E pulpless deciduous teeth are usually classified by general practi tioners and m any ch ild ren ’s dentists w ith pulpless perm anent teeth, extraction has u n fo rtu n a te ly been the rule in deal ing w ith these deciduous teeth. L ittle th o u g h t has been given to th e possibility of th eir recovery from infection since few d ata are available. M o st of us are prejudiced against the pulpless tooth, deciduous or perm anent, but because of th e serious consequences a tten d in g early loss of deciduous teeth, m ore consideration is being given the pos sibilities of successful retention of these supposed foci of infection. I t w ould be beyond reason to say th a t all pulpless deciduous teeth can be re tained in a healthy condition, b u t fa r too
S
*Read before the Section on Mouth Hygiene and Preventive Dentistry at the SeventyFourth Annual Session of the American D en tal Association, Buffalo, N. Y., Sept. 14, 1932.
lour. A. D. A., June, 1933
m any m ouths have been crippled beyond repair, by w holesale extractions, because of the economic condition of the parents. E x trac tio n of deciduous teeth is al ways indicated if ( 1 ) caries has penetrated the roots a t the b ifu rcatio n ; (2 ) tw oth ird s of the root or roots has been ab sorbed, because of norm al absorption or infection, o r (3 ) there is a fistulous open ing a t the gingival m argin of the tooth. In no oth er instance is it necessary to remove pulpless deciduous teeth ; for, as fa r as can be observed, they have no d e tri m ental effect on the physical development of the child and, if properly treated, show no g rea ter susceptibility to fu rth e r in fection. Econom ically, the retention of pulpless deciduous teeth th a t have been properly trea ted is indeed quite sound ; for, in m any instances, th e early loss of these teeth may m ean considerable expenditure of money for orthodontic trea tm e n t to correct the
1038
T h e Journal o f the A m erican D e n ta l Association
dam age th a t is the result of prejudice, a lack of know ledge and im proper tre a t m ent. B ran d h o rst1 shows th a t the prem ature loss of teeth is responsible fo r 37 per cent of dentofacial deform ities. Is this not a challenge to us to gain a b etter u n d er standing of exposed and pulpless decidu ous teeth th a t w e m ay elim inate these d entofacial deform ities w ith o u t the use of appliances and the unnecessary expendi tu re of money by so m any parents? T h e follow ing case is illustrative. H is to r y .—T he patient, aged 5, had pulpless upper second deciduous molars. Large fistulas were present between the margin of the gum tissue and the buccal flap of the cheek, appar-
oral condition and removal of tonsils and adenoids were advised. T he orthodonic examination w as made by Thom as R. Sweet, D.D.S., his report follow ing. “T he treatm ent and rose head bur opera tion is economically sound, perm itting the re tention of the very im portant deciduous mo lars in normal function until the first perm a nent molars have erupted. T he estimated cost of orthodonic interference in this case, if the second deciduous molars are lost, is $300.” T re a tm e n t a n d O u tcom ej —T reatm ent of these teeth was started, June 9, and the work completed July 7, 1931. Figure 1 shows the condition before treatm ent was instituted. One year later, July 14, 1932, a careful ex amination was made and the teeth were found clinically to be in a normal healthy condition
Fig. 2.—Condition after treatm ent. ently over the distal buccal root. The first perm anent molars had not erupted. P ro g n o sis .—It was believed that these de ciduous teeth could be successfully treated, but to eliminate the infected areas within the process the rose head bur treatm ent2 would be necessary. P h y sica l E x a m in a tion . — Examination (by Clifford D. Sweet, M.D., and H. E. Stafford, M.D.) revealed that the urine, blood and tem perature were normal. T he patient was underweight. T he tonsils were large and cryptic, with large underlined glands. The heart gave a blowing sound, with a systolic murmur over the precordium. T he general muscle tone was poor. The patient was ir ri table during the day, but slept well. T he physical condition was apparently due to infection and immediate attention to the
and surrounded by apparently healthy invest ing tissues. (Fig. 2.) T he first molars had erupted and were in normal position. The tonsils and adenoids had not been removed and continued to show positive evidence of infection. T he weight had become normal and the appetite had improved. M arked im provement was noted in the child’s disposi tion. Muscle tone and coloring were much better. T he general physical condition showed rapid improvement, but it was decided th at the tonsils and adenoids demanded immediate removal.
T h is p articu la r case is one of m any passing th ro u g h o u r offices, an d w e all concur th a t th e large m ajo rity of pulpless deciduous teeth can be successfully tre a te d w ith o u t detrim en t to the physical w elfare 1. Braindhorst, O. W .: Promoting Normal of the child. Econom ically, th is case rep Development by M aintaining Function of De resented an expenditure of about $20 ciduous Teeth, J.A.D.A., 19:1196 (July) 1932.
Sw eet— E xtra ctio n of P ulpless D eciduous T eeth against a $300 o rthodontist expense if the teeth had been lost. W e may rest assured th a t no dentofacial abnorm ality w ill re su lt from such procedure. M a n y may classify the deciduous to o th whose pulp is exposed as pulpless, but there is a doubt in my m ind th a t these teeth, if properly treated, should be so classified, since only the bulbless portion of the pulp th a t is w ithin the pulp cham ber is removed. N a tu ra lly , if the pulp tissue w ith in the canal itself is removed, these
1039
nerve tissue? T h is question should be of sufficient in terest to stim u late research, th a t w e may not have to depend entirely on clinical findings to prove th a t decidu ous teeth whose pulps are exposed can be successfully treated in every instance. T h e follow ing case, seen in A ugust, 1929, illu strates the possibility of reta in ing teeth whose pulps are exposed: A child, aged 2 i years, presented seven of the eight posterior molars with the pulp ex posed, most of the coronal portion of the tooth
Fig. 3.—Results of restoration of seven molars with pulp exposed and coronal portion of teeth destroyed.
teeth m ust be classified im m ediately as pulpless. In deciduous teeth, if the pulp tissue has not been removed, afte r a period of about six m onths, it w ill give no indica tion of sensitiveness, but w ill bleed w hen touched w ith a sharp explorer. Is it possible th a t the circulation of this tissue is restored w ith a destruction of the
destroyed and the bite closed. T reatm ent and restoration of the teeth were completed No vember 12. Figure 3 shows the results one year later, and while the patient has (eft my immediate vicinity, the reports are still favor able.
I t is hoped th a t such reports as these w ill assist us in our ju d g m e n t of deciduous teeth and th a t w e may consider w ell the possible in ju ry to the child before w e extract a tooth.
1037
For many years, my choice of anesthetic in removing impacted mandibular lower third molars was procaine. In recent years, I have been using nitrous oxide oxygen in quite a number of cases. T his has been made possible by using an aspirator with a suitable point and a tissue retractor with a light attached. Dr. G ardner mentioned the advantages of treating the soft tissues before operation. In many instances, it is impossible to treat patients for a week to ten days before operating, although one or two treatm ents with a Young rubber cup using 10 per cent chromic acid followed with tincture of metaphen will minimize post operative complications to a marked degree.
EXTRACTION OF THE PULPLESS DECIDUOUS TOOTH* B y C H A R LE S A. SW EET, D .D.S., F.A .C .D ., O ak lan d , Calif.
I N C E pulpless deciduous teeth are usually classified by general practi tioners and m any ch ild ren ’s dentists w ith pulpless perm anent teeth, extraction has u n fo rtu n a te ly been the rule in deal ing w ith these deciduous teeth. L ittle th o u g h t has been given to th e possibility of th eir recovery from infection since few d ata are available. M o st of us are prejudiced against the pulpless tooth, deciduous or perm anent, but because of th e serious consequences a tten d in g early loss of deciduous teeth, m ore consideration is being given the pos sibilities of successful retention of these supposed foci of infection. I t w ould be beyond reason to say th a t all pulpless deciduous teeth can be re tained in a healthy condition, b u t fa r too
S
*Read before the Section on Mouth Hygiene and Preventive Dentistry at the SeventyFourth Annual Session of the American D en tal Association, Buffalo, N. Y., Sept. 14, 1932.
lour. A. D. A., June, 1933
m any m ouths have been crippled beyond repair, by w holesale extractions, because of the economic condition of the parents. E x trac tio n of deciduous teeth is al ways indicated if ( 1 ) caries has penetrated the roots a t the b ifu rcatio n ; (2 ) tw oth ird s of the root or roots has been ab sorbed, because of norm al absorption or infection, o r (3 ) there is a fistulous open ing a t the gingival m argin of the tooth. In no oth er instance is it necessary to remove pulpless deciduous teeth ; for, as fa r as can be observed, they have no d e tri m ental effect on the physical development of the child and, if properly treated, show no g rea ter susceptibility to fu rth e r in fection. Econom ically, the retention of pulpless deciduous teeth th a t have been properly trea ted is indeed quite sound ; for, in m any instances, th e early loss of these teeth may m ean considerable expenditure of money for orthodontic trea tm e n t to correct the
1038
T h e Journal o f the A m erican D e n ta l Association
dam age th a t is the result of prejudice, a lack of know ledge and im proper tre a t m ent. B ran d h o rst1 shows th a t the prem ature loss of teeth is responsible fo r 37 per cent of dentofacial deform ities. Is this not a challenge to us to gain a b etter u n d er standing of exposed and pulpless decidu ous teeth th a t w e m ay elim inate these d entofacial deform ities w ith o u t the use of appliances and the unnecessary expendi tu re of money by so m any parents? T h e follow ing case is illustrative. H is to r y .—T he patient, aged 5, had pulpless upper second deciduous molars. Large fistulas were present between the margin of the gum tissue and the buccal flap of the cheek, appar-
oral condition and removal of tonsils and adenoids were advised. T he orthodonic examination w as made by Thom as R. Sweet, D.D.S., his report follow ing. “T he treatm ent and rose head bur opera tion is economically sound, perm itting the re tention of the very im portant deciduous mo lars in normal function until the first perm a nent molars have erupted. T he estimated cost of orthodonic interference in this case, if the second deciduous molars are lost, is $300.” T re a tm e n t a n d O u tcom ej —T reatm ent of these teeth was started, June 9, and the work completed July 7, 1931. Figure 1 shows the condition before treatm ent was instituted. One year later, July 14, 1932, a careful ex amination was made and the teeth were found clinically to be in a normal healthy condition
Fig. 2.—Condition after treatm ent. ently over the distal buccal root. The first perm anent molars had not erupted. P ro g n o sis .—It was believed that these de ciduous teeth could be successfully treated, but to eliminate the infected areas within the process the rose head bur treatm ent2 would be necessary. P h y sica l E x a m in a tion . — Examination (by Clifford D. Sweet, M.D., and H. E. Stafford, M.D.) revealed that the urine, blood and tem perature were normal. T he patient was underweight. T he tonsils were large and cryptic, with large underlined glands. The heart gave a blowing sound, with a systolic murmur over the precordium. T he general muscle tone was poor. The patient was ir ri table during the day, but slept well. T he physical condition was apparently due to infection and immediate attention to the
and surrounded by apparently healthy invest ing tissues. (Fig. 2.) T he first molars had erupted and were in normal position. The tonsils and adenoids had not been removed and continued to show positive evidence of infection. T he weight had become normal and the appetite had improved. M arked im provement was noted in the child’s disposi tion. Muscle tone and coloring were much better. T he general physical condition showed rapid improvement, but it was decided th at the tonsils and adenoids demanded immediate removal.
T h is p articu la r case is one of m any passing th ro u g h o u r offices, an d w e all concur th a t th e large m ajo rity of pulpless deciduous teeth can be successfully tre a te d w ith o u t detrim en t to the physical w elfare 1. Braindhorst, O. W .: Promoting Normal of the child. Econom ically, th is case rep Development by M aintaining Function of De resented an expenditure of about $20 ciduous Teeth, J.A.D.A., 19:1196 (July) 1932.
Sw eet— E xtra ctio n of P ulpless D eciduous T eeth against a $300 o rthodontist expense if the teeth had been lost. W e may rest assured th a t no dentofacial abnorm ality w ill re su lt from such procedure. M a n y may classify the deciduous to o th whose pulp is exposed as pulpless, but there is a doubt in my m ind th a t these teeth, if properly treated, should be so classified, since only the bulbless portion of the pulp th a t is w ithin the pulp cham ber is removed. N a tu ra lly , if the pulp tissue w ith in the canal itself is removed, these
1039
nerve tissue? T h is question should be of sufficient in terest to stim u late research, th a t w e may not have to depend entirely on clinical findings to prove th a t decidu ous teeth whose pulps are exposed can be successfully treated in every instance. T h e follow ing case, seen in A ugust, 1929, illu strates the possibility of reta in ing teeth whose pulps are exposed: A child, aged 2 i years, presented seven of the eight posterior molars with the pulp ex posed, most of the coronal portion of the tooth
Fig. 3.—Results of restoration of seven molars with pulp exposed and coronal portion of teeth destroyed.
teeth m ust be classified im m ediately as pulpless. In deciduous teeth, if the pulp tissue has not been removed, afte r a period of about six m onths, it w ill give no indica tion of sensitiveness, but w ill bleed w hen touched w ith a sharp explorer. Is it possible th a t the circulation of this tissue is restored w ith a destruction of the
destroyed and the bite closed. T reatm ent and restoration of the teeth were completed No vember 12. Figure 3 shows the results one year later, and while the patient has (eft my immediate vicinity, the reports are still favor able.
I t is hoped th a t such reports as these w ill assist us in our ju d g m e n t of deciduous teeth and th a t w e may consider w ell the possible in ju ry to the child before w e extract a tooth.