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Treatment Following the Removal of the Impacted Mandibular Third Molar*
1138
T he Journal o f the American D en tal Association
It is hardly necessary to enlarge on the interference with function that is involved in the presence of contractile scar, whether produced by burns or by other injuries. Obviously, it limits by its presence the functional action o f the tissues it overlays, and that action can be restored only when the tissues are given a covering under which they can freely move. Here, we enter the field of skin grafts in general, epidermic, free full-thickness, tubed pedicle and all the other variants. It is a field where ex perience and skill are demanded, and where the esthetics of the end result are of almost paramount importance. T h e patient whose face is to be exposed to the merciless gaze of society is entitled to the best that can be done for him. W e may leave that phase of the sub ject with the remark that, unless due
regard is had for function, the esthetic betterment w ill not materialize, or will not be permanent; whereas, if function is safeguarded, improvement of appear ance is vastly facilitated. A nd may I conclude by suggesting that practitioners of one and another branch of physiotherapy might do well to give a little more thought than per haps some o f them do give to the prob able consequences o f devitalizing the tissues with which they have to deal. W ith the consequences of disease and accident, we must expect always to have to deal, but there is surely a momentous significance in the fact that plastic or reconstructive surgery now has to cope with a great variety o f dysfunctions and disfigurements that originate in this field o f therapeutics.
TREATMENT FOLLOWING THE REMOVAL OF THE IMPACTED MANDIBULAR THIRD MOLAR* By GEORGE C. FAHY, D.D.S., New Haven, Connecticut
H E subject o f postoperative care in cases of removal o f the impacted mandibular third molar is most apropos after the presentation of D r. W in ter’s original w ork in its classifica tion and the technic of removal, in that it had its inception from this phase of the w ork. Previous to the working out of this technic, many o f our patients were experiencing serious postoperative results. D r. T holen, o f Los Angeles, has summed up the situation thus:
T h e seriousness o f the op era tiv e treatm ent is u n derrated and the treatm ent often re sults in traum atic lesions m ore serious to the p atien t than that associated w ith the origin a l im paction.
* R e a d b e fo re the Section on O ral Surgery, E x o d o n tia and A nesthesia at the Sixty-N inth A n n u a l Session o f the A m e rica n D en tal A s sociation, D etroit, M ich ., Oct. 24, 1927.
tects our patients from the many new ideas which are, in most instances, short lived and capable o f doing more harm
T
W h ile the profession as a whole was building up elaborate schemes fo r post operative treatment, W in ter attacked and solved the cause o f our troubles, which, as you know, is, in most cases, trauma. A ll new methods submitted to dentistry and medicine are received by the professions with skepticism. T his, I believe, is most commendable, as it pro
Fahy— Treatm ent o f Impacted M andibular Third M ola r than good. T here comes a time, how ever, when we are doing an injustice to the people w h o fall into our hands by not accepting a technic which has proved by the end results in thousands o f cases its ability to reduce trauma to an almost negligible quantity,to minimize suffer ing and to conserve tissue. Postoperative results, good or bad, are essentially; preoperative problems, and we will succeed in making our postop erative difficulties negligible directly in proportion to the correctness with which we have made our preoperative inter pretation. I should like at this time to make one point clear, and that is that there are cases, even though they are in the hands o f men thoroughly familiar and experienced in this technic, in which we have and w ill continue to have post operative trouble. D r. W in ter has given us the operative technic; D r. Rounds has furnished roentgen-ray interpreta tion. There are, however, other factors that enter into the final result: ( 1 ) age ; ( 2 ) resistance; (3 ) infection; ( 4 ) bone spiculae; ( 5 ) fractured lingual plate; (6 ) rough edges; ( 7 ) failure to eradi cate septum; ( 8 ) foreign bodies in socket, and ( 9 ) exposed osseous struc ture. It is not advisable to operate in the presence o f infection, and although there are cases in which it becomes neces sary to do so in order to establish drain age, they are infrequent. M any men do operate in these cases regardless o f the infection present, obtaining, in many in stances, a normal recovery. T o my mind, the conservative method of clearing up the cases before operating is preferable. Granting that the operator is success ful in the majority o f his cases, in which the operation is performed in the pres ence of infection, obtaining a normal recovery, it is my contention that the suffering of patients who do not react
1139
favorably is sufficient justification for adhering to the conservative method. It is w ell to bear in mind that the mandi bular third molar is distinctly individ ualistic in many respects: ( 1 ) time of eruption; (2 ) varied positions assumed in the arch and the mandible; (3 ) fre quent association of infection with its eruption; ( 4 ) its effect on the adjácent second m olar; ( 5 ) as a causative factor in periodontoclasia; ( 6 ) its effect on the arch as a w hole; ( 7 ) the part it played in disrupting the results obtained by the orthodontist, and ( 8 ) its peculiar and interesting lymphatic drainage. T h e removal o f this third molar is bone surgery, and there is one irrefuta ble axiom that must be honored in all of our cases, and that is that we must keep our fingers out o f the wound. Fail ure to do this has been the cause of many disastrous end results, though all the other factors leading to a successful termination have been observed. T h e cases with which we have the most d if ficulty are the semi-eruptive types with an associated flap and where there are no manifestations o f inflammation or in fection. T h e usual procedure is to op erate in these cases immediately, with the feeling that there w ill be no ynusual postoperative trouble. Frequently, these patients return fortyeight hours after operation complaining of intense pain and general discomfort. M y observation has been that it is due to infection under this flap which is dormant at the time o f operation but is made active by our surgical interven tion. T h e only way I know of to avoid this contingency is to treat all cases in which there is a flap present in the same way that we would treat a case which presented clinical manifestations of ac tive infection. In removing this flap, as in many cases is advisable, better re sults have been obtained by the use o f
1140
The Journal of the American D en tal Association
the actual cautery than with the knife. In treating these infections, we have had success with the use o f methylene blue powder. T h e part is first thoroughly ir rigated with a sodium-borate sodiumchlorid solution, then dried and packed off. T h e lips and chin are smeared with “ K -Y ” to prevent discoloration o f the skin. T hree or four treatments on suc cessive days w ill usually clear up the case. T h ere is more or less pain follow ing the removal o f this tooth, and this we should anticipate. It is advisable in all cases to administer some internal seda tive directly after the operation, such as a combination o f acetyl salicylic acid (aspirin), phenacetin and caffein, codein or any other drug that may be indicated. T h e employment of ice is an important factor, and the best results are obtained by application immediately after the op eration. It should be used with caution, since its use over a continued period will cause pain of another character, which is, in many cases, more severe than that associated with the original lesion. Consistently good results have been obtained by using ice in alternate peri ods of five minutes for the first half hour after the removal o f this tooth, this treatment to be continued by the patient for four hours after returning home. T h e application should be confined to the first half of each hour in alternate five-minute intervals, with a rest period of a half hour in each hour. T h e use o f ice tends to reduce hyperemia and in hibit bacterial activity. Thorough examination of the socket after operation and recognition and elim ination of the conditions which may be factors in causing postoperative dis com fort are of the utmost importance. A m ong these factors are the presence o f ( 1 ) loose spiculae o f bone; (2 ) fo r eign bodies; ( 3 ) fractured lingual plate; ( 4 ) unprotected or rough margins; (5 )
fractured septums, and (6 ) soft tissues which may degenerate. Spiculae o f bone and foreign bodies should be rem oved; also, the lingual plate and septum if fractured, rough margins and unprotected osseous struc ture should be trimmed down to a point where they are covered with tissue. Soft tissue which may subsequently degener ate should be cut away. A dry socket constitutes a circum scribed osteomyelitis, due in most cases to subacute infection and trauma. If the resistance o f the surrounding tissue were not high, we would have a general osteomyelitis. T h is is an important point to have in mind because o f the treatment which is used. T h e socket should be thoroughly cleaned and lightly curetted, sufficiently only to cause bleeding. Great care should be taken to avoid breaking through the w all of the socket and bring ing about osteomyelitis of a diffused type. T his procedure will, in most in stances, have to be repeated several times, W h en infection has been dissipated, we will have a normal clot formation. In tense pain is usually associated with this condition and the use of a local sedative treatment is indicated. T here are many effective remedies. W e have had uni form ly good results with the use of orthoform and acetyl salicylic acid in equal parts, with mineral oil as a vehicle. General medication is used when indi cated. I f a case does not clear up within a reasonable period, it is advisable to have a urinalysis, as, in cases of diabetes, we have, follow ing extraction, a condi tion simulating clinically in many re spects a dry socket. T his can readily be accounted for, as diabetes is a disease of the trophic nerves. Trismus is due to infection and trau ma. W e have an infiltration o f serum into the muscular tissue, which prevents muscle stretching. T h e absence of tris
Fahy— Treatm ent o f Impacted M andibular Third M o la r mus is particularly noticeable where the deflection is lingual. It is quite possi ble that this is due to its lymphatic in volvement. T h e drainage, as you know, is on the lingual side and through the same duct as that which drains the ton sils. A void, where possible, the forceful opening o f the mouth in the presence of trismus, as it w ill result in a tearing of muscular tissue, or, in case the posterior teeth are missing, a possible fracture. T here are many mouth washes on the market. M y experience has been that most of them are prepared with but two objects in view : to look good and to taste good. F or a wash to be used after the extraction o f teeth, I know o f noth ing better than a sodium chlorid and sodium borate combination, 3 parts by weight of sodium chlorid to 1 part of sodium borate. Flavor o f any sort may be added to suit the prescriber. CONCLUSION
1. Avoid trauma. 2. Clear up infection before operat ing. 3. Keep the fingers out of the socket. 4. Use gentle irrigation rather than force in washing out sockets. 5. A void, where possible, medication o f the socket. 6. Always use sharp cutting instru ments. 7. As a routine, use internal sedatives in all cases. 8. Remember that the reduction of temperature by the use of ice is im portant and that the best results are ob tained by using it intermittently. 9. Bear in mind that the mandibular molar is more or less o f a distinct entity and must be handled accordingly. DISCUSSION J. L. L o ftu s , M e r id e n , C o n n .: I w ish to ask D r. R o u n d s f about m edication to p r e vent traum a after the re m o v a l o f an im
1141
pacted tooth. A r e you ad v ised not to use any at a ll? S upposing there w a s no flap in fection o r that w e cle a r e d it up b e fo re the op era tion . D o you consid er it better not to pack that w o u n d ? D r. R ou n d s: A n y questions as to D r. F ahy’ s paper, I shall h a v e to answ er as p er m yself. I w ish a norm al clo t fo rm a tion as soon as possible, and I le a v e it alone as m uch as possible. E. K r ie g e r , B a ltim ore, M d .: A r e not dry sockets, m ost o f the tim e, due to the use o f e p in e p h rin ? I h ave fo u n d a num ber o f patients w h o are susceptible to epinephrin, and, in the absence o f traum a, they still h ave d ry sockets. D r . R ou n d s: I find that d ry sockets are due to m any things. I think that the use o f an excessive am ount o f ep inep hrin w ou ld h ave a tendency to suspend circu la tion at the time, and w e do not g et the im m ediate b lood flow w h ich w e w o u ld get w ith ou t it. I m ay an sw er the question better by sayin g that the soon er w e get the b lood clot, the better, reg a rd less o f the anesthetic agent. A . E . M a u n , F in d la y, O h io : In h ow m any o f these cases o f im paction, d o you pack w ith g a u z e ? D r . R o u n d s: In an in fected case, w e w ish to h ave the n orm al b lood c lot d ev elop as soon as possible. In cases o f separation, n ecessarily w e pack. C. B . C olem an, P op la r B lu ffs, M o .: W h a t p re o p e ra tiv e course is fo llo w e d in p rep a rin g an aseptic fie ld ? In gen eral su rgery, o f course, that is the m ost im portant fa ctor in p rev en tin g p ostop era tive distress. N ow , in the a v e ra g e office, w e p a y little attention to p re p a r in g an aseptic field in w h ich to operate. M an y times, the patient sits in the ch air fo r five m inutes f o r the first tim e, and, in five minutes, the teeth h ave been rem ov ed w ith no p relim in ary p rep a ra tion fro m the stand point o f asepsis. I think that an aseptic technic should be fo llo w e d in all o f our operation s. Should not this be routine ? I m ean by p re p a r in g the field not only in the reg ion o f the m an d ibu lar third m ola r on w h ich w e contem plate op era tin g, but the en tire oral cav ity . Stress w a s laid a w h ile ag o on a v o id in g the flow o f o r a l secretions into the w ou n d . Secretions fr o m the nose and fr o m the sinuses, and, in m an y instances, the con d ition o f the d igestiv e tra ct as a w hole, I t T h e paper o f D r. F a h y was read b y F ra nk W . R o u n d s, B os ton , M a ss ., in the absence o f the auth or.
1142
T h e Journal of the American D en tal Association
think, should be g iv e n m ore con sid eration than is ou r w ont. I should like to inquire as to w h eth er that is a p art o f the usual p r o ced u re b efore operation . D r . R o u n d s: It goes w ith ou t sayin g that the better the physical con d ition o f the p a tient, and the better the san ita ry con d ition s in the m outh, the better the results should be. F rom the standpoint o f op era tin g, as D r. F ahy rem arked, if the continuity o f the m u cous m em bran e has been broken in any w ay , it is a safter p roced u re, even i f not p a rticu la rly in d icated in the in d iv id u a l case, to keep that case un der ob se rv a tio n u n der the treat m ent w h ich he in d ica ted and to take ca re o f it as though it w e re an a ctiv e ly in fected case. A s fa r as the actual p re p a ra tio n o f the field is con cern ed , in m y p ra ctice the area is cleansed m ech an ically, and the field is painted and absolutely w a lle d o ff by la rg e cotton sponges, w h ich at the sam e tim e act as a throat pack d u rin g anesthesia, so there is no chance fo r saliv a, or other secretions to get to that area until the b lo o d clot has filled it up. D r. C olem a n is righ t in e m ph asizin g that a clean m outh g iv e s us a better chance to lessen the trou ble that m igh t result, and the better the physical con d ition o f the p a tient, the better fo r us in the m a jo rity o f cases. J. M a c k a y , W a u k eg a n , III.: W e are sup posed to clea r up in fection b e fo re o p era tin g. Suppose w e h a v e a p a rtia lly erupted tooth, and the patient is h a v in g p eritonitis and p a r tial trism us, the in fection lastin g f o r w eeks w ith ou t c le a r in g up. Is there any m ethod by w h ich that in fection can be cleared up b e fo re op era tion ? D r . R o u n d s: A treatm ent fo r that case w a s indicated by D r. F ahy. Some cases are stub
born , but w e w o u ld n ’ t attem pt to operate in those cases until the in fection w a s cleared up, unless it w a s n ecessa ry to operate. A question w a s asked ab ou t sedatives. W e u n ifo rm ly p rescribe internal sedatives. T h ose D r. F ahy in d icated w ere acetyl sa licy lic acid (a s p ir in ), p henacetin an d coca in com b in a tio n s; w h a tev er seem s to be in d icated by the sev erity o f the case. I usually internal sed atives im m ediately. D r.
M ackay:
Do
you
a d v ise
adm inister use
of
a
cath artic b e fo re the op era tion ? D r . R ou n d s: It is p e rfe ctly log ica l that the b ow els should be open, but unless there is som e sp ecia l reason, I see no ind ication f o r a cathartic. R . 1'. S om ers, N o r fo lk , V a .:
W h a t is the
m ost p ra ctical m eth od f o r p rev en tin g saliv a co m in g into the w ou n d in the op era tion fo r the im pacted third m o la r ? D r. R ou n d s:
M y m ethod is to use a large
cotton pad, about 4 inches square and h a lf an inch thick and v a r ie d a c c o rd in g to the size o f the m outh.
T h is
is used fo r three
p u rp o ses: (1 ) to w a ll off the field and keep the saliv a a w a y ; (2 ) to p rev en t any atm os p h eric oxygen com in g into the field and dilut in g the gas m ix tu re ; (3 ) to catch any débris, spicules o r an yth in g that m igh t escape into the throat. I find that adequ ate in protectin g the field fr o m saliv a. D r . S o m e r s: D o you use the sam e m ethod in Ideal anesthesia? D r. R o u n d s: I w o u ld use that on the lin g u a l, and, if necessary, on the m edial aspect. I w o u ld use w h a tev er w a s in d icated to p re vent saliv a g ettin g into the area o f operation .
T he Journal o f the American D en tal Association
It is hardly necessary to enlarge on the interference with function that is involved in the presence of contractile scar, whether produced by burns or by other injuries. Obviously, it limits by its presence the functional action o f the tissues it overlays, and that action can be restored only when the tissues are given a covering under which they can freely move. Here, we enter the field of skin grafts in general, epidermic, free full-thickness, tubed pedicle and all the other variants. It is a field where ex perience and skill are demanded, and where the esthetics of the end result are of almost paramount importance. T h e patient whose face is to be exposed to the merciless gaze of society is entitled to the best that can be done for him. W e may leave that phase of the sub ject with the remark that, unless due
regard is had for function, the esthetic betterment w ill not materialize, or will not be permanent; whereas, if function is safeguarded, improvement of appear ance is vastly facilitated. A nd may I conclude by suggesting that practitioners of one and another branch of physiotherapy might do well to give a little more thought than per haps some o f them do give to the prob able consequences o f devitalizing the tissues with which they have to deal. W ith the consequences of disease and accident, we must expect always to have to deal, but there is surely a momentous significance in the fact that plastic or reconstructive surgery now has to cope with a great variety o f dysfunctions and disfigurements that originate in this field o f therapeutics.
TREATMENT FOLLOWING THE REMOVAL OF THE IMPACTED MANDIBULAR THIRD MOLAR* By GEORGE C. FAHY, D.D.S., New Haven, Connecticut
H E subject o f postoperative care in cases of removal o f the impacted mandibular third molar is most apropos after the presentation of D r. W in ter’s original w ork in its classifica tion and the technic of removal, in that it had its inception from this phase of the w ork. Previous to the working out of this technic, many o f our patients were experiencing serious postoperative results. D r. T holen, o f Los Angeles, has summed up the situation thus:
T h e seriousness o f the op era tiv e treatm ent is u n derrated and the treatm ent often re sults in traum atic lesions m ore serious to the p atien t than that associated w ith the origin a l im paction.
* R e a d b e fo re the Section on O ral Surgery, E x o d o n tia and A nesthesia at the Sixty-N inth A n n u a l Session o f the A m e rica n D en tal A s sociation, D etroit, M ich ., Oct. 24, 1927.
tects our patients from the many new ideas which are, in most instances, short lived and capable o f doing more harm
T
W h ile the profession as a whole was building up elaborate schemes fo r post operative treatment, W in ter attacked and solved the cause o f our troubles, which, as you know, is, in most cases, trauma. A ll new methods submitted to dentistry and medicine are received by the professions with skepticism. T his, I believe, is most commendable, as it pro
Fahy— Treatm ent o f Impacted M andibular Third M ola r than good. T here comes a time, how ever, when we are doing an injustice to the people w h o fall into our hands by not accepting a technic which has proved by the end results in thousands o f cases its ability to reduce trauma to an almost negligible quantity,to minimize suffer ing and to conserve tissue. Postoperative results, good or bad, are essentially; preoperative problems, and we will succeed in making our postop erative difficulties negligible directly in proportion to the correctness with which we have made our preoperative inter pretation. I should like at this time to make one point clear, and that is that there are cases, even though they are in the hands o f men thoroughly familiar and experienced in this technic, in which we have and w ill continue to have post operative trouble. D r. W in ter has given us the operative technic; D r. Rounds has furnished roentgen-ray interpreta tion. There are, however, other factors that enter into the final result: ( 1 ) age ; ( 2 ) resistance; (3 ) infection; ( 4 ) bone spiculae; ( 5 ) fractured lingual plate; (6 ) rough edges; ( 7 ) failure to eradi cate septum; ( 8 ) foreign bodies in socket, and ( 9 ) exposed osseous struc ture. It is not advisable to operate in the presence o f infection, and although there are cases in which it becomes neces sary to do so in order to establish drain age, they are infrequent. M any men do operate in these cases regardless o f the infection present, obtaining, in many in stances, a normal recovery. T o my mind, the conservative method of clearing up the cases before operating is preferable. Granting that the operator is success ful in the majority o f his cases, in which the operation is performed in the pres ence of infection, obtaining a normal recovery, it is my contention that the suffering of patients who do not react
1139
favorably is sufficient justification for adhering to the conservative method. It is w ell to bear in mind that the mandi bular third molar is distinctly individ ualistic in many respects: ( 1 ) time of eruption; (2 ) varied positions assumed in the arch and the mandible; (3 ) fre quent association of infection with its eruption; ( 4 ) its effect on the adjácent second m olar; ( 5 ) as a causative factor in periodontoclasia; ( 6 ) its effect on the arch as a w hole; ( 7 ) the part it played in disrupting the results obtained by the orthodontist, and ( 8 ) its peculiar and interesting lymphatic drainage. T h e removal o f this third molar is bone surgery, and there is one irrefuta ble axiom that must be honored in all of our cases, and that is that we must keep our fingers out o f the wound. Fail ure to do this has been the cause of many disastrous end results, though all the other factors leading to a successful termination have been observed. T h e cases with which we have the most d if ficulty are the semi-eruptive types with an associated flap and where there are no manifestations o f inflammation or in fection. T h e usual procedure is to op erate in these cases immediately, with the feeling that there w ill be no ynusual postoperative trouble. Frequently, these patients return fortyeight hours after operation complaining of intense pain and general discomfort. M y observation has been that it is due to infection under this flap which is dormant at the time o f operation but is made active by our surgical interven tion. T h e only way I know of to avoid this contingency is to treat all cases in which there is a flap present in the same way that we would treat a case which presented clinical manifestations of ac tive infection. In removing this flap, as in many cases is advisable, better re sults have been obtained by the use o f
1140
The Journal of the American D en tal Association
the actual cautery than with the knife. In treating these infections, we have had success with the use o f methylene blue powder. T h e part is first thoroughly ir rigated with a sodium-borate sodiumchlorid solution, then dried and packed off. T h e lips and chin are smeared with “ K -Y ” to prevent discoloration o f the skin. T hree or four treatments on suc cessive days w ill usually clear up the case. T h ere is more or less pain follow ing the removal o f this tooth, and this we should anticipate. It is advisable in all cases to administer some internal seda tive directly after the operation, such as a combination o f acetyl salicylic acid (aspirin), phenacetin and caffein, codein or any other drug that may be indicated. T h e employment of ice is an important factor, and the best results are obtained by application immediately after the op eration. It should be used with caution, since its use over a continued period will cause pain of another character, which is, in many cases, more severe than that associated with the original lesion. Consistently good results have been obtained by using ice in alternate peri ods of five minutes for the first half hour after the removal o f this tooth, this treatment to be continued by the patient for four hours after returning home. T h e application should be confined to the first half of each hour in alternate five-minute intervals, with a rest period of a half hour in each hour. T h e use o f ice tends to reduce hyperemia and in hibit bacterial activity. Thorough examination of the socket after operation and recognition and elim ination of the conditions which may be factors in causing postoperative dis com fort are of the utmost importance. A m ong these factors are the presence o f ( 1 ) loose spiculae o f bone; (2 ) fo r eign bodies; ( 3 ) fractured lingual plate; ( 4 ) unprotected or rough margins; (5 )
fractured septums, and (6 ) soft tissues which may degenerate. Spiculae o f bone and foreign bodies should be rem oved; also, the lingual plate and septum if fractured, rough margins and unprotected osseous struc ture should be trimmed down to a point where they are covered with tissue. Soft tissue which may subsequently degener ate should be cut away. A dry socket constitutes a circum scribed osteomyelitis, due in most cases to subacute infection and trauma. If the resistance o f the surrounding tissue were not high, we would have a general osteomyelitis. T h is is an important point to have in mind because o f the treatment which is used. T h e socket should be thoroughly cleaned and lightly curetted, sufficiently only to cause bleeding. Great care should be taken to avoid breaking through the w all of the socket and bring ing about osteomyelitis of a diffused type. T his procedure will, in most in stances, have to be repeated several times, W h en infection has been dissipated, we will have a normal clot formation. In tense pain is usually associated with this condition and the use of a local sedative treatment is indicated. T here are many effective remedies. W e have had uni form ly good results with the use of orthoform and acetyl salicylic acid in equal parts, with mineral oil as a vehicle. General medication is used when indi cated. I f a case does not clear up within a reasonable period, it is advisable to have a urinalysis, as, in cases of diabetes, we have, follow ing extraction, a condi tion simulating clinically in many re spects a dry socket. T his can readily be accounted for, as diabetes is a disease of the trophic nerves. Trismus is due to infection and trau ma. W e have an infiltration o f serum into the muscular tissue, which prevents muscle stretching. T h e absence of tris
Fahy— Treatm ent o f Impacted M andibular Third M o la r mus is particularly noticeable where the deflection is lingual. It is quite possi ble that this is due to its lymphatic in volvement. T h e drainage, as you know, is on the lingual side and through the same duct as that which drains the ton sils. A void, where possible, the forceful opening o f the mouth in the presence of trismus, as it w ill result in a tearing of muscular tissue, or, in case the posterior teeth are missing, a possible fracture. T here are many mouth washes on the market. M y experience has been that most of them are prepared with but two objects in view : to look good and to taste good. F or a wash to be used after the extraction o f teeth, I know o f noth ing better than a sodium chlorid and sodium borate combination, 3 parts by weight of sodium chlorid to 1 part of sodium borate. Flavor o f any sort may be added to suit the prescriber. CONCLUSION
1. Avoid trauma. 2. Clear up infection before operat ing. 3. Keep the fingers out of the socket. 4. Use gentle irrigation rather than force in washing out sockets. 5. A void, where possible, medication o f the socket. 6. Always use sharp cutting instru ments. 7. As a routine, use internal sedatives in all cases. 8. Remember that the reduction of temperature by the use of ice is im portant and that the best results are ob tained by using it intermittently. 9. Bear in mind that the mandibular molar is more or less o f a distinct entity and must be handled accordingly. DISCUSSION J. L. L o ftu s , M e r id e n , C o n n .: I w ish to ask D r. R o u n d s f about m edication to p r e vent traum a after the re m o v a l o f an im
1141
pacted tooth. A r e you ad v ised not to use any at a ll? S upposing there w a s no flap in fection o r that w e cle a r e d it up b e fo re the op era tion . D o you consid er it better not to pack that w o u n d ? D r. R ou n d s: A n y questions as to D r. F ahy’ s paper, I shall h a v e to answ er as p er m yself. I w ish a norm al clo t fo rm a tion as soon as possible, and I le a v e it alone as m uch as possible. E. K r ie g e r , B a ltim ore, M d .: A r e not dry sockets, m ost o f the tim e, due to the use o f e p in e p h rin ? I h ave fo u n d a num ber o f patients w h o are susceptible to epinephrin, and, in the absence o f traum a, they still h ave d ry sockets. D r . R ou n d s: I find that d ry sockets are due to m any things. I think that the use o f an excessive am ount o f ep inep hrin w ou ld h ave a tendency to suspend circu la tion at the time, and w e do not g et the im m ediate b lood flow w h ich w e w o u ld get w ith ou t it. I m ay an sw er the question better by sayin g that the soon er w e get the b lood clot, the better, reg a rd less o f the anesthetic agent. A . E . M a u n , F in d la y, O h io : In h ow m any o f these cases o f im paction, d o you pack w ith g a u z e ? D r . R o u n d s: In an in fected case, w e w ish to h ave the n orm al b lood c lot d ev elop as soon as possible. In cases o f separation, n ecessarily w e pack. C. B . C olem an, P op la r B lu ffs, M o .: W h a t p re o p e ra tiv e course is fo llo w e d in p rep a rin g an aseptic fie ld ? In gen eral su rgery, o f course, that is the m ost im portant fa ctor in p rev en tin g p ostop era tive distress. N ow , in the a v e ra g e office, w e p a y little attention to p re p a r in g an aseptic field in w h ich to operate. M an y times, the patient sits in the ch air fo r five m inutes f o r the first tim e, and, in five minutes, the teeth h ave been rem ov ed w ith no p relim in ary p rep a ra tion fro m the stand point o f asepsis. I think that an aseptic technic should be fo llo w e d in all o f our operation s. Should not this be routine ? I m ean by p re p a r in g the field not only in the reg ion o f the m an d ibu lar third m ola r on w h ich w e contem plate op era tin g, but the en tire oral cav ity . Stress w a s laid a w h ile ag o on a v o id in g the flow o f o r a l secretions into the w ou n d . Secretions fr o m the nose and fr o m the sinuses, and, in m an y instances, the con d ition o f the d igestiv e tra ct as a w hole, I t T h e paper o f D r. F a h y was read b y F ra nk W . R o u n d s, B os ton , M a ss ., in the absence o f the auth or.
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T h e Journal of the American D en tal Association
think, should be g iv e n m ore con sid eration than is ou r w ont. I should like to inquire as to w h eth er that is a p art o f the usual p r o ced u re b efore operation . D r . R o u n d s: It goes w ith ou t sayin g that the better the physical con d ition o f the p a tient, and the better the san ita ry con d ition s in the m outh, the better the results should be. F rom the standpoint o f op era tin g, as D r. F ahy rem arked, if the continuity o f the m u cous m em bran e has been broken in any w ay , it is a safter p roced u re, even i f not p a rticu la rly in d icated in the in d iv id u a l case, to keep that case un der ob se rv a tio n u n der the treat m ent w h ich he in d ica ted and to take ca re o f it as though it w e re an a ctiv e ly in fected case. A s fa r as the actual p re p a ra tio n o f the field is con cern ed , in m y p ra ctice the area is cleansed m ech an ically, and the field is painted and absolutely w a lle d o ff by la rg e cotton sponges, w h ich at the sam e tim e act as a throat pack d u rin g anesthesia, so there is no chance fo r saliv a, or other secretions to get to that area until the b lo o d clot has filled it up. D r. C olem a n is righ t in e m ph asizin g that a clean m outh g iv e s us a better chance to lessen the trou ble that m igh t result, and the better the physical con d ition o f the p a tient, the better fo r us in the m a jo rity o f cases. J. M a c k a y , W a u k eg a n , III.: W e are sup posed to clea r up in fection b e fo re o p era tin g. Suppose w e h a v e a p a rtia lly erupted tooth, and the patient is h a v in g p eritonitis and p a r tial trism us, the in fection lastin g f o r w eeks w ith ou t c le a r in g up. Is there any m ethod by w h ich that in fection can be cleared up b e fo re op era tion ? D r . R o u n d s: A treatm ent fo r that case w a s indicated by D r. F ahy. Some cases are stub
born , but w e w o u ld n ’ t attem pt to operate in those cases until the in fection w a s cleared up, unless it w a s n ecessa ry to operate. A question w a s asked ab ou t sedatives. W e u n ifo rm ly p rescribe internal sedatives. T h ose D r. F ahy in d icated w ere acetyl sa licy lic acid (a s p ir in ), p henacetin an d coca in com b in a tio n s; w h a tev er seem s to be in d icated by the sev erity o f the case. I usually internal sed atives im m ediately. D r.
M ackay:
Do
you
a d v ise
adm inister use
of
a
cath artic b e fo re the op era tion ? D r . R ou n d s: It is p e rfe ctly log ica l that the b ow els should be open, but unless there is som e sp ecia l reason, I see no ind ication f o r a cathartic. R . 1'. S om ers, N o r fo lk , V a .:
W h a t is the
m ost p ra ctical m eth od f o r p rev en tin g saliv a co m in g into the w ou n d in the op era tion fo r the im pacted third m o la r ? D r. R ou n d s:
M y m ethod is to use a large
cotton pad, about 4 inches square and h a lf an inch thick and v a r ie d a c c o rd in g to the size o f the m outh.
T h is
is used fo r three
p u rp o ses: (1 ) to w a ll off the field and keep the saliv a a w a y ; (2 ) to p rev en t any atm os p h eric oxygen com in g into the field and dilut in g the gas m ix tu re ; (3 ) to catch any débris, spicules o r an yth in g that m igh t escape into the throat. I find that adequ ate in protectin g the field fr o m saliv a. D r . S o m e r s: D o you use the sam e m ethod in Ideal anesthesia? D r. R o u n d s: I w o u ld use that on the lin g u a l, and, if necessary, on the m edial aspect. I w o u ld use w h a tev er w a s in d icated to p re vent saliv a g ettin g into the area o f operation .