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Making the Most of the Roentgenogram*
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show n here today by D r. W a h l w ith ju st as good postoperative results.
Frederick S. Stillwell, Cincinnati, Ohio:
I w ish to ask, w hether, in the case of im pac tion of a th ird m olar still in its fo rm ative stage a n d in its crypt, enough pressure can be exerted to cause a m oving of the teeth a n te rio r to the th ird m olar. H ow e a rly can a th ird m o lar be rem oved? Should rem oval be attem pted before the roots of the second m olar a re fully developed? I am speaking of it from an orthodontic point of view . Very often, the th ird m olars h a v e a decided ten d ency to a n im paction. T h e ir rem oval only in terfe res w ith the progress of the w ork. H ow early can these th ird m olars be rem oved?
Dr. W ahl (closing): I am so rry th a t m any m ore d id not say som ething about th e ir ex periences. T h e experience of v a rio u s men is w o rth m ore to our o rg an izatio n th an the statem ent of one tellin g how a th in g should be done. In an sw er to D r. Feldm an I said before th a t the technic used w as as v a rie d as the colors of the rainbow . If D r. Feldm an can use a d rill better th an I can use a chisel, he should use the drill. I used the d rill in m y e a rly practice and I found m any thin g s th a t I did not like about it. T h e chisel is, in m y hand, f a r su p erio r to the drill. In an sw e r to D r. B e a r: I did not say th a t sim ply tak in g out an im pacted m an d ib u lar th ird m olar w as a p an acea fo r any ailm ents, but I w ill say th is: th ere a re a g re a t m any tim es w h ere e v erything else fa ils and the re m oval of the im pacted m an d ib u lar m olar brings about the desired results. A p riest
suffered w ith severe abdom inal pain fo r six y e ars. N obody w ould be so foolish as to tell a person so affected th a t rem oval of an im pacted tooth w ould cure him . B ut w e know th a t im pacted teeth a re abnorm al a n d a b norm al conditions, in m y estim ation, should be elim inated. W e rem oved the im pacted m an d ib u lar th ird m o lar and he obtained re lief. H e is h appy not because a th ird m olar w as rem oved but because he obtained the re sults he desired. In answ er to D r. Stillw ell, I w ould say th a t the orthodonists of New O rleans have been stru g g lin g w ith th a t ques tion fo r quite a w hile. I w ould not a t any tim e advise rem oval of an im pacted tooth, say a th ird m o la r in its form ation, before the roots of the second m olar had been fully developed. T h a t w ould be poor surgery, and the p a tie n t w ould be entirely too young at th at. B ut the e a rlie r w e can get these teeth out, the less a fte r-tro u b le w e a re going to have. T h e osseous structure is m uch softer and m uch easie r to h andle. T h e p a tie n t has m ore resistance. T h e re are no end results such as insom nia, m elancholia and other nervous conditions th a t have taken place, as yet, because the p a tie n t is so young. I f fo r no o ther reason, w e should take these teeth out as e arly as possible. A s to diet, I h ave n ev er investigated th a t phase. I said in the beginning th a t I w as touching the high spots. I think there is still m uch to be lea rn ed about im pacted m an d ib u la r th ird m olars. I m ight know how to take them out, but w h eth er diet has anyth in g to do w ith these teeth becom ing im pacted o r not, I do not know.
M AKING THE MOST OF THE ROENTGENOGRAM* By FREDERICK F. MOLT, D.D.S., Chicago, III. H E dentist possessed of a conscience accepts the roentgenogram as a re quisite preliminary to or accompani ment of his operative procedure. T h e
T
*R ead before the Section on O perative D entistry, M a te ria M edica and T h era p eu tics a t the Seventy-F irst A nnual Session of the A m erican D ental A ssociation, W ashington, D. C., Oct. 9, 1929. Jo u r. A , D , A ., M a rc h , 1930
slipshod operator, w hether because he is w illing to take chances, is timid as to the roentgenographic disclosures, assumes not to believe w hat is plainly shown or is in terested in revenue only is usually not interested in its use. As an indication of honest intention, therefore, we should examine each case by the roentgen rays.
M o lt— M a k in g the M o s t of the Roentgenogram
I t must be recognized that the roent genogram does not supplant clinical ex am ination; it is merely a valuable ad junct. Roentgenographic evidence either may be verified or it may be contradicted by clinical findings. Usually, one w ill amplify the other, and should be so utilized. I t cannot be too frequently stressed that the reading of the roentgen ogram does not constitute a diagnosis, and that the factors of clinical examina tion, symptomatology and history must all be alined therew ith in order to com plete the clinical picture. Unquestionably, the greatest good that the roentgenogram may accomplish is in relation to prophylaxis, the prevention of diseased conditions. If we have the op portunity to discover caries and gingival destruction in their incipiency, w e shall have gone a long way tow ard preventing the loss of teeth.- I t is assumed, of course, that, having the roentgenogram, the dentist w ill discover and adequately care for the conditions shown. A periodic checkup of the entire mouth is to be advocated for each patient. T his may be done w ith Raper’s bite-wing films, which show the crowns, gingivae and in terdental spaces, or with complete roent genographic exposure, including extra oral lateral jaw roentgenograms. Each has definite advantages. T h e bite-wing film eliminates all distortion by length ening or foreshortening (if properly po sitioned) and may give for the upper posterior teeth a more exact disclosure of interproximal conditions. O n the other hand, there is the knowledge of apical and periapical conditions, m alfor mation and malposition of teeth that only the complete panorama of the mouth may show. A combination of complete and bite-wing exposures is w ell w orth while. Roentgenograms may be good, poor or absolutely worthless, and, unfortunately,
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all too many of those produced by the general practitioner fall into the lastmentioned class. H e is not by any means the only offender, as many hospital tech nicians and “cut-rate” operators, in w hat Simpson designates as “radiographic shooting galleries (so much a shot, hit or m iss)” produce roentgenograms th at leave much to the imagination. An “interpretable” roentgenogram calls for perfection in many factors. P ri marily, it must be complete, consisting of a sufficient number of overlapping ex posures to perm it of no doubt as to any area. Distortion should be avoided, if possible, in all cases, and this means the avoidance of overlapping, widening, fore shortening or lengthening of the image beyond a very moderate degree. D istor tion may be due to the faulty placing or the bending of the film or to inaccurate positioning of the tube or patient; or a combination of these faults. Overexposure or underexposure may produce an almost equally undesirable re sult. T h e overexposed film obscures val uable details by making the film too black to be penetrated by the viewing light. T h e underexposed film has so little den sity th at the details are equally hard to determine. Any effort to force develop ment of an underexposed film is useless, and to underdevelop an overexposed film means a lack of detail. Overexposure may be due to too great penetration or too long exposure tim e; underexposure, the reverse. Repetition of one essential fact regarding exposure technic is there fore well w orth w h ile ; the determination of the proper exposure time for the indi vidual machine lies entirely in the devel oping room, for a properly exposed film of an average subject will develop, w ith fresh developing solution at 65 F., in five minutes. A ll the requisite chemical change will have taken place, and addi-
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tional developing time w ill only serve to fog or discolor the film. M any films th at have been properly exposed are ruined in developing. W ith the developer too w arm , fogging is in evitable and a “m uddy” film is the resu lt; too cold a developer does not accomplish the necessary chemical reaction, and the result is a “thin” film, w ithout detail. L ight leaks in the dark-room, too bright dark-room illum ination, as w ell as insufficient protection for the films from secondary roentgen rays previous to ex posure, all may result in fogging of the film. T h e fixing bath should be kept fresh and renewed at frequent intervals. Films should remain in the hyposulphite bath twice as long as is necessary to overcome their milky w hite appearance. I t is assumed th at the roentgenogram is to constitute a perm anent record of the case. M uch of its value lies in our being able to refer it at any future date. I t is essential, therefore, that the last step, washing, be ju st as carefully done as the rest. T h e films should be washed for tw enty minutes in clean running w a ter and then driedj free from dust. A n unwashed or insufficiently washed film when dried has a greasy appearance and w ill in a short time show brown hypo sulphite stains th at will, in time, obscure much of the image and render the roent genogram valueless. T h e desirable roentgenogram shows brilliancy of detail and contrast, w ith black black and w hite white. Such an ideal result cannot, of course, be obtained in every case, but if the predetermined ex posure technic is rigidly adhered to, w ith tim ing recognizing variations adapted to individual areas, and if uniform develop ment and thorough washing are followed out, the larger proportion of films pro duced w ill be most satisfactory.
T h e reading of the product assumes an im portant aspect as well. O ne should be chary about overinterpreting the roent genogram, and yet should be alive to any significant deviation from the normal. Anatomic radiolucence and radiopacity will, of course, be recognized, for the shadows of the anterior and posterior pal atine foramina, nasal and canine fossae, m axillary sinuses and m alar eminences in the maxilla, and of the incisive fossa, m ental foramen, inferior dental canal and mylohyoid groove in the mandible, have been so frequently commented on as not to need further mention. T h e tooth out line is carefully observed for any break in its contour indicating beginning caries. Restorations are carefully noted for any leakage, overhang or lack of contact point. N ext, the gingiva is carefully observed for any recession or for that space be tween the black line of the peridental membrane and the white line of the lamina dura th at indicates traum atic oc clusion and is the precursor of definite pyorrheic destruction. As we go on to the apex of the tooth, there are various conditions to be looked f o r : a thickening of the periodontium, or a more extensive periapical lesion which may be either granuloma, peri-alveolar abscess or cyst. Incidental to this ex amination, root-end conditions are noted, including hypoplastic or hyperplastic changes or malformations. These abnor malities have no particular bearing on the infection aspect of the tooth, the pulpless tooth that has been absorbed or that showing hypercementosis being no more menacing than the one roentgenographically negative; but they have a definite relation to the problem th at w ill arise if extraction is indicated. T eeth that have been long pulpless are noted, in a large proportion of cases, to
M o lt— M a k in g the M o s t of the Roentgenogram.
show no pericemental line. T h e condi tion found on extraction is identically that : the pericementum has been entirely obliterated, indentations of absorption into the cementum are found, and built into these are bony accretions. Such a situation, combined w ith the known fria bility of pulpless teeth, explains the dif ficulty encountered in so many extrac tions of “ dead” teeth. T h e cause of endless controversy and fruitless discussions, the pulpless tooth, is always in the limelight. I t should by this time be recognized that the roentgenographic appearance of such a tooth has little bearing on its relation to focal in fection manifestations. T w o statements may be made in this connection, although many w ill undoubtedly question them ; th at the “roentgenographically negative” pulpless tooth, unless recently devitalized under aseptic canal procedure, is as open to suspicion as is that one showing a periapical lesion ; and that a fluctuating degree of periapical destruction or its en tire disappearance has little significance in determining the potentiality of the in dividual tooth in relation to systemic malfunction. T h is is no doubt a radical attitude to assume, yet based, as it is, upon the observation of a m ultitude of cases as w ell as upon the findings of other observers, it becomes perfectly logical. T h e conclusions to be draw n are that u n necessary devitalization of teeth is un justifiable and that the retention of pulp less teeth, w hether the canals are well or poorly filled or w hether the tooth has been aseptically devitalized or reclaimed from putrescence, is to be determined, in greatest measure, by the individual sys temic condition. T h is fact is too often ignored or lost sight of. T h e proximity of a filling to the pulp of a tooth may in most cases be noted. T h e behavior of the pulp in one case may
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not be that in another apparently identi cal, as, in the one, there may be a protec tive formation of secondary dentin guarding against therm al shock; while, in the other, no such protection w ill be pro vided, and the pulp w ill eventually suc cumb. No prognosis may therefore be offered— simply a notation as to the ex isting condition. Ju st why pulp accretions are formed has never been satisfactorily explained, al though it is quite likely that dietary de ficiency or imbalance may be the cause. Such a condition, frequently so extreme as to involve practically every tooth, may hold out the prospect of pulp disintegra tion and putrefactive reaction in one or many of these teeth which are otherwise perfectly sound. T h e pulps or pulp rem nants are so lacking in vitality that they are either sluggish or negative in their response to the vitality test, and one may frequently expose such a pulp w ith no apparent pain. A situation may be disclosed by the roentgenogram in which, as alternatives, either devitalization or extraction is pre sented. Knowledge of the eventual possi bilities of any pulpless tooth w ould con traindicate gratuitous devitalization, and yet it may be much more desirable, the patient understanding and coinciding in the choice, to retain such a tooth asepti cally devitalized and w ith the canals filled w ith the greatest possible care. Root-canal treatm ent and filling bade fair at one time to become a specialty in itself. No doubt, if it is w orth doing, it is w orth doing well. Doing this work w ell calls for a preliminary knowledge of approximately exact root length and roentgenographic observation from time to time during the progress of the en larging of the canal, measuring wires be ing employed to determine the proximity to the root end. A rather exacting tech
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nic is required for this, not only to avoid distortion but also to perm it of duplica tion, as exactly as is possible, of the pre vious view. Overfilling of canals and filling to the apical orifices only each have, as methods, their devotees. U nderfilling has always been in disfavor; yet roentgenographically no more underfilled canals than those of the other groups w ill be found to show periapical involvement. Perhaps many of these underfilled canals still harbor fragments of vital pulp tissue and are thus even more safe than those com pletely filled. W e still may profitably in dulge in laboratory observation of these phenomena. I t may be th at we will eventually be able to make the odonto blasts do “ tricks” for us and provide a satisfactory method of canal filling au naturel. T h e alveolar structure surrounding the teeth is of course observed, and that in edentulous areas is examined for resi dual infection of either the circumscribed cystic or irregularly outlined granular type. If an interval of more than six months has elapsed since the extraction of a tooth, such an area shown in an edentulous space may be regarded with suspicion. T h e determination of the degree of calcification th at is shown in the alveolar structure in the individual case is im portant. In this connection, a fixed roentgenographic penetration is of value, in contrast to varying the penetration from case to case, as comparisons may thus be made. T hus, the highly calcified bony structure w ill unquestionably provide a more stable base for either partial or complete restoration than that showing excessive radiolucence. T his applies as well to regions in which so-called disuse atrophy has taken place, in relation to
both the extraction problem and the lack of substantial base for restoration. A ltogether the ability to produce an interpretable roentgenogram and to read it when produced, combined w ith a w il lingness to acknowledge conditions re quiring correction and to remedy them, provides many possibilities in modern dental practice. M aking the most of this adjunct means utilizing the knowl edge that it imparts in preventing the progress of caries and pyorrhea, in de term ining the need of restorative proced ures and in assuring their successful completion. In making the so-called dental diag nosis as a component of general diagnos tic observation, the roentgenogram is an essential factor. Properly made, it may be misinterpreted, but it does not itself falsify; improperly made, it may be worse than useless, suggesting conditions that do not exist. I t is w orth while, there fore, to demand or produce complete well-made roentgenograms, study them carefully and predicate our procedures upon their disclosures. 25 E ast W ash in g to n Street. DISCUSSION
L. R. M ain, St. Louis, M o.: If we a re to m ake the m ost of the roentgenogram , the first step necessary is to be able to produce a film of diagnostic value. T h is w ould in clude everything D r. M olt has said about careful technic in exposure and also the proc ess of dark-room procedure. T h e chief d if ficulty in rad io d o n tia is our inability to m ake a good roentgenogram . I w ould take it fo r g ra n te d th a t we h ave a good film of d iagnos tic quality to begin w ith, as this is p erhaps the most im portant basis fo r all our o p e ra tive procedure, w h eth er m echanical, m edical or surgical. E xcept in cases of gross p a th ologic change, w e can determ ine little from an im properly m ade roentgenogram , and even in such cases, a poorly m ade film m ay be very m isleading. A point w hich D r. M olt suggested and w hich I w ish to stress is the necessity fo r ascertaining som ething of the
M o lt— M a k in g the M o st of the Roentgenogram p a tie n t’s health, w hen in te rp reta tio n s of roentgenogram s a re considered, w ith the view of m aking recom m endations fo r ra d ic a l or conservative treatm ent. T h e re a re instances in w hich it is advisable to extract all pulpless teeth even though they are ro e ntgenographically negative. T h is devolves a n a d d itio n al responsibility on the dentist as ev ery rad io lucent a re a on the apex of a tooth is not posi tive proof of the presence of infective o rg a n isms in the a re a . N either is it tru e th a t all pulpless teeth w hich are roentgenographically neg ativ e a re fre e from the results of infec tion. In some of our cases of doubtful find ings, the g e n era l h ealth and history of the case w ill indicate the a d v isab ility of ra d ic a l or conservative treatm ent. I ag ree w ith D r. M olt in th a t u n derfilling of pulp canals is looked on w ith disfavor, but I m ost em p h a tic ally do not believe th a t underfilled or poorly filled can als show up to such good a d v an tag e in roentgenogram s as w hen canal operations have been successful in filling to o r slightly beyond the apical foram en. G en e rally speaking, a n o p e rato r w ho endeavors to fill a canal to the apical region is som e w h a t carefu l about asepsis. Such w ork is un ifo rm ly m ore nearly fre e of p eriapical destruction on roentgenographic evidence. D r. M olt refers to our possible ability to m ake the osteoblasts do “trick s” fo r us and to provide in this m ethod a satisfacto ry m ethod of canal filling. W e a re concerned about the activity of the osteoblast w h en ev er w e desire a reg en eratio n of bone in the p e ria p i cal region, w hen there is destruction. B ut if root canals a re to be filled th ro u g h some n a tu ra l process, w e w ill have to depend on the activity of the odontoblast a n d cem entoblasts fo r this desirable condition. K now l edge is pow er everyw here. W e alw ay s “ ask the m an w ho know s.’ So if, u n d e r roentgenra y observation, c ertain conditions are re vealed w hich a re abnorm al, it behooves us to m ake the necessary correction. K now ledge is pow er only w hen th a t know ledge is acted on to produce results. In fo rm atio n w hich is secured th ro u g h roentgenographic efforts m ay not be app reciated by a certain class of o p e r ators w ho p re fe r to take chances, as the doctor suggested, ra th e r th an resort to secur in g ro en tg en -ray inform ation. B u t th ere is another class w hich deserves even less con sid eratio n and th a t is represented by the m an w ho reso rts to the roentgenogram to the extent of collecting a fee and then does his
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reconstruction alm ost irrespective of the roent g en -ray findings. T h e type of roentgeno g ra p h ic w ork w hich is som etim es palm ed off on the public u n d e r the nam e of rad io d o n tia m akes it im possible, in m any instances, fo r even the d entist to “m ake the m ost of the roentgenogram ” as the chief source of in fo r m ation fo r o p erativ e procedure. T h e “ M ak ing the M ost of the R oentgenogram ” is im p o rta n t in the pro g ress of d entistry because the roentgen rays a re becom ing m ore w idely and fa v o ra b ly used y e a r a fte r year.
DeLos L. Hill, A tlanta, Ga.: One of the m ost, im p o rtan t things brought out is the necessity fo r proper distance of the tube from the object w hich is to be roentgenographed. I ag ree w ith D r. M olt in most of the technic to w hich he has called attention, fo r unless there is a definite technic in m aking roent genogram s, w e cannot depend on the results obtained fo r a roentgenographic exam ina tion. I h ardly know w h eth er the classificaof “good,” “po o r” and “w orthless” is cor rect. I feel th a t roentgenogram s a re “good” or they a re “b a d ” ; a n d if they a re bad, they a re w orse th an w orthless, because you are liable to be m isled. I f the roentgenogram is not satisfactory, it is better to discard it ra th e r th a n take the chance of bein g m isled in the re a d in g of som ething into it w hich does not exist, o r overlooking som ething w hich should be show n. W e as dentists are m aking one of the greatest m istakes in our c are er in not m ak in g roentgenogram s of every case w hen the patien t first comes in. It gives us in fo rm atio n w hich can be fo l low ed up as w e m ay see fit by f u r th e r ro e n t genographic exam ination a t a late r tim e. R oentgenographic exam ination (a n d I w ish to stress this point) does not constitute a d iag nosis. It is sim ply an aid to a diagnosis and m ust be used in conjunction w ith a clinical diagnosis in o rd e r to reach conclusions on w hich w e can depend. If w e a re going to m ake the most of the roentgenogram , the point th a t D r. M olt b rings out in the first p a rt of his p a p er on p re v en tin g trouble, or locating the trouble in its incipiency, is of the g re atest value. W recked m ouths w ould never exist if they h a d received proper consideration y ears e a rlie r and defects h a d been overcom e before they w ere discernible by a clinical exam ination alone. Let me touch on the m at te r of distance a n d technic, because there the g re atest num ber of m istakes a re m ade, resulting in so m any w orthless films. I f the
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technic is carried out so th a t the only v a r ia tions w ill be from the standpoint of exposure, we w ill get results on w hich w e can depend. I w ould say the targ e t distance should be from 18 to 24 inches; some say 36 inches. I f we use a ta rg e t distance of from 18 to 36 inches, w e elim inate certain rays w hich h ave a te n d ency to reduce the efficiency of the film, and the results a re m ore satisfactory. I w ish to stress w ashing. T h e re is not a n y th in g so u n satisfactory to a dentist as to re fe r to a roentgenogram w hich has been m ade six or tw elve m onths previously, only to find th a t it h a s tu rn ed yellow . T h e w a sh in g is ju st as m uch a point of technic as any o ther p a rt of the w ork. M any roentgenogram s w hich m ight h ave produced results h av e been ru in ed in th eir developm ent. It is w ell to rem em ber to develop the films the length of tim e called fo r and to w ash thoroughly. A n autom obile runs best u n d e r c ertain condi tions. If w e take a film th a t is supposed to be developed a certain length of tim e and develop it fo r a longer period of tim e, the best results w ill not be obtained. E v ery pulpless tooth is suspicious, but w e m ust not be too radical. W e m ust not come to the conclusion sim ply because a tooth is pulpless th a t th a t tooth (w hile it m ay be suspicious) m ust be rem oved. In the opinion of m any o p erativ e men, thousands and thousands of teeth h ave been sacrificed w hen th ere w as no direct evidence th a t they w ere the cause of system ic trouble. A s long as n a tu re is as good to hum anity as it is, there should be m any teeth left fo r treatm en t, a n d the con se rv a tiv e elem ent of o perative men, a t the present tim e, believe the best service is ren dered the patien t w hen w e tre a t these cases, in m an y instances, and give the ow ner the benefit of th e ir use as long as they a re not a m enace to health. T h is, of course, req u ires fre q u e n t observation. W e should m ake the m ost of the roentgenogram in orthodontic w ork. W e should realize its usefulness in the location of m issing teeth and th e ir cor rect position, if they exist. T h is can be done only by the use of films placed h orizontally in the m outh betw een the up p er and low er teeth and in te rp rete d in conjunction w ith norm al in tra -o ral films. A n interesting case
cam e to me from an orthodontist, w ho w as try in g to a scertain the exact position of an u pper left central incisor w hich w as placed betw een the la te ra l incisor a n d the cuspid. W e w ish to lea rn w h at p a rt of th a t m issing central incisor w as closest to the cuspid.
Dr. M olt (dosing): D r. H ill questioned the necessity of a n tic ip a tin g trouble w ith the roentgenogram . I said th a t it should be used both as p re lim in a ry to a n d a com plem ent of o p erativ e w ork. It is folly, if we are accept in g a new p atient, not to p re p a re fo r his w ork w ith a roentg en o g rap h ic exam ination, because, by o m itting this, w e a re n a tu ra lly assum ing responsibility fo r everything th at has been done previous to o u r ow n o perative w ork. R e g a rd in g technic, D r. H ill spoke of the a d v an tag e of the 18 or 24-inch distance. I m ight say th a t I use a 36-inch ta rg e t distance, w hich throw s out m ost of the secondary ra d i ation, im proving the ro entgenogram thereby. I purposely b rought up the question of p ulp less teeth, because w e a re too m uch inclined to overlook this point. W e m ust concede that, u n d e r certain circum stances, every pulpless tooth is open to question. T h e roentgenogram is not our in d e x ; the p a tie n t is the index, the pa tie n t and not the m outh. F requently, the decision m ust be m ade by the physician since to assum e to m ake such a decision ourselves m eans en te rin g into a field o th er th an our ow n. T h is m a tte r of d e te rm in in g the con nection betw een the pulpless teeth and the p a tie n t’s physical condition is a m a tte r calling fo r good ju d g m en t and common sense. W e m ust not overlook our p a tie n t and let him die ju st because w e w a n t to re ta in a few teeth. I m ight, in this connection, quote one of o u r physicians in Chicago. A p a tie n t w ith a serious case of iritis had, as w ell, a pulpless tooth, w hich m ight be c ausing the trouble. T h e logical th in g to do w a s to rem ove the tooth, but the p a tie n t’s d en tist told her th a t he could save it and w an ted to do so fo r esthetic purposes. T h e lad y told h e r physician about h e r d entist’s a ttitu d e and he said. “You can alw ays get a new tooth, b u t you can nev er g et a new e y e !” So I repeat, a rational sense of proportion w ill dictate w hen we should be conservative and w hen ra d ic al.
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show n here today by D r. W a h l w ith ju st as good postoperative results.
Frederick S. Stillwell, Cincinnati, Ohio:
I w ish to ask, w hether, in the case of im pac tion of a th ird m olar still in its fo rm ative stage a n d in its crypt, enough pressure can be exerted to cause a m oving of the teeth a n te rio r to the th ird m olar. H ow e a rly can a th ird m o lar be rem oved? Should rem oval be attem pted before the roots of the second m olar a re fully developed? I am speaking of it from an orthodontic point of view . Very often, the th ird m olars h a v e a decided ten d ency to a n im paction. T h e ir rem oval only in terfe res w ith the progress of the w ork. H ow early can these th ird m olars be rem oved?
Dr. W ahl (closing): I am so rry th a t m any m ore d id not say som ething about th e ir ex periences. T h e experience of v a rio u s men is w o rth m ore to our o rg an izatio n th an the statem ent of one tellin g how a th in g should be done. In an sw er to D r. Feldm an I said before th a t the technic used w as as v a rie d as the colors of the rainbow . If D r. Feldm an can use a d rill better th an I can use a chisel, he should use the drill. I used the d rill in m y e a rly practice and I found m any thin g s th a t I did not like about it. T h e chisel is, in m y hand, f a r su p erio r to the drill. In an sw e r to D r. B e a r: I did not say th a t sim ply tak in g out an im pacted m an d ib u lar th ird m olar w as a p an acea fo r any ailm ents, but I w ill say th is: th ere a re a g re a t m any tim es w h ere e v erything else fa ils and the re m oval of the im pacted m an d ib u lar m olar brings about the desired results. A p riest
suffered w ith severe abdom inal pain fo r six y e ars. N obody w ould be so foolish as to tell a person so affected th a t rem oval of an im pacted tooth w ould cure him . B ut w e know th a t im pacted teeth a re abnorm al a n d a b norm al conditions, in m y estim ation, should be elim inated. W e rem oved the im pacted m an d ib u lar th ird m o lar and he obtained re lief. H e is h appy not because a th ird m olar w as rem oved but because he obtained the re sults he desired. In answ er to D r. Stillw ell, I w ould say th a t the orthodonists of New O rleans have been stru g g lin g w ith th a t ques tion fo r quite a w hile. I w ould not a t any tim e advise rem oval of an im pacted tooth, say a th ird m o la r in its form ation, before the roots of the second m olar had been fully developed. T h a t w ould be poor surgery, and the p a tie n t w ould be entirely too young at th at. B ut the e a rlie r w e can get these teeth out, the less a fte r-tro u b le w e a re going to have. T h e osseous structure is m uch softer and m uch easie r to h andle. T h e p a tie n t has m ore resistance. T h e re are no end results such as insom nia, m elancholia and other nervous conditions th a t have taken place, as yet, because the p a tie n t is so young. I f fo r no o ther reason, w e should take these teeth out as e arly as possible. A s to diet, I h ave n ev er investigated th a t phase. I said in the beginning th a t I w as touching the high spots. I think there is still m uch to be lea rn ed about im pacted m an d ib u la r th ird m olars. I m ight know how to take them out, but w h eth er diet has anyth in g to do w ith these teeth becom ing im pacted o r not, I do not know.
M AKING THE MOST OF THE ROENTGENOGRAM* By FREDERICK F. MOLT, D.D.S., Chicago, III. H E dentist possessed of a conscience accepts the roentgenogram as a re quisite preliminary to or accompani ment of his operative procedure. T h e
T
*R ead before the Section on O perative D entistry, M a te ria M edica and T h era p eu tics a t the Seventy-F irst A nnual Session of the A m erican D ental A ssociation, W ashington, D. C., Oct. 9, 1929. Jo u r. A , D , A ., M a rc h , 1930
slipshod operator, w hether because he is w illing to take chances, is timid as to the roentgenographic disclosures, assumes not to believe w hat is plainly shown or is in terested in revenue only is usually not interested in its use. As an indication of honest intention, therefore, we should examine each case by the roentgen rays.
M o lt— M a k in g the M o s t of the Roentgenogram
I t must be recognized that the roent genogram does not supplant clinical ex am ination; it is merely a valuable ad junct. Roentgenographic evidence either may be verified or it may be contradicted by clinical findings. Usually, one w ill amplify the other, and should be so utilized. I t cannot be too frequently stressed that the reading of the roentgen ogram does not constitute a diagnosis, and that the factors of clinical examina tion, symptomatology and history must all be alined therew ith in order to com plete the clinical picture. Unquestionably, the greatest good that the roentgenogram may accomplish is in relation to prophylaxis, the prevention of diseased conditions. If we have the op portunity to discover caries and gingival destruction in their incipiency, w e shall have gone a long way tow ard preventing the loss of teeth.- I t is assumed, of course, that, having the roentgenogram, the dentist w ill discover and adequately care for the conditions shown. A periodic checkup of the entire mouth is to be advocated for each patient. T his may be done w ith Raper’s bite-wing films, which show the crowns, gingivae and in terdental spaces, or with complete roent genographic exposure, including extra oral lateral jaw roentgenograms. Each has definite advantages. T h e bite-wing film eliminates all distortion by length ening or foreshortening (if properly po sitioned) and may give for the upper posterior teeth a more exact disclosure of interproximal conditions. O n the other hand, there is the knowledge of apical and periapical conditions, m alfor mation and malposition of teeth that only the complete panorama of the mouth may show. A combination of complete and bite-wing exposures is w ell w orth while. Roentgenograms may be good, poor or absolutely worthless, and, unfortunately,
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all too many of those produced by the general practitioner fall into the lastmentioned class. H e is not by any means the only offender, as many hospital tech nicians and “cut-rate” operators, in w hat Simpson designates as “radiographic shooting galleries (so much a shot, hit or m iss)” produce roentgenograms th at leave much to the imagination. An “interpretable” roentgenogram calls for perfection in many factors. P ri marily, it must be complete, consisting of a sufficient number of overlapping ex posures to perm it of no doubt as to any area. Distortion should be avoided, if possible, in all cases, and this means the avoidance of overlapping, widening, fore shortening or lengthening of the image beyond a very moderate degree. D istor tion may be due to the faulty placing or the bending of the film or to inaccurate positioning of the tube or patient; or a combination of these faults. Overexposure or underexposure may produce an almost equally undesirable re sult. T h e overexposed film obscures val uable details by making the film too black to be penetrated by the viewing light. T h e underexposed film has so little den sity th at the details are equally hard to determine. Any effort to force develop ment of an underexposed film is useless, and to underdevelop an overexposed film means a lack of detail. Overexposure may be due to too great penetration or too long exposure tim e; underexposure, the reverse. Repetition of one essential fact regarding exposure technic is there fore well w orth w h ile ; the determination of the proper exposure time for the indi vidual machine lies entirely in the devel oping room, for a properly exposed film of an average subject will develop, w ith fresh developing solution at 65 F., in five minutes. A ll the requisite chemical change will have taken place, and addi-
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tional developing time w ill only serve to fog or discolor the film. M any films th at have been properly exposed are ruined in developing. W ith the developer too w arm , fogging is in evitable and a “m uddy” film is the resu lt; too cold a developer does not accomplish the necessary chemical reaction, and the result is a “thin” film, w ithout detail. L ight leaks in the dark-room, too bright dark-room illum ination, as w ell as insufficient protection for the films from secondary roentgen rays previous to ex posure, all may result in fogging of the film. T h e fixing bath should be kept fresh and renewed at frequent intervals. Films should remain in the hyposulphite bath twice as long as is necessary to overcome their milky w hite appearance. I t is assumed th at the roentgenogram is to constitute a perm anent record of the case. M uch of its value lies in our being able to refer it at any future date. I t is essential, therefore, that the last step, washing, be ju st as carefully done as the rest. T h e films should be washed for tw enty minutes in clean running w a ter and then driedj free from dust. A n unwashed or insufficiently washed film when dried has a greasy appearance and w ill in a short time show brown hypo sulphite stains th at will, in time, obscure much of the image and render the roent genogram valueless. T h e desirable roentgenogram shows brilliancy of detail and contrast, w ith black black and w hite white. Such an ideal result cannot, of course, be obtained in every case, but if the predetermined ex posure technic is rigidly adhered to, w ith tim ing recognizing variations adapted to individual areas, and if uniform develop ment and thorough washing are followed out, the larger proportion of films pro duced w ill be most satisfactory.
T h e reading of the product assumes an im portant aspect as well. O ne should be chary about overinterpreting the roent genogram, and yet should be alive to any significant deviation from the normal. Anatomic radiolucence and radiopacity will, of course, be recognized, for the shadows of the anterior and posterior pal atine foramina, nasal and canine fossae, m axillary sinuses and m alar eminences in the maxilla, and of the incisive fossa, m ental foramen, inferior dental canal and mylohyoid groove in the mandible, have been so frequently commented on as not to need further mention. T h e tooth out line is carefully observed for any break in its contour indicating beginning caries. Restorations are carefully noted for any leakage, overhang or lack of contact point. N ext, the gingiva is carefully observed for any recession or for that space be tween the black line of the peridental membrane and the white line of the lamina dura th at indicates traum atic oc clusion and is the precursor of definite pyorrheic destruction. As we go on to the apex of the tooth, there are various conditions to be looked f o r : a thickening of the periodontium, or a more extensive periapical lesion which may be either granuloma, peri-alveolar abscess or cyst. Incidental to this ex amination, root-end conditions are noted, including hypoplastic or hyperplastic changes or malformations. These abnor malities have no particular bearing on the infection aspect of the tooth, the pulpless tooth that has been absorbed or that showing hypercementosis being no more menacing than the one roentgenographically negative; but they have a definite relation to the problem th at w ill arise if extraction is indicated. T eeth that have been long pulpless are noted, in a large proportion of cases, to
M o lt— M a k in g the M o s t of the Roentgenogram.
show no pericemental line. T h e condi tion found on extraction is identically that : the pericementum has been entirely obliterated, indentations of absorption into the cementum are found, and built into these are bony accretions. Such a situation, combined w ith the known fria bility of pulpless teeth, explains the dif ficulty encountered in so many extrac tions of “ dead” teeth. T h e cause of endless controversy and fruitless discussions, the pulpless tooth, is always in the limelight. I t should by this time be recognized that the roentgenographic appearance of such a tooth has little bearing on its relation to focal in fection manifestations. T w o statements may be made in this connection, although many w ill undoubtedly question them ; th at the “roentgenographically negative” pulpless tooth, unless recently devitalized under aseptic canal procedure, is as open to suspicion as is that one showing a periapical lesion ; and that a fluctuating degree of periapical destruction or its en tire disappearance has little significance in determining the potentiality of the in dividual tooth in relation to systemic malfunction. T h is is no doubt a radical attitude to assume, yet based, as it is, upon the observation of a m ultitude of cases as w ell as upon the findings of other observers, it becomes perfectly logical. T h e conclusions to be draw n are that u n necessary devitalization of teeth is un justifiable and that the retention of pulp less teeth, w hether the canals are well or poorly filled or w hether the tooth has been aseptically devitalized or reclaimed from putrescence, is to be determined, in greatest measure, by the individual sys temic condition. T h is fact is too often ignored or lost sight of. T h e proximity of a filling to the pulp of a tooth may in most cases be noted. T h e behavior of the pulp in one case may
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not be that in another apparently identi cal, as, in the one, there may be a protec tive formation of secondary dentin guarding against therm al shock; while, in the other, no such protection w ill be pro vided, and the pulp w ill eventually suc cumb. No prognosis may therefore be offered— simply a notation as to the ex isting condition. Ju st why pulp accretions are formed has never been satisfactorily explained, al though it is quite likely that dietary de ficiency or imbalance may be the cause. Such a condition, frequently so extreme as to involve practically every tooth, may hold out the prospect of pulp disintegra tion and putrefactive reaction in one or many of these teeth which are otherwise perfectly sound. T h e pulps or pulp rem nants are so lacking in vitality that they are either sluggish or negative in their response to the vitality test, and one may frequently expose such a pulp w ith no apparent pain. A situation may be disclosed by the roentgenogram in which, as alternatives, either devitalization or extraction is pre sented. Knowledge of the eventual possi bilities of any pulpless tooth w ould con traindicate gratuitous devitalization, and yet it may be much more desirable, the patient understanding and coinciding in the choice, to retain such a tooth asepti cally devitalized and w ith the canals filled w ith the greatest possible care. Root-canal treatm ent and filling bade fair at one time to become a specialty in itself. No doubt, if it is w orth doing, it is w orth doing well. Doing this work w ell calls for a preliminary knowledge of approximately exact root length and roentgenographic observation from time to time during the progress of the en larging of the canal, measuring wires be ing employed to determine the proximity to the root end. A rather exacting tech
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nic is required for this, not only to avoid distortion but also to perm it of duplica tion, as exactly as is possible, of the pre vious view. Overfilling of canals and filling to the apical orifices only each have, as methods, their devotees. U nderfilling has always been in disfavor; yet roentgenographically no more underfilled canals than those of the other groups w ill be found to show periapical involvement. Perhaps many of these underfilled canals still harbor fragments of vital pulp tissue and are thus even more safe than those com pletely filled. W e still may profitably in dulge in laboratory observation of these phenomena. I t may be th at we will eventually be able to make the odonto blasts do “ tricks” for us and provide a satisfactory method of canal filling au naturel. T h e alveolar structure surrounding the teeth is of course observed, and that in edentulous areas is examined for resi dual infection of either the circumscribed cystic or irregularly outlined granular type. If an interval of more than six months has elapsed since the extraction of a tooth, such an area shown in an edentulous space may be regarded with suspicion. T h e determination of the degree of calcification th at is shown in the alveolar structure in the individual case is im portant. In this connection, a fixed roentgenographic penetration is of value, in contrast to varying the penetration from case to case, as comparisons may thus be made. T hus, the highly calcified bony structure w ill unquestionably provide a more stable base for either partial or complete restoration than that showing excessive radiolucence. T his applies as well to regions in which so-called disuse atrophy has taken place, in relation to
both the extraction problem and the lack of substantial base for restoration. A ltogether the ability to produce an interpretable roentgenogram and to read it when produced, combined w ith a w il lingness to acknowledge conditions re quiring correction and to remedy them, provides many possibilities in modern dental practice. M aking the most of this adjunct means utilizing the knowl edge that it imparts in preventing the progress of caries and pyorrhea, in de term ining the need of restorative proced ures and in assuring their successful completion. In making the so-called dental diag nosis as a component of general diagnos tic observation, the roentgenogram is an essential factor. Properly made, it may be misinterpreted, but it does not itself falsify; improperly made, it may be worse than useless, suggesting conditions that do not exist. I t is w orth while, there fore, to demand or produce complete well-made roentgenograms, study them carefully and predicate our procedures upon their disclosures. 25 E ast W ash in g to n Street. DISCUSSION
L. R. M ain, St. Louis, M o.: If we a re to m ake the m ost of the roentgenogram , the first step necessary is to be able to produce a film of diagnostic value. T h is w ould in clude everything D r. M olt has said about careful technic in exposure and also the proc ess of dark-room procedure. T h e chief d if ficulty in rad io d o n tia is our inability to m ake a good roentgenogram . I w ould take it fo r g ra n te d th a t we h ave a good film of d iagnos tic quality to begin w ith, as this is p erhaps the most im portant basis fo r all our o p e ra tive procedure, w h eth er m echanical, m edical or surgical. E xcept in cases of gross p a th ologic change, w e can determ ine little from an im properly m ade roentgenogram , and even in such cases, a poorly m ade film m ay be very m isleading. A point w hich D r. M olt suggested and w hich I w ish to stress is the necessity fo r ascertaining som ething of the
M o lt— M a k in g the M o st of the Roentgenogram p a tie n t’s health, w hen in te rp reta tio n s of roentgenogram s a re considered, w ith the view of m aking recom m endations fo r ra d ic a l or conservative treatm ent. T h e re a re instances in w hich it is advisable to extract all pulpless teeth even though they are ro e ntgenographically negative. T h is devolves a n a d d itio n al responsibility on the dentist as ev ery rad io lucent a re a on the apex of a tooth is not posi tive proof of the presence of infective o rg a n isms in the a re a . N either is it tru e th a t all pulpless teeth w hich are roentgenographically neg ativ e a re fre e from the results of infec tion. In some of our cases of doubtful find ings, the g e n era l h ealth and history of the case w ill indicate the a d v isab ility of ra d ic a l or conservative treatm ent. I ag ree w ith D r. M olt in th a t u n derfilling of pulp canals is looked on w ith disfavor, but I m ost em p h a tic ally do not believe th a t underfilled or poorly filled can als show up to such good a d v an tag e in roentgenogram s as w hen canal operations have been successful in filling to o r slightly beyond the apical foram en. G en e rally speaking, a n o p e rato r w ho endeavors to fill a canal to the apical region is som e w h a t carefu l about asepsis. Such w ork is un ifo rm ly m ore nearly fre e of p eriapical destruction on roentgenographic evidence. D r. M olt refers to our possible ability to m ake the osteoblasts do “trick s” fo r us and to provide in this m ethod a satisfacto ry m ethod of canal filling. W e a re concerned about the activity of the osteoblast w h en ev er w e desire a reg en eratio n of bone in the p e ria p i cal region, w hen there is destruction. B ut if root canals a re to be filled th ro u g h some n a tu ra l process, w e w ill have to depend on the activity of the odontoblast a n d cem entoblasts fo r this desirable condition. K now l edge is pow er everyw here. W e alw ay s “ ask the m an w ho know s.’ So if, u n d e r roentgenra y observation, c ertain conditions are re vealed w hich a re abnorm al, it behooves us to m ake the necessary correction. K now ledge is pow er only w hen th a t know ledge is acted on to produce results. In fo rm atio n w hich is secured th ro u g h roentgenographic efforts m ay not be app reciated by a certain class of o p e r ators w ho p re fe r to take chances, as the doctor suggested, ra th e r th an resort to secur in g ro en tg en -ray inform ation. B u t th ere is another class w hich deserves even less con sid eratio n and th a t is represented by the m an w ho reso rts to the roentgenogram to the extent of collecting a fee and then does his
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reconstruction alm ost irrespective of the roent g en -ray findings. T h e type of roentgeno g ra p h ic w ork w hich is som etim es palm ed off on the public u n d e r the nam e of rad io d o n tia m akes it im possible, in m any instances, fo r even the d entist to “m ake the m ost of the roentgenogram ” as the chief source of in fo r m ation fo r o p erativ e procedure. T h e “ M ak ing the M ost of the R oentgenogram ” is im p o rta n t in the pro g ress of d entistry because the roentgen rays a re becom ing m ore w idely and fa v o ra b ly used y e a r a fte r year.
DeLos L. Hill, A tlanta, Ga.: One of the m ost, im p o rtan t things brought out is the necessity fo r proper distance of the tube from the object w hich is to be roentgenographed. I ag ree w ith D r. M olt in most of the technic to w hich he has called attention, fo r unless there is a definite technic in m aking roent genogram s, w e cannot depend on the results obtained fo r a roentgenographic exam ina tion. I h ardly know w h eth er the classificaof “good,” “po o r” and “w orthless” is cor rect. I feel th a t roentgenogram s a re “good” or they a re “b a d ” ; a n d if they a re bad, they a re w orse th an w orthless, because you are liable to be m isled. I f the roentgenogram is not satisfactory, it is better to discard it ra th e r th a n take the chance of bein g m isled in the re a d in g of som ething into it w hich does not exist, o r overlooking som ething w hich should be show n. W e as dentists are m aking one of the greatest m istakes in our c are er in not m ak in g roentgenogram s of every case w hen the patien t first comes in. It gives us in fo rm atio n w hich can be fo l low ed up as w e m ay see fit by f u r th e r ro e n t genographic exam ination a t a late r tim e. R oentgenographic exam ination (a n d I w ish to stress this point) does not constitute a d iag nosis. It is sim ply an aid to a diagnosis and m ust be used in conjunction w ith a clinical diagnosis in o rd e r to reach conclusions on w hich w e can depend. If w e a re going to m ake the most of the roentgenogram , the point th a t D r. M olt b rings out in the first p a rt of his p a p er on p re v en tin g trouble, or locating the trouble in its incipiency, is of the g re atest value. W recked m ouths w ould never exist if they h a d received proper consideration y ears e a rlie r and defects h a d been overcom e before they w ere discernible by a clinical exam ination alone. Let me touch on the m at te r of distance a n d technic, because there the g re atest num ber of m istakes a re m ade, resulting in so m any w orthless films. I f the
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technic is carried out so th a t the only v a r ia tions w ill be from the standpoint of exposure, we w ill get results on w hich w e can depend. I w ould say the targ e t distance should be from 18 to 24 inches; some say 36 inches. I f we use a ta rg e t distance of from 18 to 36 inches, w e elim inate certain rays w hich h ave a te n d ency to reduce the efficiency of the film, and the results a re m ore satisfactory. I w ish to stress w ashing. T h e re is not a n y th in g so u n satisfactory to a dentist as to re fe r to a roentgenogram w hich has been m ade six or tw elve m onths previously, only to find th a t it h a s tu rn ed yellow . T h e w a sh in g is ju st as m uch a point of technic as any o ther p a rt of the w ork. M any roentgenogram s w hich m ight h ave produced results h av e been ru in ed in th eir developm ent. It is w ell to rem em ber to develop the films the length of tim e called fo r and to w ash thoroughly. A n autom obile runs best u n d e r c ertain condi tions. If w e take a film th a t is supposed to be developed a certain length of tim e and develop it fo r a longer period of tim e, the best results w ill not be obtained. E v ery pulpless tooth is suspicious, but w e m ust not be too radical. W e m ust not come to the conclusion sim ply because a tooth is pulpless th a t th a t tooth (w hile it m ay be suspicious) m ust be rem oved. In the opinion of m any o p erativ e men, thousands and thousands of teeth h ave been sacrificed w hen th ere w as no direct evidence th a t they w ere the cause of system ic trouble. A s long as n a tu re is as good to hum anity as it is, there should be m any teeth left fo r treatm en t, a n d the con se rv a tiv e elem ent of o perative men, a t the present tim e, believe the best service is ren dered the patien t w hen w e tre a t these cases, in m an y instances, and give the ow ner the benefit of th e ir use as long as they a re not a m enace to health. T h is, of course, req u ires fre q u e n t observation. W e should m ake the m ost of the roentgenogram in orthodontic w ork. W e should realize its usefulness in the location of m issing teeth and th e ir cor rect position, if they exist. T h is can be done only by the use of films placed h orizontally in the m outh betw een the up p er and low er teeth and in te rp rete d in conjunction w ith norm al in tra -o ral films. A n interesting case
cam e to me from an orthodontist, w ho w as try in g to a scertain the exact position of an u pper left central incisor w hich w as placed betw een the la te ra l incisor a n d the cuspid. W e w ish to lea rn w h at p a rt of th a t m issing central incisor w as closest to the cuspid.
Dr. M olt (dosing): D r. H ill questioned the necessity of a n tic ip a tin g trouble w ith the roentgenogram . I said th a t it should be used both as p re lim in a ry to a n d a com plem ent of o p erativ e w ork. It is folly, if we are accept in g a new p atient, not to p re p a re fo r his w ork w ith a roentg en o g rap h ic exam ination, because, by o m itting this, w e a re n a tu ra lly assum ing responsibility fo r everything th at has been done previous to o u r ow n o perative w ork. R e g a rd in g technic, D r. H ill spoke of the a d v an tag e of the 18 or 24-inch distance. I m ight say th a t I use a 36-inch ta rg e t distance, w hich throw s out m ost of the secondary ra d i ation, im proving the ro entgenogram thereby. I purposely b rought up the question of p ulp less teeth, because w e a re too m uch inclined to overlook this point. W e m ust concede that, u n d e r certain circum stances, every pulpless tooth is open to question. T h e roentgenogram is not our in d e x ; the p a tie n t is the index, the pa tie n t and not the m outh. F requently, the decision m ust be m ade by the physician since to assum e to m ake such a decision ourselves m eans en te rin g into a field o th er th an our ow n. T h is m a tte r of d e te rm in in g the con nection betw een the pulpless teeth and the p a tie n t’s physical condition is a m a tte r calling fo r good ju d g m en t and common sense. W e m ust not overlook our p a tie n t and let him die ju st because w e w a n t to re ta in a few teeth. I m ight, in this connection, quote one of o u r physicians in Chicago. A p a tie n t w ith a serious case of iritis had, as w ell, a pulpless tooth, w hich m ight be c ausing the trouble. T h e logical th in g to do w a s to rem ove the tooth, but the p a tie n t’s d en tist told her th a t he could save it and w an ted to do so fo r esthetic purposes. T h e lad y told h e r physician about h e r d entist’s a ttitu d e and he said. “You can alw ays get a new tooth, b u t you can nev er g et a new e y e !” So I repeat, a rational sense of proportion w ill dictate w hen we should be conservative and w hen ra d ic al.