- Email: [email protected]
Postoperative Considerations Regarding Extraction of Teeth*
Gardner— Postoperative Considerations a c id
and
not
th e
o r g a n is m
to
go
th rou gh .
S o th e a c id th e r e is th e c h ie f f a c t o r in th a t ca s e .
t r y in g
g iv e m ore
H.
F. F . W hitcom b, Omaha, N eb r.: lik e t o k n o w
I w o u ld
w h e t h e r D r . J a y p a id
a n y a t
t e n t io n to th e e lim in a t io n in h is ca s e s .
D r. Jay: th a t.
N o,
we
w ere
not
a b le
to
do
W e w e r e fo r t u n a t e to see th e c h ild r e n th e
flo r a
of
th e
t h a t o f th e m o u t h . th a t a r e
fo u n d
in
in te s tin a l
The
tra ct
w it h
a c i d u r i c o r g a n is m s
th e m o u th , in th e
th e m
d if f e r e n t
M . H awkins, Los A n geles, C a lif.: D r .
in r e g a r d to th e c o n c e n t r a t io n o f l a c t ic a c id
in te s
th e o t h e r c o c c u s f o r m s in th e m o u th , so th a t we
ca n
see
th e
r e la t iv e
We
are
c o c c i w i l l f o r m an a c id . 1 have
is o la t e d
s tu d y .
a c id
d e c a lc ify
do
n o t th in k
we
a re
ju s t ifie d
in
l a c t ic
n ot tr y in g
to g a g e
pH-, b u t w e fin d th a t c e r t a in s t a p h y lo
h a p s w i l l b e b e st d e t e c t e d t h r o u g h s e r o l o g i c I
of
D r. Jay (clo s in g ): W e h a v e d o n e a little o f th a t w o r k .
la r , b u t th e r e
th a t p e r
s tr e n g th
a c id p r o d u c e d b y e a c h f o r m ?
t in a l t r a c t a n d in th e v a g i n a l t r a c t a re s im i b e d iffe r e n c e s
u n til
J a y , h a s th e r e b e e n a n y w o r k d o n e b y y o u
th e
m ay
nam es
a b o u t th e m .
p r o d u c e d b y B. acidophilus as c o m p a r e d w it h
as o f t e n as w e d id . W e d id n o t t r y to c o r r e la te
to
w e know
235
to
d id
T h o s e s tr a in s w h ic h not
p rod u ce
s u fficie n t
teeth .
POSTOPERATIVE CONSIDERATIONS REGARDING EXTRA CTIO N OF TEETH* By BOYD S. GARDNER, D.D.S., Rochester, Minn.
N the simple or in the complicated extraction of teeth, some of the fundamental principles of surgery, as applied in general surgery, should be considered. Inflammation may be defined as a reaction o f tissue to irritation. The causes are chemical, bacterial and trau matic. Obviously, the exodontist should attempt to minimize the causes o f this phenomenon. Undue chemical irritation has ac counted for inflammatory conditions which could be avoided. For example, in attempts to sterilize the field o f oper ation in the extraction o f teeth, chemical
I
*F rom
th e
S e ctio n
on
D e n ta l
S u rgery o f
th e M a y o C lin ic . * R e a d b e f o r e th e S e c tio n o n O r a l S u r g e r y , E x o d o n tia
a n d A n e s t h e s ia
at th e S e v e n tie th
A n n u a l S e s s io n o f th e A m e r ic a n D e n t a l A s s o c ia t io n , M i n n e a p o l i s , M in n ., A u g . 2 1, 1928.
Jour. A . D . A ., February, IÇ2Q
solutions have been used in such strength as to add materially to the uncom fort able postoperative sequelae. Iodin has undoubtedly been the principal offender, as it has been used more freely than any other drug in oral work. It has been found that little if anything is accom plished by its use. Experimentation cov ering a period of years has demon strated that it is better not to attempt to sterilize the field o f operation un less a chemical can be used which does not contribute to the cause o f inflamma tion. In the experiments, iodin was ap plied around the teeth on one side of the mouth, and no attempt was made to sterilize the opposite side. A fter the extraction o f teeth on both sides, the results were far more satisfactory on the latter. In this respect, the w ork o f the exodontist can be compared to the work of the surgeon, w ho has found it im-
236
The Journal of the American D en tal Association
practical to attempt to sterilize the mucosa of the stomach and intestine. Socket medication is not used in any form, since irritation and not steriliza tion is the result. It should be borne in mind that tissue broken down by any type o f irritation offers a lowered resist ance to infection. Bacterial irritation is an important factor in the extraction o f teeth, but this can be well controlled by adherence to general surgical technic. T h e dental operator should protect his patient by wearing rubber gloves, face mask and gown. T h e patient should also be draped to assist the operator in minimizing the possibility of carrying pathogenic bac teria into the oral cavity. T h e applica tion of 50 per cent alcohol to the part of the face not covered with a sterile towel is of assistance. It should be em phasized that it is necessary to sterilize the instruments immediately before oper ation, rather than the day before. T h e dental cabinet should be considered only a storehouse for instruments rather than a surgical table or stand. In other words, instruments that are to be used in extracting teeth should be sterilized and laid out on a sterile towel which rests on a surgical stand or table in order that the operator can reach for his in struments as they are needed, or they can be handed to him by an assistant without touching anything that might not be sterile, such as the door or drawer of a dental cabinet. T h e arguments used by many dentists that such cleanliness is not necessary in dental w ork because it is not possible to sterilize the field of operation are not convincing. It is obvious that, in the extraction of teeth, trauma should be minimized in both soft and osseous tis sue. Therefore, instruments should be used that w ill cause as little trauma to
tissues as possible. I f it is necessary to retract, and particularly if it is neces sary to incise, soft tissue, care should be exercised, as such tissue plays an im portant part in protecting osseous tissue and aids materially in maintaining blood clots. Cutting instruments should be sharp, and particular attention should be given the blood supply o f the soft tissues that are to be retracted. One should not overlook the fact that post operative results require a study o f the postoperative condition o f the support ing tissues rather than o f the extracted teeth or the osseous tissue which is cut away. Osseous tissue, when cut by a small, sharp chisel driven by the proper blow from a mallet, w ill show far less trauma than when cut by any other method. In fact, in preparing the ridge for dentures, proper chisels w ill leave less trauma in the alveolar process than if it is cut out or dressed dow n by rongeur forceps. Such instruments pinch the tissue before the actual cutting is done, but are used advantageously for certain work. Postoperative results w ill be far more satisfactory if more o f the supporting osseous tissue than usual is cut away trom the more difficult impacted third molars. T h e use of instruments that re quire a fulcrum should be minimized, since the part of the osseous tissue which is used as a fulcrum might sometimes cause severe trauma. T h e injured bone is prone to become infected, and this accounts largely for postoperative dis com fort, and particularly that due to trismus. T h e use o f instruments that compress by wedging the bone that is not removed should be discouraged. T his type o f trauma adds materially to post operative pain. T h e dry socket, from the standpoint o f both prevention and treatment, still
Gardner— Postoperative Considerations occupies an important place in dental literature. G illis1 advises against the use of mouth washes for at least twenty-four hours after extraction as they delay co agulation o f the blood. I f mouth washes are omitted, the blood clot is preserved. A few years ago, a study was made to determine the possible relation of the dry socket to the general condition of the patient, and any such relationship was ruled out. It was brought out that the patients who had dry sockets were those who sucked the clots from the sockets, and spit often. Accordingly, such a habit is discouraged, and patients are in structed to spit as little as possible for at least twenty-four hours. T h e act o f spitting tends to produce negative pres sure, which, in turn, relieves the sockets of clots. It was also found that the sockets most commonly dry were those from which the greatest amount of suc tion was obtained, namely, bicuspids and first molars in both the maxilla and man dible. T h e treatment of dry sockets has been varied by different operators. M any methods have been found satis factory. A suppository has recently been put out by a well known pharmaceutical company that is especially promising. It is easily applied to the socket, and con trols pain for a longer period. T h e variable opinion o f dentists re garding suturing follow ing the extrac tion o f teeth is rather difficult to explain except on the ground that it is a new procedure to most o f them. Perhaps some o f the failures o f the method have been due to the fact that too much is expected o f it, and because it has not been carried out properly. For example, the stitches have been placed with so much tension that they cut through the tissues, or too many have been used, thus
237
causing additional trauma, and corre spondingly unsatisfactory results. Incor rect suture material and needles may also be the cause of dissatisfaction. N ot withstanding the objection to suturing, many operators have improved their postoperative results in this manner, and an effort should be made by teachers of undergraduates in dentistry to standard ize its use. Suturing is not always indi cated after the extraction of even an impacted third molar, but when it is in dicated, it should be used. T h e socket should be entirely closed in every ex traction ; another point not definitely understood. T h e number o f teeth extracted at one time may have an important bearing on postoperative conditions.2 I have been able to secure complete histories o f all patients operated on in the M ayo Clinic, and by charting conditions postoperatively, have accumulated data that em phasize the significance of discontinuing the practice of extracting all diseased teeth at one time. Results are more sat isfactory if the operation is performed in tw o or more steps, a few days or a week apart, the interval depending on the pa tient’s reaction. Patients w ho are acutely ill should be put to bed and treated medically before extraction of the infected teeth is at tempted. Symptoms should be carefully observed and examinations made to avoid mistakes in diagnosis. Pain in the region o f the mandibular third molar, with swelling, trismus and fever, does not al ways indicate that the cause is an im pacted or unerupted tooth, even though the roentgenograms reveal such a condi tion. A diagnosis o f actinomycosis is
2. G ardner, B. S.: Extraction o f T eeth : Am ount o f Surgery Feasible at One T im e, 1. G illis, R. R .: Personal communication and Treatm ent o f Acute Cases, Dent. Cos to author. mos, <7!«
238 often made, present.
T h e Journal of the Am erican D en ta l Association
if
such
symptoms
are
A dressing is seldom used after the ex traction of any tooth. But if a dressing such as iodoform gauze is used, it should not be disturbed for at least a week, which is contrary to the usual practice of changing daily. Ice packs are applied directly after ex traction and continued for at least five or six hours. Clots are not disturbed be cause of pain. Patients are given relief by the use of sedatives and opiates, if necessary. Bowel elimination is very important. '; Heat is applied , rather than ice packs, in cases in which marked swelling with trismus, cellulitis, etc., develop. T h e heat is applied intra-orally in the form o f hot water, introduced by a rubber tube from some form of an elevated ir rigation receptacle, and extra-orally by hot water bags or electric pads. This form o f treatment is continued until drainage is established. Although local postoperative condi tions are not affected materially by d if ferent. anesthetics, it is quite obvious that, by the use of block anethesia, bet ter local results can be obtained, and more easily, in the majority o f cases in which difficult extractions are to be made. T h is anesthesia, therefore, is used fo r most adult patients in the M ayo C linic in preference to any in duced by a general anesthetic. It is understood that many patients are referred to the exodontist who is w illing to make use of a general anes thetic and employ a certain technic o f extraction. H ow ever, patients want the best service that can be given them, andif they understand that the operator can w ork to a better advantage, especially in , the more difficult extractions,- under lo
cal anesthesia, and can control pain, they are w illing to have it used. O n the other hand, many patients re fuse to allow a tooth to be removed w ith out the use o f nitrous oxid, and dentists are prone to meet such a demand. But if the extraction of teeth is to be placed on the same plane as is general surgery, the general surgeon must be copied rather than the barber who cuts the hair the way the customer wishes. From the standpoint of postoperative service, the roentgenogram made directly after operation is outstanding in its im portance.3 If it shows that all roots have been removed, the patient w ill be more tolerant of ' any discomfort that may follow . I have used this procedure as a routine for many years and feel that I have proved its importance. A roent genogram that reveals that the leg or arm is properly set, or one that reveals satisfactory extraction of a tooth, is a com fort to the patient, physician and dentist. If it were general practice among those who extract teeth to make daily records of postoperative conditions, treatment follow in g such operations w ould become standardized. V aluable postoperative information can be ob tained if the operator visits patients who are not in condition to report to the o f fice after the extraction. Unless such data can be obtained, it w ill be difficult to determine the best technic of ex traction, and the best anesthetic to administer. As emphasized by W a rd ,4 Vastine5 and others, the insertion o f dentures im 3.
G a r d n e r , B . S .:
P o s t o p e r a t iv e
X -R a y
E x a m in a t io n in D e n tis tr y , R a d i o l o g y , 3 :7 4 -7 5 ( J u l y ) 1924. 4.
W ard,
A.
W .:
P erson a l
c o m m u n ic a
5. . V a s t in e , A . B . :
P erson a l
c o m m u n ic a
t io n to a u th o r. t io n to a u th o r.
239
Gardner— Postoperative Considerations
mediately after extraction is another im portant procedure. T h e dentures act as splints, and because o f the protection and resistance they afford, better and quicker repair takes place. W a rd has made use o f his surgical cement to line plates; which insures a fit and adds to the pa tient’s com fort. H e recommends that the denture be relined with this cement every ten days, at least three times, and then it can be rebased permanently by vulcanite. M an y dentists have considered the curettement of sockets, the reduction of the alveolar process and the immediate denture construction as new procedures. In a review of dental literature, it has been found that these are merely old ideas with but little refinement. Gillis has lately called my attention to early publications as follow s: A f t e r e x t r a c t in g th e teeth , I clip o ff a ll the m u c o u s tis s u e th a t fille d
th e
s p a c e b e tw e e n
th e n e c k s o f th e te e th , l e a v i n g a s m o o th b o r d er.
B u t th e d iffe r e n c e in a g e , h e a lth a n d n u m ber
of
te e th
c r it e r io n
to
be
fo r
our
I
o ffe r
o p e r a t io n .
th e s e
th e y m a y b e w o r t h
s h o u ld
be
th e
under
rem ark s
this
fo r
w hat
a n d h o p e to h e a r f r o m
s om e o f o u r a b le d e n tists o n th is o r a n y o t h e r m ode
of
p r e p a r in g
th e
m o u th
fo r
sets
of
teeth .6 I n s u ch a ca s e , the s a c w i l l n e a r l y a lw a y s b e r e t a in e d in th e a lv e o lu s a f t e r th e t o o th o r root
is
r e m o v e d ; the
d e p e n d e n t o f th e and
e ffe c t a c u r e . o f th e be
a b s ce s s n o w
ca u s e
th e e x t r a c t io n o f
w h ic h
a cts
done
in
prod u ced
th e t o o th
w ill
it,
r a r e ly
A n o p e r a t io n f o r th e r e m o v a l
a b s ce s s w i l l b e n e c e s s a r y . T h i s by
c h is e llin g
d e a d p a r t ic le s c a v i t y .7
of
or
bone
s c r a p in g
in
and
m ay
o ff
all
about
the
It is obvious that antiseptic postoper ative treatment is indicated if aseptic surgery is not practiced, but it is hoped that the time is not far distant when, by the help of dental colleges and teachers of graduate students in this specialty, the extraction o f teeth w ill be placed oil a plane with general surgery.
I th e n d is s e c t b a c k th e fib r o u s -m u c o u s D IS C U S S IO N
tis s u e f r o m th e a l v e o l a r w a l l o r b o r d e r a b o u t o n e - f o u r t h o f an in ch a n d cu t o ff w it h a p a ir of
rem oved
govern m en t
bone
fo rce p s
th e
a lv e o la r
edge
fro m
a
Earle H . first
Thomas, Chicago, III.:
p a ragrap h
of
th is
paper
In
is th e
th e
s ta te
fo u r t h to t h r e e -e ig h th s o f an in c h d e e p ; th is
m e n t th a t, in th e e x t r a c t io n o f teeth , s o m e o f
w i l l a l lo w th e e d g e s o f th e m u c o u s tis s u e to
th e
com e
a p p lie d
cu t
tog eth er
o n ly
h a v in g
a rou n d
th e
th e
a pp earan ce
d en ta l
a rch .
c a s e s I h a v e th u s f a r p r e p a r e d
of
In
a
the
th is w a y ,
I
fu n d a m e n t a l
s id e r e d . agree
p r in c ip le s
th e
ta s k
of
r e m o v in g
and
th is
a b s o r p t io n o r e ffu s io n .
a ls o
sam e
n a tu r e
m a tter
by
of
s u r g e r y m u st
b e c a u s e th e r e m o v a l o f
B y th is p r o c e s s , w e ,
g ic a l
o p e r a t io n .
sam e
to
f o l l ic le s a r o u n d th e d e n t a l b o r d e r a n d t h e r e
tissu es,
b y th ey s oon er becom e
the
and
firm . W e
s h a ll s a v e th e ris k o f h a v i n g d e t a c h e d p ie c e s
su rgery,
s h o u ld
be
as
con
m e th a t all o f th e fu n d a m e n t a l
w it h
in a m e a s u r e , d e s t r o y th e m u c o u s e x c r e t o r y h a rd
of
P o s s ib ly D r . G a r d n e r d id n o t w is h
fla m m a tio n
s u ffe r in g ,
su rg ery,
to a p p e a r t o o e m p h a tic , b u t I th in k h e w i l l
b e lie v e I h a v e s a v e d th e p a tie n t s m u c h i n and
p r in c ip le s
in g e n e r a l
a ll and
N a tu re ’ s
s u r g ic a l lik e
s h o u ld e r s
be
c o n s id e r e d ,
a n y t o o th is a s u r r e a c t io n
o p e r a t io n s
on
is
th e
s im ila r
r e s p o n s ib ilit ie s
rest
upon
th e o p e r a t o r .
L ife
its e lf
of
m a y b e in v o lv e d in m a n y in s ta n c e s.
I agree
o f b o n e in th e g u m s , t o fin d t h e ir w a y ou t
th a t m u c h p o s t o p e r a t iv e
b y a b s c e s s o r a b s o r p t io n .
c a u s e d b y a tte m p ts a t s t e r ilz in g the fie ld o f
p a t ie n t th e fo u r
m ost o f
efflu e n ce m on th s’
p a tie n ts
fo r
th e
W e s h a ll s a v e th e
d is a g r e e a b le
e ffe cts
f r o m „th e g u m s ; w e tim e
in
fitt in g
th e
a p e r m a n e n t set o f
of
have
q u e n t ly
b e tt e r m ore
shaped
e a s ily
w o rk can be done.
m o u th s
fitted
and
a n d th a t a n y a g e n t u sed
ca n . save
pu rpose
gum s
in fla m m a tio n ,
teeth ,
of
and
m u st
be
one
but
I
th a t d o e s
w o u ld
not
f o r th is not
ca u s e
recom m en d
and
n o t le a s t , in a p e c u n i a r y v i e w o f th e s u b je c t , we
o p e r a t io n
d i s c o m f o r t is o ft e n
con se
handsom er
6.
W illa r d ,
A.
T .:
A r t ic le s
in
D e n ta l
N e w s L e t te r , V o l. 6, 1852. 7.
Shadoan ,
W .
H .:
D e n t. R e g ., 2 2 :4 1 8 , 1868.
A lv e o la r
A bscess,
240
T h e Journal of the American D en tal Association
the e lim in a t io n o f th is p h a s e o f th e t e c h n ic .
s id e r a b le
E v e n t h o u g h th e s a liv a u n d o u b t e ly k e e p s all
t iv e
s u r fa c e
p roced u re in m e n tio n s th e
b a c t e r ia
in
an
a tte n u a te d
sta te,
I
h a v e a lw a y s c o n s id e r e d th a t a n a g e n t o n th e o r d e r o f a c r iv io le t , a p p lie d
a r o u n d th e g i n
tra u m a
and
d is c o m f o r t
r e s u lt in g
are
the
th is re s p e ct. p re v a le n c e o f
s o ck e ts, a n d I w o u ld
p o stop era
re s u lt
of
f a u lt y
D r. G a rd n er s o - c a ll e d d r y
lik e to h e r e e n u m e r a t e
g i v a l c r e v i c e a n d o v e r th e s ite o f h y p o d e r m ic
som e
in je c t io n s , o ffe r e d us a little m o r e p r o t e c t io n
h a v i n g a t e n d e n c y to c a u s e su ch a c o n d i t i o n :
by
fu r th e r
a tt e n u a t in g
th e
e v e r , t h e r e is o n e p l a c e I
never
use
m e d ic a t io n
b a c t e r ia .
H ow
o f th e c o n d it io n s
to
be
c o n s id e r e d
1. U s e o f n o n s t e r ile in s tr u m e n ts .
as
2. P r e s e n c e
and
one
tim e th a t
o f s a l i v a in th e s o ck e t b e f o r e th e b l o o d c lo t
of
any
k in d ,
is
all
fo rm e d .
3.
Any
in s tr u m e n t a t io n
in
th e
r e c o m m e n d a t io n s in th e lite r a t u r e r e g a r d in g p r o p r i e t a r y p r e p a r a t io n s to the c o n t r a r y n o t
s o ck e t.
w it h s t a n d in g , a n d th a t is in th e s o ck e t im
E x c e s s iv e le v e r a g e b y f o r c e p s o r e l e v a t o r s ;
m e d ia t e ly
a ft e r
th e
rem oval
of
a
to o th .
4.
P resen ce
r e s t r ic t e d
b lo o d
s te r iliz e th e fie ld o f o p e r a t io n , b u t it is u n
erage
d e n ia b le
e le v a t o r .
a s e p t ic
t e c h n ic ,
we
less
w ill
th e
o p e r a t iv e
r e a c t io n .
p o in t,
does
it
n ea rer F rom
not
approach be
th e
p ost
a p r a c t ic a l s ta n d
seem
p o s s ib le
fo r
m a jo r i t y o f us to o b s e r v e th e r o u tin e th is
lin e
bu t
th e r e
fa ll
too
th a t is f o l l o w e d is
no
fa r
q u e s tio n
sh ort o f
th a t
su gg est
a lo n g
lin e
a re
th is
c e r ta in
th a t
a ll
by
as
D r.
th a t
th e
p r in c ip le s
an
G a rd n er,
m any
id e a l.
of
The
t h e m s e lv e s fo llo w s :
in s tr u m e n ts
us
m a in to
(1 )
a re
th e
a lo n g
me
to
be
t h o r o u g h ly
s t e r iliz e d b e tw e e n ca s e s , as th e m a in d a n g e r lie s in b a c t e r ia f r o m to
a l lo w
the
th is s o u r c e ;
o p e r a t in g
fie ld
of
o p e r a t io n ,
tissu e s a r e o p e n e d in
th a t
a rea
c lo s e d
or
u n til
trau m a
s o ft
and
th e
site
by
b lo o d
s h o u ld
be
tissu e
is
very
once
th e
s a liv a
o p e r a t io n
c lo t .
I
m in im iz e d pron e
in
b o th
su ch
to
is
agree tra u
in fe c t io n .
T h i s is o n e o f th e m o s t im p o r ta n t p h a s e s o f th e t e c h n ic o f c r it ic iz e or
a n y o p e r a t io n .
th e u se o f
a n y p a r t ic u l a r
str u m e n t ou t,
in
ca u s e
w as a
of
a n y typ e
I w o u ld of
or
th e
t e c h n ic
m an n er.
t r a u m a 'i s
th e
An
not
in s tr u m e n t
t e c h n ic p r o v i d e d
u sed,
s k ilfu l
i n v o lv e
f u lc r u m
e ffe c t e v e r y b it as m u c h 6.
E xp osu re
of
u n r e a s o n a b le
le n g th
e p in e p h r in
of
e x c e s s iv e
a n e s th e tic.
8.
V ir u le n t
a p ic a l
r e g io n .
9.
of
and
as
s o ck e t tim e .
7.
age
of
M e d i c a t i n g th e s o ck e t b e f o r e
an
U se
of
in
in f e c t i o i f
O ld
an
a ir
to
s tr e n g th
le v
does
a
lo c a l
fr o m
the
p a tie n t .
10.
th e b l o o d
c lo t
f o r m s , o r w a s h i n g o u t th e m o u th b e f o r e th e b lo o d
c lo t is f o r m e d .
d r a in in th e s o ck e t. in g th e t o n g u e
11. L e a v i n g
a gauze
12. S u ctio n o n , o r p l a c
or
fin g e r
in, th e
s o ck e t, b y
th e p a tie n t. I t is m y o p in io n th a t, a f t e r th e b lo o d clo ts in th e so ck e t, m o u th w a s h e s m a y
th e c lo t th a t re s u lts in a d r y s o ck e t, a n d this
o s s e o u s tis s u e , b e c a u s e
m a t iz e d
5.
a n y t h in g b u t (3 )
of
s o ck e t.
b e u s e d to a n y e x te n t w it h o u t d a n g e r o f w a s h i n g o u t th e clo t. I t is d e c o m p o s it io n o f
of
in to, n o t to a l lo w
covered
th a t
and
never
lin in g
w it h
in s tr u
s u r fa c e s
m en ts to c o m e in c o n ta c t w it h th e
(2 )
bone,
a n d I w o u ld lik e to h e r e c a ll a tte n tio n to the f a c t th a t f o r c e p s
th e
s c le r o t ic
s u p p ly ,
O f c o u r s e it is im p o s s ib le , in th e m o u th , to th a t
of
th e
in
c a r r ie d
im p o r ta n t
exposu re
of
th e
u s u a lly ta k e s
at
le a st f o r t y - e i g h t h o u r s .
I
a g r e e th a t th e r e a re m a n y s a t i s f a c t o r y m e th o d s o f r e l i e v i n g p a in in th is c o n d it io n , a n d th e p r in c ip le o f th e t r e a tm e n t is to k e e p th e e x p o s e d b o n e p r o t e c t e d f r o m s a l i v a a n d a ir u n til N a tu r e h a s c o v e r e d it w it h g r a n u l a tio n tis s u e . T o c a u s e fu r t h e r t r a u m a b y a cu re tte m e n t o f the s u r f a c e o f th is e x p o s e d b o n e a p p e a r s to b e i l lo g i c a l. R e g a r d i n g s u t u r in g f o l l o w i n g e x t r a c t io n , I c a n o n l y s a y t h i s : I f o n e h a s n o t s u r g ic a l ju d g m e n t , h e s h o u ld n o t a tte m p t th e s e o p e r a t io n s . fo rm
an
I
s o m e t im e s p e r
a lv e o le c t o m y in th e m a x i ll a
w ith
o u t p l a c in g o n e s u tu re a n d a t tim e s I p la c e
o s s e o u s s tr u ctu re s to a ir o v e r a l o n g p e r io d
tw o
or
o f tim e , e s p e c ia lly w h e n u n d e r th e e ffe c t o f
on e
s in g le - r o o t e d
th r e e
su tu re s
a fte r
to o th .
of
c e r t a in ly
e p in e p h r in . I m u st e m p h a s iz e th e im p o r ta n c e
agree
n u m b e r o f in f e c t e d te e th at o n e tim e , e s p e
p a r t ic u la r
a tte n tio n
to
th e
b lo o d
c i a l ly
It
r e q u ir e s
clo s e
stu d y a n d c o n s id e r a b le e x p e r ie n c e to j u d g e in e a c h i n d i v i d u a l c a s e ju s t w h e r e to r e
o n e o p e r a t io n
has
som e
la r g e
g e n e r a l t r o u b le . O f c o u r s e , t h i r t y - t w o d is e a s e d teeth h a v e o ft e n b e e n r e m o v e d in
in c is io n s .
p a tie n t
a
s u p p ly o f th e s o ft tis s u es w h e n d e c i d i n g on of
th e
rem ove
th e
lo c a t io n
w hen
to
rem ova l
m ost
of
g iv in g
th a t it is u n w is e
th e
I
s e r io u s
w it h o u t s e r io u s r e a c t i o n ;
but
le a s e a n im p a c t e d to o th a n d h o w m u ch b o n e
w h y ta k e ch a n c e s w h e n l i f e is i n v o l v e d ? W e
s h o u ld
are
be
rem oved .
U n q u e s t io n a b ly ,
con
su pposed
to
be
d octors, y ou
know .
In
241
G ardner— P ostoperative Considerations d e c id in g u sed, (1 )
on
th e
th r e e th e
typ e
fa cto rs
c o n d itio n
of
a n e s th e tic
s h o u ld of
th e
be
to
be
c o n s id e r e d :
p a tie n t;
(2 )
th e
th e
c o m b a t iv e
a b ilit y
of
th e
tis s u e ,
and
if
th e a n t is e p t ic in th e s o ck e t m ilit a te s a g a in s t th is
c o m b a t iv e
f a c u lt y ,
th e
m ore
a n t is e p t ic
t y p e o f o p e r a t io n , a n d
( 3 ) th e a b ilit y o f th e
w e use, th e m o r e w e n e e d t o c o n s e r v e th a t
o p era tor
ca re fu l
c o m b a t iv e a b ilit y .
to
o p e r a t iv e under
th e
w o r th y
fo llo w
a
t e c h n ic ch osen
of
G a rd n er
in
th e
th e
a n e s th e tic.
nam e
v o ic e d
and
e fficie n t
p a r t ic u l a r No
a l lo w s
th e h o p e
ca se
op era tor
d ic t a t io n .
t h a t th e
D r.
t im e
is
D r. G ardner (clo s in g ): d e n tists
p r a c t ic e
th a n a s e p t ic s u r g e r y . have
The
a n t is e p t ic
m a jo r it y o f
su rg ery
ra th e r
It is a p p a r e n t th a t th e y
n ot kept p a ce
w it h
th e p r o g r e s s
th a t
n o t f a r d is t a n t w h e n th e e x t r a c t io n o f teeth
has
w ill
b e l ie v e th a t th e y w o u ld b e n e fit b y r e c o g n i z
be
p la c e d
su rg ery.
on
a
p la n e
H e m e n t io n e d
tw o
w ith
gen eral
c o n d it io n s t h a t
been
m ade
in
gen eral
su rg ery,
and
I
i n g th e a d v a n t a g e th a t th e o n e h a s o v e r th e
w o u ld b r i n g th is a b o u t, b u t h e f a i l e d to in
oth er.
c lu d e w h a t , to m y m in d , is p o s s ib ly a n o t h e r
m o r e p o s t o p e r a t iv e p a in f r o m
im p o r ta n t f a c t o r in h a s t e n in g th a t d a y . T h e
th a n f r o m
p u b lic
s h o u ld b e s u p p le m e n te d b y e m p h a s iz in g th e
by
sad
e x p e r ie n c e s
a re
re a liz in g ,
I
f a s t e r t h a n a c e r t a in p r o p o r t i o n o f d e n tis ts ,
n e c e s s it y
th a t th e e x t r a c t io n
in
o p e r a t io n , a n d sults
th ey
o b t a in a b le
s u r g ic a l
of
a t o o th
a re
o n ly
is
a s u r g ic a l
d e m a n d in g th e
by
fo llo w in g
re
correct
p r in c ip le s .
do
n o t b e lie v e
have
any
p r o c a i n b lo c k
a g e n e r a l a n e s th e tic. T h i s a n s w e r of
u t iliz in g
th e o p e r a t in g
gen eral
th a t w e
surgeon .
o p era tors
w it h
th e
room It
sam e
as
is
p r e c a u t io n s
a re
used
o b v io u s
th e ir q u ic k
b y th e
th a t
m any
w o r k cau se
less
in
p o s t o p e r a t iv e p a in b y u s in g a g e n e r a l a n e s th e tic . T h e p e r c e n t a g e o f r o o t s le ft is f a r
r e m o v in g a to o th , th e e n t ir e s o ft tis s u e l y i n g
le s s a n d re su lts in g e n e r a l a re b e tt e r w h e n
b etw ee n
s h o u ld
b lo c k
a
a n e s th e s ia , m o r e
G eorge Schneider, La Salle, III.:
be
th e
ro ot
rem oved ,
and
w o u ld
th e
not
a lv e o lu s
th a t
ca u s e
If,
dry
sock et?
is
u sed.
H . J. Schwarz, St. Louis, M o .: te r m
“ d ry
c o u ld
s o ck e t” ?
be
s u b stitu te d
W hat
W hat fo r
is th e n a t u r e
th e of
th e b o n e as d is t in g u is h e d f r o m a w e t s o ck e t ?
Eugene Schmitt, Chicago, III.:
I
s h o u ld
B u t,
w ith
b lo ck
a tt e n t io n m u s t b e p a i d
th e o p e r a t in g r o o m
m e d ic a l te r m
a n e s th e s ia
s e p s is
and
the
t io n o f s u r g ic a l p r in c ip le s , as m o r e tim e th e r e
is
m ore
to
a p p li c a is
con su m ed
and
m a n ip u la t io n
o f tis s u e .
I d o n o t b e lie v e th a t the g e n e r a l
c o n d i t i o n o f th e p a t ie n t is a c a u s a t iv e f a c t o r in d r y so ck e ts, a n d t h e r e a r e m a n y d iffe r e n t
lik e t o h a v e D r . G a r d n e r ’ s o p in io n as to w h e th e r , a ft e r a b l o o d c lo t h a s o r g a n i z e d , a
ty p e s
of
t io n .
The
n o n a c id m o u t h w a s h w i l l t e n d t o d is t u r b th e
p r e v e n t io n .
b l o o d c lo t a n d b r e a k it d o w n so th a t it w i l l
w ash
c lo t o v e r .
th e p a tie n ts to s p it as little as p o s s ib le f o r
G . R. B ruce, Columbus Junction, I o w a : Is t h e r e
a p a t h o lo g i c c o n d i t i o n
th a t c a u s e s
d r y s o c k e t ? T h e r e a re m a n y o f us, I k n o w , w h o h a v e t a k e n o u t teeth a n d t h e y c o m e o u t
som e
tr e a tm e n t
fo r
im p o r ta n t
fo r
By
p a in f u l to
e lim in a t io n
le n g th
of
tim e ,
th e
and
th e and
co n d i
c o n s id e r
of
tw e n ty -fo u r h o u rs
a p t to be m a in t a in e d i m iz e d .
th is
p o in t
c lo t s
is
m o u th
a d v ic e are
to
m ore
d r y s o ck e ts m in
I t is o u r o p i n i o n th a t w e h a v e f a r
less d r y s o ck e ts s in ce th e im p r o v e d m e th o d s
as a n a il co m e s o u t o f a b o a r d , w it h n o s ig n
of
o f a c lo t .
th is is d u e l a r g e l y t o th e f a c t th a t t r a u m a
C. E. B row n , Lincoln, N eb r.: I n c h e c k in g
e x t r a c t io n
is m in im iz e d .
up o n p o s t o p e r a t iv e p a in in ca s e s o f fu ll m o u th o p e r a t io n , w h a t is th e p e r c e n t a g e o f
th a t
p a i n ? Is it g r e a t e r w it h n it r o u s o x i d , o r w it h
fo r
lo c a l o r b lo c k a n e s th e s ia ?
s u p p o r t in g
H . A . Elmquist, D es M oines, Io w a :
I
d is a g r e e w it h o n e p o i n t D r . G a r d n e r m a d e , th a t is, i f s h o u ld
u se
we an
d on ’ t op era te a n tis e p tic .
a s e p t ic a lly , w e
I th in k th e s a m e
have
th e r e
is
been
in
u se.
No
d o u b t,
I n t h ir d m o la r w o r k , w e fin d fa r
less
p o s t o p e r a t iv e
p a in
w h e n th e se d ifficu lt te e th a re b e tte r p r e p a r e d rem oval
by
c u tt in g
osseou s
iz e s th e u se o f le v e r s . m in d
aw ay
s tr u ctu re .
m ore T h is
of
th e
m in im
I t s h o u ld b e b o r n e in
th a t, w h e n l e v e r s a r e u s e d , th e s a m e
p ressu re a p p lie d
e x e r te d
on
the t o o th t o
f u lc r u m
as
is
rem oved . T h ere
w ill
a p p ly
c h is e ls d r i v e n b y c o r r e c t b lo w s f r o m s u ita b le
d o u b le
m easu re,
if
we
a re
not
a s e p t ic in o u r t e c h n ic . W e n e e d to c o n s e r v e
m a lle ts
m u c h . le ss
th e be
o b je c t i o n to u s in g a n a n t is e p t ic a t a ll w o u l d in
be
is to
a re
used
th a n
trau m a
w hen
w hen
sh arp
th e p r o c e s s
is
242
T h e Journal of the Am erican D en ta l Association
cu t b y r e v o l v i n g and in
b u rs .
in s tr u m e n ts su ch
B e tt e r resu lts w o u ld
d iffic u lt
e x t r a c t io n s
if
as d r ills
b e o b ta in e d
p a tie n ts
w ere
a l
d is m is s e d .
If
t h e y w o u ld
m ake
c a lls
as
is
th e p r a c t ic e o f p h y s ic ia n s , th e s u r g ic a l a sp e ct o f d e n t is t r y w o u ld b e p u t o n a m u c h h ig h e r
l o w e d to r e m a in in b e d , w h e t h e r in th e h o s
p la n e .
p it a l o r a t h o m e f o r at le a st t w o d a y s a fte r
w h o m teeth h a v e b e e n e x t r a c t e d , b u t to th ose
I
do
not
r e fe r
to
all
p a tie n ts
fo r
th e o p e r a t io n . T h e la r g e p e r c e n t a g e o f d e n
fo r
tists
p e r f o r m e d a n d to th o s e w h o s e s y s te m ic c o n
are
n ot
re c o g n iz in g
th is,
a s k in g
th e ir
p a tie n ts to r e p o r t to t h e ir offices d a il y un til
w hom
d iffic u lt
e x t r a c t io n s
have
been
d it io n w a r r a n t s b e tte r c a r e .
FURTH ER PROGRESS AND OBSERVATIONS IN THE TREATM ENT OF MALOCCLUSION INVOLVING SPACES" By HUGH GRUN TANZEY, D.D.S., Kansas City, Mo.
V E R Y dentist is from time to time confronted with the problem of de ciding what to do about malocclu sion cases presenting such symptoms as spaces between central incisors where there is an abnormal frenum labium ; or spaces where there are one or more teeth congenitally missing (Figs. 1- ;■) ; spaces resulting directly from the ex traction of teeth, or spaces caused by un erupted or impacted teeth; by excessive overbite, by pathologic conditions, trauma anomalies of size or various other contributing causes. It will not, of course, be possible to more than mention the m ajority of these ailments in passing. Probably no other form o f malocclusion is more disconcerting to the adult patient or to the parent o f the child than those here mentioned. Aside from the small percentage of dentists who have been misguided into the belief that tooth movement in all cases is easily and quick-
E
^ P a p e r r e a d b e f o r e th e S e c tio n o n O p e r a t iv e D e n tis tr y , M a t e r i a M e d i c a a n d T h e r a p e u tics
at
the
S e v e n tie th
A nnual
S e ss io n
o f th e A m e r ic a n D e n ta l A s s o c i a t i o n , M i n n e a p o lis , M in n ., A u g . 22, 1928.
Jour. A . D . A ., February, 1929
ly effected if only the proper means are employed, and the smaller percentage o f dentists who w ill take the time and pre caution to go into a detailed analysis o f the case before attempting to treat it, there is a larger group o f more or less misinformed, disappointed dentists who have essayed to “ improve the situation” by the all too common rubber band method, or by ligating teeth together or wedging them apart, then bridging 'the space with some sort o f restoration. In many instances, part or all of teeth have been sacrificed previous to the unsuccess ful attempt to restore acceptable esthetic and sanitary conditions. T here is hope that eventually dentists w ill assume the responsibility o f advising in all such complicated cases that the patient investigate carefully before start ing wildcat methods o f correction. One point that I desire to emphasize more than all others is that teeth may move readily on the application of force, but, in the majority o f cases, it requires a much longer time to effect that nice final adjustment, and to complete the case with anything like assurance of ultimate
and
not
th e
o r g a n is m
to
go
th rou gh .
S o th e a c id th e r e is th e c h ie f f a c t o r in th a t ca s e .
t r y in g
g iv e m ore
H.
F. F . W hitcom b, Omaha, N eb r.: lik e t o k n o w
I w o u ld
w h e t h e r D r . J a y p a id
a n y a t
t e n t io n to th e e lim in a t io n in h is ca s e s .
D r. Jay: th a t.
N o,
we
w ere
not
a b le
to
do
W e w e r e fo r t u n a t e to see th e c h ild r e n th e
flo r a
of
th e
t h a t o f th e m o u t h . th a t a r e
fo u n d
in
in te s tin a l
The
tra ct
w it h
a c i d u r i c o r g a n is m s
th e m o u th , in th e
th e m
d if f e r e n t
M . H awkins, Los A n geles, C a lif.: D r .
in r e g a r d to th e c o n c e n t r a t io n o f l a c t ic a c id
in te s
th e o t h e r c o c c u s f o r m s in th e m o u th , so th a t we
ca n
see
th e
r e la t iv e
We
are
c o c c i w i l l f o r m an a c id . 1 have
is o la t e d
s tu d y .
a c id
d e c a lc ify
do
n o t th in k
we
a re
ju s t ifie d
in
l a c t ic
n ot tr y in g
to g a g e
pH-, b u t w e fin d th a t c e r t a in s t a p h y lo
h a p s w i l l b e b e st d e t e c t e d t h r o u g h s e r o l o g i c I
of
D r. Jay (clo s in g ): W e h a v e d o n e a little o f th a t w o r k .
la r , b u t th e r e
th a t p e r
s tr e n g th
a c id p r o d u c e d b y e a c h f o r m ?
t in a l t r a c t a n d in th e v a g i n a l t r a c t a re s im i b e d iffe r e n c e s
u n til
J a y , h a s th e r e b e e n a n y w o r k d o n e b y y o u
th e
m ay
nam es
a b o u t th e m .
p r o d u c e d b y B. acidophilus as c o m p a r e d w it h
as o f t e n as w e d id . W e d id n o t t r y to c o r r e la te
to
w e know
235
to
d id
T h o s e s tr a in s w h ic h not
p rod u ce
s u fficie n t
teeth .
POSTOPERATIVE CONSIDERATIONS REGARDING EXTRA CTIO N OF TEETH* By BOYD S. GARDNER, D.D.S., Rochester, Minn.
N the simple or in the complicated extraction of teeth, some of the fundamental principles of surgery, as applied in general surgery, should be considered. Inflammation may be defined as a reaction o f tissue to irritation. The causes are chemical, bacterial and trau matic. Obviously, the exodontist should attempt to minimize the causes o f this phenomenon. Undue chemical irritation has ac counted for inflammatory conditions which could be avoided. For example, in attempts to sterilize the field o f oper ation in the extraction o f teeth, chemical
I
*F rom
th e
S e ctio n
on
D e n ta l
S u rgery o f
th e M a y o C lin ic . * R e a d b e f o r e th e S e c tio n o n O r a l S u r g e r y , E x o d o n tia
a n d A n e s t h e s ia
at th e S e v e n tie th
A n n u a l S e s s io n o f th e A m e r ic a n D e n t a l A s s o c ia t io n , M i n n e a p o l i s , M in n ., A u g . 2 1, 1928.
Jour. A . D . A ., February, IÇ2Q
solutions have been used in such strength as to add materially to the uncom fort able postoperative sequelae. Iodin has undoubtedly been the principal offender, as it has been used more freely than any other drug in oral work. It has been found that little if anything is accom plished by its use. Experimentation cov ering a period of years has demon strated that it is better not to attempt to sterilize the field o f operation un less a chemical can be used which does not contribute to the cause o f inflamma tion. In the experiments, iodin was ap plied around the teeth on one side of the mouth, and no attempt was made to sterilize the opposite side. A fter the extraction o f teeth on both sides, the results were far more satisfactory on the latter. In this respect, the w ork o f the exodontist can be compared to the work of the surgeon, w ho has found it im-
236
The Journal of the American D en tal Association
practical to attempt to sterilize the mucosa of the stomach and intestine. Socket medication is not used in any form, since irritation and not steriliza tion is the result. It should be borne in mind that tissue broken down by any type o f irritation offers a lowered resist ance to infection. Bacterial irritation is an important factor in the extraction o f teeth, but this can be well controlled by adherence to general surgical technic. T h e dental operator should protect his patient by wearing rubber gloves, face mask and gown. T h e patient should also be draped to assist the operator in minimizing the possibility of carrying pathogenic bac teria into the oral cavity. T h e applica tion of 50 per cent alcohol to the part of the face not covered with a sterile towel is of assistance. It should be em phasized that it is necessary to sterilize the instruments immediately before oper ation, rather than the day before. T h e dental cabinet should be considered only a storehouse for instruments rather than a surgical table or stand. In other words, instruments that are to be used in extracting teeth should be sterilized and laid out on a sterile towel which rests on a surgical stand or table in order that the operator can reach for his in struments as they are needed, or they can be handed to him by an assistant without touching anything that might not be sterile, such as the door or drawer of a dental cabinet. T h e arguments used by many dentists that such cleanliness is not necessary in dental w ork because it is not possible to sterilize the field of operation are not convincing. It is obvious that, in the extraction of teeth, trauma should be minimized in both soft and osseous tis sue. Therefore, instruments should be used that w ill cause as little trauma to
tissues as possible. I f it is necessary to retract, and particularly if it is neces sary to incise, soft tissue, care should be exercised, as such tissue plays an im portant part in protecting osseous tissue and aids materially in maintaining blood clots. Cutting instruments should be sharp, and particular attention should be given the blood supply o f the soft tissues that are to be retracted. One should not overlook the fact that post operative results require a study o f the postoperative condition o f the support ing tissues rather than o f the extracted teeth or the osseous tissue which is cut away. Osseous tissue, when cut by a small, sharp chisel driven by the proper blow from a mallet, w ill show far less trauma than when cut by any other method. In fact, in preparing the ridge for dentures, proper chisels w ill leave less trauma in the alveolar process than if it is cut out or dressed dow n by rongeur forceps. Such instruments pinch the tissue before the actual cutting is done, but are used advantageously for certain work. Postoperative results w ill be far more satisfactory if more o f the supporting osseous tissue than usual is cut away trom the more difficult impacted third molars. T h e use of instruments that re quire a fulcrum should be minimized, since the part of the osseous tissue which is used as a fulcrum might sometimes cause severe trauma. T h e injured bone is prone to become infected, and this accounts largely for postoperative dis com fort, and particularly that due to trismus. T h e use o f instruments that compress by wedging the bone that is not removed should be discouraged. T his type o f trauma adds materially to post operative pain. T h e dry socket, from the standpoint o f both prevention and treatment, still
Gardner— Postoperative Considerations occupies an important place in dental literature. G illis1 advises against the use of mouth washes for at least twenty-four hours after extraction as they delay co agulation o f the blood. I f mouth washes are omitted, the blood clot is preserved. A few years ago, a study was made to determine the possible relation of the dry socket to the general condition of the patient, and any such relationship was ruled out. It was brought out that the patients who had dry sockets were those who sucked the clots from the sockets, and spit often. Accordingly, such a habit is discouraged, and patients are in structed to spit as little as possible for at least twenty-four hours. T h e act o f spitting tends to produce negative pres sure, which, in turn, relieves the sockets of clots. It was also found that the sockets most commonly dry were those from which the greatest amount of suc tion was obtained, namely, bicuspids and first molars in both the maxilla and man dible. T h e treatment of dry sockets has been varied by different operators. M any methods have been found satis factory. A suppository has recently been put out by a well known pharmaceutical company that is especially promising. It is easily applied to the socket, and con trols pain for a longer period. T h e variable opinion o f dentists re garding suturing follow ing the extrac tion o f teeth is rather difficult to explain except on the ground that it is a new procedure to most o f them. Perhaps some o f the failures o f the method have been due to the fact that too much is expected o f it, and because it has not been carried out properly. For example, the stitches have been placed with so much tension that they cut through the tissues, or too many have been used, thus
237
causing additional trauma, and corre spondingly unsatisfactory results. Incor rect suture material and needles may also be the cause of dissatisfaction. N ot withstanding the objection to suturing, many operators have improved their postoperative results in this manner, and an effort should be made by teachers of undergraduates in dentistry to standard ize its use. Suturing is not always indi cated after the extraction of even an impacted third molar, but when it is in dicated, it should be used. T h e socket should be entirely closed in every ex traction ; another point not definitely understood. T h e number o f teeth extracted at one time may have an important bearing on postoperative conditions.2 I have been able to secure complete histories o f all patients operated on in the M ayo Clinic, and by charting conditions postoperatively, have accumulated data that em phasize the significance of discontinuing the practice of extracting all diseased teeth at one time. Results are more sat isfactory if the operation is performed in tw o or more steps, a few days or a week apart, the interval depending on the pa tient’s reaction. Patients w ho are acutely ill should be put to bed and treated medically before extraction of the infected teeth is at tempted. Symptoms should be carefully observed and examinations made to avoid mistakes in diagnosis. Pain in the region o f the mandibular third molar, with swelling, trismus and fever, does not al ways indicate that the cause is an im pacted or unerupted tooth, even though the roentgenograms reveal such a condi tion. A diagnosis o f actinomycosis is
2. G ardner, B. S.: Extraction o f T eeth : Am ount o f Surgery Feasible at One T im e, 1. G illis, R. R .: Personal communication and Treatm ent o f Acute Cases, Dent. Cos to author. mos, <7!«
238 often made, present.
T h e Journal of the Am erican D en ta l Association
if
such
symptoms
are
A dressing is seldom used after the ex traction of any tooth. But if a dressing such as iodoform gauze is used, it should not be disturbed for at least a week, which is contrary to the usual practice of changing daily. Ice packs are applied directly after ex traction and continued for at least five or six hours. Clots are not disturbed be cause of pain. Patients are given relief by the use of sedatives and opiates, if necessary. Bowel elimination is very important. '; Heat is applied , rather than ice packs, in cases in which marked swelling with trismus, cellulitis, etc., develop. T h e heat is applied intra-orally in the form o f hot water, introduced by a rubber tube from some form of an elevated ir rigation receptacle, and extra-orally by hot water bags or electric pads. This form o f treatment is continued until drainage is established. Although local postoperative condi tions are not affected materially by d if ferent. anesthetics, it is quite obvious that, by the use of block anethesia, bet ter local results can be obtained, and more easily, in the majority o f cases in which difficult extractions are to be made. T h is anesthesia, therefore, is used fo r most adult patients in the M ayo C linic in preference to any in duced by a general anesthetic. It is understood that many patients are referred to the exodontist who is w illing to make use of a general anes thetic and employ a certain technic o f extraction. H ow ever, patients want the best service that can be given them, andif they understand that the operator can w ork to a better advantage, especially in , the more difficult extractions,- under lo
cal anesthesia, and can control pain, they are w illing to have it used. O n the other hand, many patients re fuse to allow a tooth to be removed w ith out the use o f nitrous oxid, and dentists are prone to meet such a demand. But if the extraction of teeth is to be placed on the same plane as is general surgery, the general surgeon must be copied rather than the barber who cuts the hair the way the customer wishes. From the standpoint of postoperative service, the roentgenogram made directly after operation is outstanding in its im portance.3 If it shows that all roots have been removed, the patient w ill be more tolerant of ' any discomfort that may follow . I have used this procedure as a routine for many years and feel that I have proved its importance. A roent genogram that reveals that the leg or arm is properly set, or one that reveals satisfactory extraction of a tooth, is a com fort to the patient, physician and dentist. If it were general practice among those who extract teeth to make daily records of postoperative conditions, treatment follow in g such operations w ould become standardized. V aluable postoperative information can be ob tained if the operator visits patients who are not in condition to report to the o f fice after the extraction. Unless such data can be obtained, it w ill be difficult to determine the best technic of ex traction, and the best anesthetic to administer. As emphasized by W a rd ,4 Vastine5 and others, the insertion o f dentures im 3.
G a r d n e r , B . S .:
P o s t o p e r a t iv e
X -R a y
E x a m in a t io n in D e n tis tr y , R a d i o l o g y , 3 :7 4 -7 5 ( J u l y ) 1924. 4.
W ard,
A.
W .:
P erson a l
c o m m u n ic a
5. . V a s t in e , A . B . :
P erson a l
c o m m u n ic a
t io n to a u th o r. t io n to a u th o r.
239
Gardner— Postoperative Considerations
mediately after extraction is another im portant procedure. T h e dentures act as splints, and because o f the protection and resistance they afford, better and quicker repair takes place. W a rd has made use o f his surgical cement to line plates; which insures a fit and adds to the pa tient’s com fort. H e recommends that the denture be relined with this cement every ten days, at least three times, and then it can be rebased permanently by vulcanite. M an y dentists have considered the curettement of sockets, the reduction of the alveolar process and the immediate denture construction as new procedures. In a review of dental literature, it has been found that these are merely old ideas with but little refinement. Gillis has lately called my attention to early publications as follow s: A f t e r e x t r a c t in g th e teeth , I clip o ff a ll the m u c o u s tis s u e th a t fille d
th e
s p a c e b e tw e e n
th e n e c k s o f th e te e th , l e a v i n g a s m o o th b o r d er.
B u t th e d iffe r e n c e in a g e , h e a lth a n d n u m ber
of
te e th
c r it e r io n
to
be
fo r
our
I
o ffe r
o p e r a t io n .
th e s e
th e y m a y b e w o r t h
s h o u ld
be
th e
under
rem ark s
this
fo r
w hat
a n d h o p e to h e a r f r o m
s om e o f o u r a b le d e n tists o n th is o r a n y o t h e r m ode
of
p r e p a r in g
th e
m o u th
fo r
sets
of
teeth .6 I n s u ch a ca s e , the s a c w i l l n e a r l y a lw a y s b e r e t a in e d in th e a lv e o lu s a f t e r th e t o o th o r root
is
r e m o v e d ; the
d e p e n d e n t o f th e and
e ffe c t a c u r e . o f th e be
a b s ce s s n o w
ca u s e
th e e x t r a c t io n o f
w h ic h
a cts
done
in
prod u ced
th e t o o th
w ill
it,
r a r e ly
A n o p e r a t io n f o r th e r e m o v a l
a b s ce s s w i l l b e n e c e s s a r y . T h i s by
c h is e llin g
d e a d p a r t ic le s c a v i t y .7
of
or
bone
s c r a p in g
in
and
m ay
o ff
all
about
the
It is obvious that antiseptic postoper ative treatment is indicated if aseptic surgery is not practiced, but it is hoped that the time is not far distant when, by the help of dental colleges and teachers of graduate students in this specialty, the extraction o f teeth w ill be placed oil a plane with general surgery.
I th e n d is s e c t b a c k th e fib r o u s -m u c o u s D IS C U S S IO N
tis s u e f r o m th e a l v e o l a r w a l l o r b o r d e r a b o u t o n e - f o u r t h o f an in ch a n d cu t o ff w it h a p a ir of
rem oved
govern m en t
bone
fo rce p s
th e
a lv e o la r
edge
fro m
a
Earle H . first
Thomas, Chicago, III.:
p a ragrap h
of
th is
paper
In
is th e
th e
s ta te
fo u r t h to t h r e e -e ig h th s o f an in c h d e e p ; th is
m e n t th a t, in th e e x t r a c t io n o f teeth , s o m e o f
w i l l a l lo w th e e d g e s o f th e m u c o u s tis s u e to
th e
com e
a p p lie d
cu t
tog eth er
o n ly
h a v in g
a rou n d
th e
th e
a pp earan ce
d en ta l
a rch .
c a s e s I h a v e th u s f a r p r e p a r e d
of
In
a
the
th is w a y ,
I
fu n d a m e n t a l
s id e r e d . agree
p r in c ip le s
th e
ta s k
of
r e m o v in g
and
th is
a b s o r p t io n o r e ffu s io n .
a ls o
sam e
n a tu r e
m a tter
by
of
s u r g e r y m u st
b e c a u s e th e r e m o v a l o f
B y th is p r o c e s s , w e ,
g ic a l
o p e r a t io n .
sam e
to
f o l l ic le s a r o u n d th e d e n t a l b o r d e r a n d t h e r e
tissu es,
b y th ey s oon er becom e
the
and
firm . W e
s h a ll s a v e th e ris k o f h a v i n g d e t a c h e d p ie c e s
su rgery,
s h o u ld
be
as
con
m e th a t all o f th e fu n d a m e n t a l
w it h
in a m e a s u r e , d e s t r o y th e m u c o u s e x c r e t o r y h a rd
of
P o s s ib ly D r . G a r d n e r d id n o t w is h
fla m m a tio n
s u ffe r in g ,
su rg ery,
to a p p e a r t o o e m p h a tic , b u t I th in k h e w i l l
b e lie v e I h a v e s a v e d th e p a tie n t s m u c h i n and
p r in c ip le s
in g e n e r a l
a ll and
N a tu re ’ s
s u r g ic a l lik e
s h o u ld e r s
be
c o n s id e r e d ,
a n y t o o th is a s u r r e a c t io n
o p e r a t io n s
on
is
th e
s im ila r
r e s p o n s ib ilit ie s
rest
upon
th e o p e r a t o r .
L ife
its e lf
of
m a y b e in v o lv e d in m a n y in s ta n c e s.
I agree
o f b o n e in th e g u m s , t o fin d t h e ir w a y ou t
th a t m u c h p o s t o p e r a t iv e
b y a b s c e s s o r a b s o r p t io n .
c a u s e d b y a tte m p ts a t s t e r ilz in g the fie ld o f
p a t ie n t th e fo u r
m ost o f
efflu e n ce m on th s’
p a tie n ts
fo r
th e
W e s h a ll s a v e th e
d is a g r e e a b le
e ffe cts
f r o m „th e g u m s ; w e tim e
in
fitt in g
th e
a p e r m a n e n t set o f
of
have
q u e n t ly
b e tt e r m ore
shaped
e a s ily
w o rk can be done.
m o u th s
fitted
and
a n d th a t a n y a g e n t u sed
ca n . save
pu rpose
gum s
in fla m m a tio n ,
teeth ,
of
and
m u st
be
one
but
I
th a t d o e s
w o u ld
not
f o r th is not
ca u s e
recom m en d
and
n o t le a s t , in a p e c u n i a r y v i e w o f th e s u b je c t , we
o p e r a t io n
d i s c o m f o r t is o ft e n
con se
handsom er
6.
W illa r d ,
A.
T .:
A r t ic le s
in
D e n ta l
N e w s L e t te r , V o l. 6, 1852. 7.
Shadoan ,
W .
H .:
D e n t. R e g ., 2 2 :4 1 8 , 1868.
A lv e o la r
A bscess,
240
T h e Journal of the American D en tal Association
the e lim in a t io n o f th is p h a s e o f th e t e c h n ic .
s id e r a b le
E v e n t h o u g h th e s a liv a u n d o u b t e ly k e e p s all
t iv e
s u r fa c e
p roced u re in m e n tio n s th e
b a c t e r ia
in
an
a tte n u a te d
sta te,
I
h a v e a lw a y s c o n s id e r e d th a t a n a g e n t o n th e o r d e r o f a c r iv io le t , a p p lie d
a r o u n d th e g i n
tra u m a
and
d is c o m f o r t
r e s u lt in g
are
the
th is re s p e ct. p re v a le n c e o f
s o ck e ts, a n d I w o u ld
p o stop era
re s u lt
of
f a u lt y
D r. G a rd n er s o - c a ll e d d r y
lik e to h e r e e n u m e r a t e
g i v a l c r e v i c e a n d o v e r th e s ite o f h y p o d e r m ic
som e
in je c t io n s , o ffe r e d us a little m o r e p r o t e c t io n
h a v i n g a t e n d e n c y to c a u s e su ch a c o n d i t i o n :
by
fu r th e r
a tt e n u a t in g
th e
e v e r , t h e r e is o n e p l a c e I
never
use
m e d ic a t io n
b a c t e r ia .
H ow
o f th e c o n d it io n s
to
be
c o n s id e r e d
1. U s e o f n o n s t e r ile in s tr u m e n ts .
as
2. P r e s e n c e
and
one
tim e th a t
o f s a l i v a in th e s o ck e t b e f o r e th e b l o o d c lo t
of
any
k in d ,
is
all
fo rm e d .
3.
Any
in s tr u m e n t a t io n
in
th e
r e c o m m e n d a t io n s in th e lite r a t u r e r e g a r d in g p r o p r i e t a r y p r e p a r a t io n s to the c o n t r a r y n o t
s o ck e t.
w it h s t a n d in g , a n d th a t is in th e s o ck e t im
E x c e s s iv e le v e r a g e b y f o r c e p s o r e l e v a t o r s ;
m e d ia t e ly
a ft e r
th e
rem oval
of
a
to o th .
4.
P resen ce
r e s t r ic t e d
b lo o d
s te r iliz e th e fie ld o f o p e r a t io n , b u t it is u n
erage
d e n ia b le
e le v a t o r .
a s e p t ic
t e c h n ic ,
we
less
w ill
th e
o p e r a t iv e
r e a c t io n .
p o in t,
does
it
n ea rer F rom
not
approach be
th e
p ost
a p r a c t ic a l s ta n d
seem
p o s s ib le
fo r
m a jo r i t y o f us to o b s e r v e th e r o u tin e th is
lin e
bu t
th e r e
fa ll
too
th a t is f o l l o w e d is
no
fa r
q u e s tio n
sh ort o f
th a t
su gg est
a lo n g
lin e
a re
th is
c e r ta in
th a t
a ll
by
as
D r.
th a t
th e
p r in c ip le s
an
G a rd n er,
m any
id e a l.
of
The
t h e m s e lv e s fo llo w s :
in s tr u m e n ts
us
m a in to
(1 )
a re
th e
a lo n g
me
to
be
t h o r o u g h ly
s t e r iliz e d b e tw e e n ca s e s , as th e m a in d a n g e r lie s in b a c t e r ia f r o m to
a l lo w
the
th is s o u r c e ;
o p e r a t in g
fie ld
of
o p e r a t io n ,
tissu e s a r e o p e n e d in
th a t
a rea
c lo s e d
or
u n til
trau m a
s o ft
and
th e
site
by
b lo o d
s h o u ld
be
tissu e
is
very
once
th e
s a liv a
o p e r a t io n
c lo t .
I
m in im iz e d pron e
in
b o th
su ch
to
is
agree tra u
in fe c t io n .
T h i s is o n e o f th e m o s t im p o r ta n t p h a s e s o f th e t e c h n ic o f c r it ic iz e or
a n y o p e r a t io n .
th e u se o f
a n y p a r t ic u l a r
str u m e n t ou t,
in
ca u s e
w as a
of
a n y typ e
I w o u ld of
or
th e
t e c h n ic
m an n er.
t r a u m a 'i s
th e
An
not
in s tr u m e n t
t e c h n ic p r o v i d e d
u sed,
s k ilfu l
i n v o lv e
f u lc r u m
e ffe c t e v e r y b it as m u c h 6.
E xp osu re
of
u n r e a s o n a b le
le n g th
e p in e p h r in
of
e x c e s s iv e
a n e s th e tic.
8.
V ir u le n t
a p ic a l
r e g io n .
9.
of
and
as
s o ck e t tim e .
7.
age
of
M e d i c a t i n g th e s o ck e t b e f o r e
an
U se
of
in
in f e c t i o i f
O ld
an
a ir
to
s tr e n g th
le v
does
a
lo c a l
fr o m
the
p a tie n t .
10.
th e b l o o d
c lo t
f o r m s , o r w a s h i n g o u t th e m o u th b e f o r e th e b lo o d
c lo t is f o r m e d .
d r a in in th e s o ck e t. in g th e t o n g u e
11. L e a v i n g
a gauze
12. S u ctio n o n , o r p l a c
or
fin g e r
in, th e
s o ck e t, b y
th e p a tie n t. I t is m y o p in io n th a t, a f t e r th e b lo o d clo ts in th e so ck e t, m o u th w a s h e s m a y
th e c lo t th a t re s u lts in a d r y s o ck e t, a n d this
o s s e o u s tis s u e , b e c a u s e
m a t iz e d
5.
a n y t h in g b u t (3 )
of
s o ck e t.
b e u s e d to a n y e x te n t w it h o u t d a n g e r o f w a s h i n g o u t th e clo t. I t is d e c o m p o s it io n o f
of
in to, n o t to a l lo w
covered
th a t
and
never
lin in g
w it h
in s tr u
s u r fa c e s
m en ts to c o m e in c o n ta c t w it h th e
(2 )
bone,
a n d I w o u ld lik e to h e r e c a ll a tte n tio n to the f a c t th a t f o r c e p s
th e
s c le r o t ic
s u p p ly ,
O f c o u r s e it is im p o s s ib le , in th e m o u th , to th a t
of
th e
in
c a r r ie d
im p o r ta n t
exposu re
of
th e
u s u a lly ta k e s
at
le a st f o r t y - e i g h t h o u r s .
I
a g r e e th a t th e r e a re m a n y s a t i s f a c t o r y m e th o d s o f r e l i e v i n g p a in in th is c o n d it io n , a n d th e p r in c ip le o f th e t r e a tm e n t is to k e e p th e e x p o s e d b o n e p r o t e c t e d f r o m s a l i v a a n d a ir u n til N a tu r e h a s c o v e r e d it w it h g r a n u l a tio n tis s u e . T o c a u s e fu r t h e r t r a u m a b y a cu re tte m e n t o f the s u r f a c e o f th is e x p o s e d b o n e a p p e a r s to b e i l lo g i c a l. R e g a r d i n g s u t u r in g f o l l o w i n g e x t r a c t io n , I c a n o n l y s a y t h i s : I f o n e h a s n o t s u r g ic a l ju d g m e n t , h e s h o u ld n o t a tte m p t th e s e o p e r a t io n s . fo rm
an
I
s o m e t im e s p e r
a lv e o le c t o m y in th e m a x i ll a
w ith
o u t p l a c in g o n e s u tu re a n d a t tim e s I p la c e
o s s e o u s s tr u ctu re s to a ir o v e r a l o n g p e r io d
tw o
or
o f tim e , e s p e c ia lly w h e n u n d e r th e e ffe c t o f
on e
s in g le - r o o t e d
th r e e
su tu re s
a fte r
to o th .
of
c e r t a in ly
e p in e p h r in . I m u st e m p h a s iz e th e im p o r ta n c e
agree
n u m b e r o f in f e c t e d te e th at o n e tim e , e s p e
p a r t ic u la r
a tte n tio n
to
th e
b lo o d
c i a l ly
It
r e q u ir e s
clo s e
stu d y a n d c o n s id e r a b le e x p e r ie n c e to j u d g e in e a c h i n d i v i d u a l c a s e ju s t w h e r e to r e
o n e o p e r a t io n
has
som e
la r g e
g e n e r a l t r o u b le . O f c o u r s e , t h i r t y - t w o d is e a s e d teeth h a v e o ft e n b e e n r e m o v e d in
in c is io n s .
p a tie n t
a
s u p p ly o f th e s o ft tis s u es w h e n d e c i d i n g on of
th e
rem ove
th e
lo c a t io n
w hen
to
rem ova l
m ost
of
g iv in g
th a t it is u n w is e
th e
I
s e r io u s
w it h o u t s e r io u s r e a c t i o n ;
but
le a s e a n im p a c t e d to o th a n d h o w m u ch b o n e
w h y ta k e ch a n c e s w h e n l i f e is i n v o l v e d ? W e
s h o u ld
are
be
rem oved .
U n q u e s t io n a b ly ,
con
su pposed
to
be
d octors, y ou
know .
In
241
G ardner— P ostoperative Considerations d e c id in g u sed, (1 )
on
th e
th r e e th e
typ e
fa cto rs
c o n d itio n
of
a n e s th e tic
s h o u ld of
th e
be
to
be
c o n s id e r e d :
p a tie n t;
(2 )
th e
th e
c o m b a t iv e
a b ilit y
of
th e
tis s u e ,
and
if
th e a n t is e p t ic in th e s o ck e t m ilit a te s a g a in s t th is
c o m b a t iv e
f a c u lt y ,
th e
m ore
a n t is e p t ic
t y p e o f o p e r a t io n , a n d
( 3 ) th e a b ilit y o f th e
w e use, th e m o r e w e n e e d t o c o n s e r v e th a t
o p era tor
ca re fu l
c o m b a t iv e a b ilit y .
to
o p e r a t iv e under
th e
w o r th y
fo llo w
a
t e c h n ic ch osen
of
G a rd n er
in
th e
th e
a n e s th e tic.
nam e
v o ic e d
and
e fficie n t
p a r t ic u l a r No
a l lo w s
th e h o p e
ca se
op era tor
d ic t a t io n .
t h a t th e
D r.
t im e
is
D r. G ardner (clo s in g ): d e n tists
p r a c t ic e
th a n a s e p t ic s u r g e r y . have
The
a n t is e p t ic
m a jo r it y o f
su rg ery
ra th e r
It is a p p a r e n t th a t th e y
n ot kept p a ce
w it h
th e p r o g r e s s
th a t
n o t f a r d is t a n t w h e n th e e x t r a c t io n o f teeth
has
w ill
b e l ie v e th a t th e y w o u ld b e n e fit b y r e c o g n i z
be
p la c e d
su rg ery.
on
a
p la n e
H e m e n t io n e d
tw o
w ith
gen eral
c o n d it io n s t h a t
been
m ade
in
gen eral
su rg ery,
and
I
i n g th e a d v a n t a g e th a t th e o n e h a s o v e r th e
w o u ld b r i n g th is a b o u t, b u t h e f a i l e d to in
oth er.
c lu d e w h a t , to m y m in d , is p o s s ib ly a n o t h e r
m o r e p o s t o p e r a t iv e p a in f r o m
im p o r ta n t f a c t o r in h a s t e n in g th a t d a y . T h e
th a n f r o m
p u b lic
s h o u ld b e s u p p le m e n te d b y e m p h a s iz in g th e
by
sad
e x p e r ie n c e s
a re
re a liz in g ,
I
f a s t e r t h a n a c e r t a in p r o p o r t i o n o f d e n tis ts ,
n e c e s s it y
th a t th e e x t r a c t io n
in
o p e r a t io n , a n d sults
th ey
o b t a in a b le
s u r g ic a l
of
a t o o th
a re
o n ly
is
a s u r g ic a l
d e m a n d in g th e
by
fo llo w in g
re
correct
p r in c ip le s .
do
n o t b e lie v e
have
any
p r o c a i n b lo c k
a g e n e r a l a n e s th e tic. T h i s a n s w e r of
u t iliz in g
th e o p e r a t in g
gen eral
th a t w e
surgeon .
o p era tors
w it h
th e
room It
sam e
as
is
p r e c a u t io n s
a re
used
o b v io u s
th e ir q u ic k
b y th e
th a t
m any
w o r k cau se
less
in
p o s t o p e r a t iv e p a in b y u s in g a g e n e r a l a n e s th e tic . T h e p e r c e n t a g e o f r o o t s le ft is f a r
r e m o v in g a to o th , th e e n t ir e s o ft tis s u e l y i n g
le s s a n d re su lts in g e n e r a l a re b e tt e r w h e n
b etw ee n
s h o u ld
b lo c k
a
a n e s th e s ia , m o r e
G eorge Schneider, La Salle, III.:
be
th e
ro ot
rem oved ,
and
w o u ld
th e
not
a lv e o lu s
th a t
ca u s e
If,
dry
sock et?
is
u sed.
H . J. Schwarz, St. Louis, M o .: te r m
“ d ry
c o u ld
s o ck e t” ?
be
s u b stitu te d
W hat
W hat fo r
is th e n a t u r e
th e of
th e b o n e as d is t in g u is h e d f r o m a w e t s o ck e t ?
Eugene Schmitt, Chicago, III.:
I
s h o u ld
B u t,
w ith
b lo ck
a tt e n t io n m u s t b e p a i d
th e o p e r a t in g r o o m
m e d ic a l te r m
a n e s th e s ia
s e p s is
and
the
t io n o f s u r g ic a l p r in c ip le s , as m o r e tim e th e r e
is
m ore
to
a p p li c a is
con su m ed
and
m a n ip u la t io n
o f tis s u e .
I d o n o t b e lie v e th a t the g e n e r a l
c o n d i t i o n o f th e p a t ie n t is a c a u s a t iv e f a c t o r in d r y so ck e ts, a n d t h e r e a r e m a n y d iffe r e n t
lik e t o h a v e D r . G a r d n e r ’ s o p in io n as to w h e th e r , a ft e r a b l o o d c lo t h a s o r g a n i z e d , a
ty p e s
of
t io n .
The
n o n a c id m o u t h w a s h w i l l t e n d t o d is t u r b th e
p r e v e n t io n .
b l o o d c lo t a n d b r e a k it d o w n so th a t it w i l l
w ash
c lo t o v e r .
th e p a tie n ts to s p it as little as p o s s ib le f o r
G . R. B ruce, Columbus Junction, I o w a : Is t h e r e
a p a t h o lo g i c c o n d i t i o n
th a t c a u s e s
d r y s o c k e t ? T h e r e a re m a n y o f us, I k n o w , w h o h a v e t a k e n o u t teeth a n d t h e y c o m e o u t
som e
tr e a tm e n t
fo r
im p o r ta n t
fo r
By
p a in f u l to
e lim in a t io n
le n g th
of
tim e ,
th e
and
th e and
co n d i
c o n s id e r
of
tw e n ty -fo u r h o u rs
a p t to be m a in t a in e d i m iz e d .
th is
p o in t
c lo t s
is
m o u th
a d v ic e are
to
m ore
d r y s o ck e ts m in
I t is o u r o p i n i o n th a t w e h a v e f a r
less d r y s o ck e ts s in ce th e im p r o v e d m e th o d s
as a n a il co m e s o u t o f a b o a r d , w it h n o s ig n
of
o f a c lo t .
th is is d u e l a r g e l y t o th e f a c t th a t t r a u m a
C. E. B row n , Lincoln, N eb r.: I n c h e c k in g
e x t r a c t io n
is m in im iz e d .
up o n p o s t o p e r a t iv e p a in in ca s e s o f fu ll m o u th o p e r a t io n , w h a t is th e p e r c e n t a g e o f
th a t
p a i n ? Is it g r e a t e r w it h n it r o u s o x i d , o r w it h
fo r
lo c a l o r b lo c k a n e s th e s ia ?
s u p p o r t in g
H . A . Elmquist, D es M oines, Io w a :
I
d is a g r e e w it h o n e p o i n t D r . G a r d n e r m a d e , th a t is, i f s h o u ld
u se
we an
d on ’ t op era te a n tis e p tic .
a s e p t ic a lly , w e
I th in k th e s a m e
have
th e r e
is
been
in
u se.
No
d o u b t,
I n t h ir d m o la r w o r k , w e fin d fa r
less
p o s t o p e r a t iv e
p a in
w h e n th e se d ifficu lt te e th a re b e tte r p r e p a r e d rem oval
by
c u tt in g
osseou s
iz e s th e u se o f le v e r s . m in d
aw ay
s tr u ctu re .
m ore T h is
of
th e
m in im
I t s h o u ld b e b o r n e in
th a t, w h e n l e v e r s a r e u s e d , th e s a m e
p ressu re a p p lie d
e x e r te d
on
the t o o th t o
f u lc r u m
as
is
rem oved . T h ere
w ill
a p p ly
c h is e ls d r i v e n b y c o r r e c t b lo w s f r o m s u ita b le
d o u b le
m easu re,
if
we
a re
not
a s e p t ic in o u r t e c h n ic . W e n e e d to c o n s e r v e
m a lle ts
m u c h . le ss
th e be
o b je c t i o n to u s in g a n a n t is e p t ic a t a ll w o u l d in
be
is to
a re
used
th a n
trau m a
w hen
w hen
sh arp
th e p r o c e s s
is
242
T h e Journal of the Am erican D en ta l Association
cu t b y r e v o l v i n g and in
b u rs .
in s tr u m e n ts su ch
B e tt e r resu lts w o u ld
d iffic u lt
e x t r a c t io n s
if
as d r ills
b e o b ta in e d
p a tie n ts
w ere
a l
d is m is s e d .
If
t h e y w o u ld
m ake
c a lls
as
is
th e p r a c t ic e o f p h y s ic ia n s , th e s u r g ic a l a sp e ct o f d e n t is t r y w o u ld b e p u t o n a m u c h h ig h e r
l o w e d to r e m a in in b e d , w h e t h e r in th e h o s
p la n e .
p it a l o r a t h o m e f o r at le a st t w o d a y s a fte r
w h o m teeth h a v e b e e n e x t r a c t e d , b u t to th ose
I
do
not
r e fe r
to
all
p a tie n ts
fo r
th e o p e r a t io n . T h e la r g e p e r c e n t a g e o f d e n
fo r
tists
p e r f o r m e d a n d to th o s e w h o s e s y s te m ic c o n
are
n ot
re c o g n iz in g
th is,
a s k in g
th e ir
p a tie n ts to r e p o r t to t h e ir offices d a il y un til
w hom
d iffic u lt
e x t r a c t io n s
have
been
d it io n w a r r a n t s b e tte r c a r e .
FURTH ER PROGRESS AND OBSERVATIONS IN THE TREATM ENT OF MALOCCLUSION INVOLVING SPACES" By HUGH GRUN TANZEY, D.D.S., Kansas City, Mo.
V E R Y dentist is from time to time confronted with the problem of de ciding what to do about malocclu sion cases presenting such symptoms as spaces between central incisors where there is an abnormal frenum labium ; or spaces where there are one or more teeth congenitally missing (Figs. 1- ;■) ; spaces resulting directly from the ex traction of teeth, or spaces caused by un erupted or impacted teeth; by excessive overbite, by pathologic conditions, trauma anomalies of size or various other contributing causes. It will not, of course, be possible to more than mention the m ajority of these ailments in passing. Probably no other form o f malocclusion is more disconcerting to the adult patient or to the parent o f the child than those here mentioned. Aside from the small percentage of dentists who have been misguided into the belief that tooth movement in all cases is easily and quick-
E
^ P a p e r r e a d b e f o r e th e S e c tio n o n O p e r a t iv e D e n tis tr y , M a t e r i a M e d i c a a n d T h e r a p e u tics
at
the
S e v e n tie th
A nnual
S e ss io n
o f th e A m e r ic a n D e n ta l A s s o c i a t i o n , M i n n e a p o lis , M in n ., A u g . 22, 1928.
Jour. A . D . A ., February, 1929
ly effected if only the proper means are employed, and the smaller percentage o f dentists who w ill take the time and pre caution to go into a detailed analysis o f the case before attempting to treat it, there is a larger group o f more or less misinformed, disappointed dentists who have essayed to “ improve the situation” by the all too common rubber band method, or by ligating teeth together or wedging them apart, then bridging 'the space with some sort o f restoration. In many instances, part or all of teeth have been sacrificed previous to the unsuccess ful attempt to restore acceptable esthetic and sanitary conditions. T here is hope that eventually dentists w ill assume the responsibility o f advising in all such complicated cases that the patient investigate carefully before start ing wildcat methods o f correction. One point that I desire to emphasize more than all others is that teeth may move readily on the application of force, but, in the majority o f cases, it requires a much longer time to effect that nice final adjustment, and to complete the case with anything like assurance of ultimate