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Treatment of Periapical Infection by Conservative Methods*
TREATMENT OF PERIAPICAL INFECTION BY CONSERVATIVE METHODS* B y L O U IS I. G RO SSM A N , D .D .S., D r. M ed. D ent. (R o sto c k ), P h ilad elp h ia, P a.
A T this time, when the city of Chicago / - \ is celebrating a century of progress, it seems fitting for us to determine w hat progress we have made. Leaving other dental problems aside, and confin ing ourselves for the present to the prob lem of the pulpless tooth, w hat progress can be recorded in its behalf? W h a t is the status of the pulpless tooth today? W h a t improvements have been made in root-canal therapy, th at pulpless teeth may be retained safely? L et us tu rn back a leaf and recall an im portant event of the past. Several years have now elapsed since W illiam H u n te r1 focused the attention of both the dental and the medical pro fession on dental sepsis and its systemic relationship. W hile he did not specifically aim his remarks at the pulpless tooth, but at oral sepsis from neglected mouths and at poorly fitting dentures around which bacteria and food debris accumulated, the pulpless tooth has come in for the lion’s share of criticism. T h e extraction orgy which followed H u n te r’s declaration has since been deprecated even by the most ardent advocates of the focal infection theory (Billings,2 M ayo,3 etc.). Today, the conservative treatm ent of pulpless *Read at the Seventy-Fifth Annual Session of the American Dental Association in con junction w ith the Chicago Centennial Dental Congress, Aug. 9, 1933. 1. Hunter, W illiam : Importance of Oral Sepsis, lecture given at M cGill University, Oct. 3, 1910. Jour. A .D .A ., September, 1934
teeth is beginning to be regarded as a safe procedure again. T h ere is a renewed in terest at dental meetings in methods of root-canal therapy. You will, I believe, agree w ith me that the chief difference in the practice of rootcanal therapy today from th at of the past is in the application of bacteriologic prin ciples. T h e dawn of a better root-canal therapy began w ith the introduction of an aseptic technic, when the principles of asepsis rather than antisepsis were intro duced into dental practice. T his marked a distinct departure from the previous concept of root-canal management, w ith the attainment of better results. I believe that still better results can be expected ju st as soon as we come to apply bacteri ologic methods w ith greater frequency to determine whether the periapical area is sterile before the canal is filled. . Bacteriologic methods have not alone fostered better root-canal work. O f in estimable value have been the roentgen rays. Further, im portant contributions to our knowledge of the pulpless tooth have been made by histologic methods. L et us examine some recent studies in each of these fields. In th at way, we can perhaps 2. Billings, Frank, quoted by Buckley, J. P .: Pulpless Tooth Pathology and Conserva tion; and New Method and Technic of Fill ing Root Canals, J.A.D.A., 16:44-61 (Jan.) 1929. 3. Mayo, C. H .: Interdependence of M edi cine and Dentistry, J.A.D.A., 15:2011-2017 (Nov.) 1928.
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gain a better idea of the present status of the pulpless tooth. I t should be mentioned here th a t a pulpless tooth is not a “ dead” tooth. T h e word “ dead” in this connection is a mis nomer. Ju s t how dead such a tooth is can easily be determined by attem pting to remove it w ithout the use of an anes thetic. I t is unfortunate th at this term has crept into dental usage and literature. T h e principal factor in determining whether a tooth is actually dead tissue, and hence a foreign body, is the periden tal membrane. T h e biologic studies of Boulger4 show that a noninfected pulp less tooth cannot be considered a foreign body. Boulger implanted root ends in the muscle tissue of white rats and later studied the tissue histologically. H e ob served no abnormal reaction in the sur rounding muscle tissue from the presence of either root ends of sound, healthy teeth or of roentgenologically negative pulpless teeth. Conversely, round-cell infiltration was observed when root ends which showed pathosis roentgenologically were implanted. I t is perhaps unnecessary to go into detail other than to mention the wealth of roentgenologic evidence of successful treatm ent of pulpless teeth. Roentgen ologic proof alone is insufficient unless it is supported by histologic and bactério logie evidence. T h e studies of Cram er and Rieth5 are therefore pertinent. In a quan titative bacteriologic study of 200 teeth, they observed a correlation between roent genologic and bacteriologic findings. T hey found that, generally speaking, the greater the degree of pathosis shown by 4. Boulger, E. P.: Reaction of R at Tissue to Implanted Root Ends, J.A.D.A., 18:988-1008 (June) 1931. 5. Cramer, H. C., and Reith, A. F.: Quan titative Bacteriologic Study of Pulpless Teeth Correlated w ith Dental Roentgenograms, J.A.D.A., 19:976-982 (June) 1932.
the roentgenogram, the greater the degree of bacterial involvement. As far as the relationship existing be tween roentgenologic and histologic evi dence is concerned, H atto n 8 says: “T h e histologic studies made by a considerable number of men in this country and abroad tend to verify the conclusion based on x-ray examination.” Referring far ther to the histology of the periapical tissue, H atton says: T he nature of the changes that take place after the tooth has been treated and filled is similar to the healing of a broken bone. First, there is a period in which the necrotic and damaged tissues are removed or resorbed. Sec ond, there occurs a regenerating phase in which new tissues are formed in the apical region and about the filling m aterial; the den tin and cementum of the apex both inside and outside of the canal are covered by new layers of osteoid cementum which is quite dense and solid. Occasionally this layer even covers the filling material.
T h is description of the periapical area of healed pulpless teeth tallies closely w ith that of a case described by Coolidge7 after root resection. A nd yet root-resected teeth have seldom been challenged. I have made an attem pt to determine the bacteriologic status of the periapical area some time after root-canal therapy.8 Cultures were obtained from the periap ical region of twenty-three teeth at time intervals varying from a few months to three years after root-canal therapy and filling. O f this number, twenty-two were found to be sterile. T h e few studies just cited tend to show (1) that at least in some instances the periapical area of a pulpless tooth can be rendered safe to the patient, as deter 6. Hatton, E. H .: D. Cosmos, 70:249-253 (M arch) 1928. 7. Coolidge, E. D .: Root Resection as Cure for Chronic Periapical Infection, J.A.D.A., 17:239-249 (Feb.) 1930. 8. Grossman, L. I.: J. D. Res., 12:939-944 (Dec.) 1932.
Grossman— Treatm ent of Periapical Infection mined by roentgenologic, bacteriologic and histologic criteria; and (2) that, once rendered sterile, the periapical area w ill probably remain so. T h is leads us directly to a discussion of the method of treatm ent. From a clinical standpoint at least, regardless of whether an infected pulpless tooth pre sents a granulomatous area, an apical abscess or a putrescent pulp, the method of treatm ent is essentially the same. Fundam ental principles of surgery and of chemotherapy, i. e., removal of all organ ic debris and necrotic m aterial, establish ment of drainage, if necessary, and disin fection of the tooth and periapical area, apply equally to each of the pathologic conditions mentioned. I f these principles are correctly applied and the root canal wall, and especially the periapical area, is rendered sterile, repair of the damaged soft tissues in this region w ill follow. T h e conservative treatm ent of pulpless teeth can be divided arbitrarily into three somewhat overlapping phases; namely, mechanical, chemical and therapeutic. I t is assumed th at certain preliminary re quirements for the successful manage m ent of infected pulpless teeth w ill be complied with, such as adjustm ent of the rubber dam and sterilization of the field of operation. In considering mechanical preparation of the root canal, it should not be necessary to describe the procedure in detail. Briefly, the following rules should be observed : 1. D irect access to the root canal must be obtained. 2. In cleansing the canal, smooth in struments must precede rough or barbed ones. 3. In enlarging the canal, small instru ments must precede those of larger size. 4. C utting instruments such as files must be used w ith the pull stroke; i. e., from the apex tow ard the pulp chamber. 5. T h e canal must be opened through
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the apical foramen, th at contact of the medicament w ith the periapical area may be established. 6. N o organic débris shall pass through the apical foramen. 7. T h e apical tissues must not be traumatized. Finally, it is w ell to remember to cleanse the canals thoroughly, for it is often not so much w hat we put into the canals as w hat we take out th at matters. In addition to mechanical instrumen tation, chemical agents may be used to destroy the organic pulp remnants and to assist in enlarging the root canals. F or disorganizing and destroying pulp débris, sodium-potassium alloy can be highly rec ommended. T his chemical was intro duced by Schreier of Vienna at the W o rld ’s Columbian D ental Congress in 1893. Sodium-potassium alloy has a pow erful affinity for moisture and when it comes in contact w ith organic material, a violent chemical reaction takes place. T h e moisture present in the organic tissue combines w ith the sodium-potassium to form the respective hydroxides in a nas cent state. As a result of this reaction, the organic tissue is destroyed and, in a sense, incinerated. T h e sodium-potassium alloy should be used sparingly and carefully. I t should not be passed through the apical foramen into the periapical area. A small quantity may be carried into the canal on a fine broach. A fter it has disintegrated the organic tissue, a barbed broach should be used to cleanse the canal of its débris. If more organic material remains in the canal, the application of sodiumpotassium may be repeated until the canal is entirely devoid of organic tissue. W here a canal is narrow or obstructed and will not allow an instrum ent to pass through it to the apex, or if enlargement of the canal is indicated, a 30 per cent so lution of hydrochloric acid may be used. T h e acid is placed in the pulp chamber
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and worked into the canal as far as pos sible w ith a smooth broach or pick. Picks are especially serviceable for this purpose. A fter access has been gained to the apex of the tooth, the use of files is indicated to widen or enlarge the canal. W h en the canal is greatly obstructed and 30 per cent hydrochloric acid has failed to open the canal farther, a 50 per cent solution of reverse aqua regia as recommended by P rin z9 may be tried. T h e formula for this solution is as fol lows: hydrochloric acid, 1 p a rt; nitric acid, 4 p arts; distilled w ater, 5 parts. T h is acid is extremely powerful and dissolves tooth structure quickly. O nly a drop of the acid should be used at a time, being placed directly over the orifice lead ing to the canal. Because it readily dis solves steel, it should preferably be worked into the canal w ith a fine plati num wire. If a steel broach is used, it should be changed frequently, to mini mize the risk incident to the broach’s be coming corroded and weakened by the acid. Picks, broaches or files should also be used simultaneously with, or after the use of, the acid. A concentrated solution of sodium bicarbonate or sodium dioxide in substance should then be carried into the canal to neutralize the acid. Finally, the canals should be thoroughly dried by means of paper points in preparation for the next stage in the treatm ent. T w o distinct therapeutic methods are available. T h e first and more commonly used is the topical application of a drug; i. e., the simple procedure of sealing a medicament in the root canal. T h e sec ond method requires the use of a direct electric current in conjunction w ith a medicament. T h e form er method may be used when the periapical tissue has not yet been de
stroyed, as in a case of gangrenous or putrescent pulp showing no apical pathosis. T h e latter method is indicated when apical pathosis is present or when the former method has failed to eliminate the infection. W e shall discuss the first method first. O f the many antiseptics used in the treat m ent of pulpless teeth, chlorine prepara tions seem to have given the best results. T h e objection to such preparations is their chemical instability and lack of pro longed disinfectant action. These disad vantages have been overcome in mono chlorphenol, which is made by passing chlorine gas through liquefied phenol. T h ree isomers exist, the one used for our purpose being paramonchlorphenol. I t appears in almost colorless crystals having a weakly pungent odor and is soluble in alcohol, ether, benzol and chloroform and slightly soluble in w ater. I t is not affected by ordinary exposure to light or heat. In order to reduce its slight escharotic effect, monochlorphenol is mixed w ith camphor in the proportions of 3 parts monochlor phenol to 2 parts camphor. T h e crystals of monochlorphenol combine readily w ith the camphor, and on being triturated in a m ortar, the two w ill form a clear, trans parent, somewhat oily liquid. 'F o r topical application, camphorated chlorphenol approaches an ideal rootcanal antiseptic. In accordance w ith gen eral principles of root-canal management, dressings of camphorated chlorphenol should be renewed, preferably every forty-eight hours, although the drug re mains effective even after a longer period of time. In sealing the medicament into the tooth, the canal w all should be well coated with the medicament, and because it is nonirritating, a drop of the medica ment may even be pumped through the foramen into the periapical area. O w ing 9. Prinz, Herm ann: Diseases of Soft Struc to its slight solvent action on guttapercha, tures of Teeth, Philadelphia: Lea & Febiger, dressings should either be sealed with 1928; p. 185.
Grossman— T reatm ent of Periapical Infection temporary cement or w ith a double layer of guttapercha. Before insertion of the cement or guttapercha, the walls of the tooth should be wiped w ith chloroform to remove any excess of the drug and thereby insure a tight seal. T h e second method of therapy is w ith electrosterilization. W h a t advantage does this method have over the ordinary topi cal application of a root-canal medica ment ? According to the studies of Gross man and Appleton,10 a distinct advantage is afforded in th at a greater antibacterial effect is obtained. T hey have found that, for the same root-canal disinfectant, the antibacterial effect is more than twice as great w ith electrolysis than w ithout it. Further, my own clinical studies11 and those of W erth er12 show th at it requires fewer treatm ents by this method to obtain a negative culture, and th at it has been possible to obtain the sterility of the root canal and periapical area by the electro sterilization method after the usual method of medication had failed. W hen applied intelligently, the electrosteriliza tion method is probably the best that we have at our command for the conserva tive treatm ent of pulpless teeth. Follow ing is a brief outline of the electrosteril ization technic: I t is assumed that the mechanicochemical preparation of the canal has already been done. T h e n : 1. T h e rubber dam is applied and the field of operation is sterilized. 2. T h e dressing from the previous sit ting is removed and the canal is dried w ith sterile paper points. 3. T h e canal is flooded to the apex w ith the following solution: zinc iodide, 10. Grossman, L. I., and Appleton, J. L. T., J r .: D. Cosmos, 73:147-160 (Feb.) 1931. 11. Grossman, L. I.: D. Cosmos, 74:324-327 (A pril) 1932. 12. W erther, R .: D. Cosmos, 74:328-331 (A pril) 1932.
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15 g m .; iodine crystals, 0.6 gm .; distilled w ater, 50 c.c. O nly iridioplatinum or stainless steel instruments are used in conveying this solution into the root canal. 4. A suitable iridioplatinum electrode is then selected, one which w ill fit the root canal somewhat loosely and reach to the apical foramen. T h e electrode is flamed, allowed to cool and placed in the root-canal as near the apex as possible. (M ake certain this electrode is in circuit w ith the positive pole of the battery.) 5. T h e current is switched off by tu rn ing the rheostat dial back to zero, and the patient is given the negative tube electrode, which is held firmly in the palm of the hand. (See th at no metallic objects such as bracelets, rings, etc., come into contact w ith the hand electrode.) 6. T h e current is then turned on grad ually and the patient is requested to in form you when a tingling sensation is felt in the tooth. W hen the patient re sponds, the current strength is diminished slightly so th a t the tooth feels entirely comfortable. 7. T h e number of milliamperes on the m eter is then noted. T h e dosage is cal culated by dividing the number of m illi amperes into thirty, according to the form ula 30 _ ma.
in minutes. In other words, the product obtained by m ultiplying the number of milliamperes by the time in minutes should equal 30 milliampere-minutes. 8. If necessary, a drop of the electro lyte is deposited in the root canal from tim e to time to replenish that which has evaporated or has been carried beyond the root apex. T h e current must be turned off before the electrode is removed from the root canal; otherwise the patient may experience a sudden shock. 9. O n expiration of the required time, the current is turned off and the elec-
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trodes are removed. In m ultirooted progress in the conservative treatm ent of teeth, each root canal should be treated periapical infection w ill depend on a more separately. rigorous bacteriologic control of the root 10. A sterile paper point is then sat canal and periapical area before the canal urated w ith the zinc iodide-iodine elec filling is inserted. Unless this is done, trolyte and sealed in the tooth. T re a t we shall d rift back again to the uncertain ments should be renewed preferably every methods of the past until another H u n ter forty-eight hours. W hen the tooth yields will arise to point an accusing finger at a negative smear and culture, the canal us, w ith this difference: T h e practices is ready for filling. of the past can be condoned because of In conclusion, I should like to repeat a lack of bacteriologic knowledge at and emphasize the last sentence: “W hen th at tim e; those of the present and fu the tooth yields a negative smear and ture cannot be condoned because that culture, the canal is ready for filling.” knowledge is now available. Shall we T o my mind, the next im portant bit of apply it?
GOLD FOIL By HERBERT ELY WILLIAMS, D.D.S., Red Bank, N . J. O L D from the beginning of time to the present day has been the one and only virtually changeless standard of value. I t is sought, held and cherished by all peoples and nations of the earth. G old foil likewise is the standard filling m aterial in the realm of operative dentistry. G old foil being the accepted standard, the various other filling ma terials, w ith all their adaptable uses, are substitutes. I desire to present the subject from a psychologic angle rather than a technical one, as the profession seems to be already rather “over technicked.” W ebster defines psychology as “the science of m ental phenomena.” As applied to dentistry, we are more concerned in w hat it does or should do than in w hat it really is; not in the w ord itself, but in its effect on us in accomplishing certain tasks in an easier, quicker fashion. I prefer to appeal to the reader’s reason
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and ambition rather than to his methods or technical skill. “Fear is m an’s greatest enemy,” F ranklin D . Roosevelt says. “T h e only thing we have to fear is fear itself.” T h e chief obstacle in handling gold foil is fear. Fear th at the rubber dam w ill leak, fear th at the foil w ill fail to weld, fear th at the filling w ill tumble out when half done, fear of this and of that, fear of everything. I t is fear th at makes the manipulation of gold foil an arduous, painstaking task rather than a pleasurable, profitable pastime. I am reminded of a physical giant of the gridiron, hero of many a game, un afraid of m an or m atter but who would break out in beads of perspiration over the very thought of a foil filling. F ear is offset by confidence. Con fidence is gained only in doing hundreds of easy accessible foil fillings on occlusal surfaces. Confidence can be gained in no other way. I t would seem unwise to
A T this time, when the city of Chicago / - \ is celebrating a century of progress, it seems fitting for us to determine w hat progress we have made. Leaving other dental problems aside, and confin ing ourselves for the present to the prob lem of the pulpless tooth, w hat progress can be recorded in its behalf? W h a t is the status of the pulpless tooth today? W h a t improvements have been made in root-canal therapy, th at pulpless teeth may be retained safely? L et us tu rn back a leaf and recall an im portant event of the past. Several years have now elapsed since W illiam H u n te r1 focused the attention of both the dental and the medical pro fession on dental sepsis and its systemic relationship. W hile he did not specifically aim his remarks at the pulpless tooth, but at oral sepsis from neglected mouths and at poorly fitting dentures around which bacteria and food debris accumulated, the pulpless tooth has come in for the lion’s share of criticism. T h e extraction orgy which followed H u n te r’s declaration has since been deprecated even by the most ardent advocates of the focal infection theory (Billings,2 M ayo,3 etc.). Today, the conservative treatm ent of pulpless *Read at the Seventy-Fifth Annual Session of the American Dental Association in con junction w ith the Chicago Centennial Dental Congress, Aug. 9, 1933. 1. Hunter, W illiam : Importance of Oral Sepsis, lecture given at M cGill University, Oct. 3, 1910. Jour. A .D .A ., September, 1934
teeth is beginning to be regarded as a safe procedure again. T h ere is a renewed in terest at dental meetings in methods of root-canal therapy. You will, I believe, agree w ith me that the chief difference in the practice of rootcanal therapy today from th at of the past is in the application of bacteriologic prin ciples. T h e dawn of a better root-canal therapy began w ith the introduction of an aseptic technic, when the principles of asepsis rather than antisepsis were intro duced into dental practice. T his marked a distinct departure from the previous concept of root-canal management, w ith the attainment of better results. I believe that still better results can be expected ju st as soon as we come to apply bacteri ologic methods w ith greater frequency to determine whether the periapical area is sterile before the canal is filled. . Bacteriologic methods have not alone fostered better root-canal work. O f in estimable value have been the roentgen rays. Further, im portant contributions to our knowledge of the pulpless tooth have been made by histologic methods. L et us examine some recent studies in each of these fields. In th at way, we can perhaps 2. Billings, Frank, quoted by Buckley, J. P .: Pulpless Tooth Pathology and Conserva tion; and New Method and Technic of Fill ing Root Canals, J.A.D.A., 16:44-61 (Jan.) 1929. 3. Mayo, C. H .: Interdependence of M edi cine and Dentistry, J.A.D.A., 15:2011-2017 (Nov.) 1928.
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gain a better idea of the present status of the pulpless tooth. I t should be mentioned here th a t a pulpless tooth is not a “ dead” tooth. T h e word “ dead” in this connection is a mis nomer. Ju s t how dead such a tooth is can easily be determined by attem pting to remove it w ithout the use of an anes thetic. I t is unfortunate th at this term has crept into dental usage and literature. T h e principal factor in determining whether a tooth is actually dead tissue, and hence a foreign body, is the periden tal membrane. T h e biologic studies of Boulger4 show that a noninfected pulp less tooth cannot be considered a foreign body. Boulger implanted root ends in the muscle tissue of white rats and later studied the tissue histologically. H e ob served no abnormal reaction in the sur rounding muscle tissue from the presence of either root ends of sound, healthy teeth or of roentgenologically negative pulpless teeth. Conversely, round-cell infiltration was observed when root ends which showed pathosis roentgenologically were implanted. I t is perhaps unnecessary to go into detail other than to mention the wealth of roentgenologic evidence of successful treatm ent of pulpless teeth. Roentgen ologic proof alone is insufficient unless it is supported by histologic and bactério logie evidence. T h e studies of Cram er and Rieth5 are therefore pertinent. In a quan titative bacteriologic study of 200 teeth, they observed a correlation between roent genologic and bacteriologic findings. T hey found that, generally speaking, the greater the degree of pathosis shown by 4. Boulger, E. P.: Reaction of R at Tissue to Implanted Root Ends, J.A.D.A., 18:988-1008 (June) 1931. 5. Cramer, H. C., and Reith, A. F.: Quan titative Bacteriologic Study of Pulpless Teeth Correlated w ith Dental Roentgenograms, J.A.D.A., 19:976-982 (June) 1932.
the roentgenogram, the greater the degree of bacterial involvement. As far as the relationship existing be tween roentgenologic and histologic evi dence is concerned, H atto n 8 says: “T h e histologic studies made by a considerable number of men in this country and abroad tend to verify the conclusion based on x-ray examination.” Referring far ther to the histology of the periapical tissue, H atton says: T he nature of the changes that take place after the tooth has been treated and filled is similar to the healing of a broken bone. First, there is a period in which the necrotic and damaged tissues are removed or resorbed. Sec ond, there occurs a regenerating phase in which new tissues are formed in the apical region and about the filling m aterial; the den tin and cementum of the apex both inside and outside of the canal are covered by new layers of osteoid cementum which is quite dense and solid. Occasionally this layer even covers the filling material.
T h is description of the periapical area of healed pulpless teeth tallies closely w ith that of a case described by Coolidge7 after root resection. A nd yet root-resected teeth have seldom been challenged. I have made an attem pt to determine the bacteriologic status of the periapical area some time after root-canal therapy.8 Cultures were obtained from the periap ical region of twenty-three teeth at time intervals varying from a few months to three years after root-canal therapy and filling. O f this number, twenty-two were found to be sterile. T h e few studies just cited tend to show (1) that at least in some instances the periapical area of a pulpless tooth can be rendered safe to the patient, as deter 6. Hatton, E. H .: D. Cosmos, 70:249-253 (M arch) 1928. 7. Coolidge, E. D .: Root Resection as Cure for Chronic Periapical Infection, J.A.D.A., 17:239-249 (Feb.) 1930. 8. Grossman, L. I.: J. D. Res., 12:939-944 (Dec.) 1932.
Grossman— Treatm ent of Periapical Infection mined by roentgenologic, bacteriologic and histologic criteria; and (2) that, once rendered sterile, the periapical area w ill probably remain so. T h is leads us directly to a discussion of the method of treatm ent. From a clinical standpoint at least, regardless of whether an infected pulpless tooth pre sents a granulomatous area, an apical abscess or a putrescent pulp, the method of treatm ent is essentially the same. Fundam ental principles of surgery and of chemotherapy, i. e., removal of all organ ic debris and necrotic m aterial, establish ment of drainage, if necessary, and disin fection of the tooth and periapical area, apply equally to each of the pathologic conditions mentioned. I f these principles are correctly applied and the root canal wall, and especially the periapical area, is rendered sterile, repair of the damaged soft tissues in this region w ill follow. T h e conservative treatm ent of pulpless teeth can be divided arbitrarily into three somewhat overlapping phases; namely, mechanical, chemical and therapeutic. I t is assumed th at certain preliminary re quirements for the successful manage m ent of infected pulpless teeth w ill be complied with, such as adjustm ent of the rubber dam and sterilization of the field of operation. In considering mechanical preparation of the root canal, it should not be necessary to describe the procedure in detail. Briefly, the following rules should be observed : 1. D irect access to the root canal must be obtained. 2. In cleansing the canal, smooth in struments must precede rough or barbed ones. 3. In enlarging the canal, small instru ments must precede those of larger size. 4. C utting instruments such as files must be used w ith the pull stroke; i. e., from the apex tow ard the pulp chamber. 5. T h e canal must be opened through
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the apical foramen, th at contact of the medicament w ith the periapical area may be established. 6. N o organic débris shall pass through the apical foramen. 7. T h e apical tissues must not be traumatized. Finally, it is w ell to remember to cleanse the canals thoroughly, for it is often not so much w hat we put into the canals as w hat we take out th at matters. In addition to mechanical instrumen tation, chemical agents may be used to destroy the organic pulp remnants and to assist in enlarging the root canals. F or disorganizing and destroying pulp débris, sodium-potassium alloy can be highly rec ommended. T his chemical was intro duced by Schreier of Vienna at the W o rld ’s Columbian D ental Congress in 1893. Sodium-potassium alloy has a pow erful affinity for moisture and when it comes in contact w ith organic material, a violent chemical reaction takes place. T h e moisture present in the organic tissue combines w ith the sodium-potassium to form the respective hydroxides in a nas cent state. As a result of this reaction, the organic tissue is destroyed and, in a sense, incinerated. T h e sodium-potassium alloy should be used sparingly and carefully. I t should not be passed through the apical foramen into the periapical area. A small quantity may be carried into the canal on a fine broach. A fter it has disintegrated the organic tissue, a barbed broach should be used to cleanse the canal of its débris. If more organic material remains in the canal, the application of sodiumpotassium may be repeated until the canal is entirely devoid of organic tissue. W here a canal is narrow or obstructed and will not allow an instrum ent to pass through it to the apex, or if enlargement of the canal is indicated, a 30 per cent so lution of hydrochloric acid may be used. T h e acid is placed in the pulp chamber
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The Journal of the American D ental Association
and worked into the canal as far as pos sible w ith a smooth broach or pick. Picks are especially serviceable for this purpose. A fter access has been gained to the apex of the tooth, the use of files is indicated to widen or enlarge the canal. W h en the canal is greatly obstructed and 30 per cent hydrochloric acid has failed to open the canal farther, a 50 per cent solution of reverse aqua regia as recommended by P rin z9 may be tried. T h e formula for this solution is as fol lows: hydrochloric acid, 1 p a rt; nitric acid, 4 p arts; distilled w ater, 5 parts. T h is acid is extremely powerful and dissolves tooth structure quickly. O nly a drop of the acid should be used at a time, being placed directly over the orifice lead ing to the canal. Because it readily dis solves steel, it should preferably be worked into the canal w ith a fine plati num wire. If a steel broach is used, it should be changed frequently, to mini mize the risk incident to the broach’s be coming corroded and weakened by the acid. Picks, broaches or files should also be used simultaneously with, or after the use of, the acid. A concentrated solution of sodium bicarbonate or sodium dioxide in substance should then be carried into the canal to neutralize the acid. Finally, the canals should be thoroughly dried by means of paper points in preparation for the next stage in the treatm ent. T w o distinct therapeutic methods are available. T h e first and more commonly used is the topical application of a drug; i. e., the simple procedure of sealing a medicament in the root canal. T h e sec ond method requires the use of a direct electric current in conjunction w ith a medicament. T h e form er method may be used when the periapical tissue has not yet been de
stroyed, as in a case of gangrenous or putrescent pulp showing no apical pathosis. T h e latter method is indicated when apical pathosis is present or when the former method has failed to eliminate the infection. W e shall discuss the first method first. O f the many antiseptics used in the treat m ent of pulpless teeth, chlorine prepara tions seem to have given the best results. T h e objection to such preparations is their chemical instability and lack of pro longed disinfectant action. These disad vantages have been overcome in mono chlorphenol, which is made by passing chlorine gas through liquefied phenol. T h ree isomers exist, the one used for our purpose being paramonchlorphenol. I t appears in almost colorless crystals having a weakly pungent odor and is soluble in alcohol, ether, benzol and chloroform and slightly soluble in w ater. I t is not affected by ordinary exposure to light or heat. In order to reduce its slight escharotic effect, monochlorphenol is mixed w ith camphor in the proportions of 3 parts monochlor phenol to 2 parts camphor. T h e crystals of monochlorphenol combine readily w ith the camphor, and on being triturated in a m ortar, the two w ill form a clear, trans parent, somewhat oily liquid. 'F o r topical application, camphorated chlorphenol approaches an ideal rootcanal antiseptic. In accordance w ith gen eral principles of root-canal management, dressings of camphorated chlorphenol should be renewed, preferably every forty-eight hours, although the drug re mains effective even after a longer period of time. In sealing the medicament into the tooth, the canal w all should be well coated with the medicament, and because it is nonirritating, a drop of the medica ment may even be pumped through the foramen into the periapical area. O w ing 9. Prinz, Herm ann: Diseases of Soft Struc to its slight solvent action on guttapercha, tures of Teeth, Philadelphia: Lea & Febiger, dressings should either be sealed with 1928; p. 185.
Grossman— T reatm ent of Periapical Infection temporary cement or w ith a double layer of guttapercha. Before insertion of the cement or guttapercha, the walls of the tooth should be wiped w ith chloroform to remove any excess of the drug and thereby insure a tight seal. T h e second method of therapy is w ith electrosterilization. W h a t advantage does this method have over the ordinary topi cal application of a root-canal medica ment ? According to the studies of Gross man and Appleton,10 a distinct advantage is afforded in th at a greater antibacterial effect is obtained. T hey have found that, for the same root-canal disinfectant, the antibacterial effect is more than twice as great w ith electrolysis than w ithout it. Further, my own clinical studies11 and those of W erth er12 show th at it requires fewer treatm ents by this method to obtain a negative culture, and th at it has been possible to obtain the sterility of the root canal and periapical area by the electro sterilization method after the usual method of medication had failed. W hen applied intelligently, the electrosteriliza tion method is probably the best that we have at our command for the conserva tive treatm ent of pulpless teeth. Follow ing is a brief outline of the electrosteril ization technic: I t is assumed that the mechanicochemical preparation of the canal has already been done. T h e n : 1. T h e rubber dam is applied and the field of operation is sterilized. 2. T h e dressing from the previous sit ting is removed and the canal is dried w ith sterile paper points. 3. T h e canal is flooded to the apex w ith the following solution: zinc iodide, 10. Grossman, L. I., and Appleton, J. L. T., J r .: D. Cosmos, 73:147-160 (Feb.) 1931. 11. Grossman, L. I.: D. Cosmos, 74:324-327 (A pril) 1932. 12. W erther, R .: D. Cosmos, 74:328-331 (A pril) 1932.
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15 g m .; iodine crystals, 0.6 gm .; distilled w ater, 50 c.c. O nly iridioplatinum or stainless steel instruments are used in conveying this solution into the root canal. 4. A suitable iridioplatinum electrode is then selected, one which w ill fit the root canal somewhat loosely and reach to the apical foramen. T h e electrode is flamed, allowed to cool and placed in the root-canal as near the apex as possible. (M ake certain this electrode is in circuit w ith the positive pole of the battery.) 5. T h e current is switched off by tu rn ing the rheostat dial back to zero, and the patient is given the negative tube electrode, which is held firmly in the palm of the hand. (See th at no metallic objects such as bracelets, rings, etc., come into contact w ith the hand electrode.) 6. T h e current is then turned on grad ually and the patient is requested to in form you when a tingling sensation is felt in the tooth. W hen the patient re sponds, the current strength is diminished slightly so th a t the tooth feels entirely comfortable. 7. T h e number of milliamperes on the m eter is then noted. T h e dosage is cal culated by dividing the number of m illi amperes into thirty, according to the form ula 30 _ ma.
in minutes. In other words, the product obtained by m ultiplying the number of milliamperes by the time in minutes should equal 30 milliampere-minutes. 8. If necessary, a drop of the electro lyte is deposited in the root canal from tim e to time to replenish that which has evaporated or has been carried beyond the root apex. T h e current must be turned off before the electrode is removed from the root canal; otherwise the patient may experience a sudden shock. 9. O n expiration of the required time, the current is turned off and the elec-
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T he Journal of the American D ental Association
trodes are removed. In m ultirooted progress in the conservative treatm ent of teeth, each root canal should be treated periapical infection w ill depend on a more separately. rigorous bacteriologic control of the root 10. A sterile paper point is then sat canal and periapical area before the canal urated w ith the zinc iodide-iodine elec filling is inserted. Unless this is done, trolyte and sealed in the tooth. T re a t we shall d rift back again to the uncertain ments should be renewed preferably every methods of the past until another H u n ter forty-eight hours. W hen the tooth yields will arise to point an accusing finger at a negative smear and culture, the canal us, w ith this difference: T h e practices is ready for filling. of the past can be condoned because of In conclusion, I should like to repeat a lack of bacteriologic knowledge at and emphasize the last sentence: “W hen th at tim e; those of the present and fu the tooth yields a negative smear and ture cannot be condoned because that culture, the canal is ready for filling.” knowledge is now available. Shall we T o my mind, the next im portant bit of apply it?
GOLD FOIL By HERBERT ELY WILLIAMS, D.D.S., Red Bank, N . J. O L D from the beginning of time to the present day has been the one and only virtually changeless standard of value. I t is sought, held and cherished by all peoples and nations of the earth. G old foil likewise is the standard filling m aterial in the realm of operative dentistry. G old foil being the accepted standard, the various other filling ma terials, w ith all their adaptable uses, are substitutes. I desire to present the subject from a psychologic angle rather than a technical one, as the profession seems to be already rather “over technicked.” W ebster defines psychology as “the science of m ental phenomena.” As applied to dentistry, we are more concerned in w hat it does or should do than in w hat it really is; not in the w ord itself, but in its effect on us in accomplishing certain tasks in an easier, quicker fashion. I prefer to appeal to the reader’s reason
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Jour. A .D .A .J Septem ber, 1934
and ambition rather than to his methods or technical skill. “Fear is m an’s greatest enemy,” F ranklin D . Roosevelt says. “T h e only thing we have to fear is fear itself.” T h e chief obstacle in handling gold foil is fear. Fear th at the rubber dam w ill leak, fear th at the foil w ill fail to weld, fear th at the filling w ill tumble out when half done, fear of this and of that, fear of everything. I t is fear th at makes the manipulation of gold foil an arduous, painstaking task rather than a pleasurable, profitable pastime. I am reminded of a physical giant of the gridiron, hero of many a game, un afraid of m an or m atter but who would break out in beads of perspiration over the very thought of a foil filling. F ear is offset by confidence. Con fidence is gained only in doing hundreds of easy accessible foil fillings on occlusal surfaces. Confidence can be gained in no other way. I t would seem unwise to