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No. 1012 WALNUT STREET, PHILADELPHIA. HANDBOOK 
OF 
Dental Anatomy 
AND 
SURGERY. 
BY 
HENRY SEWELL, M.D., D.D.S., 
MEMBER OF THE ROYAL COLLEGE OF SURGEONS ; HONORARY SECRETARY ODONTO- 
LOGICAL SOCIETY OF GREAT BRITAIN; DENTIST TO WEST LONDON HOSPITAL. 
SEVENTY-SEVEN ILLUSTRATIONS. 
PHILADELPHIA: 
P. BLAKISTON, SON & CO., 
1012 WALNUT STREET. 
1882. PREFACE. 
No department of physiology or surgery has of late 
years made greater progress than that connected with 
the teeth, and this advance has been necessarily attended 
by a corresponding increase in the literature of the sub- 
ject, which has now become so voluminous as to form a 
source of embarrassment to those who are entering upon 
a course of dental education. Under these circumstances 
the projectors of the “Student’s Guide” manuals have 
considered a work on Dental Anatomy and Surgery a 
desirable addition to the series. It is designed that these 
manuals should be free from needless technicalities; that 
they should facilitate the labors of the student; and that 
whilst each volume—although presenting merely an out- 
line of the subject—should be complete in itself, it should 
at the same time lead the reader to desire, and direct him 
in seeking, the fuller knowledge afforded by more ex- 
tended treatises. These designs I have striven to accom- 
plish in this volume. 
It must, however, not be supposed that the student 
can profitably peruse even the most rudimentary text- VI 
PREFACE. 
book on any special branch of physiology or surgery 
without an adequate knowledge of the fundamental 
principles of those sciences; and evidently it can but 
confuse him to encounter such terms as “ nucleus ” and 
“ cell/’ or “ inflammation ” and “ abscess/’ unless he 
have a clear conception of their signification. Such 
knowledge must be obtained previously from element- 
ary works on physiology and surgery. 
Whilst in a work of this kind it is essential that, as 
far as practicable, facts only should be laid before the 
student, it is not possible to avoid altogether the discus- 
sion of controverted points, or at least the description 
of subjects that have as yet been insufficiently inves- 
tigated. Among these subjects must be placed the devel- 
opment of the teeth. The description of this process 
which is found in physiological text-books, even the latest 
editions, is entirely based upon the investigations of 
Goodsir, which were published by him in the Edinburgh 
Medical and Surgical Journal, in the year 1838. Since 
that date the subject has been investigated by numerous 
physiologists, among whom may be specially mentioned 
Marcusen, Dursy, Kolliker, and Waldeyer, and they are 
agreed with regard to the main facts of the process. 
Aided by the advance of microscopical science since the 
time of Goodsir, they have traced the phenomena of den- 
tal evolution from a period of embryonic life much ear- 
lier than that at which it was supposed to commence by 
that renowned physiologist, and have thus necessarily 
overthrown much of his theory. PREFACE. 
VII 
Messrs. Legros and Magitot have issued the latest 
monograph on the subject—a most elaborate and minute 
description, entirely based upon original observations— 
and the corroboration it receives from previous investi- 
gations, leaves no doubt that it is substantially accurate. 
The section which I have in this manual devoted to the' 
developement of the teeth is merely a summary of the 
work of these physiologists. 
The histogenesis of the dental tissues—the changes 
which take place in the tooth-germ by which its ele- 
ments are gradually converted into these tissues—has 
been, like the preceding subject, investigated by numer- 
ous physiologists, and like it has given rise to consider- 
able difference of opinion. The majority of more recent 
observers (Lent, Kolliker, Marcusen, Huxley, Robin, 
Magitot, Tomes, and Waldeyer) are, however, in accord 
with regard to essential points, and in the account which 
I have given I have attempted to epitomize the main 
facts elucidated by these authorities without entering 
upon controverted topics. 
The theory of the etiology and pathology of caries 
which I have adopted, is entirely based upon generally 
admitted facts; it is that which I believe can alone be 
arrived at by reasoning upon such facts; it is that which 
recently has been enunciated by the best authorities, and 
eventually must be, in my opinion, universally accepted. 
It will be perceived that decay of the teeth is a process 
entirely dissimilar to caries of bone, and that although the VIII 
PREFACE. 
term caries is retained for the sake of convenience, it is 
not really indicative of the true character of the disease. 
No more than passing reference has been made to 
those injuries and diseases of the mouth and jaws that 
are not intimately associated with dental pathology. 
Although these affections necessarily fall much under 
the notice of the dental surgeon, who is therefore required 
to possess a knowledge of their nature, their discussion 
belongs more properly to works on general surgery than 
to those devoted entirely to dental subjects. 
A knowledge having been obtained of the principles 
upon which operative procedures are carried out, and of 
the materials and instruments employed, the student can- 
not commence too soon to acquire skill by practice and 
experiment. This practice is easily obtained by the 
dental student. He may begin by plugging with tinfoil 
cavities cut in bone or ivory or in extracted teeth, each 
stopping after completion being carefully broken up to 
discover in what detail it has failed, or in what direction 
it is capable of improvement. In the same way such 
operations as capping the pulp and fang-filling may also 
be practiced. As soon as the student can with rapidity 
and certainty fill difficult cavities in extracted teeth fixed 
in a vice, he may safely proceed to operate upon simple 
cavities in the mouth of the living subject. Similar re- 
marks may be made with regard to the operation of ex- 
traction. The anatomy of the teeth and of the parts 
around being understood, the student may proceed to PREFACE. 
IX 
apply the forceps to the dilferent kinds of teeth, and 
familiarize himself with the mode in which the instru- 
ment is held, the tooth grasped, and the force applied. 
Every student should subsequently go through a course of 
extracting operations on the dead subject, opportunities 
for which are afforded at every school of medicine. 
Of the illustrations some are original, some are copied, 
and some are borrowed from works the property of the 
publishers. Those illustrating the development of the 
teeth are copied from Messrs. Legros and Magitot’s mono- 
graph. For some of the most valuable I am indebted 
to the admirable works of Messrs. Tomes, Mr. Christo- 
pher Heath, and Mr. Salter. Figs. 33, 35, and Figs. 73 
to 77 are taken by permission from the Transactions of 
the Odontological Society. Among the original engrav- 
ings, those in the sections on preparing cavities and gold 
filling, have been most kindly contributed by my friend 
Mr. Howard Mummery. The cuts of the instruments 
have been supplied by the eminent and well-known firm 
of Ash & Sons, of 7 Broad Street, Golden Square. 
6 Wimpolk Street, W., 
Feb. 1876. CONTENTS. 
PAGE 
Anatomy and Histology of the Teeth, .... 13 
Development of the Teeth, 26 
Growth of the Jaws. Dentition, 37 
Malformations and Irregularities of the Teeth, . 50 
Caries, 76 
Treatment of Caries, 87 
Exposure of the Pulp. Diseases of the Pulp, . . 122 
Dental Periostitis. Alveolar Abscess. Periostitis 
and Necrosis of the Maxillae. Dental Exostosis 
and Necrosis. Absorption of Eoots of Permanent 
Teeth, 137 
Diseases of the Gums and Oral Mucous Membrane, . 151 
Abrasion of the Teeth. Mechanical Injuries, . . 155 
Salivary Calculus or Tartar, 158 
Morbid Growths connected with the Teeth, . . 161 
Diseases of the Antrum, 171 
Pivoting Teeth, 173 
Neuralgia and Diseases of the Nervous System, . 176 
Extraction of Teeth, ....... 182 LIST OF AUTHORS. 
Structure and Development of the 
Teeth. Strieker’s Histology. 
1. Waldeyer, 
Origine du Folliculo Dentaire-Jour- 
nal de l’Anatomie, 1873. 
2. Legros and Magitot, 
3. "VVedl, . . . Pathology of the Teeth. 
4. Tomes, J. & C. S., System of Dental Surgery. 
5. Tomes, Charles S., 
The Attachment of Teeth. Trans. 
Odont. Soc. Vol. VII. New 
Series. 
Nasmyth’s Membrane. Journal of 
Microscopical Science, 1872. 
6. Tomes, Charles S., 
7. Salter, . . . Dental Pathology and Surgery. 
8. Magitot, . . . Traite de la Carie Dentaire. 
9. Heath, . . . Injuries and Diseases of the Jaws. 
Irregularities of the Teeth. Trans. 
Odont. Soc. Vol. V. New Series. 
10. Mason, 
11. Cattlin, 
Accidents in Dental Surgery. Trans. 
Odont. Soc. New Series. 
12. Sewill, 
Irregularities of the Teeth. Lancet, 
1870. 
13. Sewill, 
Papers on Dental Surgery. Dental 
Journal, 1868-72. 
14. Sewill, 
Irregularities and Diseases of the 
Teeth. 
15. Sewill, 
Absolute Alcohol in Dental Opera- 
tions. Trans. Odont. Soc. Vol. VII. 
New Series. THE 
STUDENT’S GUIDE 
TO 
DENTAL ANATOMY AND SURGERY. 
ANATOMY AND HISTOLOGY OF THE TEETH. 
Human teeth are hard structures of a bony charac- 
ter, implanted in the alveoli along the margins of the 
jaws for the purpose of triturating the food preparatory 
to its passage into the stomach, and solution by the gas- 
tric juice. Two sets of teeth are developed during life 
—the first, the temporary, deciduous, or milk teeth, ten 
in each jaw, and the second or permanent teeth, sixteen 
in each jaw. 
The teeth are divided into classes according to their 
function and external configuration, but they have all 
certain characters in common. Every tooth consists of 
a crown, the portion which appears above the gum, a 
root or roots imbedded in the jaw, and a neck, the por- 
tion which unites the crown and root, and which is sur- 
rounded by the free edge of the gum. 
The permanent set is made up of four incisors, formed 14 
ANATOMY AND HISTOLOGY 
for cutting, two canines for cutting and tearing, and 
four bicuspids and six molars for grinding the food. 
The upper incisors have chisel-shaped crowns, the 
front surface convex, the back concave. Viewed later- 
ally the crown is wedge-shaped, the base of the wedge 
being at the gum, the apex at the catting edge. The 
cutting edge is horizontal, its distal angle being rounded, 
its mesial acute. Before becoming worn by mastication 
the edge is marked by three small tubercles, which give 
it a serrated appearance. The root is single, conical, 
and slightly compressed laterally. The central are about 
one-third larger than the lateral incisors. 
The lower incisors are similar in shape to the upper, but 
they are smaller, the root is more flattened at the sides, 
both angles of the cutting edge are acute, and unlike the 
upper teeth the central is less in size than the lateral. 
The canines, or eye teeth, are stronger than the in- 
cisors, to which they bear a general resemblance. The 
crown is convex anteriorly, concave posteriorly, and 
may be compared to that of an incisor with the angles 
bevelled off, and terminating in a sharp central cusp. 
These teeth have one root which is stronger and longer 
than any other of the set. It is conical in shape and 
slightly more flattened laterally than that of an incisor. 
The lower canines are smaller than the corresponding 
upper teeth, the cusp is more obtuse, the root more flat- 
tened at the sides. 
The upper bicuspids viewed from the front, bear a 
close resemblance to the canines, than which however 
they are smaller. The crown springs vertically from 
the neck, its labial and lingual aspects being convex, its 
mesial and distal surfaces somewhat flattened. Its long 
diameter is across the jaw. The masticating surface is OF THE TEETH. 
15 
divided by a deep antero-posterior groove into two cusps, 
of which the inner is the smaller. The root is conical, 
and more compressed laterally than that of either the 
incisor or canine. It is deeply grooved and often bifid, 
the cleft occasionally dividing the root throughout the 
greater part of its length. 
The lower bicuspids are smaller than the upper, the in- 
ternal cusp is less well marked, and the root is much 
compressed, but rarely bifid. 
The molars have crowns of a cube-like form, the labial 
and lingual aspect rounded, the mesial and distal flat- 
tened. The grinding surface is divided by grooves into 
tubercles or cusps. The neck is rounded and well- 
defined. The molars of each jaw decrease in size from 
before backwards. 
The masticating surface of an upper molar has four 
cusps, one at each angle, but in the third molar or wis- 
dom tooth the internal cusps are blended into one mass. 
The first and second upper molars have three conical 
roots, two external spreading apart upwards towards the 
antrum, and one, the smallest, directed towards the pal- 
ate. The latter is occasionally bifid. The root of the 
wisdom tooth is, as a rule, single, forming an irregular 
conical mass, which is often either deeply grooved or 
shows traces of subdivision into three roots. The crowns 
of the lower molars are a little larger than those of the 
upper jaw, and they are surmounted by five cusps, one 
at each angle, and the fifth between the two posterior 
cusps. The first and second lower molars have each 
two roots, one anterior and one posterior. They are 
broad, compressed, and grooved on the surfaces turned 
towards each other, and they have an inclination slightly 
backwards in the jaw. The root of the lower wisdom 16 
ANATOMY AND HISTOLOGY 
tooth, like that of the upper, is often connate, but occa- 
sionally it is bifid or divided into two distinct fangs. 
The entire set of teeth in each jaw are arranged in an 
elliptical curve, the incisors, canines, and bicuspids form- 
ing an almost perfect semicircle, the molars and bicuspids 
continuing the lines backwards. The lower teeth are 
placed vertically in front and looking somewhat inwards 
at the sides and behind, whilst the corresponding upper 
teeth have an inclination forwards in front and outwards 
behind, so that the upper teeth slightly overhang the 
lower. In consequence of this arrangement and the 
difference in size between the teeth of the two jaws, each 
upper tooth on closure of the jaws, impinges partly on 
the corresponding lower tooth and partly on the tooth 
next following; but the upper dental arch being larger 
than the lower, and the upper molars being smaller than 
those of the lower jaw, the upper wisdom teeth do not 
extend backwards beyond the range of the lower teeth. 
The teeth are fixed in position by the implantation of 
their roots in the alveoli of the jaws, the bone, lined 
with periosteum, investing and accurately fitting them 
and providing a separate socket for each root. This 
form of articulation has been termed gomphosis, from 
the resemblance to the impaction of a nail driven into 
wood. 
The annexed diagram from Wedl (3) (Fig. 1), shows 
at one view the form and character of a normal set of 
teeth, the direction and arrangement of the roots within 
the bone, and the relation of the upper and lower sets to 
each other when closed. 
The temporary teeth resemble, the permanent set, but- 
are considerably smaller. There are no bicuspids in 
this set. It is made up of four incisors, two canines, OF THE TEETH. 
17 
and four molars. The first upper molar is smaller than 
the second, and has three cusps, two external, one inter- 
nal. The second upper molar has four cusps. The 
first lower molar is smaller than the second, and has 
Fig. 1. 
four cusps. The second lower molar has five cusps, 
three external, two internal. The roots of the tempo- 
rary set are similar to those of the corresponding perma- 
nent teeth. The fangs of the molars are, however, more 
divergent from the neck of the tooth, and are hollowed 
on their inner aspect to afford space for the crypts of the 
developing bicuspids situated beneath them. 
On section (Fig. 2), each tooth is seen to be composed 
of three tissues, distinct in structure but intimately 
united with each other, the enamel which covers the 
crown, the cement which coats the roots, and the dentine 
which forms the great bulk of the organ. When the 
teeth first make their appearance the enamel is covered 18 
ANATOMY AND HISTOLOGY 
by a thin layer of peculiar tissue, the cuticula dentis or 
Nasmyth’s membrane, which however becomes soon worn 
off by mastication. In the centre of the tooth is the 
pulp-cavity, a chamber similar in shape to the external 
outline of the tooth, and containing a vascular and ner- 
Fig. 2. 
Vertical section of a molar tooth (Huxley). 
a. Enamel. 6. Pulp-cavity, c. Cement, d. Dentine. 
vous structure, the dental pulp. The vessels and nerves 
of the pulp enter the chamber through foramina in the 
apices of the roots. 
The enamel forms a cap or layer adapted to the sur- 
face of the dentine. It attains its greatest thickness on 
the cutting edges and summits of the masticating surface 
of the teeth, whence gradually decreasing, it slopes 
towards the neck and terminates beneath the free edge 
of the gum, where it is slightly overlapped by the cement. 
It is an extremely hard translucent substance, either of 
a yellowish or of a bluish-white color. It is the hard- 
est tissue of the body, ranking in density with limpid 
quartz, and emitting a spark when struck with steel. OF THE TEETH. 
19 
It contains not more than from one to three per cent, of 
organic matter, ninety per cent, of calcium phosphate 
with a trace of fluorine, and four to five per cent, of 
calcium carbonate, the remainder being made up of traces 
of magnesium phosphate and other salts. It is entirely 
soluble in acids, leaving but the smallest trace of organic 
matter. Enamel is devoid of sensibility. 
Examined microscopically enamel is found to consist 
of solid fibres or prisms mostly hexagonal, but some 
nearly square, others nearly circular (Fig. 3), lying par- 
Fig. 3. 
Enamel fibres, viewed in transverse section. 
allel side by side without any intermediate substance. 
These fibres spring from depressions on the surface of 
the dentine, and radiate outwards in an undulating course 
towards the exterior of the tooth, so that their direction 
varies between vertical at the masticating surface and 
horizontal at the sides. Most of the fibres extend through 
the whole thickness of the tissue; and although they 
cannot be demonstrated, there must exist, probably, 
shorter fibres to fill up the intervals which would other- 
wise exist in consequence of the divergence of the longer 
prisms in their outward course. The diameter of the 
prisms is about 5S'50 of an inch. They are mostly 
marked at short regular intervals by transverse striae, so 20 
ANATOMY AND HISTOLOGY 
that each fibre resembles a sheatli containing a line of 
granular masses, but this condition is not very visible 
in young and in dense well-formed 
tissue. The prisms (Fig. 4) also show 
at intervals slight bulgings or vari- 
cosities. No generally accepted ex- 
planation of the origin of the strise 
and varicosities has yet been made. 
They perhaps constitute the remain- 
ing trace or expression of the soft cell 
elements in which the tissue existed 
before calcification. The decussation 
of the prisms, a peculiar pattern ex- 
hibited by enamel in section beneath 
the microscope, is only apparent, not real. The tissue 
is made up of many layers, the fibres in each layer being 
parallel, but the direction pursued by fibres of different 
layers varying considerably. The appearance of decus- 
sation is visible only under a high magnifying power, in 
a thin section which is made up of several layers of 
prisms, and which is of course transparent. Hence the 
crossing of fibres, which actually lie on different planes, 
gives rise to the apparent free decussation of prisms lying 
on the same plane. 
Dentine or ivory forms the great bulk of the tooth, 
and incloses the central cavity. It is a yellowish-white 
elastic tissue, presenting a finely fibrous fracture, and 
intermediate in hardness between enamel and dense bone, 
which latter it resembles somewhat in its general aspect 
and chemical characteristics. It contains twenty-eight 
per cent, of animal and seventy-two of earthy matter. 
Treated with acids the earthy constituents are dissolved, 
and there remains a material called dentinal cartilage, 
Fig. 4. 
Enamel prisms separated 
and viewed laterally. OF THE TEETH. 
21 
which retains the form of the tooth, and which is pre- 
cisely similar to ossein, the animal basis of ordinary bone 
tissue. The seventy-two per cent, of earthy constituents 
are made up of 64 parts of calcium phosphate, 5 of cal- 
cium carbonate, and 3 of magnesium phosphate and 
other salts, with a trace of fluorine. 
Examined microscopically (Fig. 5), dentine is found 
to consist of innumerable minute tubes having distinct 
walls, and running close together through an interme- 
diate substance—the intertubular substance or matrix. 
Commencing by open orifices on the walls of the pulp- 
cavity, the tubes radiate outwards in an undulating 
course, giving off numerous branches, which freely anas- 
tomose. In the upper part of the crown they have a 
vertical direction, towards the sides they become oblique, 
then horizontal, finally inclined downwards towards the 
point of the root. Each tube, as a rule, extends through- 
out the whole thickness of the tissue. Their diameter 
is about 4 g1)) (j of an inch, the inner ends being larger 
than at a distance from the pulp-cavity. The distance 
between adjacent tubes is about two or three times their 
width. The tubes and their branches are occupied by 
soft fibrils which anastomose. These fibrils proceeding 
from the central pulp are probably elongated processes 
of the odontoblasts, the special cells of the pulp. The 
inner walls of the tubes surrounding the fibrils consti- 
tute the dentinal sheaths. These sheaths are apparently 
of fibrous structure, but are believed by some observers 
to be calcified. They can be demonstrated most clearly 
after removal of the fibres by maceration, and they 
remain as a white fibrous felt even after boiling in 
strong muriatic acid, or in caustic alkalies. 
The dentinal tubes terminate in the crown by fine 22 
ANATOMY AND HISTOLOGY 
processes, which either anastomose or become extremely 
minute, and are lost beneath the enamel, into which 
tissue, however, a few may penetrate. In the root they 
Fig. 5. 
Transverse section of the root of a canine tooth. 
1. Cement. 2. Granular layer. 3. Dentine. 
end beneath the cement, by opening into the irregular 
spaces of the granular layer. 
The intertubular substance or matrix is translucent 
and finely granular, resembling compact bony tissue. 
It contains the greater part of the earthy constituents of 
the dentine. 
The granular layer of the root (Fig. 5), which exists OF THE TEETH. 
23 
between the dentine and cement, may be said to consti- 
tute the line of transition where these tissues blend. 
The layer is made up of granules or minute globules, 
and contains numerous spaces apparently due to imper- 
fect coalescence of these elements. Into these spaces 
(as above mentioned) the dentinal tubes open, and the 
spaces are again connected with the lacunae of the cement 
by fine canaliculi. 
Dentine is endowed with a considerable amount of 
sensibility, due to the soft fibrils which permeate its 
tubes, and which, as we have seen, directly emanate 
from the pulp. It is more sensitive immediately be- 
neath the enamel than deeper, until the pulp-chamber 
is approached. The sensibility disappears when the 
death of the pulp takes place. 
The cement forms a thin layer, which, commencing at 
the neck, where it slightly overlaps the enamel, grad- 
ually increases towards the apex of the root. It is a true 
bone structure, having the same chemical and micro- 
scopical characters as that tissue. Existing only in a 
thin layer in man, cement is, however, destitute of 
Haversian canals. It contains, as a rule, canaliculi 
throughout, and lacume at its thicker parts; but either 
or both of these may be wanting where the tissue is 
extremely thin. In the latter ease it presents, on sec- 
tion, a perfectly homogeneous appearance. 
The cement is invested with periosteum, which is 
intimately connected with the submucous layer of the 
gum, and with the periosteum of the alveolar process. 
It is a delicate connective-tissue membrane, containing 
abundance of vessels and nerves,* which are derived 
from those of the submucous tissue, from those which 24 
ANATOMY AND HISTOLOGY 
supply the pulp, and from those of the contiguous al- 
veolar wall. 
Nasmyth’s membrane is an extremely thin homoge- 
neous membranous layer, covering the enamel. It exists 
only on young teeth which have not been long used in 
mastication. It resists the action of the strongest mineral 
acids, but softens when boiled in caustic potash. It is 
destitute of calcareous matter, the traces found being 
probably due to adherent particles of enamel. Although 
other theories as to its nature exist, the majority of 
authorities are agreed that Nasmyth’s membrane is 
merely a thin layer of cement modified in structure, 
and exactly corresponding to the thick coronal-cement 
found on the teeth of herbivorous animals. This theory 
has lately been confirmed by the investigations of Mr. 
Charles Tomes (6), who has especially pointed out that 
coronal cement of well-marked structure, containing 
lacunae and eanaliculi, occasionally occurs in human 
teeth, and that when such a layer does not exist, it may 
be often found that fissures of the enamel are filled with 
a bone-like tissue continuous with Nasmyth’s mem- 
brane. 
The dental pulp which occupies the central cavity 
constitutes the remains of the original papilla from 
which the dentine was developed. It consists of fine 
fibrous connective tissue, containing numerous cells, 
and is well supplied with bloodvessels and nerves, 
which enter the cavity through the small orifices in the 
apices of the roots. Its external surface, lying in con- 
tact with the walls of the pulp-cavity, is made up en- 
tirely of a layer of dentinal cells (odontoblasts). These 
cells have numerous processes, one set of which enter OF TIIE TEETH. 
25 
the dentinal tubes and form the fibrils, whilst others 
unite together contiguous cells. 
As age advances, gradual calcification of the pulp 
takes place, until at last it is reduced to a few fibrous 
filaments, with the remains of vessels and nerves. The 
tissue resulting from this calcification is called secondary 
dentine. In some cases the process commences in the 
external layer of odontoblasts, and the new-formed tis- 
sue coalesces from the first with the previously formed 
dentine, and the tubes of the two are continuous. In 
other cases secondary dentine is deposited in isolated 
nodules scattered through the pulp. These nodules 
sometimes unite and form larger masses, which again 
may become attached to the walls of the pulp-cavitv. 
The masses of secondary dentine are occasionally trav- 
ersed by canals containing bloodvessels, and surrounded 
by concentric lamellae, like the Haversian canals of bone. 
This variety is called osteodentine. At the same time 
that the slow conversion of the pulp is taking place, the 
dentinal fibrils also become impregnated with earthy 
matter and solidified. 26 
TIIE DEVELOPMENT OF THE TEETH. 
THE DEVELOPMENT OF THE TEETH. 
The first trace of dental development in man is visi- 
ble as early as the seventh week of intrauterine life, 
when the embryo is not more than one inch and a quar- 
ter in length. This trace, which can be seen by the 
naked eye, consists of a smooth oval ridge extending 
Fir. 6. 
Section of the incisive region of the lower jaw of an embryo sheep, magnified 
eighty diameters. (The dental development in the sheep and in man are iden- 
tical.) 
ar.. Epithelial ridge or band which extends the whole length of the maxillary 
arch, but of which the section only is here visible. From this band the epithe- 
lial lamina will be given off later. 
along the whole length of the rudimentary alveolar bor- 
der (a, Fig. 6). Section of this ridge shows it to be a 
continuous vertical band composed of a thick layer of 
epithelial cells, and it is, in fact, a prolongation of the 
epithelial layer of the mouth which has sunk into the 
embryonic tissue of the jaw. Before the end of the 
eighth week there has become developed, at about the 
middle of the buried or deep surface of the ridge, a p ro- THE DEVELOPMENT OF THE TEETH. 
27 
jection or lamina (b, Fig. 7), which like the layer from 
which it is derived, extends the whole length of the 
maxillary border. Its shape is a little flattened from 
Fig. 7. 
Section of the incisive region of the lower jaw of an embryo sheep, magnified 
eighty diameters. 
a. Epithelial ridge. 
b. Epithelial lamina originating from the epithelial ridge. 
above downwards, with its extremity rounded and 
curved in the form of-a crook. It is “composed exter- 
nally of columnar cells of the deep or Malpighian layer 
of the mucous membrane, internally of squamous cells. 
Within a few more days there can be demonstrated along 
the border of epithelial lamina in each jaw a series of 
ten small club-shaped enlargements (c, Fig. 8j. These 
enlargements or buds are the rudimentary enamel Organs 
of the temporary teeth, and they are situated at intervals 
corresponding to the position of the future teeth. They 
are composed of the same epithelial elements as make 
up the lamina, and they are destined by subsequent de- 
posit of calcareous matter to become the external or 
enamel layer of the crown of the tooth. They remain 
for some time united to the lamina by a narrow portion 28 
THE DEVELOPMENT OF THE TEETH. 
in the form of a neck, which grows longer as the enamel 
organ increases in size. The enamel organs soon begin 
to assume the form of the crowns of the future teeth, 
but at first their shape is not well defined, and resembles 
Fig. 8. 
Section of the ramus of the lower jaw of an embryo sheep, magnified eighty 
diameters. 
a. Buccal epithelium and epithelial ridge. 
b. Epithelial lamina. 
c. First appearance of the enamel organ. 
a cap with the concavity directed towards the depths of 
the jaw. 
By tliis time (the ninth week) the first appearance of 
the dentinal pulp may be detected. This pulp (d, Fig. 
9) eventually becomes converted by calcification into the 
dentine or ivory forming the bulk of the tooth. Its 
elements first manifest themselves in the depths of the 
jaw independently of the enamel organ, but directly 
contiguous to its deeper surface. The pulp at first con- 
sists of a small papilla composed of nucleated cells, and 
penetrated by a vascular loop, and it is, in fact, at this 
stage merely a special division of the mucous tissue 
unusually rich in vessels and cells. Later on, when it THE DEVELOPMENT OF THE TEETH. 
29 
has assumed more definite shape, nerve-filaments can be 
traced into it. It grows until it impinges upon the en- 
amel organ, which becomes moulded upon it like a cap, 
whilst the papilla gradually assumes the form of the 
Fig. 9. 
Section of the ramus of the lower jaw of an embryo sheep, magnified eighty 
diameters. 
a. Buccal epithelium. b. Epithelial lamina. 
C. Enamel organ. d. Dentinal pulp. 
e. First appearance of the enamel organ of the permanent tooth. 
F. Fibrous tissue whence is derived the dental sac. 
crown of the future tooth. Thus, for the incisors it be- 
comes conical, and for the molars develops outgrowths 
corresponding to the cusps of these teeth. 
By the beginning of the fourth month each rudiment- 
ary temporary tooth has become enveloped in a distinct 
closed sac composed of subepithelial connective tissue. 
This sac begins to appear as soon as the dentinal pulp is 
slightly advanced in development. An opaque fibrous 
outgrowth springs from each side of the base of the pulp, 
and grows towards the summit of the tooth, where it 
unites with that of the opposite side, and so forms the 
dental sac. Bv this time the connection between the 30 
THE DEVELOPMENT OF THE TEETH. 
enamel organ and the epithelial process from which it 
emanated has become severed, owing to resorption of the 
uniting neck or band of epithelium at the surface of the 
sac, and this resorption slowly progresses until the whole 
of the process disappears, leaving the sac completely 
isolated. 
The origin of the permanent set, consisting of sixteen 
teeth in each jaw, has now to be described. The enamel 
organs of the ten teeth which replace the temporary set 
—namely, the incisors, canines, and bicuspids—originate 
from a bud for each tooth, which is given off from the 
elongated extremity of the epithelial lamina at its point 
of junction with the enamel organ of the temporary 
tooth (e, Figs. 9 and 10). 
The enamel organ of the first permanent molar is 
given off from the posterior extremity of the same epi- 
thelial band as gave origin to the temporary tooth. From 
the epithelial process of this enamel organ a bud springs 
for the second permanent molar in exactly the same 
manner as the permanent successors of the temporary set 
were evolved from the epithelial processes of that set. 
In a precisely similar fashion the enamel organ of the 
third molar, or wisdom tooth, arises from the epithelial 
process of the second molar. 
These sixteen germs in each jaw constitute the first 
traces of the permanent teeth, and they each pass through 
the same phases of development as we have seen under- 
gone by the germs of the temporary set, these phases 
being the appearance of the dentinal pulp, its junction 
with the enamel organ, and their inclosure in the sac. 
The only further difference to be noted between the de- 
velopment of the permanent and deciduous teeth is in 
the time which particular teeth take to pass through the THE DEVELOPMENT OF THE TEETH. 
31 
successive stages of evolution. For example, the tempo- 
rary teeth are usually all cut by the third year, whilst 
Fig. 10. 
Section of the incisive region of the ramus of the lower jaw of a human em- 
bryo. (In this preparation the epithelial cord or process whence is developed 
the enamel organ of the permanent tooth, is seen partly isolated from its origin 
in the follicle of the temporary tooth.) 
a. Buccal epithelium. 
b. Epithelial process or cord of the temporary follicle. 
c. Enamel organ. 
d. Dentinal pulp covered by a small cap of dentine. 
e. Epithelial cord, whence is developed the enamel organ of the permanent 
tooth. 
f. Rudimentary cartilage of the jaw. 
g. Section of the dental artery. 
h. Traces of ossific matter in the jaw. 
i. Section of the dental nerve. 
the first permanent molar, although its germ appears at 
the fifteenth week of foetal life, is not erupted until the 32 
THE DEVELOPMENT OF THE TEETH. 
sixth year. Similar remarks apply to the rest of the 
permanent set; but it will suffice now to give the dates 
of the phases of their development so far as above de- 
scribed. The enamel organs of the incisors, canines, and 
bicuspids make their appearance about the sixteenth week 
of intrauterine life; those of the first permanent molars 
about the fifteenth week; those of the second molars 
about the third month after birth; and those of the wis- 
dom teeth can be demonstrated towards the third year. 
The dentinal pulps of the ten first-mentioned teeth appear 
at the twentieth week; those of the first molars at the 
seventeenth week ; those of the second molars about the 
first year after birth; and those of the wisdom teeth 
towards the end- of the sixth year. The complete clos- 
ure of the sacs of these teeth is accomplished in the 
order in which they have been above mentioned at the 
following dates—9th month, 20th week, 1st year, and 
6th year. 
The histological changes which take place in the tooth 
germ by which its elements are gradually converted into 
the dental tissue, must be now more fully described. 
It has been seen that the enamel organ when first 
formed is composed entirely of epithelial cells—exter- 
nally of the columnar, internally of the squamous vari- 
ety. It retains its epithelial nature throughout the pro- 
cess of calcification. This process begins at the surface 
of the dentine, and progresses outwards. Prior to the 
deposition of earthy matter the columnar cells immedi- 
ately in contact with the dentine increase greatly in length, 
and form six-sided prismatic bodies so arranged as to 
constitute a columnar epithelium, which, according to 
Waldeyer, is the most beautiful and regular found in 
any part of the animal body. This layer is called the THE DEVELOPMENT OF THE TEETH. 
33 
internal epithelium of the enamel organ. The external 
cells of the enamel organ (termed external epithelium) 
are shorter and more cubical in form. Numerous vascu- 
lar papillae, arising from the contiguous tissue of the 
dental sac, penetrate to a slight depth the external epi- 
thelium, and serve doubtless to provide nutriment to the 
developing tissue. The cells forming the interior of the 
organ undergo transformation during the formation of 
the enamel. At first small and round, they soon become 
stellate in form, united with each other by their processes, 
and from the cells of this layer (called stratum interme- 
dium), in contact and united with the internal epithe- 
lium, a continuous development of columnar enamel 
cells proceeds. 
It has been stated that the deposition of calcareous 
matter commences in the enamel organ at the surface of 
the dentine and proceeds outwards. The completed tis- 
sue results from the direct calcification of the internal 
epithelium. The calcification progresses from the periph- 
ery of each cell towards its centre, at the same time 
uniting together the contiguous columns. Prior to the 
completion of the enamel the external epithelium and 
remaining portion of the stratum intermedium undergo 
atrophy, and it is a question whether these cells ulti- 
mately disappear, or take part in forming Nasmyth’s 
membrane (cuticula dentis), the thin layer of peculiar 
horny tissue which envelops new-formed enamel. 
Calcification of the dentinal pulp begins before that 
of the enamel organ. The process by which the conver- 
sion is effected closely resembles the histological forma- 
tion of bone. It commences at the surface and proceeds 
inwards, the central portion with the vessels and nerves 
remaining to constitute the persistent dental pul]) or 34 
THE DEVELOPMENT OF THE TEETH. 
“nerve” of the tooth. The dentinal pulp (as already 
mentioned) at first consists of a special division of the 
rudimentary mucous tissue, rich in vessels and cells. Its 
fibrous elements consist of a fine connective tissue, 
through which the cells are scattered. When the pulp 
has arrived at a certain stage of development the cells 
begin to be specially organized and arranged. By this 
time the pulp contains numerous nerve-fibrils besides 
bloodvessels. The latter form a plexus close to the sur- 
Fig. 11. 
From Waldever (1). 
Longitudinal section of a milk-tooth from the foetal sheep carried through the 
margin of the dentinal pulp and adjoining portion of the enamel organ, magni- 
fied 200 diameters. 
1. Dental sac. 
2. External epithelium of enamel organ. 
3. Internal epithelium of enamel organ. 
4. Young layer of enamel detached from the enamel cells. 
5. Dentine. 
6. Odontoblasts. 
7. Part of the dentinal pulp. 
face. The specialized cells are termed odontoblasts. 
They are developed from the cells lying at the periphery THE DEVELOPMENT OF THE TEETH. 
35 
where they become arranged in a layer so as to form a 
kind of columnar epithelium. This layer is termed the 
membrana eboris. The cells are finely granular, have 
no membrane, and contain a large rounded nucleus. 
They are each provided with numerous processes, which 
unite them with the contiguous odontoblasts, and with 
subjacent developing cells. The nuclei of the odonto- 
blasts disappear, and they become converted into a gelat- 
inous matrix, which undergoes direct calcification, and 
forms the whole of the hard constituents of the dentine. 
These changes take place from the periphery of each cell 
towards the centre. The central portion of each cell 
remains uncalcified, and forms the soft fibril which occu- 
pies the completed dentinal tube. The membrana eboris 
is constantly fed from the deeper layer of cells, which, 
united with the odontoblasts by means of their processes, 
form an uninterrupted series, and provide for the conti- 
nuity of the dentinal tubes and fibrils. The layer of 
matrix immediately around the fibrils becomes converted 
into the dentinal sheaths—the lining walls of the tubes. 
It has not yet been ascertained whether the sheaths are 
calcified or not, since their structure cannot be examined 
except after maceration or incineration of the tissue. 
By the end of the seventeenth week of intrauterine 
life a cap of dentine may be demonstrated on the pulps 
of all the temporary teeth. By the sixth month the 
first permanent molar has advanced to a similar stage 
of development. By the first month after birth the 
permanent incisors and canines are advanced to the same 
stage; and at the third year and twelfth year respect- 
ively, calcification has commenced in the second molars 
and wisdom teeth. 
The entire crown of each tooth is represented in soft 36 
THE DEVELOPMENT OF THE TEETH. 
tissue before the deposition of earthy salts commences, 
and as the tootli elongates by growth of the pulp from 
below, successive portions undergo calcification to form 
the root. 
The development of the cement, or crusta petrosa, 
has not been made out beyond dispute. It probably 
takes place in a matrix formed by the investing fibrous 
coat of the dental sac. A special cement pulp has not 
been demonstrated in man. Cement is, in fact, a thin 
layer of bone, and the process of its formation is doubt- 
less similar to intramembranous ossification of other 
bones of the body. 
The cuticula dentis (Nasmyth’s membrane), already 
mentioned, is believed by some authorities to be formed 
from the residuum of the pulp of the enamel after the 
completion of that tissue. It is, however, much more 
probable that it is merely a thin layer of modified osse- 
ous tissue continuous with the cement, having a similar 
origin, and analogous to the coronal cement found on 
the teeth of certain herbivorous animals. FIRST AND SECOND DENTITION. 
37 
GKOWTH OF THE JAWS. 
FIRST AND SECOND DENTITION. 
Commencing as early as the fifth week of foetal life, 
ossification of the maxillary bones proceeds rapidly, and 
is well advanced at birth. The lateral halves both of 
the upper and lower jaws at this period are, however, 
still united by cartilage, and the alveoli of the tempo- 
rary teeth are represented by a deep trench, divided by 
incomplete bony plates into large crypts, in which the 
teeth lie inclosed by the dental sac and submucous tissue. 
The temporary teeth are represented by their partly cal- 
cified crowns, the stage of development varying in the 
different teeth according to the period at which their 
eruption is destined to take place. Thus the crowns of 
the central incisors are nearly complete, whilst the apices 
alone of the rudimentary crowns of the canines have 
become converted into a cap of calcified material. 
During the first few months after birth, the develop- 
ment of the maxillie is most active at the surface adja- 
cent'to the connecting cartilages and at the alveolar bor- 
der. The alveoli increase in depth, and by the growth 
of their free margins overhang and protect the contained 
teeth. A little later they become nearly closed. 
The age at which the eruption of the temporary teeth 
commences, varies somewhat in different individuals, 
but it is rarely earlier than the fifth, or later than the 
ninth month. The eruption of the teeth is a process of 38 
GROWTH OF THE JAWS. 
gradual elongation of the teeth on the one hand, and of 
simultaneous absorption of the superimposed tissues on 
the other. The absorption commences first in the over- 
hanging margins and front walls of the alveoli, which 
gradually disappear until room is afforded for the free 
passage of the advancing tooth. The growth of the 
tooth keeps pace with this absorption, and the crown at 
length pressing against its membranous coverings these 
undergo atrophy, and, becoming by degrees thinner, and 
at last transparent, give way and disclose the advancing 
crown. 
It occasionally happens that these various actions are 
not perfectly harmonious in their course, the advance of 
the tooth being more rapid than the disappearance of 
the inclosing bony and soft tissues. The tooth is thus 
mechanically held in position, and irritation is set up, 
which manifests itself by inflammation and induration 
of the gums, and even by reflex nervous disorders, and 
constitutional disturbance of various kinds. It is for 
the relief of such diseases that the operation of lancing 
the gums of infants is performed. This operation has 
for its object the division of the abnormally indurated 
gum, and the release of the advancing tooth. It is 
obvious that the utility of this procedure must be ex- 
tremely doubtful when it is carried out prior to the pas- 
sage of the tooth through the contracted bony orifice of 
the alveolus; but that it may be reasonably expected 
to afford relief in cases where the advancing tooth can 
be distinguished beneath the indurated, tense, and swol- 
len gum. 
The order in which the temporary teeth are erupted 
seldom varies. The lower central incisors are the first 
which appear. They are followed, after an interval FIRST AND SECOND DENTITION. 
39 
varying between a week and two or three months, by 
the corresponding members of the upper set. After 
another similar lapse of time, the lower quickly fol- 
lowed by the upper lateral incisors present themselves. 
Next, after like intervals, the first molars, and then the 
canines are protruded. Lastly, the second molars take 
their places, and complete the series. By the time that 
the eruption of the temporary teeth is completed (be- 
tween the second and third years), considerable progress 
has been made in the development both of the jaws and 
permanent teeth. The maxillae have increased in size, 
and the fibro-cartilages uniting the lateral halves are 
completely ossified ; the alveoli which had been absorbed 
to give exit to the teeth have since grown up with the 
advancing organs, and now closely invest them; the 
angle of the lower jaw which recently after birth is 
very obtuse has become more acute, coincident with the 
development and lengthening of the ramus, and of the 
articular and coronoid processes. Excepting those of 
the wisdom teeth, the crowns of the permanent set are 
all well advanced in calcification, their progress being, 
however, proportionate to the respective periods of their 
evolution. The incisors, canines, and bicuspids are com- 
pletely inclosed in bony crypts. The incisors are situ- 
ated in the upper jaw above and behind, and in the 
lower jaw below and behind the roots of the teeth 
which subsequently they respectively replace. The ca- 
nines are deeply placed between the crypts of the lateral 
incisors and first bicuspids. The bicuspids lie within 
the divergent roots of the temporary molars. The mo- 
lars, surrounded by incomplete casings of bone, occupy 
the portion of jaw posterior to the temporary set, extend- 40 
GROWTH OF THE JAWS. 
ing into the ramus of the inferior and the tuberosity of 
the superior maxilla. The anatomy of the jaws at this 
period, is admirably displayed in Fig. 12, from Mr. 
Fig. 12. 
Tomes’s work (4). It may be noted, that this is the 
epoch at which the greatest number of teeth are held 
in the jaws at one time. The whole of the deciduous 
set, and the whole of the permanent set, are present, 
and of these the wisdom teeth alone are still totally 
un calcified. 
Within two years after the completion of the tem- 
porary set, a process is commenced by which their roots 
are gradually removed by resorption, until in time the 
teeth lose their attachment to the jaws, and are cast off* 
one by one, to be afterwards replaced by the advancing 
members of the permanent set. The resorption does 
not begin simultaneously throughout the whole set, but 
attacks the teeth according to the order in which they FIRST AND SECOND DENTITION. 
41 
are to be shed. It commences and proceeds, as a rule, 
at that part of the root towards which the permanent 
tooth is advancing, but occasionally it affects other parts 
at the same time. The wasting surface, which on ex- 
amination is found irregular in outline and broken up 
into minute pits or depressions, resembles that of bone 
when undergoing absorption. Closely applied to the 
whole of this surface there is found a vascular papilla 
of slight depth, the absorbent organ, the active agent in 
the removal of the tissues. This papilla consists of a 
vascular and cellular structure, the portion in contact 
with the teeth being entirely made up of large multi- 
form nucleated cells. These cells occupy the pits in 
the wasting tissues. The papilla originates from the 
contiguous vascular layer of the alveolar periosteum, 
and it constitutes a special provision in the economy for 
the removal of the deciduous teeth. Abundant evidence 
exists that the absorption is not (as was once supposed) 
due to the pressure of the advancing permanent teeth, 
and the following are some of the main facts composing 
this evidence: 1st. In some of the lower animals, nota- 
bly in the serpent, conditions exist during the evolution 
of successive sets of teeth, which prove beyond doubt 
that absorption of deciduous teeth, similar to what 
occurs in man, may take place independently of pressure. 
This fact has been recently demonstrated clearly by Mr. 
Charles Tomes (5). He has pointed out that the suc- 
cession of teeth in snakes is endless, new teeth continu- 
ing to be developed at the inner side of the teeth already 
in place throughout the lifetime of the animal; that 
when a tooth is about to be shed, both it and the bone 
at its base are attacked bv absorption, this taking place 42 
GROWTH OF THE JAWS. 
at its inner side before the outer side is at all involved, 
and that the advancing tooth moves forward, the delicate 
cells of its enamel organ remaining in situ, even after 
absorption has been effected to such an extent that the 
inner side of the old tooth has been cut away, and the 
successional tooth has passed into the space thus gained. 
“ It is obvious that if the successional tooth had ever 
come into contact with its predecessor, these cells, at the 
point of impact, could not have escaped destruction.” 
2d. Absorption of a human temporary tooth occasion- 
ally goes on at points remote from the permanent suc- 
cessor. 
3d. The permanent do not impinge upon the tempo- 
rary teeth during their advance, and, on the contrary, 
they are separated from them throughout by the bony 
walls of the crypts in which they are inclosed. 
The process of the eruption of the permanent teeth 
closely resembles that which lias been described as oc- 
curring in the first dentition. By the time each tem- 
porary tooth is shed, absorption has commenced in the 
plate of bone which up to this period has closed the 
crypt of the permanent successor, and this absorption 
proceeds until the opening is large enough to permit 
the free passage of the emerging crown. When the 
crowns of the teeth are fully protruded the development 
of the alveoli again becomes active, and the bone in 
time firmly embraces the necks of the teeth, and invests 
the roots in accurately fitting sockets. 
The age at which second dentition commences varies, 
like the first, in different individuals, but the order in 
which the teeth appear is rarely irregular. The follow- 
ing may be taken as average dates at which the eruption FIRST AND SECOND DENTITION. 
43 
of the different teeth is completed. The teeth of each 
class appear somewhat later in the upper than in the 
lower jaw: 
First molars, -v 
Central inferior incisors, / 
YEARS. 
5 to 7 
Central superior incisors, 
6 to 8 
Lateral incisors, 
7 to 9 
Anterior bicuspids, . 
. 8 to 10 
Canines, .... 
. 9 to 12 
Posterior bicuspids, . 
. 10 to 12 
Second molars, 
. 12 to 14 
Wisdom teeth,. 
. 17 to 25 
The eruption of the permanent teeth is seldom at- 
tended with constitutional disorders due to reflex nerv- 
ous disturbance, such as commonly accompany first den- 
tition ; and local irritation is rare, except in the case of 
the lower wisdom teeth. The protrusion of these teeth 
is, however, often attended by considerable suffering. 
They make their appearance after the completion of 
dentition, at the time when, owing to insufficient back- 
ward development of the horizontal ramus of the jaw, 
crowding of the teeth frequently exists, and the space 
which should remain for their reception is encroached 
upon by the second molar. The wisdom teeth in their 
advance thus become wedged between the posterior sur- 
face of the second molar and the coronoid process, and 
give rise to pressure upon the overhanging mass of gum 
and mucous membrane. This condition is alone some- 
times enough to give rise to considerable swelling and 
inflammation of the gum, and the mischief becomes 
aggravated when the opposing teeth of the upper jaw 
come forcibly in contact with the swollen tissues in 
mastication. The inflammation spreads to the alveolar 44 
GROWTH OF THE JAWS. 
periosteum, and to the uvula, soft palate, and tonsil, and 
the neighboring lymphatic glands become swelled and 
painful. The pain is severe, often throbbing in charac- 
ter, and is increased by attempted movements of the 
jaw and by swallowing. These symptoms are attended 
with considerable febrile disturbance. If the disease 
run on suppuration takes place, and an abscess forms 
and discharges within the mouth, at some point about 
the swollen gum or adjacent structures. From this time 
the symptoms may slowly subside, or the inflammation 
may remain chronic, increasing again into the acute 
form, from time to time, under the influence of cold or 
other irritation. 
Treatment.—If the teeth of the affected side be sound 
and the space is too small to allow the full protrusion of 
the emerging wisdom tooth, it should be at once ex- 
tracted. This operation should also be performed with- 
out hesitation, in order to cut short the patient’s suffer- 
ing, should extensive acute inflammation exist. If the 
tooth, as sometimes happens, be malplaced, and with the 
crown so directed as to render it useless in mastication, 
it should be removed. Under other circumstances the 
preservation of the tooth may be attempted. Some- 
times the necessary space may be obtained by the ex- 
traction of the first or second molar, should either of 
these teeth be extensively decayed. In other cases the 
excision of the gum covering the tooth will suffice to 
give relief. The flap of gum should be seized with a 
dissecting forceps, and cut away with a small bistoury. 
The mere lancing or division of the gum rarely does 
much good, as the divided parts fall again at once into 
contact, and become rapidly united. After the extrac- 
tion of the tooth or excision of the gum the persistent FIRST AND SECOND DENTITION. 
45 
application of warm fomentations within the mouth 
usually soon effects a subsidence of the inflammatory 
symptoms. 
Throughout the entire period of their growth the 
process by which the maxillae are moulded into their 
destined form is similar to that which takes place in all 
developing bones. It consists, on the one hand, of con- 
tinuous deposition of bone, and on the other of occa- 
sional absorption. It has been already explained how 
the processes of growth and absorption alternate during 
the process of dentition and the development of the 
alveolar border of the jaws. The enlargement of the 
maxillary arch is produced mainly by deposition of bone 
upon the facial surface, and as the new layers of bone 
are deposited absorption takes place upon the lingual 
surface. In the same way in the development of the 
posterior portion of the lower jaw, whilst the ascending 
ramus is increasing in size by the deposition of bone 
upon the posterior surfaces of the coronoid and the con- 
dyloid processes, absorption is going on upon these parts 
anteriorly, and thus the bones are moulded into their 
destined form. The deposition of new material is prin- 
cipally subperiosteal, but it also takes place beneath the 
articular cartilage of the lower jaw, and at the surfaces 
contiguous to the cartilages which in the infant unite 
the separate portions of bone in both maxillae; and 
the increase in the bulk of the jaws is thus entirely 
effected, not by interstitial growth or expansion of the 
bones, but by constant additions to the external surfaces. 
Up to a certain period in the growth of the jaws, as 
previously mentioned, there is not sufficient room in the 
alveolar arch for the crypts of the developing permanent 
molars, which, therefore, are inclosed in the base of the 46 
GROWTH OF THE JAWS. 
eoronoid process of the lower, and in the tuberosity of 
the upper jaw. The space taken up by the ten anterior 
permanent teetli almost exactly corresponds to that occu- 
pied by the milk teeth, and it is therefore in the back- 
ward direction that the required increase in size of the 
arch takes place. The depth of the bones becomes 
greater in accordance with the dental and muscular de- 
velopment. Examination of a large series of human 
maxillae of different ages, enabled Mr. Tomes to demon- 
strate the fact, first pointed out by John Hunter, that 
the growth of the alveolar border, both during the first 
and second dentition, follows and is dependent upon the 
growth of the teeth, and that the position of the teeth 
is not, as was once believed, predetermined by indepen- 
dent growth of the bone. This fact has also lately re- 
ceived confirmation from the observations of Mr. Charles 
Tomes, upon the mode of attachment of the teeth in 
fishes and reptiles. He has proved that in the attach- 
ment of a tooth by simple anchylosis, or by ever so 
rudimentary a socket, as it takes place in the varied 
species, the bone is modelled to the tooth in full sub- 
serviency to the position of that tooth, and that the 
tooth does not come to take its place upon a spot prede- 
termined for it by any disposition of the bone, made 
prior to its advent. 
The portions of bone which give attachment to the 
muscles of mastication augment in bulk as these organs 
develop in size and power. 
When the teeth are lost from age or other causes, the 
alveoli waste by absorption ; and at the same time mas- 
tication being discontinued, the muscles, together with 
the portions of bone to which they are attached, undergo FIRST AND SECOND DENTITION. 
47 
atrophy, and the jaws assume the peculiar form charac- 
teristic of age. 
It happens occasionally that permanent teeth remain 
imbedded within the jaws instead of making their ap- 
pearance at the natural epoch of their eruption. It has 
been just explained, and illustrated in Fig. 12, that at 
one period in the growth of the maxillae, before the 
jaws have attained their full size, enough space for the 
extended arrangement of the set in an unbroken arch 
does not exist, and the teeth are therefore crowded 
within the jaw, the canines and bicuspids being deeply 
placed, whilst the upper and lower wisdom teeth are 
situated in the tuberosity of the upper and in the ramus 
of the lower jaw respectively. If, owing to arrest of 
development or other cause, the jaws remain unduly 
small or contracted, enough room for the presence of 
the entire set of teeth in the dental arch may be always 
wanting, and some of the set, although fully formed, 
may continue buried within the bone. This condition, 
although it may happen in the case of any tooth, most 
commonly arises, as might be expected, with those teeth 
—such as wisdom teeth, canines, and bicuspids—which 
are cut at a late stage of dentition, when the whole 
available space in an abnormally small maxilla may be 
taken up by the rest of the set. The eruption of such 
teeth may be also in the same way prevented by the 
presence of supernumerary teeth or by persistent tempo- 
rary teeth holding their position after the time at which 
they ought to be cast off'. 
In another class of cases imbedded teeth hold such 
abnormal positions within the bone that, although room 
may exist for them in the dental arch, their eruption is 
impossible. In some of these instances there is evidence 48 
GROWTH OF THE JAWS. 
that the malposition is due to deflection of the growing 
tooth from its normal course by obstacles, such as tem- 
porary teeth, or supernumerary teeth, but in others the 
tooth is situated far from the alveolus, and its misplace- 
ment cannot be accounted for. Fig. 13, from Mr. 
Heath’s work (9), shows an upper canine situated 
Fig. 13. 
within the jaw in a position which it may have possi- 
bly assumed in consequence of wrant of space, whilst 
Fig. 14 from the same work, exhibits an unaccountable 
misplacement of an upper canine, which lies horizon- 
tally in the floor of the nose, with the crown directed 
backwards. Imbedded teeth, especially those regularly 
situated within the bone, sometimes make their appear- 
ance after a lapse of time when room is afforded by the FIRST AND SECOND DENTITION. 
49 
loss of other teeth, and the eruption of such teeth late 
in life has given rise to the unfounded belief in the 
occasional occurrence of a third dentition. 
Flo. 14. 
In the majority of instances, imbedded teeth remain 
through iife, perhaps without the patient being aware 
of their existence, but in some few individuals they 
become the centre of cystic disease or of other morbid 
growths. Such growths connected with teeth are de- 
scribed in a later section. 50 
.MALFOlfalXTIONS and irregularities 
MAT7Pt)l>MvVTI0XS AND IRREGULARITIES OF 
THE TEETH. 
Dilaceration.—When the mode of development of the 
teeth is considered, and it is remembered that they are 
liable to injury at the period when they are but partially 
calcified, it is easy to understand why teeth are occasion- 
ally met with the crowns and roots of which are more 
or less distorted. In such cases some force—such as a 
blow—has been transmitted to the developing organ, by 
which a part or the whole of the crown has become dis- 
placed, without severance of its connection with the un- 
calcified portion of the pulp, and has become subsequent- 
ly fixed in its malposition by the completion of the pro- 
cess of calcification. This kind of injury has been 
termed dilaceration. Section of such teeth displays 
evident marks of the bending which the tissues under- 
went in the soft state. It is possible that a tooth might 
be distorted during growth to the extent of dilaceration 
in consequence of crowding and pressure within the jaw 
from want of space, and this opinion is strengthened by 
the fact that the deformity seldom or never occurs except 
in teeth situated at the front of the jaw where a crowded 
condition is common. 
Teeth which have undergone dilaceration are of course 
easily recognized when the injury affects the tissues of 
the crown, but when the crown is well formed and merely 
bent at an angle with the root, careful examination is 
sometimes required to distinguish the case from one in OF THE TEETH. 
51 
which a well-formed tooth is lying in an abnormal posi- 
tion. The latter case might be amenable to treatment, 
which would be inapplicable to dilaceration. Teeth the 
subject of dilaceration often present marked bulgings 
upon either surface close to the neck, which is frequently 
constricted and well defined ; they occasionally display 
marked mobility under slight pressure, and the distorted 
root may be in some cases traced by the finger through 
the alveolar wall. Fig. 15, from Wedl, represents a case 
of dilaceration or flexion occurring in an upper central 
incisor, of which a side view is 
presented. The crown is perfectly 
developed, but the root is short and 
thick and much curved, its apex 
being directed towards the lips. 
Fig. 16, from Wedl, shows a lower 
central incisor the seat of dilacera- 
tion, the crown is bent at a right angle to the root, and 
the cutting edge is directed towards the lips. 
Gemination or organic union of two neighboring teeth 
sometimes occurs, due to coalescence of contiguous prim- 
itive pulps during development. It rarely affects any 
but incisors, and the union may extend through crown 
and root, or may affect only a part of the teeth. Blended 
crowns contain as a rule a common pulp-cavity, but in 
blended roots the chamber is divided or distinct. Gem- 
ination does not necessarily give rise to marked deform- 
ity in the appearance of the teeth. Fig. 17, from Tomes, 
exhibits a lingual and labial view of two incisors of the 
upper jaw, the crowns of which are thus united. 
Supernumerary teeth are frequently met with. They 
are as a rule easily recognized, being mostly of an irreg- 
ular conical form, unlike any member of the normal set of 
Fig. 15. 
Fig. 16. 52 
MALFORMATIONS AND IRREGULARITIES 
teeth. Their most common situation is towards the front 
of the mouth, where they are usually placed irregularly 
among the other teeth. Sometimes a supernumerary 
tooth is both placed within the dental arch and symmet- 
Fig. 17. 
rical in form, and hardly distinguishable from its neigh- 
bors—an individual in this way possessing an extra or 
supplemental incisor or canine. 
Other abnormal teeth, presenting several forms, vary- 
ing between so-called warty teeth, studded with nodules 
of enamel, and monstrous teeth, mere shapeless masses 
of dental tissue, must be considered identical with the 
morbid growths termed odontomes, the nature of which 
will be described in a future section. 
The sole treatment available in each variety of the 
above-described abnormalities is the extraction of the 
deformed teeth, an operation which may be called for 
when the faulty tooth is unsightly, or when it is causing 
displacement of adjoining teeth. 
Irregularities of the teeth may be divided into two great 
classes. 1st. Those in which teeth occupy abnormal posi- 
tions in well-formed jaws; 2d, those associated with 
malformation either of the alveolar border or of the body 
of the jaw. OF THE TEETH. 
53 
The first class of irregularities rarely occurs in decid- 
uous teeth, for the reason that in this case the chief cause 
of irregularity—obstruction by preceding teeth—is absent. 
Instances of the second class in the infant, although sel- 
dom manifest to casual observation, are often perceptible 
to careful examination, especially when the deformity 
affects the jaw generally. Irregularities of the temporary 
teeth, whatever their character, are, however, of little 
practical importance, since the teeth are shed in early life, 
and the deformities do not call for treatment. 
It was explained in the previous section that, during 
the process of eruption, the teeth are not closely embraced 
by bone, and that it is not until some time after the 
crowns have fully emerged from the wide orifices of the 
crypts that the alveoli become fully formed, and invest 
closely the necks and roots of the teeth. During this 
stage of growth, when the advancing teeth are surrounded 
by soft, readily yielding tissues only, any slight obstacle 
to their progress suffices to divert them from their proper 
direction, and to retain them in a wrong position. The 
most frequent of such obstacles consist of temporary 
teeth, or decayed portions of temporary teeth, which have 
retained their places, after the time at which they ought 
to have been cast off. The most common example of 
this kind of irregularity, is illustrated in Fig. 18 (Tomes), 
where the permanent incisors of the upper jaw are seen 
to occupy a posterior position, owing to the persistence 
of the temporary teeth. A corresponding irregularity 
occurring in the lower jaw, is shown in Fig. 19. By 
similar causes teeth may be twisted upon their axes, 
crowded together so as to overlap, or displaced in almost 
any direction. In such cases if the temporary teeth be 
extracted sufficiently early, those that are displaced tend 54 
MALFORMATIONS AND IRREGULARITIES 
spontaneously to assume their proper positions; but 
should the deformity be allowed to continue for any great 
length of time, the teeth become fixed, either by the con- 
solidation of the bone of the jaw, by the advance of the 
Fig. 18. 
contiguous teeth, or by the locking together of the upper 
and lower sets when closed. For example, the prompt 
extraction of the temporary teeth in the case depicted in 
Fig. 18, would enable nature to effect a cure; but if the 
Fir. 19. 
operation were delayed until the permanent teeth were 
fully protruded they would pass, as seen in Fig. 20, on 
closure of the jaws, behind instead of in front of the 
lower incisors, and an impediment to their forward move- 
ment would be thus constantly opposed. This impedi- 
ment could then be overcome only by the mechanical OF THE TEETH. 
55 
means to be presently described. Similar remarks apply 
to the corresponding irregularity of the lower teeth. 
Delay here is, however, not so dangerous as in the case 
of the upper set. The normal position of the lower 
Fig. 20. 
front teeth being behind those of the upper jaw the 
danger of locking does not exist; and after the extrac- 
tion of the temporary teeth mechanical treatment is 
rarely required. This operation nevertheless should not 
be too long delayed, lest the adjoining teeth, taking a 
forward position, prevent the advance of those that are 
displaced. 
Other causes of the class of irregularities at present 
under consideration are to be found in injuries, such as 
blows upon the month, the presence of supernumerary 
teeth, or constant pressure, such as is kept up in thumb- 
sucking—a habit sometimes acquired by children. Then 
again, alveolar abscess connected with a temporary tooth 
may cause displacement of the developing permanent 
successor; whilst lastly, some cases of simple displace- 
ment of one or more teeth alone, in well-formed jaws, 
can be traced to hereditary predisposition, or to other 
causes acting prior to the eruption of the teeth. 
Fig. 21, from Wedl, exemplifies the form of displace- 
ment of the upper front teeth, produced partly by the 56 
MALFORMATIONS AND IRREGULARITIES 
persistence of temporary teeth, and partly by the pres- 
ence of a supernumerary tooth. The supernumerary 
tooth (a) presented itself within the dental arch upon 
the right side, adjacent to the left central incisor, and 
thus caused a displacement of the right central incisor 
(6) upwards and forwards. The lateral incisor (c) is 
Fig. 21. 
twisted on its axis, and the permanent canine (e) pushed 
somewhat outwards, in consequence of the retention of 
the temporary canine (d). 
It is of course not necessary to describe in detail all 
the varieties of displacement of teeth of the kind under 
discussion. The preliminary treatment of them all is 
the same—namely, the prompt removal, when possible, 
of the cause. 
And it may be here remarked, that whilst uncalled- 
for interference should be guarded against, there need 
be no hesitation in extracting temporary teeth, the re- 
moval of which is necessary for the cure of irregular- 
ities. It is a somewhat popular belief, that the prema- 
ture extraction of these teeth may act as a cause of 
subsequent contraction of the jaw, and thus of irregu- 
larity of the teeth. This belief is refuted by physio- 
logical fact, as well as by practical experience. The OF THE TEETH. 
57 
growth of the alveoli of the permanent teeth (as pointed 
out on a previous page) goes on quite independently of 
the temporary set; and cases are on record in which, 
even after the premature loss of the entire temporary 
set, the jaw attained its normal development, and the 
permanent teeth assumed their proper positions. 
With a knowledge of the order in which the teeth 
are erupted, and of the characteristics which distinguish 
the permanent from the temporary set, the mistake of 
extracting one of the former instead of one of the latter, 
is not likely to oceur. An error of this kind is, howT- 
ever, hardly possible, except in the case of the incisors 
and canines. The permanent molars may be known 
from their position posterior to the temporary teeth ; 
whilst the bicuspids may be easily recognized, since no 
such tooth exists in the deciduous set. The permanent, 
if present during the persistence of the temporary, in- 
cisors, will be found posterior to the teeth which they 
replace, and their cutting edges are serrated, whilst those 
of the temporary set by this time are worn smooth. 
The permanent canines may be distingushed by their 
great size in comparison with the corresponding tempo- 
rary teeth, and by their position, which is external and 
prominent, the root being perceptible as a vertical pro- 
jecting ridge on the external alveolar wall. 
Irregularities, due to malformations of the alveoli or 
of the body of the jaws themselves, have now to be 
described. It has been before stated that the normal 
dental arch is semi-elliptical in shape. The front por- 
tion of the figure, containing the incisors, canines, and 
bicuspids, forms an almost perfect semicircle; whilst the 
portions containing the molars continue the line back- 
wards at each side. Flattening or contraction of this 58 
MALFORMATIONS AND IRREGULARITIES 
arch, or abnormal development of any part of it, neces- 
sarily give rise to irregularities of the teeth. This class 
of irregularities is most commonly congenital, and at 
the same time often hereditary, a peculiar abnormality 
in the form of the jaws being in this manner sometimes 
reproduced in many members of a large family. They 
may, however, be due to injury or other accidental 
causes. The deformity may exist in one or both max- 
illa), or may be confined to one side only of the bone. 
The almost marvellous manner in which the jaws (like 
other bones) may be modified in shape, especially during 
early life, by the continued application of force in one 
direction, is not uncommonly exemplified in surgical 
cases. The sequel of extensive burns of the neck occa- 
sionally furnishes a striking instance in point. The 
cicatrice resulting from such an injury has a constant 
Fig. 22. 
tendency to contract, and unceasingly drawing the chin 
towards the chest, causes the body of the jaw gradually 
to curve downwards. In cases from time to time met 
with, the curvature is so great that the alveoli are com- 
pletely everted, and the teeth directed outwards, or even OF THE TEETH. 
59 
downwards. One of these cases is figured in the an- 
nexed engraving (Fig. 22), taken from Mr. Tomes’s 
work. 
The nature of these irregularities, associated with 
Fig. 23. 
malformations of the jaw, will be rendered evident by 
a few typical examples. Fig. 23 represents an extreme 
Fig. 24. 
instance of a common variety, a protrusion of the central 
incisors, apparently due to an abnormal outgrowth of 60 
MALFORMATIONS AND IRREGULARITIES 
the anterior portion of the alveolar processes. A some- 
what similar deformity of the lower jaw (Fig. 24) 
(Tomes), gives rise to projection of the lower beyond 
the upper front teeth. An individual affected with this 
deformity is said to be underhung. The V-shaped or 
contracted arch, instances of which daily present them- 
selves, is illustrated in Fig. 25. This gives rise to al- 
Fig. 25. 
most endless varieties of displacements of the teeth. 
The incisors or bicuspids are often forced inwards, and 
the canines, appearing after these are in position, remain 
external and prominent. The deformities due to crowd- 
ing in that class of case in which a small though well- 
shaped jaw contains disproportionately large teeth, closely 
resemble those occurring in the V-shaped maxilla. 
In a somewhat rarer example of deformity (Fig. 26) 
(Tomes) the molars alone approximate on closure of the 
jaws and the incisors remain apart and cannot be brought 
into contact. This is in consequence of a malformation 
of the posterior portion of the lower jaw, as a result of 
which the molars, being plaeed on too high a level, pre- 
vent the rest of the set from coming together. OF THE TEETH. 
61 
These examples will suffice to render manifest the 
distinction between the two great classes of irregulari- 
ties, and little would be gained by multiplying them. 
In any case except the simpler instances of the first 
class, in which removal of the cause is enough to bring 
Fig. 26. 
about a cure, it may be necessary in the first place to 
consider the expediency of extracting permanent teeth 
for the sake of obtaining space; next comes the ques- 
tion of the extraction of such malplaced teeth as are 
not amenable to mechanical treatment; and lastly, there 
is the construction and application of a mechanical ap- 
paratus when it is required for the completion of the 
treatment. With regard to the extraction of permanent 
teeth for the sake of affording room, it may be at once 
stated that the sacrifice of an incisor or canine, is rarely 
necessary or justifiable. They are the most durable of 
the teeth, they contribute most to the symmetry of the 
dental arch, and moreover a tooth may generally be 62 
MALFORMATIONS AND IRREGULARITIES 
chosen, the removal of which will better serve towards 
the desired end. The choice will as a rule fall upon the 
first molar. This tooth is the most liable to decay, and 
even in early life is often so extensively carious as to re- 
quire extraction, or at least is in a condition so defective 
that it cannot be expected to last many years. After 
the extraction of a tooth from a crowded jaw the pres- 
sure is relieved, and the teeth spread equally apart until 
in a comparatively short time (very rapidly in early life) 
the space previously occupied by a large tooth becomes 
obliterated. In most cases to relieve crowding it is de- 
sirable to remove a tooth at each side of the jaw. If 
only one tooth be extracted, the movement of the 
crowded members takes place towards that side, and 
the regularity of the dental circle is disturbed. 
Nothing conduces more to the onset and rapid advance 
of decay than a crowded, irregular condition of the 
teeth, and when this condition exists the removal of 
one or two even sound teeth has a highly beneficial 
influence over the future health of the rest of the set, 
and on this ground alone the operation is often advis- 
able. 
Should the first molar be free from defect, any other 
tooth which shows signs of decay, or of imperfect struc- 
ture, may of course be chosen instead, and where doubt 
exists, the relative liability of the different classes of 
teeth to decay will govern the choice. This liability 
has been ascertained from carefully collected statistics. 
The first molars, as just stated, are much more often 
attacked by decay than any others of the teeth; next 
in this respect come the second molars; after these the 
second bicuspids; fourthly, the first bicuspids; fifthly, 
the lateral incisors; sixthly, the canines; and lastly, OF THE TEETH. 
63 
the central incisors are less frequently the seat of caries 
than any other teeth of the set. Space having been ob- 
tained by the extraction of teeth, nature may be trusted 
unaided to effect a cure in some few cases of irregularity 
due to crowding alone, in which the direction of the 
teeth is good, and where they are not locked in their 
malpositions by those of the opposing jaw; but in many 
cases mechanical treatment will be necessary. 
Numerous instances, however, present themselves in 
which one or more teeth are so far displaced as to pre- 
clude the possibility of their reduction by any means to 
their proper positions. Such instances are specially 
those in which not only the crown, but the entire root 
is out of its normal situation. For example, an upper 
canine being erupted after the lateral incisor and bicus- 
pid are in position, often presents itself external to and 
prominent over the space between these teeth, which is 
too narrow to contain it. When the direction of the 
canine is correct it will in time take its proper place if 
room be afforded, but should it appear in an oblique 
direction and with its root lying at an angle across the 
alveolar border, as in the case depicted in Fig. 27, it is 
unlikely that it could be brought into the desired posi- 
tion even were mechanical treatment employed. In 
such cases the extraction of the malplaced tooth is the 
sole resource. An example of an irremediable displace- 
ment of a bicuspid of a kind which is also frequently 
met with in the case of other teeth is shown in Fig. 28, 
from Wedl. The wisdom teeth more than any other of 
the set are liable to total displacement of this kind, for 
the reason which has been mentioned in a previous sec- 
tion, in speaking of the eruption of these teeth—namely, 
that they make their appearance after the rest of the 64 
MALFORMATIONS AND IRREGULARITIES 
teeth are in place, and when insufficient room in the 
jaw for their normal progress remains. Displaced wis- 
Fig. 27. 
dom teeth do not call for interference unless they consti- 
tute a source of discomfort or give rise to irritation. 
Fig. 28. 
When this occurs extraction may be performed without 
hesitation, the tooth from its position being useless in 
mastication. 
Instruments for the purpose of regulating the teeth 
are constructed to fulfil several objects—to prevent the 
locking together of the teeth or closure of the mouth, 
and to exert such continued pressure or traction on those 
that are displaced, that they may be gradually compelled 
to assume their normal positions. It has been seen that 
irregularities vary between the simplest kind — mere 
slight displacements of growing teeth—and the severest 
form associated with malformation of the maxilla. It 
will be understood, therefore, that the effect required to 
be produced in different cases by mechanical treatment OF THE TEETH. 
65 
varies also considerably; and it will be perceived also 
that the treatment can be carried ont much more rapidly 
and effectually in the child than in the adult. At the 
former period of life when the alveoli are in process of 
growth a malplaced tooth can be drawn into position in 
a short time, and with the exercise of but slight force, 
whereas at a later date, the jaw having become consoli- 
dated, the treatment becomes long and tedious. It will 
be evident also that in the simplest cases the instrument 
is not required to do much more than guide the develop- 
ing tooth in the desired direction, whilst in the more 
difficult, it will be necessary to keep up such pressure 
as shall cause absorption of the bone which opposes the 
movement of the tooth. To give rise to absorption by 
continued pressure, it is well known, is not difficult 
either in the jaw or in other bones. The precaution 
must be taken in dental cases not to cause irritation 
sufficient to pass into destructive inflammation. Some 
amount of congestion or perhaps even inflammation of 
the slightest extent must necessarily accompany the ab- 
sorption, but it is not difficult to arrange the apparatus 
to exert with great nicety any amount of force required, 
without exciting inflammation of undesirable severity. 
The more slowly the teeth are moved the less danger 
will there be of mischief arising. It is only experience 
in each case that can determine the degree of force which 
may be safely applied, and it is well, therefore, to com- 
mence always with a small amount, and gradually in- 
crease it. 
That the movement of teeth under the influence of 
pressure must be accompanied in some instances by ab- 
sorption of bone is beyond doubt, but from the fact that 
the opportunity for post-mortem examination never pre- 66 
MALFORMATIONS AND IRREGULARITIES 
sents itself during the treatment of these cases, the exact 
mode in which the changes in the tissues are effected 
cannot be ascertained, and for a similar reason it is im- 
possible to explain the well-known circumstance that 
even after the absorption of bone has been apparently 
induced, and the teeth have taken the desired positions, 
they tend invariably to fall back into their former situ- 
ation unless mechanically fixed by the teeth of the oppos- 
ing jaw, or retained for a considerable time by an instru- 
ment constructed for the purpose. Thus in the case 
shown on a previous page, Fig. 16, the treatment might 
cease safely so soon as the upper teeth had been pushed 
into their normal position, in front of the corresponding 
lower teeth when closed; whilst in such a case as depicted 
in Fig. 21, if after the reduction of the deformity the 
treatment were discontinued a relapse would speedily 
take place. In all such cases as the latter, after the 
irregularity is cured, a plate must be arranged to hold 
the teeth in their new positions, and must be worn from 
six months to two years, according to the age of the 
patient and the severity of the deformity. 
The simplest form of regulating apparatus consists of 
a plate accurately adapted to the teeth and gums, the 
crowns of the molars being covered when desirable witli 
a sufficient thickness to prevent the upper and lower 
front teeth from meeting. A fixed point is thus provided 
to which screws, springs, or levers, elastic bands or wedges 
of wood, may be attached to act upon the teeth in any 
desired direction. The material of which the plate is 
constructed may be either metal (gold or silver) or vul- 
canized india-rubber. Either of these materials answers 
almost equally well; some operators prefer one, some 
another. The author believes that vulcanite has some OF THE TEETH. 
67 
slight advantages over metal. It is easier to make it 
firm in the mouth. If a perfect model be taken and the 
plate vulcanized upon it, the accuracy of the fit alone in 
most instances will suffice to fix it in the mouth. Addi- 
tional rigidity may be obtained by paring the model 
slightly at the necks of the temporary molars before 
vulcanizing, and after this it is rarely necessary to attach 
the plate by ligatures, an expedient which must be adopt- 
ed more frequently where metal is used. Vulcanite 
again affords a more congenial surface for mastication 
than metal, and it is less liable to chafe the surface and 
injure the enamel of the teeth with which it is in contact. 
Of whatever material the plate is constructed it ought 
to be removed at intervals of a day or two for the pur- 
pose of thoroughly cleansing it as well as the crowns of 
the teeth which it envelops. 
Fig. 29. 
Ill order to make the character of these instruments 
clearly understood, the description of two or three cases 
will suffice. Fig. 29 shows in position the instrument 
employed in the regulation of the case represented in 
Fig. 30. This was an irregularity of a simple kind, one 
upper lateral incisor being displaced inwards, and held 
in its malposition by the lower teeth. The plate cover- 68 
MALFORMATIONS ANJ) IRREGULARITIES 
ing the molars kept the jaws sufficiently apart to prevent 
the front teeth from meeting, and the obstacle to the 
forward movement of the tooth being in this way removed, 
but a slight amount of pressure was required to force it 
into its right position. The pressure was obtained by a 
Fig. 30. 
wedge of compressed hickory fixed in a chamber in the 
vulcanite behind and in contact with the irregular tooth, 
the moisture of the mouth causing the wood to expand 
and in expanding to push the tooth slowly forward. The 
wood was renewed by larger pieces at intervals of a day 
or two, as the cure progressed, until the tooth having 
been driven sufficiently outward the patient was dis- 
missed. 
The next case (Fig. 31) was of a somewhat different 
character. The irregularity consisted of a twisting of 
Fig. 31. 
the central incisors on their axes. It was probably of 
congenital origin. The instrument with which it was 
treated is shown in position in Fig. 32. It consisted of OF THE TEETH. 
69 
a vulcanite frame closely in contact with the inner angles 
of the twisted teeth, but clear of the rest of their sur- 
faces. From each side of this frame there proceeded a 
flat spring of hard gold wire, and these extending round 
in front were so arranged, that their free extremities kept 
Fig. 32. 
up constant pressure on the prominent edges of the inci- 
sors. In this way the distorted teeth were compelled 
Fig. 33. 
gradually to revolve, and the deformity was in time 
entirely removed. Fig. 33, from Mason (10), illustrates 70 
MALFORMATIONS AND IRREGULARITIES 
another method of treating these irregularities. A metal 
plate is fitted to the mouth, backing the twisted incisors, 
and carrying screws to act upon the inverted angles, 
whilst a metal bar passing round in front, and pressing 
upon the prominent surfaces, causes the teeth to revolve 
instead of move forward. 
Cases like the last, in which the teeth are merely 
turned in their sockets, are treated by some practitioners 
by an operation which has been called “ actual torsion.” 
This operation is performed by seizing each tooth firmly 
with a pair of forceps, and slowly and deliberately turn- 
ing it by force, until reduced to its proper position. By 
this means it is believed that the alveolar wall may be 
made to yield, and the tooth turned without permanent 
rupture of its vascular connections, or injury to its vi- 
tality. The forceps ought to be specially constructed 
with broad flat blades lined with leather, or better with 
lead, so as to avoid crushing the tooth or damaging the 
enamel. A plate previously prepared must be in read- 
iness for insertion immediately after the operation, and 
must be worn for some months to retain the teeth in 
the new position. The subjects of this operation ought 
to be young children in good general health. There 
must obviously exist, after the operation of “ actual 
torsion,” a danger of the occurrence of inflammation, 
perhaps involving the loss of the tooth, but such un- 
toward results are stated to be, in well-chosen cases, 
extremely rare. Symptoms of inflammation would be 
best treated by leeches to the gum, followed by warm 
fomentations and the administration of a saline purge. 
The advantage of “actual torsion” consists in the ra- 
pidity with which a cure is accomplished; but in pro- 
posing the operation, it must be borne in mind that it OF THE TEETH. 
71 
involves unquestionably a risk, whilst the desired effect 
can be produced with certainty by other means, without 
any danger whatever. 
Cases similar to that shown in Fig. 23 may be treated 
by an instrument (Fig. 34) much the same as in that 
Fig. 34. 
illustrated in Fig. 32. In these cases, however, the gold 
wires are made to terminate in front of the canine teeth, 
and each has affixed at its extremity a small gold stud 
or hook. An elastic band stretched between these hooks 
over the faces of the protruding teeth, affords the pres- 
sure necessary to reduce them in time to their proper 
position. The same effect might be produced equally 
well by means of elastic bands passed over the teeth, 
and attached behind to the surface of the plate; but 
this method sometimes causes discomfort by interfering 
with the movements of the tongue, or with the lower 
teeth, during mastication. An apparatus of this kind 
is depicted in Fig. 35, from Mason (10). The plate is 
of metal. The projecting central incisors are acted upon 
by elastic ligatures attached to a stud on the lingual 72 
MALFORMATIONS AND IRREGULARITIES 
surface of the plate. The lateral incisors being dis- 
placed inwards, are forced in the desired direction by 
Fig. 35. 
screws passing through the plate, and pressing upon 
their posterior surface. 
The following case, the models of which are in the 
museum of the Odontological Society, illustrates several 
points in the treatment of irregularities. In June, 1873, 
a young lady, then aged fourteen, received a blow in the 
mouth which caused a fracture, extending vertically 
through the crown of the left upper central incisor. In 
January, 1875, she was brought to me, when finding 
the fracture involved the root, and rendered its preser- 
vation impossible, I extracted the tooth. The accom- 
panying cut (Fig. 36) shows exactly the appearance of 
the upper jaw after this operation. The right central 
and lateral incisors, and the left canine, fell considerably 
beyond the range of the lower teeth on closure of the 
mouth, whilst the right canine and first molar were 
displaced inwards, the cusp of the former locking within OF THE TEETH. 
73 
the lower teeth. Considering all the circumstances, it 
was deemed preferable to attempt to regulate the teeth, 
and to bring about at the same time closure of the gap 
in front, rather than to condemn the patient to wear an 
artificial tooth. An apparatus was accordingly made to 
exert constant outward pressure, by means of wooden 
Fig. 36. 
wedges, on those teeth which were within the normal den- 
tal circle, and flat springs of hard gold wire were brought 
round at each side in front, to act in the opposite direc- 
tion upon the projecting incisors and canine. The next 
engraving (Fig. 37) shows the elfect produced after 
three months of this treatment, by the exercise of an 
amount of force so slight as to give rise throughout 
to no irritation beyond a trivial passing tenderness of 
some of the teeth. The rapid favorable progress of this 
case was due to a great extent to the youth of the patient, 
and to the ample room which the loss of the incisor 
provided for the spreading apart of the crowded teeth, 
and their movement in the desired directions. The 74 
MALFORMATIONS AND IRREGULARITIES 
case is still under treatment, and no doubt in a short 
time still greater improvement will be effected in the 
arrangement of the teeth. 
Fig. 37. 
By contrivances similar in action to those already de- 
scribed, the entire alveolar border of the jaw might be 
modified in form. For instance, in the contracted or V- 
shaped palate, an apparatus would be made to maintain 
equal pressure from within outwards along the alveolar 
margin of the jaw, until in time the required expansion 
of the arch could be accomplished. Some few cases 
may be advantageously dealt with by instruments fixed 
externally. Thus, the case depicted in Fig. 26, would 
be treated by constant upward traction of the chin, a 
cap of leather adapted to that part being attached to a 
strap across the head by strong elastic bands at each 
side, as seen in Fig. 38. 
It is not within the scope of this manual to enter fur- 
ther upon, a description of all the numerous expedients 
which may be adopted in the devising of instruments OF THE TEETH. 
75 
for regulating the teeth. Enough has been said to make 
clear the principles upon which the construction and 
action of the apparatus are uniformly based, and indeed 
these principles alone being understood, there are few 
Fig. 38. 
cases which can present serious difficulty to any opera- 
tor possessing a moderate amount of mechanical inge- 
nuity. 76 
CARIES. 
CARIES. 
Caries, or decay of the teeth, consists essentially of 
a process of gradual softening and disintegration of the 
tissues, due mainly to the action of acid. The onset of 
the disease is favored, and its progress is hastened pri- 
marily, by certain structural defects in the enamel and 
dentine, and secondarily, by some diseases of the oral 
mucous membrane and some derangements of the gene- 
ral health. The progress of the disease is accompanied 
by pathological changes in some of the tissues affected 
by it. Commencing invariably at the exterior, it ad- 
vances towards the interior of the tooth, forming a 
cavity which increases in size until the crown, and even 
the greater part of the root also are destroyed. It is 
attended with pain, which often commences in a mild 
form as soon as the dentine is slightly penetrated, and 
becomes most severe when the central chamber is laid 
open, and the pulp, being exposed to the action of ex- 
ternal irritants and to injury, becomes the seat of inflam- 
mation. 
The acid, the active agent in caries, may be derived 
from several sources. It may be secreted by the mucous 
membrane. The normal secretion of the membrane is 
small in quantity and slightly acid. In health the acid 
is at once neutralized by the alkaline saliva, with which 
it mingles; but when the membrane is congested or in- 
flamed the mucus increases in quantity, and becomes 
more strongly acid in character, and is sufficiently CARIES. 
77 
powerful to slowly dissolve the dental tissues. This 
may be proved by experiment. If a small pellet of 
cotton-wool, or other foreign substance, be forced be- 
tween two teeth, and left so as to press upon the gum, 
the secretion from the mucous membrane at that point 
will be found in the course of a few hours increased in 
quantity and strongly acid. If this irritation be kept 
up, it will be seen after a short time that the enamel of 
the teeth adjacent to the acid secreting surface is under- 
going slow solution. 
During the decomposition of particles of food which, 
mingled with shreds of mucus and other such substances, 
lodge about the teeth, acid is formed which is capable of 
producing an effect exactly similar to that just described. 
These statements with regard to the susceptibility of 
the dental tissues to the action of acids have received 
ample corroboration from the results of experiments 
upon extracted teeth. Teeth submitted to the influence 
of dilute acids not more powerful than would be gene- 
rated in the mouth under the circumstances above men- 
tioned, become slowly decalcified. Magitot allowed 
teeth to remain in a solution of lactic acid in the pro- 
portion of one part of acid to 100 parts water, and in a 
solution of butyric acid of similar strength, and in citric 
acid solution one part acid to 1000 water. After the 
lapse of two years it was found that the roots of the 
teeth immersed in the two first mentioned solutions had 
become flexible owing to the abstraction of their earthy 
constituents, and the enamel was chalky, friable, sepa- 
rated from the coronal surfaces in places, and readily 
reducible to a white powder by trituration. The den- 
tine presented a general brown discoloration. 
Citric acid acted in the same manner, but with greater 78 
CAKIES. 
rapidity. Fluid containing fermenting albuminoid sub- 
stances—such as are represented in the mouth by parti- 
cles of food and shreds of mucus lodged about the teeth 
—were found to produce precisely similar effects. Dur- 
ing the putrefaction of these substances fatty acids are 
formed of the acetic and benzoic series. 
Teeth immersed in either of the abovementioned fluids, 
bid protected from their action, except at one point, become 
affected at the exposed portion by softening and disinte- 
gration exactly resembling in essential characteristics true 
caries. In the mouth there is of course always added 
to the action of acid the decomposition of the animal 
basis of the tissues, which is accompanied and hastened 
by the development of low vegetable organisms presently 
to be mentioned. 
Caries may commence on a sound unbroken surface 
of the tooth, especially on the lateral aspects, close to 
which acid is commonly generated by the decomposition 
of particles of food and irritation of the mucous mem- 
brane. It frequently has a starting-point at some part 
of the enamel and dentine, the seat of structural defects. 
Imperfections in structure, from which few sets of teeth 
are altogether free, may be owing to defect either in the 
quantity or in the quality of the tissues. Defects in 
quantity consists of pits and fissures in the enamel and 
dentine. These vary in extent between minute cracks per- 
ceptible only under the microscope, and cavities plainly 
visible by the naked eye. They may penetrate the 
enamel alone, or may extend to a greater or less depth 
into the dentine also. Their most common situation is 
in the depths of the natural depressions in the contour 
of the tooth, as for example between the cusps of the 
molars. Fissures which involve the dentine as well CARIES. 
79 
as the enamel are the most favorable to the attacks of 
caries. 
Defects in the quality of the tissues may affect the 
whole body of the tooth or may be confined to certain 
spots in the enamel and dentine. The fact is well 
known that the durability of the dental tissues varies 
considerably in different individuals—in one the teeth 
withstand the extremest hard usage combined with neg- 
lect, in another they show traces of disease within the 
earliest years of childhood, and are destroyed sooner or 
later even in spite of active treatment. If the enamel 
and dentine of such delicate teeth be examined, it will 
be found that they present well-marked evidences of 
imperfect formation. The enamel instead of appearing 
a densely hard, almost homogeneous mass, is compara- 
tively soft owing to imperfect calcification, and porous 
in consequence of incomplete coalescence of its forma- 
tive elements. It retains a marked fibrous character. 
The fibres are imperfectly blended; their transverse 
strife are clearly evident, and they are often penetrated 
at their centres by tubes or small cavities. At parts 
the fibrous character may be altogether lost, the tissue 
consisting of an imperfectly united granular mass. 
The dentine in addition to undue softness exhibits 
throughout its structure, and especially immediately 
beneath the enamel, patches of defective tissue similar 
in character to the granular layer which in well-formed 
teeth exists only at. the point of juncture with the cement. 
In the spaces within this defective tissue — sometimes 
called interglobular spaces—the tubes end, or they may 
even run on and terminate in dilated extremities within 
the substance of the enamel. 
It does not always happen by any means that all the 80 
CARIES. 
structural defects which have been just mentioned in 
the quantity and quality of the dental tissues exist to- 
gether in one tooth. Their degree and character vary 
considerably. It is not uncommon to find in teeth of 
otherwise good organization one or two pits or fissures, 
or small patches of defective tissue; whilst in teeth of 
generally inferior structure there are often to be discov- 
ered portions of still feebler formation. 
The local and constitutional diseases which favor the 
onset and progress of caries are those which are accom- 
panied by, or which tend to aggravate inflammation of 
the oral mucous membrane, and those which give rise 
to the formation or deposit of acid within the mouth. 
Among the former may be particularly enumerated all 
the varieties of stomatitis; among the latter scrofula, 
syphilis, phthisis, diabetes, chlorosis, and chronic alco- 
holism. These constitutional affections exert their bane- 
ful effect upon the teeth in great part by reason of the 
chronic inflammation of the gums, the vitiation (even 
general acidity) of the secretions of the mouth, and the 
dyspepsia with which they are all so commonly accom- 
panied. For the same reason caries is frequently active 
during pregnancy. During febrile diseases, in which 
the secretion of saliva is scanty and the teeth remain 
coated with sordes, accumulations of epithelial scales, 
viscid mucus and other foul secretions, caries, as might 
be expected, is often originated, and when previously 
present is always accelerated. 
The fact that enamel and dentine are readily soluble 
in the acids the presence of which in the mouth com- 
monly arises from various sources, and that structural 
defects in the enamel and dentine not only furnish places 
favorable for the lodgment of acid-forming substances, CARIES. 
81 
but at the same time render some portions of the teeth 
more readily acted upon than others, suffice to explain 
both the origin of caries and the reason why the disease 
commences at certain isolated spots, and does not affect 
uniformly and at once the entire surface of the crowns 
of the teeth. 
The physical signs of caries, consisting mainly of 
discoloration and softening of the tissues, bear a general 
resemblance in every case. They differ only in conse- 
quence of the mode of onset, the situation, and rapidity 
of the disease. The discoloration in the incipient stage 
on an unbroken surface of enamel usually amounts to 
no more than slight opacity of that tissue, a condition 
which also as a rule prevails throughout the later stages 
on the borders of the cavity of decay. When the dis- 
ease begins in a fissure, and when a cavity is formed, 
the discoloration is more marked, the softened dentine 
assuming a brown tint, or becoming stained to a black- 
ish hue by decomposition, aided by the entry of foreign 
substances, and by the deposit of the peculiar fungoid 
growth, the leptothrix bucealis. Cavities in which the 
disease extends deeply and is progressing rapidly show 
least discoloration. 
The softening or disintegration perceptible in the 
successive stages of the disease varies considerably. 
When a surface of enamel is first affected it appears 
eroded, rough, and full of small holes, and is readily 
scraped away by a steel instrument. When the mischief 
has commenced in a fissure, but little softening may be 
apparent for a time at the surface, until later the under- 
mined enamel breaking down or being cut away dis- 
closes a cavity in the dentine filled with disorganized 
tissue. Such a cavity is formed in every case in the 82 
CARIES. 
later stages of the disease. Carious cavities are often 
cone-shaped, the apex of the' cone being at the surface. 
This form of cavity (which more particularly arises 
where a fissure has existed) is due to the more rapid de- 
struction of the deeper than the superficial parts. The 
former are kept in intimate unceasing contact with the 
acid-generating contents of the cavity, whilst the latter 
are as constantly washed by the alkaline saliva. Then 
again when caries penetrates to a mass of interglobular 
substance, it is easy to understand how the disease ad- 
vances with greater rapidity at that part than at the 
superficies. The differences in the physical character of 
the disease have given origin to such distinctions as 
spreading, penetrating, soft and hard caries. 
Microscopical examination of carious teeth shows that 
the action of the acid is more energetic in sotne elements 
of the tissues than in others. Thus in the enamel the 
central portion of the fibres is as a rule the first to be 
removed, whilst in the dentine the intertubular substance 
and the walls of the tubes are the first to disappear, leav- 
ing the sheaths and fibrils, the animal basis of the tissue, 
to become subsequently decomposed and destroyed. The 
tubes at the later stages of the disease appear dilated, 
and present occasional varicosities. Besides the disinte- 
grated tissues and foreign particles, there is to be found 
by the microscope in most carious cavities abundance of 
the peculiar fungoid growth leptothrix buccalis, similar 
to that which is deposited upon the surfaces of the teeth 
in all mouths in which the most extreme care is not taken 
in frequently cleaning the teeth. The leptothrix assumes 
the appearance of minute threads projecting from the 
surface of the carious dentine in enormous numbers. It 
enters and occupies the disorganized and dilated tubes, CARIES. 
83 
forming a molecular mass therein, and it penetrates the 
tissue in every direction in which the calcareous salts 
have been removed. It has been supposed by some few 
observers that the leptothrix, if not the exciting cause of 
the disease, takes the principal part in promoting the 
advance of caries. There is no more than the slightest 
evidence to support the former part of this opinion, and 
but little to substantiate the latter. It can be conceived, 
however, that the growth may have some share in hasten- 
ing the destruction of the already decomposing tissues. 
Examination of carious teeth in various stages of decay 
demonstrates the fact that certain changes apparently 
take place prior to actual disintegration in that portion 
of dentine through which the disease is advancing, and 
which is situated immediately contiguous to the already 
disorganized tissue. This altered dentine has a trans- 
lucent appearance, and forms either a regular zone, or 
exists in isolated patches around the walls of the cavity. 
The appearance was once thought to indicate invariably 
a vital or pathological action, a natural effort to arrest 
the disease by calcification of the dentinal fibrils, similar 
to that which occurs as a natural phenomenon as age 
advances. Such a change does doubtless really occur in 
some cases, especially in slowly advancing caries in teeth 
of good formation, and it renders the tissue harder and 
better able to resist the progress of decay, and even some- 
times to arrest it altogether. It is found, however, that 
a precisely similar translucent appearance is always pro- 
duced during the gradual softening of dentine by acid, 
and to this softening and not to consolidation, the appear- 
ance in caries is due in the majority of instances. 
Enamel being devoid of sensibility the pain during 
caries (as already stated) does not begin before the den- 84 
CARIES. 
tine is affected, and it is due in the earlier stages of the 
disease solely to the exposure of this sensitive tissue to 
sudden changes of temperature and pressure of foreign 
particles and contact with irritating substances. In the 
later stages pain arises from the transmission of similar 
irritation to the pulp when that structure is either insuffi- 
ciently protected by a layer of dentine, or actually ex- 
posed. Finally, if the disease run on, there is added 
the pain due to the extension of the inflammation from 
the pulp to the peridental membrane. 
The amount and character of the pain in all the phases 
of caries are much diversified in different persons. In 
some there is almost from the beginning constant pain 
of a dull aching character, augmenting from time to time 
as decay advances into severe or even agonizing parox- 
ysms, whilst in others the teeth are altogether destroyed 
without any suffering beyond slight occasional aching 
and uneasiness. It is impossible to account for this differ- 
ence, but it may be noted that the very young suffer as 
a rule more acutely than adults or the aged, and that in 
certain conditions of health, of which pregnancy fur- 
nishes the most striking instance, toothache, if it occurs, 
is usually of the severest kind. Leaving out such ex- 
ceptional cases it may be broadly stated, however, that 
in the vast majority of instances there comes on from 
time to time, after the dentine is affected, slight attacks 
of transient aching, particularly after entry into the cav- 
ity of irritating substances, such as sugar and salt, and 
a smart pang slowly subsiding is often inflicted when a 
hard fragment of food is forced in during mastication. 
The pathology and symptoms of irritation and inflam- 
mation of the pulp of dental periostitis associated with 
caries are discussed in a later chapter. It may be re- CARIES. 
85 
peated that the most severe pain which arises during 
the progress of caries is due to inflammation of the pulp. 
It is by the extension of this inflammation that the den- 
tal periosteum becomes involved. When periostitis has 
supervened the tooth becomes slightly loosened, and 
exquisitely sensitive to the touch. 
It is a remarkable fact, and one that has some practical 
application (as was seen in a preceding section), that the 
teeth are not all equally liable to be affected by caries. 
Series of cases have been tabulated from time to time by 
various observers, and these agree in the main with each 
other. The following statistics of 10,000 cases collected 
by Magitot, show the relative frequency of caries in the 
different kinds of permanent teeth : 
Central incisors, 
642 f Superior, 
. 612 
\ Inferior, 
30 
Lateral incisors, 
f Superior, 
. 747 
l Inferior, 
30 
Canines, . 
515 /Superior, 
. 445 
l Inferior, 
70 
First bicuspids, 
1310 / SuPeriori 
. 940 
/ Inferior, 
. 370 
Second bicuspids, 
1310 / SuPeri°r, 
l Inferior, 
. 810 
. 500 
First molars, 
. 3350 / Superior, • • 
. 1,540 
l Inferior, 
. 1,810 
Second molars, . 
1736 /Superior, 
. 690 
l Inferior, 
. 1,046 
Third molars, . 
360 { Superior, 
. 220 
/ Inferior, 
. 140 
10,000 
10,000 
The first point which attracts attention in these tables 
is the great relative frequency of caries in the first mo- 86 
TREATMENT OF CARIES. 
lars; the next the much greater frequency of the disease 
in the front teeth of the upper than in those of the 
lower jaw. The latter circumstance may perhaps be 
accounted for by the fact, that the lower front teeth are 
protected from the action of acid by the saliva with 
which, owing to their position, they are constantly 
bathed. It must be admitted, however, that no entirely 
satisfactory explanation of the ratio of frequency pre- 
sented by the several classes of teeth has yet been 
afforded. TREATMENT OF CARIES. 
87 
TREATMENT OF CARIES. 
PREYENTIYE—THE INCIPIENT STAGE—THE OPERATION 
OF FILLING THE TEETH. 
Preventive Treatment.—The pathology and etiology of 
dental caries being understood, it will be obvious that 
much can be done to prevent attacks of the disease, and 
to delay its progress. The treatment of constitutional 
conditions predisposing to decay of the teeth, falls be- 
yond the province of the dentist, and although it can be 
therefore only mentioned here, too much stress cannot 
be laid upon its importance. If it be omitted, the most 
active local measures may prove in some cases ineffec- 
tual. 
Locally, the prophylaxis of caries in part consists in 
combating diseased conditions of the mucous membrane 
of the mouth, which are attended with vitiation of the 
secretions; but as these conditions are discussed in later 
pages, there need be considered here only the means 
which are available locally in preventing the formation 
of acid, the active agent in caries, in neutralizing it, and 
in preventing its hurtful effects upon the teeth. Fore- 
most among these means must be placed the main- 
tenance of the mouth in perfect cleanliness. The teeth 
should be carefully brushed, at least twice daily, and 
the patient should be taught not only to cleanse their 
external surfaces, but to apply the brush to every part 
which it can reach. The spaces between the teeth 88 
TREATMENT OF CARIES. 
should be frequently freed from the particles of food 
which lodge there. For this purpose a few threads of 
floss silk, or a fold of any similar soft material slipped 
into the spaces, and rubbed briskly to and fro, answers 
well. Tooth-powders and lotions are of considerable 
value. Tooth-powders ought not to be made of materials 
like levigated pumice, which are often used to whiten 
the teeth, and which produce this effect by grinding 
away the enamel; but should be composed of strongly 
alkaline, bland, and soluble substances, having no 
more mechanical power than enables them to remove 
the well-known soft fur which coats the surfaces of the 
teeth in most mouths, even within a few hours after 
every application of the tooth-brush. The desired 
objects are well fulfilled by such a mixture as that of 
precipitated chalk and soap, commonly known as sap- 
onacious tooth-powder. The soap, of which a nearly 
tasteless variety is used, having been dried, is pulverized 
and mixed with the chalk, and to this there may be 
added perfume and flavoring ingredients, to render the 
dentifrice agreeable to the patient. A powder having 
as its principal ingredients chalk and a soluble alkali, 
such as carbonate of soda, is almost equally efficacious. 
Mouth-washes may be composed with advantage of 
tincture of myrrh or of rhatany. The spirit which 
these tinctures contain, besides rendering them more 
astringent, is antiseptic, and it is a good plan to use 
them to moisten the floss silk, or other material which 
is employed in cleansing the spaces between the teeth. 
With the same design, Eau de Cologne, lavender-water, 
and similar perfumes, are pleasant applications. With 
these lotions there may be combined carbonate of soda, 
or other soluble alkalies, when the acidity of the secre- TREATMENT OF CARIES. 
89 
tions is great, or where the patient is obliged to take 
acid medicines. 
Perhaps the most beneficial procedure that can be 
adopted for the prevention of caries, in cases in which 
the teeth are of a generally defective structure, and where 
great crowding of the teeth exists, is the extraction of two or 
more permanent teeth from eacli jaw, during the period 
of second dentition. In such cases, after the second 
molars are in place, the first, which are often exten- 
sively carious, can be well spared; but even when sound, 
their sacrifice will be repaid, in many instances, by the 
improved condition of the remainder of the set. Not 
only does the room afforded by the equal spreading 
apart of the teeth render the origination of caries less 
possible, but it enables the cleansing of the interstices 
to be easily performed, and affords the dentist the oppor- 
tunity of detecting, and dealing with the decay in these 
difficult situations, in its incipient and most amenable 
form. 
The treatment of incipient caries may be confined, in 
many instances, to cutting away the diseased tissues, 
polishing the surface, and leaving it of such a form that 
it may be readily cleansed, and not allow of the adhesion 
of decomposing particles of food. Tins procedure is in 
imitation of an operation which is sometimes effected 
accidentally during the progress of the disease, and 
which suffices to arrest permanently the process of cari- 
ous disintegration. The disease occasionally commences 
on the grinding surface of a tooth, the external portion 
of which is of defective structure. This portion having 
been destroyed, the denser subjacent tissue is laid bare, 
and becomes smoothed and highly polished by mastica- 
tion, whilst at the same time calcification of the dentinal 90 
TREATMENT OP CARIES. 
fibrils gradually takes place, and renders the surface 
extremely hard. 
The treatment of caries by the simple operation of 
excising the diseased tissue is applicable only in rare 
cases to the grinding surfaces of the teeth, but is com- 
monly resorted to with success in dealing with decay of 
the contiguous surfaces, especially those of the incisors 
and canines. The operation is performed under the 
most favorable circumstances when the enamel alone is 
affected, but it may be often carried out with permanent 
advantage even when the dentine has been penetrated 
to some depth. As a rule it should not be undertaken 
in mouths where chronic inflammation and sponginess 
of the gums prevail; neither should it be proposed in 
any case when the carious surface extends below the 
gum. At the level of the gum it is desirable in many 
cases that a portion of sound tissue should remain pro- 
jecting from each tooth, so as to prevent their surfaces 
from coming into close apposition. The rest of the sur- 
faces should be left perfectly plane, and with such an 
inclination towards each other that the space between 
them is V-shaped, the wider part so directed as to be 
easily accessible to the tooth-brush and to the tongue, 
and subject to the constant beneficial friction of mastica- 
tion. In forming the surfaces in this manner it is of 
course necessary to cut away a considerable quantity of 
sound tissue. The amount which may be safely re- 
moved varies with the size of the tooth, but it must be 
borne in mind throughout, that if too much be removed 
the tooth maybe left unbearably sensitive, owing to near 
exposure of the pulp. In the case of the incisors and 
canines the excision of sound tissue may be confined 
always to a great extent, and sometimes entirely, to the TREATMENT OF CARIES. 
91 
lingual aspect of the teeth, which are thus preserved 
from perceptible disfigurement. The instruments re- 
quired in the operation consist of enamel chisels and 
files; with the chisels—when applied in the direction of 
the enamel fibres—the decayed tissue may be rapidly 
and painlessly broken down ; with files of different 
degrees of coarseness the operation may be continued, 
and the surface made ready for the final polishing. 
This latter process is accomplished by rubbing the sur- 
faces first with finely powdered pumice, carried on tape 
or on a strip of cane, to remove the file marks, and 
afterwards with a strip of wet - slate-stone, to make it 
perfectly smooth. Fig. 39 (from Arthur) shows the 
Fig. 39. 
most favorable form in which the interstices of the teeth 
can be left after this treatment. The slight sensibility 
in the exposed dentine, varying in amount in different 
cases, which often remains for a time after the operation, 
may be rapidly diminished by the occasional application 
of solution of chloride of zinc, or the use of a lotion 
containing spirit. 
The operation of Filling the Teeth.—When, owing to its 
extent or to other circumstances, caries cannot be dealt 
with by the method just described, it must be treated 
by the operation of plugging or filling the tooth. This 92 
TREATMENT OF CARIES. 
operation comprises cutting out the diseased tissues and 
forming the cavity for the retention of the filling, dry- 
ing the cavity, and filling it with some suitable material. 
It is conducted always on the same principles, but its 
details vary somewhat according to the position, charac- 
ter, and extent of the decay. The present section will 
be restricted to the treatment of cases in which the cen- 
tral chamber of the tooth has not yet been laid open by 
the caries, and in which the dental pulp is free from 
disease. 
The operation of filling, throughout all its details, is 
much facilitated by the use of a dentist’s chair, which 
allows the patient to be firmly and comfortably placed 
in the most suitable position, raised when a tooth of the 
upper jaw, and lowered when a tooth of the under jaw, 
is to be filled, with the head tilted forwards or back- 
wards, the face turned towards or from the operator, ac- 
cording to the position of the tooth and of the cavity of 
decay. 
The instruments used in excising the carious tissues 
consist of enamel chisels, drills, and excavators. The 
chisels are sufficiently described by their name, both as 
regards their nature and use. They are made with 
blades of different sizes, bent at various angles, so as to 
reach the decay vdierever situated. With them the 
carious enamel of the of cavities can be speedily 
broken down with but little pain to the patient. The 
chisel should be held firmly with the handle in the palm 
of the hand, the thumb being lodged securely against 
the tooth to control the instrument and to prevent it 
from slipping. It should be applied in the direction in 
vdiich the enamel fibres run. 
Dental drills are of two kinds, the rose or bur-head, TREATMENT OF CARIES. 
93 
and the sharp-pointed drill. The cutting point of the 
rose-head forms a circular or conical file. It is used to 
open up the ragged orifices of cavities and to grind away 
the carious tissues within. The sharp drills serve to 
open up small cavities and fissures in the enamel, to 
shape the cavity, and to cut retaining points into which 
the filling is to be dovetailed. These drills are now 
commonly employed in conjunction with the burring 
engine. This instrument consists of a flexible shaft 
rotated by a band, which is driven by a treadle and fly- 
wheel. The extremity of the shaft carries burs, grind- 
ing wheels or drills of any desirable size and shape, 
and, revolving with great rapidity, enables the operator 
to excise the tissues with great nicety, and speedily to 
reduce to smoothness the ragged or rough surfaces. 
Excavators serve to pare away the dentine. They are 
made of all sizes, with flat blades, sharp-pointed, curved 
and bent at various angles to reach the differently situ- 
ated cavities. 
With regard to the performance of the preliminary 
step in the operation of filling, at present under discus- 
sion, it may be laid down in the first place as a rule, 
subject to important exceptions to be mentioned further 
on, that the whole of the carious structures should be 
removed. If the margin at least of the cavity be not 
formed of sound tissue, decay will proceed unchecked 
after the insertion of the filling. At this part of the 
cavity the beginner is much more liable to err, by too 
limited than too free use of the chisel and excavator. 
In the next place it must be observed, that although 
the sensibility of the teeth varies in a great degree in 
different individuals, the excision of the carious tissues 
is always a more or less painful operation. In most 94 
TREATMENT OF CARIES. 
cases, however, it will be found that it inflicts no more 
than an easily bearable amount of pain, when it is done 
rapidly with instruments thoroughly sharp. The suf- 
fering may be lessened in all cases, by applications 
which diminish the sensibility of the dentine. Amongst 
the most useful of these applications in common use, 
may be mentioned chloride of zinc and arsenious acid. 
The cavity may be swabbed with a strong solution of 
the former, or a minute quantity of the latter may be 
applied, and this will usually have the desired effect. 
These remedies, especially the latter, must be used with 
great caution when the pulp is nearly approached by 
decay, lest they penetrate to that structure and excite 
inflammation. 
The exceptions to the rule with regard to the excision 
of the whole of the carious tissues, present themselves 
in cases in which the pulp-cavity is closely approached 
by the decay. In such cases the greatest care must be 
exercised to avoid laying open the chamber, for, if this 
accident happen, the chances of saving the tooth are 
much diminished. When danger of the accident exists, 
the softened dentine must be slowly and cautiously 
removed, and if it be found that the excision of all the 
affected dentine cannot be accomplished without risk, it 
is better to leave a layer of partly decayed tissue of 
sufficient thickness in the depths of the cavity. Carious 
dentine, in the earlier stages of decay, may be, in fact, 
always left with safety in the deeper parts of large cav- 
ities, and in the later stages, unless utterly disorganized, 
it can be brought into such a condition, and placed under 
such circumstances as will prevent it from decaying 
further. Caries — it has been shown — cannot vo on 
© 
without the influence of external agencies, and all that TREATMENT OF CARIES. 
95 
is wanted, in the cases in question, is in fact to harden 
so far as possible the diseased tissue, to abstract com- 
pletely its moisture, and to protect it by a permanent 
filling from the action of these external agencies. Par- 
tially disorganized dentine may be hardened by filling 
the cavity with a plug of cotton-wool, saturated with a 
solution of gutta-percha and tannin in chloroform, or 
gum mastic in spirits of wine—a dressing of wool with 
carbolic acid being applied beneath, and the whole being 
renewed at intervals of a few days, over as long a period 
as necessary. In many cases, the drying alone of the 
tissues by means of a. hot-air syringe, or better by the 
application of absolute alcohol, will suffice. This pro- 
cess is described on a later page. 
There are no grounds upon which the deliberate ex- 
posure of a healthy pulp during the progress of excava- 
tion can be justified. Like other somewhat similarly 
situated structures of the body, the pulp, whether it has 
been wounded or not, is very commonly attacked by 
inflammation, after mere exposure to the air, in conse- 
quence of the opening of the chamber in which it is 
confined. The existence of a layer of partly disorgan- 
ized tissues treated as described, and inclosed beneath a 
filling in the depths of a cavity, can be productive of no 
harm. If it be cut away, it must be afterwards replaced 
by a cap — an artificial substitute, the application of 
which is difficult, which often sets up irritation, and 
which, even if of the most perfect construction, must be 
necessarily less adapted to its purpose than a layer of 
imperfect dentine. 
In excavating the tissues preparatory to the insertion 
of filling, it is necessary not only to remove decay, but 
to adapt the cavity for the retention of the plug. It 96 
TREATMENT OF CARIES. 
will be presently seen that, with one exception, none of 
the materials used in filling teeth adhere as cements to 
the walls of the cavity—they are all retained by either 
plugging, wedging, or dovetailing. The simplest kinds 
of cavities are such as, after removal of the decay, 
assume the form of a hole or trench with vertical walls; 
and those which require most modification are such as 
have a narrow irregular orifice, and those which either 
wholly or partly take the form of a shallow saucer- 
shaped excavation. It being impossible to pack a filling 
beneath the overhanging margins of a cavity, these por- 
tions must be, when necessary, freely cut away, whilst, 
as it is also impossible to fix a plug upon a shallow con- 
cave depression, the walls of such a cavity must be ren- 
dered either vertical or slightly undercut, or retaining- 
points may be formed. Retaining-points are made by 
drilling small pits in different parts of the cavity. Into 
these pits portions of filling are packed, and to these 
portions, more and more being securely joined, the 
whole mass is fixed immovably in position. The num- 
ber, size, and depth of the retaining-points must be 
regulated according to the circumstances of the case. 
They need never be very deep, and of course due care 
must be taken in using drills to avoid laying open the 
pulp-cavity. 
The annexed enlarged diagrams may serve to make 
this subject more clearly understood. Fig. 40 exhibits 
the aspect of the commonest form of simple cavity in 
the grinding surface of a molar. Such a cavity, after 
the excavation of the carious tissues, including the en- 
largement of the orifice to the extent indicated in the 
dotted lines, would require no further modification to fit 
it for the reception of a filling. TREATMENT OF CARIES. 
97 
Fig. 41 shows a cavity after excavation on the lateral 
surface of an incisor. The cavity is of some depth to- 
Fig. 40. 
wards its centre; but from that point slopes gradually in 
every direction towards the lingual and labial margins, 
and towards the cutting edge and neck of the tooth. It 
forms, therefore, a uniformly concave saucer-shaped cav- 
Fig. 41. 
ity incapable of retaining a filling. Such a cavity might 
well be prepared by giving it the form of a trench, as 
shown in Fig. 42, with slightly undercut walls, render- 
ing it a little smaller at the orifice than within. 
The next diagrams illustrate the formation of retain- 
ing-points. A cavity of typical character on the lateral 
surface of an incisor is shown in Fig. 43. After re- 98 
TREATMENT OF CARIES. 
moval of the carious tissues, it forms a shallow con- 
cavity, broad at the upper part and sloping and narrow- 
ing towards the cutting edge of the tooth, near which 
Fig. 42. 
point it terminates. The preparation of such a cavity 
would consist, after slightly deepening the labial and 
Fig. 43. 
lingual walls, in drilling two pits (as shown in Fig. 44) 
in the upper aspect, and one in the lower angle of the 
depth and in the direction indicated by the dotted lines. 
The later section on gold filling will be further ex- 
planatory of this subject. 
The difficulties which present themselves in dealing 
with cavities, which being situated on the contiguous 
surfaces of teeth, are neither fully visible nor sufficiently 
accessible, must be overcome either by free chamfering, 
or by temporarily forcing the teeth apart. The benefi- TREATMENT OF CARIES. 
99 
cial effect of permanently separating teeth was explained 
in the section on the treatment of incipient caries, and 
the procedure there must be adopted in the 
Fig. 44. 
majority of cases preparatory to the filling of the cavi- 
ties in question. In treating the incisors and canines 
the plan described in the section on incipient caries must 
be adhered to, and the chamfering must be as far as 
possible confined to the lingual aspect of the teeth. 
This suffices in most cases to render the cavity accessi- 
ble to the filling instruments from behind, whilst the 
labial surface remaining intact, the normal appearance 
of the tooth is preserved, and the filling, unless large, is 
rendered invisible to casual observation. The instances 
in which it is better to force the teeth temporarily apart 
are those in which small cavities exist in teeth—especi- 
ally front teeth—of otherwise sound structure, and 
where permanent separation would cause disfigurement. 
Sometimes the plan may be well adapted of chamfering 
the affected surfaces to some extent, and pressing the 
teeth apart in order to obtain the further space necessary 
for the use of the filling instruments. 
The temporary separation of teeth is easily effected by 100 
TREATMENT OF CARIES. 
slipping between them a strip of india-rubber, and allow- 
ing it to remain for twenty-four hours. A very slight 
amount of pressure suffices for the object; the rubber 
should not therefore be thicker than the space which it 
is desired to make, and this space should not be greater 
than suffices to allow the use of the necessary instru- 
ments. If much force be exercised great pain is set up, 
and the presence of the rubber soon becomes intolerable. 
After the removal of the rubber the teeth fall together 
again in the course of a few hours, and the tenderness 
which the process has caused also rapidly subsides. 
A similar effect can be produced by packing a plug 
of cotton-wool, saturated with mastic cement, between 
the teeth, and allowing it to remain for a day. This 
plan is preferable in cases in which a mass of swollen 
gum projects into the cavity, the pressure of the plug 
causing the mass to shrink and forcing it out of the way 
of the instruments. 
During the subsequent steps of the filling operation, 
the insertion of a wooden wedge between the necks of 
the defective teeth is often useful. A piece of compressed 
hickory of suitable size is cut so as to fit with a moder- 
ate degree of tightness, the V-shaped space which natu- 
rally exists between the necks of the teeth. This is 
steadily pushed between the teeth, and the ends being 
cut short, it is allowed to remain until the filling is 
completed. The use of a wedge alone in this manner, 
in some cases in which the teeth are not closely in con- 
tact, is sufficient to afford room for the satisfactory per- 
formance of the filling operation. The wedge often also 
subserves the purpose of forcing away the gum and pre- 
venting it from bleeding and from being wounded by TREATMENT OF CARIES. 
101 
the files and other instruments. It also often serves to 
hold in position the rubber dam. 
Drying the Cavity.—The cavity having been prepared 
for the reception of the filling, the next step consists in 
drying it and guarding against the access of moisture 
until the completion of the operation. The difficulty in 
accomplishing the latter part of this process is much 
greater in every case at some positions in the mouth than 
at others, whilst the extremely profuse flow of saliva in 
certain patients is even under favorable circumstances 
hard to control. The teeth situated at the anterior part 
of the upper jaw are the most easily managed, the orifices 
of the salivary glands being distant, and the fluid natu- 
rally gravitating towards the back of the mouth. In 
most cases during the filling of upper incisors, canines, 
or bicuspids, the cavity may be kept dry by the inser- 
tion of a roll of cotton-wool beneath the lip, a fold of 
napkin being at the same time laid across the lower 
front teeth, to prevent the tongue from carrying up 
moisture from beneath. 
The duct of the largest salivary gland—the parotid— 
opens through the mucous membrane of the cheek, where 
it lies against the upper molars, and its flow must there- 
fore be directed or controlled before these teeth can be 
dried. Where the flow is not profuse, and the cavity is 
situated on the masticating surface, precautions such as 
described for the front of the upper jaw may suffice. In 
other cases these measures may be supplemented by the 
temporary closure of the orifice of the duct. This may 
be accomplished by the application of clamps specially 
contrived for the purpose, or the exit of saliva may be 
sometimes prevented temporarily by a small patch of 
impervious sticking plaster. 102 
TREATMENT OF CARIES. 
In the lower jaw the exclusion of the saliva during 
plugging presents more difficulties than in the upper. 
The saliva naturally accumulates in the floor of the 
mouth, and the movements of the tongue and the efforts 
of swallowing have a constant tendency to throw it over 
the crowns of the teeth. In patients who cannot swal- 
low with the mouth open the difficulties are increased. 
Where the tooth has to be kept dry for no more than a 
moment or two the influx of saliva may be guarded 
against by the insertion of a roll of wool or of bibulous 
paper beneath the tongue, and another between the cheek 
and side of the jaw, these rolls being firmly held in 
position by the fingers of the left hand. In more pro- 
longed operations the tongue-depressor is extremely use- 
ful. By it the tongue can be held down, and any desir- 
able amount of pressure can be kept upon the ducts of 
the glands which open in the floor of the mouth. 
It will be found in the majority of cases possible to 
keep the faulty tooth dry during the insertion of the 
filling by the means just described, which were those 
alone available until late years. There has, however, 
been recently introduced the contrivance known as the 
rubber dam. This simple invention, for which the pro- 
fession is indebted to Dr. Barnum, of the United States, 
enables the dentist to keep the tooth perfectly dry 
throughout the most prolonged operation. The dam is 
formed of a thin sheet of india-rubber specially prepared 
for these operations. A piece is taken a few square inches 
in size, and towards its centre is punched a small hole, 
one about as large as an ordinary pin-head being big 
enough for a molar. This hole is stretched and slipped 
over the tooth, so that the rubber closely embraces the 
neck and leaves the crown surrounded by an impervious TREATMENT OF CARIES. 
103 
dam. In practice it is well to make a series of holes in 
the rubber the same distance apart as the crowns of the 
teeth adjoining the one to be operated upon, and to pass 
the rubber over them also. By this means the rubber 
is securely fixed and kept effectually out of the way. 
Difficulties in applying and securing the dam arise 
where the teeth are in extremely close contact, and where, 
from the conical shape of their crowns, the elasticity of 
the rubber causes it to spring off. The first of the diffi- 
culties may be overcome by forcing down the highly 
stretched rubber by a thin strand of waxed floss silk. 
It is found that by the pressure of the tense thread the 
teeth can be forced slightly apart at the point where their 
crowns are in contact at the masticating surface, and this 
point being passed, the rubber is readily carried down 
to the gum, at which position an interval invariably 
exists between the teeth. To prevent the dam from spring- 
ing off the tooth a steel clamp of suitable design may be 
used. This clamp grips tightly the neck of the tooth, 
and forms a projecting flange, under which the rubber 
slips, and is thus held secure. The same purpose is ful- 
filled by the insertion of wooden wedges between the 
teeth after the dam is applied. The dam having been 
fixed by one of these methods, the borders of the rubber 
projecting from the mouth may be turned back and held 
out of the way by hooks attached to elastic bands pass- 
ing over the patient’s head. The rubber dam gives less 
annoyance to the patient, whilst answering the purpose 
better than any other contrivance of the kind, besides 
which it leaves both hands of the operator free for the 
manipulation of the stopping instruments. 
The influx of saliva having been guarded against, the 
cavity has next to be dried, a comparatively easy mat- 104 
TREATMENT OF CARIES. 
ter. It may be done roughly by wiping the surface with 
cotton-wool, or better with bibulous paper, or amadou. 
It is however by no means easy to procure perfect dry- 
ness by mere wiping with these materials. Better to 
achieve this end several varieties of hot-air syringes have 
been devised, by which the moisture may be driven off 
by a current of heated air. These instruments are super- 
seded by the use of absolute alcohol, in the manner first 
suggested by the author. When applied to a wet surface, 
the alcohol, having a great affinity for water, combines 
with it, and if exposed to the atmosphere evaporates. 
In this way it not only carries off the superficial moist- 
ure, but it also abstracts the water which the tissues 
intrinsically contain. Cavities to be dried with this fluid 
should be first wiped out with wool and then swabbed 
with a small pellet saturated with alcohol. After a pause 
of a moment to allow the spirit to unite with the water, 
the cavity can be again wiped with dry cotton, and this 
will leave a surface as dry as could be obtained by the 
hot-air syringe. The swabbing and wiping can be re- 
peated when called for, as in those cases already referred 
to under a previous heading, in which it is desired to 
harden a layer of carious dentine, which to avoid expo- 
sure of the pulp must be left in the depths of a cavity 
beneath a filling. Like every other fluid which has a 
strong affinity for water, absolute alcohol will of course 
produce irritation if allowed to flow upon the skin or 
mucous membrane, although this will be but slight if 
the surface be wet and the quantity of spirit small. 
Accidents of this kind need not occur if ordinary care 
be taken. 
The materials used in filling teeth may be conveniently 
arranged for the purpose of description according to their TREATMENT OF CARIES. 
105 
durability in the mouth. One (gold) only is practically 
imperishable, several others, although subject to slight 
physical and chemical changes, are sufficiently lasting to 
deserve the name of permanent filling, whilst a third 
group, being liable to rapid decomposition, must be classed 
as temporary fillings. Permanent fillings are, of course, 
always intended to act as substitutes for the tissues de- 
stroyed by disease. Temporary fillings—as was noted 
incidentally in the section on excavating the carious tis- 
sues—are used in the preparatory treatment of cavities. 
Further explanation of their employment in the same 
and in other ways will appear in later chapters. 
With regard to the choice of materials in cases ready 
for the reception of permanent fillings, it may be said 
that there occur few cavities in which the insertion of a 
gold plug is impossible, and regarded from a merely the- 
oretical point of view the instances are rare in which the 
use of any other material as a stopping intended to be 
permanent is justifiable. Practically, however, it is often 
necessary to employ inferior and less durable substances. 
In the first place the expense of gold puts it beyond the 
reach of the lower and of the poorest classes. In the 
next place, the operation of gold filling in large and 
difficult cavities is long, tedious, and frequently painful, 
and there are many patients who either cannot or will 
not. submit to it. Lastly, exceptional cases occasionally 
present themselves, as for example, in neglected caries 
of a front tooth, in which the crown—the preservation 
of which is of great importance—is so extensively exca- 
vated as to form a mere thin shell of enamel, incapable 
of withstanding the force required in gold filling. In 
all such instances the substitute for gold best adapted to 
the circumstances must be employed. With Sullivan’s 106 
TREATMENT OP CARIES. 
cement, the author in hospital practice alone has filled 
and saved in a useful condition numbers of grinding 
teeth which must have been lost had there not been 
available any such material, at once inexpensive and 
rapid of application; whilst he has seen an equal num- 
ber of fragile front teeth preserved for years by such 
comparatively perishable materials as oxychloride of zinc, 
and especially gutta-percha. 
The gold used for filling teeth is pure—without any 
alloy whatever—for in this condition alone it possesses the 
qualities necessary for the production of perfect plugs. 
It is prepared by the manufacturers in two forms—in 
foil and in a spongy mass. The leaves are produced by 
beating, the sponge is formed by precipitating the metal 
from a solution. The leaf gold suitable for filling teeth, 
is much thicker than that which is used in gilding, and 
comes to hand in sheets about four inches square, the 
lightest of which weigh four grains. Thicker qualities 
are made to suit the fancy of different operators, and 
the exigencies of cases. Sheets from four to six grains in 
weight are the most generally useful. Two qualities of 
gold foil are manufactured for dental purposes, non- 
adhesive and adhesive, and these differ in the fact that 
pieces of the former pressed together do not cohere, 
whilst portions of the latter forced closely into contact 
become inseparably united. These peculiarities are due 
to difference in the molecular condition of the foils, the 
adhesive variety being more crystalline in character than 
the non-adhesive. The adhesive quality of all foils is 
increased by annealing, and the non-adhesive variety 
may be rendered adhesive by the same operation. The 
adhesive property of pure gold (when in a certain mo- 
lecular condition), is one that it possesses in common TREATMENT OF CARIES. 
107 
with some other metals, such as platinum, silver, tin, 
and lead, which are comparatively soft at ordinary tem- 
peratures. The adhesion is in fact due to welding, the 
metals being capable of union of this kind when in their 
cold state, just as iron, and some others are when ren- 
dered plastic by heat. Sponge gold, owing to its per- 
fectly crystalline form, is the most adhesive variety 
prepared for dental purposes. The adhesive property 
of gold is destroyed by moisture, but can be again re- 
stored by annealing. 
Tin foil, of which permanent fillings can be made, 
is composed of the pure metal. It is sent out by the 
manufacturers in leaves of the same size as the gold foil, 
and in thickness about the same as six-grain sheets of 
that metal. Pure tin, as just mentioned, can be welded 
in the cold state, but the union cannot be brought about, 
unless the surfaces of the separate portions are bright 
and free from oxidation. This chemical change affects 
tin foil after a few hours’ exposure to the atmosphere, 
and destroys to a great extent its cohesive property. 
This does not, however, much lessen its usefulness as a 
filling material. In plugging it is manipulated in the 
same way as non-adhesive gold foil. 
Amalgam fillings come next to gold and tin in point 
of durability. These are all formed by combination of 
mercury, either with a single metal or with an alloy of 
several. Perhaps one of the first of these compounds 
used in dentistry, was that composed of coin silver and 
mercury. The silver reduced to filings was rubbed up 
in a mortar with mercury, until a stiff pasty mass was 
formed, which became hard in the course of a few hours. 
This amalgam, although of considerable durability under 
favorable conditions in the mouth, had the disadvantages 108 
TREATMENT OF CARIES. 
of becoming itself blackened by oxidation, and of gradu- 
ally staining the tooth in which it was inserted. In 
spite of numerous attempts to do away with them, either 
or both of these imperfections in a greater or less degree 
are common to all the amalgams since introduced. Most 
of these have as their basis* silver alloyed with small 
quantities of tin, gold, and platinum, the alloy being 
reduced to tilings to facilitate union with mercury. 
Palladium amalgam, and copper amalgam or Sulli- 
van’s cement, are each composed of pure metals with 
mercury. The palladium is manufactured for the pur- 
pose by precipitation, which produces a tine powder. 
Sullivan’s cement is supplied to the dentist in the form of 
small solid pellets—masses of amalgamated copper and 
mercury. To prepare it for use, a sufficient quantity is 
placed in an iron spoon, and held over the flame of a 
spirit-lamp, until globules of mercury appear on the 
surface. It is then ground down in a mortar and forms 
a smooth paste, with an evident excess of mercury. It 
is then folded in wash leather, and forcibly squeezed 
until much of the mercury having escaped, the mass 
assumes a drier and somewhat granular character. 
This amalgam more than any other is subject to the 
disadvantages to which reference has been already made. 
It has been proved by the experiments of Mr. Charles 
Tomes, that all the amalgams in common use contract 
during the process of hardening, although the extent to 
which this' occurs varies considerably in the different 
compounds. The amount of contraction has been closely 
ascertained, by obtaining the specific gravities of masses 
of the amalgams when recently mixed, and afterwards 
when hardened. In the former state their density is found 
to be always less than in the latter, the difference being, of TREATMENT OF CARIES. 
109 
course, due to contraction. It is obvious that when the 
shrinkage is more than infinitesimal in amount a per- 
meable space must be formed between the filling and 
wall of the cavity after the hardening of the amalgam, 
and in such a case the stopping must necessarily fail to 
arrest decay. 
The following table from Mr. Tomes’s paper exhibits 
a comparison of the weight gained (i. e., shrinkage) by 
different amalgams while hardening;: 
O o 
Palladium, . 037 
Sullivan’s, ....... .07 
*Ash’s, ........ .14 
*Smale’s, ........ .14 
Tin and silver (55 to 45),. .... .35 
Tin and silver (equal parts), . . . . .38 
The compounds marked with an asterisk may be 
taken as fair specimens of the amalgams in ordinary 
use, composed mainly of silver and tin, with a slight 
admixture of gold or platinum. These experimental 
results accord in the main with those of practice. Pal- 
ladium amalgam and Sullivan’s cement, when packed 
with due care, form plugs of great durability; whilst, 
although it appears probable that some of the contrac- 
tion, which in theory would appear an insuperable ob- 
stacle to their employment, may be counteracted by 
skilful manipulation; and although in well-chosen cases 
they may endure for many years, still, in the majority 
of instances, the filling of a tooth with any other of the 
amalgams at present in use must be considered a merely 
temporary expedient. 
Many points with regard to the properties of amal- 
gams are still undecided. Among them the question as 110 
TREATMENT OF CARIES. 
to the proportion of mercury which it is best to use with 
the different compounds is still an open one, the balance 
of evidence being, however, in favor of the admixture 
of a quantity no greater than will suffice to produce a 
friable mass, which, under slight pressure, becomes co- 
herent. 
In the case of those amalgams whose basis is an alloy, 
the mercury should not be added in excess, and then 
squeezed out. The error should be corrected by the 
gradual addition of more filings. If the mercury be 
pressed out of such an amalgam, it carries with it an 
undue proportion of those of the constituent metals that 
are most soluble in it, and so the chemical character of 
the resulting compound is altered. Palladium and cop- 
per amalgam, on the other hand, may be freely mixed 
with an excess of mercury, care being afterwards taken 
to expel sufficient to reduce them to the proper degree 
of dryness. 
In addition to staining the tissue, some amalgams 
have the effect of rendering the surface of dentine 
against which they rest extremely hard. This appears 
due to the saturation of the tissue to some slight depth 
by the metallic salts set free during the oxidation of the 
amalgam. In the case of Sullivan’s cement the tissue 
in time becomes so hard as to resist effectually the 
further inroads of caries, and this effect doubtless has a 
share in increasing the permanence of this amalgam as 
a filling, counterbalancing the effect of the slight con- 
traction which it undergoes whilst hardening. 
Among filling materials of a more perishable nature 
than the metallic compounds just described, to gutta- 
percha may be assigned the first place; indeed, although 
its physical characters render it unfit to sustain the wear TREATMENT OF CARIES. 
111 
of mastication, in power of resisting decomposition it is 
hardly inferior to the lower class of amalgams. For 
dental purposes, gutta-percha is prepared in the form 
known as Jacobs’s and Hill’s stoppings. These consist 
of gutta-percha bleached and intimately blended with 
silica, or some like substance, in the form of an impal- 
pable powder, to render the material harder and more 
durable. 
There has been introduced, during late years, a nu- 
merous class of useful compounds for temporary fillings, 
amongst which those known as Roberts’s, Guillois’s, and 
Fletcher’s cements are of the most value. These are all 
mainly composed of oxide of zinc, mixed either with 
silica or marl. This pulverulent mixture, when re- 
quired for use, is worked into a paste with a strong 
solution of zinc chloride. Chemical combination takes 
place, and a hard mass is rapidly formed, consisting of 
oxychloride of zinc, with the earthy ingredients mechan- 
ically mixed. These latter serve to impart greater hard- 
ness to the filling. 
For the purpose of sealing up cavities in the teeth 
for a few hours or days, nothing answers better than a 
pellet of cotton-wool saturated with a solution of gum 
mastic in spirit, or of gutta-percha in chloroform. After 
the insertion of the pellet the fluid evaporates, leaving 
a tough mass impervious to moisture. 
Instruments used in Filling Teeth.—A pair of plugging 
tweezers, a set of 18 pluggers, on I)r. Ihitler’s pattern 
(Fig. 45), and a mallet, will be found sufficient in filling 
the vast majority of cavities with gold. The tweezers 
(Fig. 46) are for the purpose of carrying portions of 
gold into the cavity, and fixing them there prior to con- 
solidation. Of the pluggers, seven or eight will have 112 
TREATMENT OF CARIES. 
serrated wedge-shaped points, of various sizes, and bent 
at different angles convenient for reaching cavities wher- 
ever situated. These are used for carrying gold into 
position, and in packing or welding it there. Six foot- 
pluggers of different patterns will be included in the 
Fig. 45. 
Fig. 46. 
sot. These serve to consolidate the component parts of 
the plug. In addition, there will be four or five instru- 
ments with working extremities, flat-faced and serrated, TREATMENT OF CARIES. 
113 
and so bent or twisted on the shaft as to reach cavities 
to which straight foot-pluggers could not be applied. 
Lastly, there will be provided a burnisher, having a 
rounded, highly polished steel point. The mallet, espe- 
cially useful with adhesive gold foil, supplements pres- 
sure of the hand in consolidating the filling, and in 
uniting its component portions. The same set of in- 
struments serve in filling with tin foil. Aset of instru- 
ments (six or eight), with smooth round steel points, are 
most suitable for packing amalgams. If the points 
which are used with these materials be serrated, the 
rough surface soon becomes clogged with amalgam, 
which lodges and hardens there, forming a layer, which, 
softened again by the mercury, is apt to mingle with 
an amalgam of another kind on a subsequent occasion. 
A set of small spatulas are required for the insertion 
of oxychloride of zinc cement, and the blades of these 
may be advantageously made of silver or platinum, steel 
being rapidly oxidized and destroyed by these fillings. 
A similar set with smooth steel blades will suffice in 
packing gutta-percha. 
Temporary plugs of cotton-wool and cement are easily 
inserted by means of ordinary excavators. 
Filling with Gold.—It has been already stated that 
two varieties of gold—non-adhesive and adhesive—are 
used in filling teeth, and that their difference consists in 
the fact that fragments of the former kind do not cohere 
when pressed together, whereas separate portions of the 
latter may be welded and united into a solid mass. 
Plugs of non-adhesive gold must be formed always by 
the wedging together of folds or layers of foil; whilst 
on the other hand, in fillings composed of adhesive gold, 
the mode of arrangement of the successive portions is of 114 
TREATMENT OF CARIES. 
little importance, provided they be made to unite with 
each other. Although portions of non-adhesive foil do 
not actually coalesce under pressure, they become suffi- 
ciently dense to take a high polish, to resist mastication 
perfectly, and to constitute a stopping absolutely imper- 
meable to moisture. Indeed it is much easier to make 
a water-tight plug of non-adliesive than of adhesive 
gold. An adhesive gold plug can be perfectly built up 
only when it is composed of small pieces slowly and 
thoroughly welded together. If an attempt be made to 
consolidate a mass of adhesive foil it condenses on the 
surface beneath the instrument and no amount of force 
which can be safely applied to a tooth is sufficient after- 
wards to affect the deeper portions which therefore remain 
imperfectly united and porous. The presence even of a 
trace of moisture, such as is liable to be deposited on the 
surface of the gold from the breath of the patient during 
the operation also prevents perfect welding from being 
accomplished. Either variety of gold, adhesive or non- 
adhesive foil or sponge, be used exclusively in almost 
any cavity, but the properties of non-adhesive foil make 
it most useful in simple cavities—i.e., those of the form 
of a hole or trench with vertical or nearly vertical walls 
—whilst the peculiar qualities of adhesive gold render 
it invaluable in irregular, difficult cavities, and where a 
plug has to be built up from a limited foundation. It 
is in many cases good practice to combine two kinds of 
foil, commencing with non-adhesive and using adhesive 
to build up the plug, or to key together securely the 
separate portions. 
If the cavity be small in size and simple in form, the 
following method may be adopted. A sufficient quantity 
of non-adhesive foil—four to six grain sheets—is folded TREATMENT OF CARIES. 
115 
lengthwise by means of a spatula into narrow ribbons, 
each containing a third or a quarter of a sheet. These 
ribbons are next cut into short strips, which may be con- 
veniently spread upon a wooden tray covered with smooth 
woollen cloth. The point of a wedge-shaped plugger is 
next pressed upon a few of the strips one after the other, 
which are thus fixed lightly to the instrument. The 
gold is thus carried into the tooth and lodged, so that 
one extremity of the folds rests on the floor of the cavity 
and the other protrudes from the orifice. Portion after 
portion of gold is inserted in the same way, and forced 
against the walls of the cavity, until it becomes difficult 
to make the instrument enter. A smaller point is then 
used, and this is forced into the centre of the filling, the 
hole so formed being again filled with strips. The sur- 
face of the filling is .next compressed by a broad, followed 
by a small pointed instrument. Finally it is filed smooth, 
and then polished by means of slate stone and water 
followed by a burnisher. The surface of gold fillings 
should be left convex in shape, and slightly above the 
level of the surrounding tooth, unless the projection inter- 
fere with the bite. They should not overlap the margin 
of the cavity. 
This procedure may be varied by the use of adhesive 
gold towards the end of the operation to fill the holes 
made by the perforating instrument. Again the entire 
cavity can be filled with adhesive gold. A loosely folded 
ball or pellet is packed on the floor of the cavity, and 
consolidated, and to this piece after piece is added, each 
being thoroughly welded or kneaded to the mass by 
means of small pointed serrated instruments. Adhesive 
gold in the form of foil may be prepared for use in strips 
similar to those of non-adhesive foil, just described, and 116 
TREATMENT OF CARIES. 
like them may he carried into position on the point of a 
plugger; or portions of the foil or fragments of sponge 
may be torn from the leaf and fixed by the plugging 
tweezers, and afterwards condensed by other instruments. 
Large cavities of simple form may be most rapidly 
and effectually plugged with cylinders or rolls of non- 
adhesive foil. The cylinders are to be obtained of the 
foil makers, or they may be prepared by the operator. 
They are formed by winding a ribbon of foil round the 
point of a thin broach. They should be of such a size 
that several are required to fill the cavity, and of such 
a depth that when inserted endwise they project slightly 
from the orifice. Those used to commence the plug 
should be loosely rolled so as to be soft and malleable, 
but those for the latter part of the operation may advan- 
tageously be rolled more solidly or compressed slightly 
before insertion. In commencing the filling one of the 
cylinders is carried by the plugging forceps into the cav- 
ity and gradually condensed against one of the walls by 
a foot plugger. Another and another are then introduced 
in the same way until the cavity is full. A wedge-shaped 
instrument is then forced between the two last inserted 
cylinders, and the hole so made is filled with strips either 
of non-adhesive or adhesive foil. The rest of the sur- 
face may be next tested by a sharp-pointed plugger, and 
at any point at which it can be made to enter gold is 
added. The surface of the plug is finally filed down 
and polished. 
In cases in which adhesive gold is to compose the 
whole or the greater bulk of the filling, the first and 
most important step consists in fixing portions of gold 
securely in the cavity. Upon these portions fragments 
of foil or sponge are successively welded until the cavity TREATMENT OF CARIES. 
117 
is filled with a solid plug. In many instances the shape 
of the cavity after excavation allows of the secure for- 
mation of the foundation of the filling, or affords suit- 
able positions for the packing of retaining-points without 
further preparation, and the filling is commenced with 
strips, pellets, or cylinders. In some cases small pits, or 
retaining-points of the kind already described must he 
cut, into which the gold being packed, the completed 
filling becomes dovetailed immovably in position. 
The operation of filling with cylinders is illustrated 
in Figs. 47, 48, 49. In the first of these the commence- 
Fig. 47. 
ment of the filling is seen, two soft cylinders having 
been placed in position by the plugging forceps ready for 
consolidation, by the foot-plugger, against the wall of 
the cavity. The next diagram (Fig. 48) shows a later 
stage of the operation. The filling now approaches com- 
pletion, the masses of gold are condensed, and a small 
central space alone remains to be plugged with strips of 
non-adhesive or fragments of adhesive foil. Fig. 49 
exhibits this latter process in operation, and it also shows 
the proportionate extent to which a ping should project 118 
TREATMENT OF CARIES. 
from the cavity before the surface is finally consolidated, 
filed smooth, and polished. 
Fig. 48. 
Fig. 50 shows a mode of beginning a filling with non- 
adhesive foil in a cavity of the trench-like form already 
Fig. 49. 
described, and illustrated in Figs. 41 and 42. The till- 
ing is commenced by fixing a mass of gold in the upper 
and lower extremity of the cavity. These masses may 
be composed of strips or small cylinders, and are made 
to project slightly from the mouth of the cavity. The 
filling is completed by packing between these buttresses TREATMENT OF CARIES. 
119 
successive portions of foil in strips in the manner described 
in speaking of small simple cavities. If adhesive foil 
be used, either partly or entirely, the filling may be com- 
menced in the same way, or a loosely rolled pellet may 
Fig. 50. 
be packed on to the floor of the cavity, and the plug is 
completed by welding to the first securely fixed masses, 
portion after portion of foil in the form of strips, pieces 
of loosely rolled ropes of foil or fragments of sponge or 
crystal gold. 
Fig. 51 shows the commencement of a filling in the 
cavity already illustrated in Fig. 44, three portions of 
Fig. 51. 
gold being fixed in the retaining-points there displayed. 
Each of these pits or points has been separately dealt 
with as a simple cavity, and packed with strips, each 
mass of gold projecting beyond the orifice of the main 
cavity. This part of the operation being accomplished, 120 
TREATMENT OF CARIES. 
the construction of a plug on one of the methods already 
described presents no difficulty. The same principles 
are applied to the filling of more complicated cavities 
in which retaining-points arc necessary, or in cases in 
which a plug has to be built up from a limited founda- 
tion. The first thing to be done is to form the points of 
support, anchorage, or foundation, care being taken that 
the masses of gold extend into the main cavity or project 
beyond its orifice when a filling on the wedging system 
is to be inserted. 
In the construction of adhesive and non-adhesive 
gold fillings the consolidation and the welding of the 
metal is much facilitated by the aid of the mallet, an 
instrument which has come into general use in late 
years. A quick succession of sharp blows, carefully 
regulated, and given by a mallet of proper weight, does 
not inflict more pain upon the patient than the pressure 
of the hand alone, whilst the effect is to weld and con- 
dense the foil more rapidly and thoroughly. The heads 
of the hand mallets which are manufactured for this 
purpose are made of lead or some such soft metal, and 
weigh about 2 ounces. In order to facilitate the use of 
the mallet and to leave one hand of the operator free, 
automatic instruments are now constructed to which a 
series of plugging-points of various sizes and shapes can 
be adjusted as required. 
Filling with Tin Foil.—This material is manipulated 
and packed in precisely the same way as non-adhesive 
gold foil. 
Filling with Amalgams.—Many of the remarks which 
have been made with regard to gold apply equally to 
amalgams. The durability of these materials as fillings 
depends very much upon the mode in which they are TREATMENT OF CARIES. 
121 
manipulated. They should never be inserted in a mass, 
but should be thoroughly packed piece after piece, and 
retaining-pits should be freely used on shallow sloping 
surfaces. It is important in packing to obtain absolute 
contact of the amalgam with the walls of the cavity, 
and to prevent a layer of mercury (which is often 
squeezed from the mass) from remaining around the 
forming plug. These objects are best achieved by ren- 
dering the cavity absolutely free from moisture, using 
the pluggers with a rubbing movement, and adding 
portions of the dryer amalgam to absorb the mercury 
as it oozes towards the centre of the cavity. 
It is of the utmost importance after the filling has 
hardened to file it level with the margin of the cavity, 
and to polish it. If this precaution be neglected the 
overlapping portions of the filling in time break away, 
and leave a rough surface around, which favors the ad- 
hesion of decomposing particles, and soon becomes the 
seat of carious action. This precaution is even more 
important when either oxychloride of zinc or gutta-percha 
is employed as a filling. The former of these materials 
is used as a mortar or cement. It attaches itself with 
great tenacity to any surface which is perfectly free from 
moisture; it is the only filling which can be securely 
fixed by mere adhesion to the walls of the cavity; it 
forms a perfectly water-tight stopping; it is a non- 
conductor of heat, and were it not for its perishable 
nature it would perhaps constitute a more perfect substi- 
tute for the lost dental tissues than any other substance 
at present available. 
In plugging with gutta-percha a mass of sufficient 
size is softened over the flame of a spirit-lamp, and 
packed into the cavity by means of heated instruments. 122 
DISEASES OF TIIE PULP. 
EXPOSURE OF TIIE PULP—DISEASES OE TIIE 
PULP. 
Exposure of the Pulp.—In the last section the treat- 
ment of caries uncomplicated with exposure of the pulp 
was discussed, and the precautions were described which 
ought to be taken to prevent the laying open of the 
central cavity of the tooth during the excavation of ca- 
rious tissue. This event is, however, sometimes unavoid- 
able, owing to the complete disorganization of the den- 
tine. Its occurrence will be known by the characteristic 
sharp pang which it inflicts, whilst on examination the 
exposed surface—from which, if wounded, slight bleed- 
ing takes place—is visible. If in such a case the pulp 
be free from disease the operation of “capping” the 
pulp, followed by filling, should be performed. The 
healthiness of the pulp may be inferred from the his- 
tory of the case, and the absence of the signs and symp- 
toms of irritation and inflammation to be presently men- 
tioned. 
The object of capping an exposed pulp is to provide 
a covering which shall protect the sensitive structure 
from pressure and from changes of temperature. Vari- 
ous materials, such as quill, parchment paper, gold- 
beater’s skin, or thin sheet cork, are used for the pur- 
pose by different operators, and either of them answers 
well. When the exposure is but slight some are content 
with laying a few folds of gold foil over the surface. 
The haemorrhage having ceased, the cavity should be EXPOSURE OF THE PULP. 
123 
freely washed out by means of a syringe" with warm 
water containing a small quantity of carbolic acid, and 
should then be dried. In this latter part of the opera- 
tion in these cases absolute alcohol must not be used. 
Next a piece of the chosen material having been cut of 
suitable shape and size, is carefully fixed by the plug- 
ging tweezers over the opening into the pulp-cavity, 
resting upon the margin of the opening and closely in 
contact with, whilst at the same time not pressing upon, 
the subjacent pulp. The cap being thus arranged, the 
tilling of the tooth may be proceeded with. Seeing that 
even in the best-managed cases irritation, or even in- 
flammation, of the pulp sometimes follows this opera- 
tion, and that the danger of this mishap is increased 
when a metal plug is inserted, which requires great 
pressure in packing, besides being a rapid conductor of 
heat, it appears desirable after capping to employ tem- 
porarily materials such as oxychloride of zinc or gutta- 
percha, which are not only non-conductors, but are 
easily inserted without pressure, and are readily re- 
moved on the occurrence of untoward symptoms. The 
author prefers the oxychloride, particularly in large 
cavities on the masticating surface of the molars. In 
these situations the filling can be trusted to endure at 
least for a few months, and within that time, if all goes 
well, it may be cut away, with the exception of a pro- 
tective layer over the depths of the cavity, and may be 
replaced by a more lasting material. 
Diseases of the Pulp—Irritation.—It has been seen 
that the dentine is intimately connected with the pulp 
by means of the fibrils which permeate it and endow it 
with vitality and sensibility. This connection renders 
intelligible the facts, firstly, that influences may be com- 124 
DISEASES OF THE PULP. 
municated through the dentine to the pulp in conse- 
quence of disease or injury affecting that tissue; and 
secondly, that the condition termed irritation of the 
pulp occasionally is produced during the progress either 
of caries or of abrasion of the tooth long before the cen- 
tral chamber has been nearly approached or opened. 
When the pulp is insufficiently protected by a thin layer 
of dentine only it is of course liable to be acted upon 
directly by external agencies. Irritation of the pulp is 
manifested by one symptom alone—namely, more or less 
dull aching pain, associated sometimes with a feeling of 
tenderness, and increased sensibility to changes of tem- 
perature, and it is not always easy to distinguish between 
this pain and the aching arising solely from exposed 
dentine. Sympathetic toothache, or that occurring in a 
sound tooth in the neighborhood of others the seat of 
advanced caries, has been ascribed to irritation of the 
pulp, but the pain in most of such instances is more 
probably neuralgic. 
Irritation is liable to run on to inflammation, especi- 
ally in cases of caries, in which the dentine displays ex- 
alted sensibility, and in which metallic fillings, rapid 
conductors of changes of temperature, have been inserted 
without previous treatment. If a pulp could be exam- 
ined during an attack of irritation it would probably be 
found the scat of increased vascularity, disappearing 
with the cessation of the attack. Pulps which have been 
subject to long-continued irritation almost always be- 
come more or less calcified. The newly formed tissue 
is identical in structure with that already described as 
secondary dentine, and like it may be developed either 
in a layer organically united with the pre-existing tissue, 
or in isolated nodules scattered throughout the substance EXPOSURE OF THE PULP. 
125 
of the pulp. When a layer of secondary dentine be- 
comes developed over the surface of the pulp it protects 
the latter structure, and where waste of the hard tissues 
is in progress owing to attrition or to caries, it prevents 
the exposure of the pulp, which would be otherwise in 
the end surely brought about. Secondary dentine of 
this kind is often displayed in teeth which have been 
gradually ground down to the level of the central 
chamber by mastication. 
The treatment of irritation of the pulp varies some- 
what in different cases, but the indications always are 
to remove the cause by protecting the exposed tissues 
from irritating influences, and to diminish the sensi- 
bility of the dentine. Where the dentine has been laid 
bare, owing to fracture of the tooth or to attrition, and 
must remain ever after exposed, its sensibility mav be 
often destroyed at once by solid chloride of zinc. The 
same effect may be more slowly produced by frequent 
friction of the surface with spirits of wine, or better by 
the occasional application of absolute alcohol, and with 
this treatment may be advantageously combined the use 
of tooth powders, containing astringents such as tannin, 
with alkalies like carbonate of soda. 
When irritation of the pulp exists in connection with 
caries, the permanent filling of the cavity is in the great 
majority of cases sufficient to effect a cure. Caution 
must, however, be exercised where abnormal sensibility 
of the dentine exists, and it must be remembered that 
in some few individuals the insertion of a filling even in 
a cavity of slight depth in the dentine is enough to ex- 
cite acute inflammation of the pulp. This danger is 
necessarily increased with the extent of the decay, and 
where the pulp is nearly approached, it is well to shield 126 
DISEASES OF THE PULP. 
it by a layer of oxychloride of zinc, in the manner which 
has been already described. The sealing up of a cavity 
for a few months with a non-conducting filling material 
is often alone sufficient both to abate sensibility of the 
dentine and to cure irritation of the pulp. 
Inflammation.—This is the commonest affection of the 
dental pulp. Its most frequent cause by far is caries, 
which, having laid open the central chamber of the 
tooth, has exposed the sensitive structure within to the 
action of external irritants. . It may arise (as was men- 
tioned in the preceding section) from irritation communi- 
cated through the dentine when that tissue has been 
penetrated to a greater or less extent. In rare cases it 
originates as an extension of inflammation, which, having 
commenced in the periosteum, has involved the dental 
vessels and nerves in their passage to the pulp-cavity 
through the foramina of the root. 
Inflammation of the pulp.assumes either an acute or 
chronic form, and it gives rise to pathological changes 
in the tissues essentially similar to those occurring in 
other like structures of the body. It may produce gan- 
grene, ulceration, suppuration, outgrowth of new tissue, 
or degeneration. 
Pain is the most prominent symptom of acute inflam- 
mation of the pulp. It varies in amount according to 
the extent and intensity of the inflammatory action, is 
more severe in some individuals than in others—in the 
young than in the old—and in all is increased by some 
derangements of the general health, of which pregnancy 
affords the most remarkable example. At the com- 
mencement of an attack it is dull and aching, confined 
to the affected tooth, soon assuming a more intense lan- 
cinating or throbbing character, and finally, becoming EXPOSURE OF THE PULP. 
127 
almost intolerable, it appears to spread to the adjoining 
teeth and to the whole side of the head and face. The 
pain of this form of toothache is more severe than arises 
in any other dental disease, and its severity is accounted 
for by the fact that the pulp, a highly vascular and ner- 
vous substance, is confined within the rigid walls of a 
chamber where swelling is impossible, and whence the 
inflammatory exudations cannot freely escape. 
The diagnosis of acute inflammation rarely presents 
any difficulty. The character of the pain can hardly be 
mistaken, whilst in the vast majority of cases there 
exists a carious cavity in which after excavation of the 
softened dentine the pulp is exposed and visible. 
Where the opening is extensive the surface of the pulp 
may be seen red and injected with blood or dotted with 
suppurating points, and it bleeds readily and freely if 
touched. From dental periostitis it may be distin- 
guished by the fact that in that disease the earliest 
symptom is tenderness upon pressure, and slight eleva- 
tion of the tooth in the socket, whilst, where the pulp is 
alone inflamed, it is not until the last stage of the affec- 
tion—when in fact the inflammation has extended to the 
periosteum—that these symptoms are displayed. 
The tendency of acute inflammation of the pulp, which 
runs on unchecked, is to terminate in gangrene or spha- 
celus, but this termination is of most frequent occurrence 
when the pulp-cavity is but slightly opened, or where 
the pulp is altogether confined beneath a layer of den- 
tine, or beneath a tilling. Under such circumstances, 
there being no room for swelling, and little or no escape 
for the inflammatory exudations, such constriction is 
produced as causes death of the whole mass. Death of 
the pulp may be recognized by the cessation of the pain, 128 
DISEASES OF THE PULP. 
the insensibility of the dentine during excavation, whilst 
on examination the pulp is found devoid of sensation, 
softened and discolored, and emitting a characteristic 
fetid odor. The entire tooth at the same time assumes 
a darker tint, and occasionally becomes stained of a red- 
dish hue in consequence of the diffusion of the coloring 
matter of the blood of the pulp through the dentine. 
An attack of acute inflammation when the pulp is 
freely exposed rarely produces gangrene of the entire 
structure. The inflammation is sometimes limited to 
the exposed surface alone. In many cases swelling 
having taken place, and the exudation having found 
vent, the attack slowly subsides and assumes a chronic 
form, to be renewed again and again from time to time 
under the influence of increased irritation. 
If a pulp the seat of acute inflammation be examined 
recently after the extraction of a tooth the affected por- 
tion will be found deeply red in color, the vessels being 
visibly injected, and small patches of extravasated blood 
will be observed upon the surface. Where swelling has 
been possible a red cedematous mass, studded, with sup- 
purating patches, is found projecting into the carious 
cavity through the opening into the pulp-chamber. 
Some amount of suppuration is almost always present, 
but it is generally confined to the exposed surface, and 
abscess in the substance of the pulp is rarely formed. 
The general characteristics of a pulp in which gangrene 
has supervened have been already mentioned. Close 
examination shows that the tissues in this condition are 
reduced to a semifluid mass of a dirty reddish-gray or 
yellow color, with a marked gangrenous odor. In this 
mass portions of the disintegrated walls of the blood- EXPOSURE OF THE PULP. 
129 
vessels, with numerous fat-cells interspersed, and disor- 
ganized nerve-fibrils, may be traced by the microscope. 
The treatment of acute inflammation of the pulp must 
be modified in accordance with the circumstances of the 
case and the phase which the process has assumed. In 
some instances the extraction of the tooth is called for; 
in others the reduction of the inflammation and the con- 
servation of the complete vitality of the tooth may be 
reasonably aimed at; whilst in a third group the extir- 
pation of the pulp is the sole resource. 
The extraction of the tooth is most frequently required 
in childhood. At this period an attack of acute inflam- 
mation usually runs a rapid course, the pain becomes 
excruciating, the inflammation quickly spreads to the 
periosteum, and the tooth becomes so exquisitely sensi- 
tive to the touch that manipulation of any kind is un- 
bearable. The rapid spread of the inflammation in these 
cases is accounted for by the yet incomplete condition of 
the roots, the apices of which are represented by a por- 
tion of uncalcified pulp, freely communicating with the 
alveolar tissues. This condition renders inadmissible 
any attempt at the destruction of the pulp by means of 
escharotics in the manner presently to be described, 
whilst the advantages previously referred to, which in 
many cases accrue from the extraction of the first per- 
manent molars (the teeth by far the most frequently the 
seat of caries in children), render their preservation in- 
expedient. In the temporary teeth, the roots of which 
are undergoing resorption, the course of acute inflamma- 
tion of the pulp closely resemble that which takes place 
in the permanent teeth at the same age. The treatment 
of the affection, except by the extraction of the tooth, is 
in most cases unsatisfactory. 130 
DISEASES OF THE PULP. 
In the case of children, as in every other case of acute 
inflammation of the pulp in its earlier stages, the attack 
may be often cut short by removing the cause. With 
this view the cavity should be excavated, and in doing 
this with proper care it is possible to avoid wounding 
the pulp and inflicting (besides the injury) severe suffer- 
ing upon the patient. Foreign particles pressing upon 
the pulp may be dislodged by the excavator, aided by 
the syringe and warm water, the free use of which should 
be continued to encourage bleeding from the exposed 
surface, should it occur. The cavity may be then lightly 
tilled with a temporary plug of cotton-wool saturated 
with mastic solution, over a pellet of wool moistened 
with carbolic acid, and external irritation being thus 
guarded against, the inflammation will often subside. 
The temporary filling may be renewed at intervals of a 
few days. When all symptoms have disappeared the 
operation of capping the now healthy pulp and filling 
the tooth may be proceeded with. The cases favorable 
for this treatment are those in which the periosteum is 
unaffected and in which the pulp fully retains its 
vitality, not having been partly destroyed by gangrene 
or ulceration, resulting from former attacks of inflam- 
mation. 
In cases in which preservation of the pulp is contra- 
indicated the treatment consists in destroying its vitality 
by means of arsenious acid, in extirpating it, and after- 
wards permanently filling the chamber and root canals, 
as well as the external cavity of decay. A very minute 
quantity—less than of a grain of the escharotic—is 
sufficient to destroy the vitality of the pulp of the 
largest molar. The mode of applying it is as follows. 
The cavity having been excavated and dried, the arsenic EXPOSURE OF THE PULP. 
131 
is carried to the exposed surface of the pulp by means of 
a few filaments of cotton-wool saturated with carbolic 
acid, and is then at once sealed in by a wool and mastic 
filling. The addition of a small quantity of morphia to 
the escharotic appears to prevent increase of the pain 
from this application. The pain is, however, rarely 
severe, and often altogether absent. The action of the 
arsenic being rapid, the treatment often, indeed, serves 
to arrest almost instantly the suffering arising from an 
aggravated attack of inflammation of the pulp. There 
are some disadvantages attending the use of wool with 
mastic solution as a covering for the escharotic. It is 
sometimes difficult to avoid pressure upon the exposed 
pulp, an accident which is attended with great pain, 
whilst the liquid constituents tend to wash away the 
pulp-destroying dose. These disadvantages are over- 
come by the use of beeswax as a temporary filling. A 
small piece of wax is carried by the tweezers to the 
cavity, and by means of a small heated spatula is melted 
over the orifice, so as to effectually exclude the saliva for 
a few hours. The spatula should have a wooden handle 
and a short metal blade, so as to avoid burning the 
patient’s lips. 
The temporary filling may be removed in about 
twenty-four hours, when it will be usually found that 
the pulp has lost its vitality, and that no pain results 
from probing the canal. It happens, however, occasion- 
ally, that in consequence of the smallness of the open- 
ing into the pulp-cavity, or of the presence of nodules 
of secondary dentine preventing the free access of the 
escharotic, the deeper portion of the pulp will be found 
to retain its vitality. In these cases the opening into 132 
DISEASES OF THE PULP. 
the chamber can be enlarged, and a second effectual 
application of arsenic can be made. 
The devitalization of the pulp of single-rooted teeth 
—incisors and canines—can be effected instantaneously 
by means of instruments alone, and the pain of this 
operation, especially where the pulp has been previously 
destroyed to some extent by disease, is not so severe as 
might be supposed. The operation is performed by 
thrusting rapidly a thin flexible broach to the apex of 
the canal, and rotating it, so as to sever at once the 
vascular and nervous connections of the pulp. 
The next step consists in removing the dead pulp. 
This is, as a rule, accomplished with little difficulty bv 
means of the barbed pulp extractors especially made for 
the purpose. One of these instruments passed into the 
canal entangles the pulp, and brings it away on with- 
drawal. The operation is much facilitated by the free 
cutting away of the crown of the tooth, where necessary, 
to render visible—or at least to render accessible—the 
orifices of the canals, whilst if difficulty arise in con- 
sequence of smallness of the canals, or the presence of 
nodules of secondary dentine, they must be overcome by 
the use of fine flexible broaches. Some slight haemor- 
rhage from the canal usually follows the extraction of 
the pulp. When this has ceased, the filling of the canals 
may be proceeded with. Either gold or oxychloride of 
zinc cement may be employed, but the author has no 
hesitation in affirming that the latter of these materials 
is much the preferable of the two. In using it, it is 
seldom necessary to enlarge the pulp-cavity, as it can be 
made to flow into any canal into which a fine flexible 
wire will pass. The canals, after cleansing by the 
syringe and warm water, should be dried, and absolute EXPOSURE OF THE PULP. 
133 
alcohol is valuable in this part of the process. Shreds 
of cotton-wool soaked in the fluid should be passed into 
each root, and allowed to remain for a few moments. 
By this means not only are the canals more thoroughly 
dried than is possible by any o; her means, but any 
minute particle of soft tissue which has escaped the 
nerve-extracting instruments is shrivelled by the spirit, 
and left in a condition in which, after insertion of the 
filling, decomposition is impossible. The oxychloride 
cement is next mixed to the consistence of cream. A 
few filaments of cotton-wool saturated with the fluid are 
then taken on the point of a wire or root-plugger of 
suitable size, and passed to the apex of the canal, por- 
tion after portion being afterwards carried in in the same 
way until the root is filled. The wool is used to facili- 
tate the insertion of the cement, as it is often difficult to 
force the fluid alone into the depths of the canals. This, 
however, may be sometimes accomplished by carrying a 
portion of the liquid cement to the orifice of the root, 
and then with a pumping action, by means of a wire, 
having a few threads of wool fixed at its extremity, 
causing it flow into the canal. After the cement has 
hardened, the external cavity may be filled with a more 
durable material. The advantages of oxychloride of 
zinc over other substances used in fang-filling are the 
following. It is antiseptic in its properties; it forms a 
perfectly water-tight filling; it is a non-conductor of 
heat; it can be applied, as a rule, without enlarging the 
canals, and without other manipulation likely to set up 
irritation; and lastly, it can be easily removed by a drill 
and excavator, should it be necessary. The objection to 
the filling, owing to its perishable nature, which holds 
good in ordinary situations, does not apply in root-filling 134 
DISEASES OF THE PULP. 
where the material remains buried deeply beneath a 
plug, and protected from the action of decomposing 
agencies. 
Filling fangs with gold is a more laborious operation, 
and presents no advantages over that just described. 
It is often necessary to open up the canals to a consider- 
able extent before plugging instruments to carry in the 
gold can be made to enter. Gold is, moreover, a rapid 
conductor of heat; it is extremely difficult to remove 
when once packed, and in the author’s experience its use 
in fang-filling is often followed by periostitis, a result 
which very rarely follows the employment of oxy- 
chloride of zinc. 
Chronic inflammation of the pulp arises from the same 
causes which originate acute inflammation, by far the 
most common being the exposure of the pulp by caries. 
It often remains as a sequel to an acute attack, and 
again assumes a more active character, from time to 
time, under the influence of increased irritation. 
The pain, usually of a dull aching or gnawing kind, 
is less severe than in acute inflammation, it may be al- 
most altogether absent if there be a free vent for the 
discharges, or may be manifested at a distance in the 
form of neuralgia. The exposed surface is red, swollen, 
and pours out a thin puriform or serous secretion, hav- 
ing a characteristic phosphatic odor. On examination, 
the redness due to injection is found to be confined to 
the superficial portion alone of the pulp. This condi- 
tion may resolve itself into a process of ulceration under 
which the pulp gradually disappears; in other cases 
degeneration and atrophy ensue, and effect complete 
destruction of the pulp, often without the occurrence of 
any pain. EXPOSURE OF THE PULP. 
135 
In a certain number of instances chronic inflammation 
gives rise to the development of new tissue in the form 
of polypus of the pulp. This occurs mostly in young 
subjects, in teeth the crowns of which are extensively 
excavated by caries and with the pul}) fully exposed. 
The new growth consists of a rounded fleshy mass, red 
or bluish-red in color, occupying or projecting from the 
cavity of decay, and may attain a size between that oi 
a small pea and a Spanish nut. It is usually covered 
with an offensive muco-pnrulent secretion. It bleeds 
readily if wounded, but displays but little sensibility. 
Examination shows that polypus is united with the 
pulp, from which it springs, and that it consists of a 
mass of rounded and spindle-shaped cells, supported by 
a small quantity of fibrous tissue, and provided with 
numerous comparatively large bloodvessels. 
Treatment.—In cases of uncomplicated chronic inflam- 
mation of the pulp in which there is neither an out- 
growth of new tissue (polypus), nor loss of substance 
from ulceration or gangrene, nor periostitis of marked 
extent, an attempt may be made to bring the structure 
into a healthy condition. With this object the cavity 
having been excavated and cleansed, a dressing of car- 
bolic acid, creasote, or chloride of zinc on cotton-wool 
may be lightly applied to the pulp, covered by a tempo- 
rary filling. This must be renewed at intervals of a 
day or two until all symptoms of inflammation have 
subsided. The operation of capping the pulp and filling 
the carious cavity must then be carried out in the man- 
ner already described. 
In cases in which there has occurred an outgrowth of 
new tissue sufficient to constitute a polypus, the extrac- 136 
DISEASES OF THE PULP. 
tion of the tooth is the sole treatment that can be rec- 
ommended. 
The treatment of a pulp partly destroyed by ulcera- 
tion must be directed to the destruction of the remainder 
by arsonious acid, extirpation of the mass, and the subse- 
quent filling of the fangs and cavity by the method al- 
ready explained. It will sometimes happen (as before 
stated) that after repeated attacks of acute or long-con- 
tinued chronic inflammation the pulp is entirely de- 
stroyed, and on examination the canals are found to 
contain nearly a semifluid mass of decomposing tissues. 
The treatment in these cases consists in thoroughly 
clearing out the canals, in disinfecting them by the ap- 
plication of carbolic acid, in afterwards filling them in 
the usual manner. It is in most of such cases well to 
dress the canals with carbolic acid at intervals during 
a week or more (keeping in a temporary filling), until 
all danger of periostitis, which sometimes supervenes, 
has passed away. This is a precaution which may well 
be adopted before fang filling, in all cases in which 
the occurrence of unfavorable symptoms appears prob- 
able. DENTAL PERIOSTITIS. 
137 
DENTAL PERIOSTITIS—ALVEOLAR ABSCESS- PE- 
RIOSTITIS AND NECROSIS OF. THE MAXILLAE, 
DENTAL EXOSTOSIS AND NECROSIS—ABSORP- 
TION OF ROOTS OF PERMANENT TEETH. * 
Periostitis.—Inflammation of the dental periosteum 
may be confined to one or two teeth, or may involve 
many or all the teeth of each jaw. The former variety 
is that most frequently met with, the commonest cause 
being the extension of inflammation from the diseased 
dental pulp. Periostitis also often arises after the filling 
of a cavity in which portions of suppurating or decom- 
posing pulp have been improperly left, and in which the 
matter, not finding any escape, penetrates to the depths 
of the root canals, reaches the periosteum and sets up 
irritation. It may extend from one tooth, to those adja- 
cent through the periosteum of the jaw, or may spread 
from the gums, inflammation of which indeed if at all 
extensive, always in some degree involves the perios- 
teum. Periostitis may result from mechanical injuries 
of the teeth or alveoli, it may be caused by the con- 
tinued inhalation of fumes of phosphorus, or may arise 
from rheumatism, syphilis or scrofula, or from cold, or 
from the effects of mercury upon the system (when, 
however, is is an extension from the gums), or from de- 
bility; whilst finally certain cases of general subacute 
or chronic periostitis, associated with absorption of the 
alveoli, frequently present themselves, in which the cause 
cannot be satisfactorily ascertained. Periostitis due to 138 
DENTAL PERIOSTITIS. 
constitutional causes usually affects several or all of the 
teeth of one or both jaws. 
The symptoms of acute periostitis commence with a 
feeling of uneasiness in the affected tooth, which in- 
creases in the course of a few hours into aching pain, 
accompanied by tenderness of the tooth, especially when 
pressed into the socket as in mastication. If allowed 
to continue these symptoms increase in intensity. The 
pain becomes severe, and the sensibility of the tooth ex- 
treme ; and the tooth is felt evidently protruded to a 
small extent from the alveolus, and slightly loosened 
owing to swelling of the lining membrane of the socket. 
The neighboring teeth become tender, the inflammation 
involves the neighboring gum and spreads thence to the 
palate and cheek, which become swollen and oedematous 
—the oedema often extending to the eyelids when an 
upper front tooth is the centre of the disease. With 
these symptoms more or less febrile disturbance is asso- 
ciated in accordance with the extent of the inflammation 
and the condition of the patient’s general health. The 
tongue is foul, the breath tainted, the skin is hot, and 
there are thirst and headache. At this stage suppuration 
takes place, pus is formed, points and finds its way to 
the surface, and this is followed at once by diminution 
of the pain and by slow subsidence of all the symptoms. 
The acute stage of such an attack, uninfluenced by treat- 
ment, usually lasts from six to ten days. Perfect re- 
covery may take place, the inflammation may remain 
chronic, it may end in partial or complete necrosis of 
the tooth, or spreading to the periosteum of the jaw, 
may cause necrosis of the bone to a greater or less ex- 
tent. 
On the extraction of a tooth the seat of acute perios- DENTAL PERIOSTITIS. 
139 
titis, the periosteum in the early stage of the attack is 
found thickened, red, and injected; later it presents 
] atches of lymph, and when pus has formed it is not 
uncommon to find a distinct sac containing matter at- 
tached to the extremity of the fang. This arises from 
suppuration of the internal layer of the periosteum, which 
becomes detached from the cement, thickened and di- 
lated, and filled with purulent matter. 
The treatment of acute periostitis must be governed 
by the cause of the disease and other circumstances, and 
although the great majority of cases yield to active treat- 
ment, the question of the extraction of the tooth will 
sometimes arise. Teeth or roots which have been long 
the seat of previous chronic inflammation, or alveolar 
abscess, or which are loose owing to absorption of their 
alveoli, may be often extracted without hesitation on the 
appearance of an attack of acute periostitis, whilst it is 
sometimes necessary to sacrifice a tooth to cut short the 
attack and avert the dangers of suppuration. And it 
may be here pointed out that if extraction be deemed 
desirable there need be no hesitation in performing the 
operation at any stage of the affection. There is a pop- 
ular error on this subject, which prevails to some extent 
even among the more intelligent classes. The belief is, 
that it is both difficult and dangerous to remove a tooth 
when great swelling and inflammation of the soft parts 
are present, but there are no grounds whatever for such 
belief. The tooth is loose, and there are no special diffi- 
culties attending its extraction. No harm can possibly 
arise from the operation, whilst on the contrary in cases 
in which it is called for, much good must follow it, since 
the tooth constitutes the sole cause of the mischief. 
If it be resolved to save the tooth, local abstraction 140 
DENTAL PERIOSTITIS. 
of blood and the assiduous use of warm fomentations 
are of the first importance in the early stages of the attack. 
One or two leeches can be easily applied to the gum over 
the affected tooth, and fomentation can be practiced bv 
the patient washing the mouth with warm water. The 
carious cavity and the exposed pulp must be dealt with 
conformably to the circumstances by the methods de- 
scribed in the previous sections. 
In most cases the administration of a brisk purge will 
be found beneficial. In some patients an ordinary saline 
draught, such as a Seidlitz powder, will suffice ; to others, 
with muddy complexion, foul tongue, and constipation, 
calomel or blue pill, with colocynth, may be administered, 
followed by a saline draught if necessary. 
So soon as swelling occurs, and even before pus can be 
detected, free incisions should be made through the gum 
down to the bone at the position where it appears prob- 
able matter may form, whilst at the same time the warm 
fomentations are persevered with. 
Chronic dental periostitis may arise from any of the 
causes which originate the acute form of the disease. It 
often remains as a result of an acute attack, whilst peri- 
ostitis due to constitutional causes is generally chronic, 
and rarely passes at all beyond a subacute stage. The 
symptoms comprise in a modified degree those present 
in acute inflammation. The teeth are tender on pressure; 
they are the seat of a varying amount of pain; they arc 
more or less loosened and raised from their sockets, owing 
to the swelling within ; and they are surrounded by red- 
dened and swollen gum. On pressing the mucous mem- 
brane in some cases either pus or muco-purulent matter 
oozes from around the necks of the teeth, or escapes 
through a fistulous opening in the gum. These symp- DENTAL PERIOSTITIS. 
141 
toms may continue for months or years, until becoming 
completely loose, in consequence of absorption of the 
alveoli, the teeth are at last lost. 
Roots the seat of chronic inflammation exhibit vari- 
ous pathological changes. The periosteum is always 
thickened and more or less injected, and covered with 
patches of lymph. A complete sac, containing pus simi- 
lar to those occurring in acute inflammation, is often 
found attached to the apex. In the same situation there 
are often found masses of fibrous tissue—hypertrophied 
root membrane—which are often undergoing ossification 
at the point of junction with the cement. In other cases 
partial necrosis exists, and the effects of absorption of 
the cement and dentine, indicated by a rough excavated 
surface, are commonly observable. 
Treatment.—The question of the extraction of the 
affected tooth will arise in many instances, and must be 
decided in accordance with the circumstances of the case. 
The condition of the carious cavity (when one exists), 
the degree of loosening of the tooth owing to absorption of 
the alveolus, and the presence of symptoms indicating 
pathological changes in the cement, will determine 
whether there is a fair prospect of bringing the organ 
into a useful condition. 
The first step in the treatment will consist in remov- 
ing the cause—when discoverable—of the disease. When 
the inflammation is associated with disease of the pulp 
that structure must be dealt with by appropriate meas- 
ures. Sources of local irritation, such as tartar deposited 
upon the necks of the teeth or necrosed roots must be 
removed. Local depletion is of considerable service, and 
the blood may be abstracted by incising deeply with a 
scalpel the swollen gum occupying the spaces between 142 
ALVEOLAR ABSCESS. 
the teeth. When the gum is separated from the necks 
of the teeth, and a purulent discharge is poured out, the 
part should be swabbed frequently with a solution of 
chloride of zinc—20 grains to an ounce—by means of a 
small probe and a pellet of cotton-wool, passed beneath 
the free edge of the gum. Lotions of permanganate of 
potash or carbolic acid may be used to overcome the fetor 
of the breath. 
In periostititis due to or aggravated by constitutional 
causes, attention must be directed to the general health 
—rheumatism, syphilis, debility, and mercurialization 
each receiving its appropriate treatment. 
Alveolar Abscess.—Certain phases of the suppurative 
stage of dental periostitis constitute the conditions most 
commonly spoken of under the designation of alveolar 
abscess. This class of abscess is seen in its simplest and 
most familiar form in the ordinary gum-boil, which con- 
sists of a collection of pus between the gum and the bone, 
external to the root of the tooth, from which the disease 
originates. In severer forms of the same affection the 
cheek having become involved in the inflammation, great 
swelling having taken place, and suppuration to consid- 
erable extent ensuing, the matter if it do not find a ready 
exit into the mouth may point and burst externally. 
Thus there results a fistulous track between the diseased 
tooth and the surface of the cheek, which remains open 
and discharging as long as the inflammation continues. 
This termination, although it occasionally supervenes 
upon suppuration around other teeth, much more com- 
monly follows alveolar abscess connected with the lower 
molars. Suppuration in alveolar abscess always com- 
mences in the socket at the surface of the tooth, but as ALVEOLAR ABSCESS. 
143 
soon as matter forms absorption of the bone is set up and 
the matter escapes into the surrounding tissues. The 
external alveolar plate being the thinner, is almost inva- 
riably alone perforated, and the perforation often takes 
place with great rapidity, a few hours sufficing for the 
formation of a hole in the bone of considerable size. In 
some cases the thin alveolar plate becomes dilated and 
forms a bony sac around the abscess. 
Abscesses connected with diseased teeth are usually 
traceable without difficulty to their origin. The matter 
does occasionally, however, burrow through the soft tissue 
and appear about the palate, cheek, or jaws in situations 
so unusual that the relation of the discharge to the teeth 
is not at first sight suspected. In cases of abscess about 
the mouth or face, the origin of which is not otherwise 
evident, it is therefore desirable that an examination of 
the teeth should be made. 
When the matter escapes through the cheek the 
symptoms closely simulate necrosis of the jaw. The 
orifice of the sinus is surrounded by granulations, which 
often increase so as to form a papilla-like projecting 
mass, and from it issues a more or less constant secretion 
of purulent fluid. Such a case may be distinguished 
from necrosis of the bone by the following circumstances: 
firstly, that there is as a rule but one sinus when a tooth 
alone is implicated, whereas when a sequestrum exists 
there are several; secondly, dead bone may be detected 
by the probe; and thirdly, if necrosis have not taken 
place the symptoms speedily disappear on the extraction 
of the tooth. 
The treatment of alveolar abscess is necessarily associ- 
ated in many cases with that of dental periostitis, which 
has been already described. In the acute stage free in- 144 
ALVEOLAR ABSCESS. 
eisions into the swelling within the mouth and warm 
fomentations are the principal measures called for. 
Poultices and warm applications to the cheek should be 
avoided, as they encourage the escape of the matter 
through the skin. Painting the surface with tincture 
of iodine may assist in averting this danger. It must 
be remembered that although most cases either yield to 
treatment or subside after running a certain course, the 
progress of the disease may be arrested at once by the 
extraction of the tooth—an operation which may be per- 
formed without hesitation when the tooth is useless 
owing to chronic disease or extensive decay, or when the 
abscess threatens to burst externally. This latter event 
will be known to be imminent when fluctuation close to 
the surface is recognizable, and when the skin over the 
pointing abscess looks dusky or livid, and feels thin, and 
ready to give way. If the escape of pus through the 
skin appears inevitable, the abscess should not be al- 
lowed to burst spontaneously, but should be opened as 
soon as symptoms of pointing appear, in order to pre- 
vent the disfiguring cicatrix which must otherwise re- 
suit in consequence of destruction of a portion of skin. 
The treatment of chronic alveolar abscess must be di- 
rected first to the tooth and the exposed and inflamed or 
gangrenous pulp. The abscess having been then laid 
open by the bistoury, may be mopped out or syringed 
daily with a solution of carbolic acid, 20 grains to the 
ounce, or chloride of zinc, 20 grains to the ounce. 
These measures will in most cases suffice to effect a com- 
plete cure. In some instances, however, in which ne- 
crosis of the apex of the root exists, a small fistulous ori- 
fice remains permanently in the gum, from which a 
minute quantity of pus is constantly discharged, which PERIOSTITIS AND NECROSIS. 
145 
causes no inconvenience to the patient, who, indeed, often 
remains ignorant of its existence. 
Periostitis and Necrosis of the Maxillae.—The slight 
limited periostitis of the alveolus or jaw, which, from 
the intimate relation of the parts, is necessarily associ- 
ated with the dental diseases just described, subsides in 
most cases on the removal of the cause; but in some in- 
stances the inflammation continues or extends, and may 
terminate in suppuration, followed sometimes by necro- 
sis, to a greater or less extent, of the bone, in conse- 
quence of separation of the periosteum. On the other 
hand, cases occur in which inflammation, involving both 
teeth and bone, originates, independently of the teeth, in 
the periosteum of the maxilla. This form of inflamma- 
tion may be caused by injury, such as fracture of the 
alveoli during extraction in an unhealthy subject, or by 
any of those constitutional conditions which give rise 
also to dental periostitis, and which have been already 
enumerated. C. O. Weber and Mr. Salter have both 
observed and recorded cases of a form of necrosis, which 
the latter has termed exanthematous necrosis. It occurs 
at the period of the commencement of second dentition 
in children, especially such as are badly nourished, who 
have been debilitated by attacks of the eruptive fevers. 
The necrosis in these cases is usually confined to the 
alveoli of the temporary teeth, the bone being exfoli- 
ated and thrown off together with the teeth which it 
supports. 
The symptoms of periostitis of the jaw resemble in an 
aggravated form those attending the dental disease. 
There are violent pain and great swelling, and oedema 
accompanied by fever. The occurrence of suppuration 146 
PERIOSTITIS AND NECROSIS. 
is marked by rigors, and is often attended with increase 
rather than diminution of pain, unless the matter find 
immediate vent. The skin assumes a shining, erysipela- 
tous aspect, and pits on pressure, and after a time the 
abscesses point and discharge pus through openings cor- 
responding to the position of the diseased bone, to which 
they lead by fistulous passages. These openings are 
similar to those described as occurring in alveolar abscess 
discharging through the cheek. When necrosis has su- 
pervened the rough denuded surface of bone can be felt 
by probing. 
In exanthematous necrosis the symptoms commence 
in the gum, which, with the periosteum, ulcerates and 
lays bare the bone. It is accompanied by a discharge of 
fetid pus. It gives rise to little or no pain. 
The treatment of periostitis of the jaw consists of local 
bleeding by means of leeches, and free incisions through 
the gum down to the bone, with assiduous application of 
warm fomentations. All sources of irritation, such as 
hopelessly decayed and necrosed teeth, must be removed. 
As soon as matter forms it must be evacuated by the 
bistoury. The general health will of course receive due 
attention. 
When necrosis has supervened the treatment is di- 
rected to maintaining a free vent for the discharges, de- 
stroying their fetor by antiseptic lotions, and removing 
the dead bone. In exanthematous necrosis the amelio- 
ration of the general health is the first care, locally de- 
tergent lotions are called for, but incisions or bleeding 
are not required. 
Detergent lotions may be composed of carbolic acid, 
two grains to the ounce of water, or of Condy’s fluid, 
half a drachm to the ounce; and it is a good plan not DENTAL EXOSTOSES. 
147 
only to wash the mouth frequently with these fluids, but 
also to inject them by means of a syringe into the si- 
nuses when these exist. 
No attempt should be made to remove the dead bmie 
until it has become detached from the living tissue, 
wdiich event may not occur for many weeks or months, 
and will be known by the mobility of the sequestrum 
on examination. It is especially important that force 
should not be applied in extracting the dead bone in 
the case of children, lest the rudimentary permanent 
teeth lying within the jaw be injured or removed in the 
operation. 
By the time the sequestrum has become detached the 
orifices of the sinuses have usually become so enlarged 
as to allow the mass to be readily withdrawn by means 
of a pair of sequestrum forceps, but in some cases a 
few touches of the scalpel may be required to complete 
the operation. To avoid subsequent disfigurement the 
necessary incisions should be confined to within the 
mouth. 
Dental exostoses consist of an outgrowth of osseous 
tissue from the surface of the cement, and takes the 
form either of prominent rounded nodules or of smooth 
and regular masses connected with a large portion of 
the root. These outgrowths are in most cases situated 
towards the apex of the root. The new tissue is simi- 
lar in structure to ordinary cement, but when developed 
in a considerable quantity it is frequently penetrated by 
vascular canals, which, proceeding from the exterior, 
give off branches throughout the mass. 
The cause of exostosis is chronic periostitis. In this 
disease—as we have seen — the periosteum becomes 148 
DENTAL NECROSIS. 
thickened and vascular, and coated with masses of 
lymph. If the inflammation continue the lymph be- 
comes organized into fibrous tissue, which, under favor- 
able circumstances, undergoes ossification. The ossifi- 
cation commences upon the surface of the root, and pro- 
ceeds outwards, the soft tissues becoming dense and 
almost cartilaginous in texture prior to impregnation 
with earthy matter. It happens occasionally that roots 
of adjacent teeth become surrounded and united by the 
same inflammatory exudation, and when this exudation 
becomes subsequently organized and ossified organic 
union of the teeth is brought about. Adjacent lower 
molars thus united are shown in Fig. 77 in a later page. 
The symptoms of dental exostosis are almost identical 
with those of periostitis, and it is often difficult to dis- 
tinguish between the two diseases. Exostosis may, 
however, exist without any distinct symptoms being ap- 
parent, except, perhaps, slight congestion of the gum 
around the tooth; and teeth the seat of hypertrophy of 
the cement, although they may be the seat of no pain, 
sometimes give rise to facial neuralgia. 
The only available treatment is extraction, an opera- 
tion which must be performed when the tooth is the seat 
of severe or persistent pain, or is in any way a source of 
constant annoyance to the patient. 
Necrosis.—The teeth derive their vitality from two 
sources,—the central pulp and the periosteum. When 
from any cause the pulp has been destroyed and the 
cementum denuded of periosteum complete necrosis of 
the tooth results, and it is reduced to the condition of a 
foreign body. Complete necrosis of this kind is occa- 
sionally met with, but cases ai’e much more common in DENTAL NECROSIS. 
149 
which the necrosis is only partial. The pulp may be 
destroyed, whilst the connection of the cementum with 
the periosteum remains intact; or the pulp may retain 
its vitality, whilst the cementum has to a greater or less 
extent lost its connection with the periosteum. 
A tooth entirely necrosed becomes speedily loosened 
and cast off, but if the necrosis affect a small portion 
only of the cementum, the tooth—whether the pulp 
be living or not—may remain useful for an indefinite 
time without giving rise to important pain or irritation. 
The causes, symptoms, and treatment of gangrene of 
the pulp have been described in a previous section. 
The most frequent cause of necrosis of the cement is 
periostitis. It is sometimes due to absorption of the 
gums and alveoli, and it may arise, especially in the 
case of the front teeth, from an injury, such as a blow, 
which has partly dislocated the tooth and severed at once 
its vascular connections. 
Necrosis of the cement manifests itself by suppura- 
tion, the amount varying, of course, with the extent of 
the disease. The matter escapes through a fistulous 
opening in the gum or wells up around the root from 
within the alveolus. 
The surface of necrosed roots is rough and discolored. 
The roughness is due to the denudation of the perios- 
teum and to absorption, which almost always affects to 
some extent the necrosed cement. In cases where the 
periosteum is entirely detached a thin probe can be 
passed along the root within the alveolus to near the 
apex. Hoots in this condition exposed to the access of 
saliva become coated with tartar or studded with small 
nodules, and the deposit is usually of the hard black 
variety. 150 
ABSORPTION OF THE ROOTS. 
The sole treatment of necrosis of the cement is ex- 
traction, but the operation is, of course, not called for 
so long as the tooth remains useful and free from severe 
pain. 
Absorption of the roots of permanent teeth is a common 
accompaniment of chronic periostitis and of necrosis. 
If the roots, especially the apices, of teeth affected with 
these diseases be examined after extraction it will be 
found that they often display patches of roughened ex- 
cavated surface closely resembling that presented by 
bone and by the roots of temporary teeth when under- 
going absorption. Although several are recorded, cases 
of complete or even of considerable absorption of the roots 
of permanent teeth are rare—no doubt, because the 
teeth are usually lost before the process is far advanced. 
The disease, when extensive, manifests itself by loosen- 
ing of the tooth. Extraction is the sole treatment. 
Absorption of the alveoli, sometimes described as a 
distinct disease, occurs in the vast majority of cases 
merely as a consequence of chronic dental periostitis, 
and calls for similar treatment. The same treatment 
can be alone applied in those cases of obscure origin in 
which the teeth are lost in middle life by a gradual 
wasting of the sockets, closely resembling that which 
takes place as a natural process in advanced age. DISEASES OF THE GUMS, ETC. 
151 
DISEASES OF THE GUMS AND ORAL MUCOUS 
MEMBRANE. 
Inflammation of the gums may be due to various causes. 
Some amount always accompanies dental periostitis; it 
may arise from the irritation of tartar accumulated 
around the necks of the teeth, or from the presence of 
necrosed teeth and roots; it may be associated with dis- 
orders of the digestive organs, especially such as occur 
in pregnancy and gouty subjects, and in those who 
habitually take alcohol to excess. It is also often 
caused by constitutional syphilis, it forms a prominent 
symptom in ptyalism and in chronic mercurialization, 
and it is present in diseases which, like scurvy, are due 
to a depraved state of the blood. 
The inflammation may involve a small part only of 
the gum, or may attack the whole surface in each jaw. 
The limited variety is most commonly occasioned by 
local irritation ; general inflammation of the gums gen- 
erally arises from constitutional disorder. 
Symptoms.—The gums are deep red or purple in color, 
swollen, spongy, and tender, and they bleed on the 
slightest touch. Pus oozes, or can be squeezed from 
around the teeth at the free edge of the gum, where 
ulceration often also occurs. If the disease continue for 
any length of time, it always spreads to the dental peri- 
osteum, rendering the teeth loose and tender, and lead- 
ing to absorption of the alveoli. Chronic inflammation 
sometimes leads to hypertrophy of the gum. The put- 152 
DISEASES OF TIIE GUMS AND 
growth is at first soft, but after the lapse of time may 
become hard and fibrous in character. 
The treatment must be first directed to the removal 
of the exciting cause, and all sources of local irritation 
must be done away with, tartar and hopelessly loose and 
necrosed teeth being at once removed. The gums may 
be unloaded by free scarification, followed by warm fo- 
mentation, in the acute stage, and by astringents, such 
as tannin, in the chronic form. Where a fetid discharge 
exists detergent lotions may be prescribed, and the neck 
of the teeth may be swabbed with solutions of chloride 
of zinc or carbolic acid. Where the inflammation is 
associated with constitutional disorder local treatment is 
of secondary importance, and the remedies must be ap- 
plied to the amelioration of the general health. 
Thrush is an inflammation of the mouth occurring in 
infants. The entire mucous membrane is reddened and 
studded at parts with vesicles, especially inside the lips 
and on the tip of the tongue. These vesicles give place 
to patches of exudation, which are thrown off, leaving 
the membrane exposed and deeply red in color beneath. 
With these symptoms there is fever and often diarrhoea. 
The treatment must be directed to the general health. 
Locally, soothing applications, such as lotions of glyc- 
erin or borax and honey, are most useful. 
Aphthous, or follicular ulceration, occurs both in adults 
and in children. The first stage of the malady takes 
the form of simple inflammation of the mucous mem- 
brane. In the next stage, small, round, transparent 
vesicles appear, which burst, leaving small spreading 
ulcers with red and swollen margins. Both in this dis- 
ease and in thrush, in some cases, the ulcers become 
coated with a layer of a microscopical parasite (oidium ORAL MUCOUS MEMBRANE. 
153 
albicans). Besides constitutional treatment, which is of 
the first importance in this affection, the ulcers may be 
touched with sulphate of copper or nitrate of silver, and 
a lotion may be prescribed to destroy the vegetable par- 
asite, composed of sulphate of soda, 5j to 5j. 
Ulcers of the tongue and lips often originate from fric- 
tion against the ragged edges of broken and decayed 
teeth, and ulcers in these situations arising from other 
causes—such as syphilis and dyspepsia—are frequently 
aggravated by similar irritation. Ulcers due to irrita- 
tion of ragged teeth vary in size with the length of time 
they have existed, and they may attain large dimensions. 
They are of irregular form, with slightly hardened bases, 
and are situated as a rule on the surface of the mucous 
membrane lying against the faulty tooth, those on the 
tongue appearing on the side and under surface. These 
ulcers, when neglected, may assume an aspect closely 
simulating epithelioma, and the resemblance is rendered 
more complete in some cases by the induration of the 
glands beneath the jaw which accompanies them. 
In all cases of ulcers in the neighborhood of decayed 
teeth, it is desirable to file down and polish the rough 
and ragged surfaces. Should the ulcer be of a simple 
character it will then soon heal. The cure may be 
hastened by the use of astringent lotions, such as nitrate 
of silver, two grains to the ounce of water. 
One of the commonest symptoms of constitutional 
syphilis is the occurrence of ulceration of the mucous 
membrane of the mouth, which assumes various forms, 
sometimes not easily distinguishable in appearance from 
the varieties above described, due to other causes. Such 
cases can be diagnosed by the presence of other symp- 154 
DISEASES OF THE GUMS, ETC. 
toms indicative of syphilis, and by their obstinacy under 
any but specific treatment. 
Cancrum Oris.—This comparatively rare disease is 
confined entirely to young ill-fed children inhabiting 
low crowded neighborhoods. The disease may be well 
defined as sloughing phagedaena of the gums and cheeks. 
It may begin at any part of the mucous membrane, but 
in many cases makes its appearance at the edge of the 
gum about the necks of the central incisors, in the form 
of a yellowish or ash-colored ulcer. Thence it spreads 
with great rapidity, and speedily attacks the inside of 
the cheek, which is, however, often swollen, and the seat 
of ulceration from the first. The ulceration extends in 
the direction of the sockets of the teeth, destroying the 
gums and periosteum, and causing necrosis of the teeth 
and bone. The affected soft parts slough, and a large 
ragged ulcer of a dirty blackish appearance is formed, 
which perforates the cheek. A profuse discharge of fetid 
purulent fluid and saliva accompanies the progress of 
the ulceration. In the early stages, and until slough- 
ing has commenced, there is little or no pain. The 
disease often ends fatally, the patient dying from ex- 
haustion. 
The treatment consists in supporting the patient’s 
strength by nourishment, together with quinine, am- 
monia, and brandy. Locally, the sloughing surface 
must be destroyed by nitric acid, or acid nitrate of mer- 
cury, whilst detergent lotions are employed to destroy 
the fetor of the discharges. ABRASION OF THE TEETH. 
155 
ABRASION OF THE TEETH—MECHANICAL 
INJURIES. 
As age advances the teeth become ground down by 
mastication. The enamel is first worn off*, next the den- 
tine suffers, and in time the pulp would be laid bare were 
it not that it almost invariably undergoes calcification 
on the surface pari passu with the slow destruction of 
the hard tissues. The amount of abrasion in every case 
depends of course on the density of the teeth, and on the 
kind of usage to which they are subjected, and to some 
extent on the bite—the manner in which the teeth artic- 
ulate. If the bite be normal, abrasion of the front teeth 
becomes rarely excessive, but if these teeth meet edge to 
edge they are worn down, sometimes even to the level of 
the gum. In rare cases, from some unexplained cause, 
the front teeth are ground down more rapidly than the 
molars, so that after a time, on closure of the mouth, the 
incisors of the opposing jaws cannot be brought into 
contact. Abrasion of the teeth of this slow kind is in 
most instances unattended with suffering, but it is occa- 
sionally accompanied by tenderness or pain due to expo- 
sure of sensitive dentine, or to approaching exposure of 
the pulp. 
The treatment of abrasion of this kind is the same as 
that prescribed in a previous section for sensitive dentine 
and irritated pulp. 
Transverse grooves or slits sometimes met with on the 
labial aspects of teeth can be traced in most cases to the 156 
MECHANICAL INJURIES. 
use of hard toothbrushes and gritty tooth powders. They 
are most frequently found on the surfaces of teeth, which 
owing to their position or prominence are most exposed 
to the friction. The exposed surface often becomes ex- 
tremely sensitive. The treatment is the same as for 
ordinary abrasion, but where the groove is of great depth 
it is often good practice to reduce the walls to a suitable 
shape, or cut retaining-points and put in a permanent 
filling. 
Fracture of the teeth may arise from injury, such as a 
blow upon the mouth, or may occur during mastication, 
as when a fragment of bone, a small gritty particle, or 
a shot in game is bitten upon. If the fracture, however 
caused, do not lay open the pulp-cavity it will often 
suffice to file down the rough surface, and carefully polish 
it. In other cases, if the fractured surface is of such a 
shape as to form a cavity, or so situated that it appears 
desirable, a filling may be inserted. If the pulp be ex- 
posed by the injury, and the fracture extend in a vertical 
direction into the root, the extraction of the tooth will 
be called for, but if the fracture involves only the crown 
an attempt may be made to save the tooth, or at least 
the root. The pulp in most cases must be at once de- 
stroyed, after which fang-filling may be performed; or 
should the tooth be an incisor or canine, an artificial 
crown may be attached to the root in the manner else- 
where described. 
Dislocation of the teeth, and more particularly front 
teeth, is not an uncommon effect of blows upon the mouth. 
Sometimes the tooth is oidy started from the socket or 
partly dislocated ; sometimes it is completely dislodged. 
Treatment.—If partly dislocated the tooth must be 
pushed back into the socket. In complete dislocation, MECHANICAL INJURIES. 
157 
if the case be seen within a few hours, the tooth may be 
replanted in the socket. The socket should be first 
washed out with syringe and warm water, to clear it of 
coagnlated blood, and the tooth having been also cleansed, 
should be replaced in the socket. If but a short time 
has elapsed after the tooth was knocked out, if great care 
be taken to support the tooth by ligatures and to guard 
it from injury, it will in favorable cases regain its attach- 
ment to the socket, and may remain firm for years. 
Upon this treatment, as well as upon partial disloca- 
tion, there may supervene an attack of acute periostitis, 
which must be treated in the manner described on an- 
other page. 158 
SALIVARY CALCULUS OR TARTAR. 
SALIVARY CALCULUS OR TARTAR. 
Saliva, among its other constituents, holds in solu- 
tion a small proportion of earthy salts, and these salts 
are very liable to be deposited upon the teeth in the form 
of a concretion—salivary calculus or tartar. There are in- 
deed few mouths, however healthy, which are absolutely 
free from deposits of tartar, whilst in some individuals 
with disordered health, and with local conditions favorable 
to the formation, it accumulates in enormous quantities. 
Diseases associated with disorders of the digestive or- 
gans and with vitiation of the secretions of the mouth 
predispose to the formation of tartar. It is deposited 
upon teeth which are not subject to the friction of mas- 
tication, and it is common to see the teeth of one side of 
the jaw covered by the concretion when the presence of 
tender teeth compels the patient to use the other side 
alone. It accumulates often in great masses around teeth 
the alveoli of which are undergoing absorption. The 
accumulation is always greatest upon the external labial 
surfaces of the upper molars and on the lingual aspects 
of the lower front teeth, owing to the proximity of these 
surfaces to the orifices of the salivary ducts. 
The density and color of tartar vary considerably. 
When rapidly deposited it is soft and friable, and light 
yellow in color; when slowly formed it is hard and 
darker in color—brown, greenish, or even quite black. SALIVARY CALCULUS OR TARTAR. 
159 
Analysis of tartar shows its composition to be as fol- 
lows : 
Earthy phosphates, ...... 79.0 
Salivary mucus, ...... 12.5 
Ptyalin, ........ 1.0 
Animal matter, ...... 7.5 
According to Tomes, salivary calculus differs some- 
what in chemical composition according to the situation 
in the mouth where it is deposited. Thus that formed 
near Stenon’s duct contains most carbonate of lime, 
whilst in that deposited on the lower incisors phosphate 
of lime preponderates. 
Microscopical examination shows that the animal 
matter entering into the formation of tartar is largely 
made up of epithelium, whilst numerous filaments of 
leptothrix are always present in the mass. 
The peculiar green discoloration occurring upon the 
teeth of children, and most frequently affecting the 
labial surfaces of the front teeth, appears to be due to 
staining of Nasmyth’s membrane and deposit of lepto- 
thrix. 
Deposition of tartar occasionally begins around the 
necks of the teeth beneath the free edge of the gum, and, 
acting as a foreign body, it keeps up chronic inflamma- 
tion of the gums and periosteum, and thus constitutes in 
numerous instances the sole cause of absorption of both 
gums and alveoli. 
Treatment.—Careful use of the toothbrush and due 
exercise of the teeth in mastication will do much to re- 
tard and prevent the deposition of tartar, but where 
these measures fail the deposit, if of great extent, must 
be removed by suitable scaling instruments. The blade 160 
SALIVARY CALCULUS OR TARTAR. 
of an instrument should be inserted beneath the edge of 
the tartar around each tooth below the gum, and levered 
outwards. By this means it is possible in many cases 
to detach the concretion in scaly masses, leaving the 
enamel smooth and intact beneath. Flat thin-bladed 
instruments are required to pass between the teeth and 
dislodge the deposit which occupies the interstices. In 
some cases, being densely hard and adhering with great 
tenacity, the tartar can be removed only by gradual 
scraping. Superficial discoloration—such as occurs in 
children—is best removed by pumice powder, with water, 
and a wooden or cane point. 
In the operation of scaling it is of the utmost impor- 
tance that every particle of tartar be removed, and that 
the enamel be left perfectly smooth, since a rough sur- 
face favors rapid redeposition. The teeth, when neces- 
sary, can be polished after the operation by pumice pow- 
der, followed by chalk or slate stone. MORBID GROWTHS CONNECTED WITH THE TEETH. 
161 
MORBID GROWTHS CONNECTED WITH THE 
TEETH. 
Odontomes.—Under this name there have been classed 
and described during late years several varieties of mal- 
formed and monstrous teeth and tumors composed of 
confused masses of dental tissues. The etiology of these 
morbid products has not yet been clearly made out. 
It appears, however, certain that they can originate only 
during the development of the teeth. At this period 
(as we have seen) the teeth are represented by soft tis- 
sues, which gradually assume the form of the future 
organs, and become calcified. During this stage of 
growth the formative elements may become the seat of 
partial or general hypertrophy, or atrophy, or other 
morbid action, followed by more or less complete calcifi- 
cation. The morbid process may be confined to the 
enamel organ, or to the dentine pulp, or may involve all 
the tissues of the tooth. The most simple form of these 
morbid growths is displayed in what have been called 
warty teeth—teeth which present nodules or excrescences 
projecting from some part of the surface. The excres- 
cences most frequently spring from the neck of the tooth 
below the gum, and occasionally they assume the ap- 
pearance of a supernumerary tooth lying in contact with 
the tooth to which they are attached. Section of these 
outgrowths shows them to be composed of dentine coated 
with enamel, and they sometimes contain a pulp-cavity 
continuous with that of the tooth. The roots of warty 162 
MORBID GROWTHS CONNECTED 
teeth are often well formed, but in some cases, especi- 
ally where numerous excrescences exist on the crown, 
the root is stunted and ill-formed. In these cases, along 
with hypertrophy of the tissues of the crown there 
appears to have occurred arrest of development of the 
root. 
On the other hand, cases sometimes occur in which the 
crown of the tooth is normal in form, whilst the root is 
abnormally large, and is composed of a confused mass 
of dentine and osseous tissue (cement), inclosing a vas- 
cular structure, doubtless the hypertrophied dentinal 
pulp. 
Another class of odontome, consists of irregular masses 
of dental tissues mingled without definite arrangement, 
and bearing no resemblance to a tooth. The mass may 
not exceed in bulk the tooth whose place it occupies, or 
it may form a tumor of considerable size. 
Still another variety of tumor having the same origin 
as those just mentioned is mainly fibrous in structure, 
containing scattered spots of calcification or imperfectly 
developed dental tissues. These tumors are usually en- 
cysted, having no attachment to the surrounding struc- 
tures except such as may have arisen from inflammatory 
adhesion. 
Odontomes do not necessarily give rise to irritation or 
disease, and the variety in which the morbid changes 
are confined to the root may, on the contrary, remain in 
position for years, serving the purpose of a tooth. 
Should they, however, constitute a deformity, become a 
source of irritation, or the centre of inflammatory action, 
they must be removed. Their extraction can be accom- 
plished in some cases by means of an ordinary tooth- 
forceps, and, should it be necessary, the bone may be WITH THE TEETH. 
163 
divided by the bone-forceps to facilitate the operation. 
The fibrous variety may be removed by similar means. 
The cyst having been laid open, the mass may be turned 
out with the handle of a strong scalpel. It may be here 
remarked that in all cases of tumor of the jaw of doubt- 
ful diagnosis exploratory incisions—within the mouth if 
possible—ought to be made to ascertain the true charac- 
ter of the disease, before a formidable operation like ex- 
cision of the jaw is proposed. An operation of this 
magnitude and severity was not infrequently performed 
for the removal of odontomes in former times before the 
real nature of these growths was recognized. 
Fig. 52. 
Fig. 52, from Mr. Salter’s work (7), shows a magni- 
fied section of an odontome in the Museum of the Col- 164 
MORBID GROWTHS CONNECTED 
lege of Surgeons, of which the natural size is displayed 
in Fig. 53. The crown of the tooth, a molar, is normal 
in size, but the root is enlarged into a mass more than 
twice the size of the tooth. The outer layer of this 
Fig. 53. 
mass is composed of cementum, within this is a layer of 
dentine, whilst the centre is composed of “ a confused 
mass of bone structure and dentine structure arranged 
around and separating an elaborate vascular network of 
the same character as that of the dentinal pulp.” 
Fig. 54, from the Transactions of the Odontological 
Society, vol. iii, exhibits an odontome (natural size) re- 
moved by Mr. Hare, of Limerick, from the upper jaw 
of a man. The growth occupied the position of the 
antrum, in which situation pain had long existed and 
where suppuration had occurred, leading to the forma- 
tion of a fistulous opening through the cheek. Its struc- 
ture is identical in its main features with that of the 
specimen in the College of Surgeons’ Museum. 
The engraving (Fig. 55) from Mr. Heath’s work, ex- 
hibits an odontome occupying the left side of the lower 
jaw. The following is a summary of the account of 
this tumor as given by Mr. Heath : The patient, a man 
aged twenty, had suffered with disease of the lowrer jaw WITH TIIE TEETH. 
165 
since he was five years old. Upon looking into the 
mouth, a round, smooth tumor, hard and unyielding, 
was seen occupying nearly the whole of the left side of 
the jaw. None of the teeth, beyond the first bicuspid, 
Fig. 55. 
were present. The portion of jaw shown in the en- 
graving was removed by operation by M. Forget, under 
whose care the case came. Examination of this portion 
showed that the jaw between the first bicuspid and the 
ramus was converted into a cavity which was occupied 
by a hard oval mass, of the size of an egg, having an 
uneven surface covered here and there with minute tu- 
bercles, which were invested by a layer of enamel pene- 
trating into the substance of the bone. Section and 
microscopical examination showed the tumor to consist 
of dentine with enamel on the surface and dipping into 
the crevices, at the bottom of which as well as in other 
parts portions of cementum were found. Between the 
tumor and osseous cyst inclosing it was a thick mem- 166 
MORBID GROWTHS CONNECTED 
brane of a fibro-cellular structure. Dr. Forget regarded 
the case as one of fusion and hypertrophy of the last 
two molars. 
At, the date of the occurrence of this tumor (1855) 
the exact nature of growths of this kind had not been 
clearly ascertained, and hence excision of a portion of 
the jaw was performed, instead of enucleation of the 
tumor, which evidently would have served equally well 
for the cure of the disease. 
The letters a and b indicate portions of the tumor 
projecting through the bone; at c, where the inclosing 
bone is cut away, the crown of an inverted molar is seen 
lying between the tumor and the jaw; d is the second 
bicuspid lying beneath the first, e. 
Cysts of the jaw may be either simple or dentigerous, 
that is, containing one or more complete or rudimen- 
tary teeth. They may occur in either jaw, and are 
usually situated towards the posterior part of the bone. 
They are more common in the young than in the aged. 
Cysts commence as a gradual painless enlargement 
of the bone, and may in time attain a great size. Some- 
times they inflame and suppurate. On manipulation in 
some cases the expanded walls of the cyst yield to pres- 
sure, and give beneath the fingers a stiff parchment-like 
crackling; but in other instances they are so hard as to 
resemble solid growths. When the tumor is punctured 
a serous fluid escapes. The course and symptoms of 
simple and dentigerous cysts are alike, and it is often 
impossible to distinguish between them except by ex- 
ploratory incisions. Dentigerous cysts, however, gener- 
ally occur during childhood, often commencing at the 
period of second dentition, and when teeth are missing 
from their position after the time they should appear, a WITH THE TEETH. 
167 
clew to the nature of the case is afforded. These cysts 
are almost always connected with permanent teeth, but 
they may contain temporary or supernumerary teeth. 
In most cases the cyst contains only a single tooth, but 
instances are recorded in which many supernumerary 
teeth have been found in one tumor. Cysts of the jaw 
may contain only one cavity, or may be multilocular— 
that is, made up of several small cells separated by osse- 
ous or fibrous walls. The etiology of simple cysts is 
not clear, but there is evidence that they may in some 
cases be caused by dental disease. It has been before 
mentioned that in ordinary alveolar abscess the bone 
often expands and incloses the accumulating pus, and 
it is easy to perceive how such a cyst might attain a 
considerable size, and might commence to secrete serous 
fluid, and still progress after the suppurative process 
was arrested. 
The origin of dentigerous cysts is more evident. Each 
developing tooth at one stage of its progress is inclosed 
in a complete bony cyst, and it is not difficult to under- 
stand that if the eruption of the tooth be prevented, and 
from any cause fluid be slowly poured out within the 
cavity, the bony walls gradually expand and a tumor is 
formed. Mr. Tomes has pointed out that when the de- 
veloping crown of a tooth is completed a small quantity 
of fluid is to be found between the surface of the enamel 
and the investing soft tissue, and he believes that it is 
the gradual secretion and collection of this fluid in ab- 
normal quantity which causes expansion of the bone. 
The treatment of cysts of the jaw consists in laying 
them open freely, in removing teeth when these are con- 
tained within, and plugging the cavity with lint, so as 
to set up suppuration and destroy the secreting surface. 168 
MORBID GROWTHS CONNECTED 
The incisions ought to be made within the mouth when 
possible, so as to avoid subsequent deformity. 
The following case with the illustration taken from 
Mr. Heath’s work (9), will serve to exemplify the com- 
mon course and history of dentigerous cysts, and also to 
make evident the importance of the rule already men- 
tioned, that in cases of doubtful diagnosis the nature of 
tumors of the jaws should be ascertained by incisions 
and explorations before further operative procedures are 
u ndertaken. 
In this case the cyst occurred in the lower jaw, and 
gave rise to a general expansion of the bone rather than 
a distinct tumor, and the disease was mistaken for a 
solid tumor of the lower jaw. The patient was a girl 
aged thirteen. The tumor was large and resistant, and 
occupied the left side of the lower jaw, and had been 
growing six months. No opening could be detected in 
the tumor, though there was a constant offensive discharge 
from the surface. The surgeon in charge of the case 
removed the left half of the jaw, from the symphysis to 
the articulation. “The tumor (Fig. 56) gave exit to a 
quantity of fetid pus on being opened, and it proved to 
be a bony cyst formed by the expansion of the two plates 
of the jaw. The cavity was lined with a thick vascular 
membrane, and at the bottom the canine tooth was seen 
projecting from the wall. The case was evidently, there- 
fore, one of dentigerous cyst due to the non-development 
of the canine tooth, the contents of which had from some 
cause become purulent.” 
jEpulis is a fibro-plastic or fibrous tumor attached to 
and springing from the maxillary periosteum. It gen- 
erally commences between two teeth, which become grad- 
ually pushed apart and loosened ; but it sometimes springs WITH THE TEETH. 
169 
from a part of the bone distant from the teeth. It grows 
slowly and painlessly, forming a firm, rounded, often 
lobulated mass, covered with mucous membrane. A case 
Fig. 56. 
of epulis in its simplest form is shown in Fig. 57, from 
Mr. Heath’s work. It sometimes reaches an enormous 
Fig. 57. 
size, encroaches upon the cavities of the nose and eye, 
and produces great deformity. In the latter stages it 
may ulcerate, and frequent haemorrhages taking place, 
the growth closely simulates malignant disease. Epulis 
is believed to be due in some cases to the irritation of 
decayed teeth or to injuries of the alveoli, such as some- 
times occur in extracting teeth, but in most instances the 
tumor cannot be clearly traced to these causes- The 
treatment consists in cutting out the tumor, together 
with the portion of bone from which it springs, and from 170 
MORBID GROWTHS CONNECTED WITH TOE TEETH. 
which, if allowed to remain, it would probably again 
grow\ 
Osseous tumors, or exostoses of the jaws, are occasion- 
ally met with. The most common situation of exos- 
toses is on the inside of the lower jaw, where they form 
hard, round, smooth protuberances. They sometimes 
spring from the angle, and they may also grow from the 
neighborhood of the antrum and other parts of the upper 
jaw. Osseous tumors are slow in growth and painless, 
and are not commonly developed to such an extent as to 
cause inconvenience. Their cause is obscure, but in 
some few' cases they would appear to be associated with 
persistent irritation spreading from the teeth. There is 
evidence that these tumors are sometimes due to ossifica- 
tion of growths originally cartilaginous in structure. 
The treatment is excision of the tumor, wdiich may 
be called for if the growth becomes a source of deformity 
or inconvenience. DISEASES OF THE ANTRUM. 
171 
DISEASES OE TIIE ANTItUM. 
Inflammation of the antrum is by no means common. 
It arises sometimes from injury, or from the presence 
of a foreign body, such as a tooth-fang which has been 
pushed into the cavity in an attempted extraction, but 
it is more commonly caused by the irritation of decayed 
teeth—molars and bicuspids—the roots of which either 
enter or approach closely the floor of the cavity. The 
symptoms are acute throbbing pain, with great swelling 
of the cheek, accompanied by more or less feverishness. 
If the disease run on, the pain becomes more severe, 
extending to the nose and frontal sinus, and an erysi- 
pelatous blush appears on the skin. The gums are red, 
spongy, and swollen, and sometimes there is a discharge 
of pus from the nostril of the affected side. The for- 
mation of pus is attended by rigors. If the matter find 
vent, the pain and other symptoms may subside; but if 
it do not find an exit the symptoms persist, and the walls 
of the antrum become distended, and encroaching upon 
the neighboring cavities occasion pressure upon the con- 
tents of the orbit, with protrusion of the eyeball, closure 
of the lachrymal duct, and blocking up of the nostril. 
Inflammation of the antrum, except in its severest 
symptoms, resembles some cases of dental periostitis, 
and it is indeed often merely an extension of that dis- 
ease to the contiguous lining membrane of the cavity. 
Treatment.—Foreign bodies are best removed by open- 
ing the cavity freely and syringing with warm water. 
The exciting cause must be removed, whether it be a 172 
DISEASES OF THE ANTRUM. 
root lodged within, or a decayed tooth in the neighbor- 
hood of the cavity. The extraction of the tooth will 
often be followed by subsidence of the symptoms, the 
matter, if suppuration have occurred, escaping through 
the alveolus. If the antrum remain distended, the 
matter not freely escaping, the opening may be enlarged 
by pushing a trocar through the bone in the apex of 
the alveolus, or an opening may be made through the 
external wall of the cavity. This operation must be 
followed by warm fomentations and the injection of 
warm water into the cavity. If the discharge continue 
after subsidence of the acute symptoms, lotions of nitrate 
of silver or chloride of zinc may be thrown into the 
cavity. 
Dropsy.—When the natural outlet of the antrum be- 
comes from any cause obstructed, an accumulation of 
fluid may take place, causing gradual distension of the 
walls of the cavity, and giving rise to considerable de- 
formity. The disease is usually slow in progress, and 
unattended with pain. A puncture with an exploring 
needle, or an incision, will establish the diagnosis where 
doubt exists. 
Treatment.—A free vent for the fluid having been 
afforded by one of the methods already mentioned, the 
cavity must be frequently injected with a lotion com- 
posed of chloride of zinc, 3 grains to the ounce of water; 
nitrate of silver, 2 grains to the ounce; or tincture of 
iodine, 1 drachm to the ounce. 
The antrum is sometimes the seat of dentigerous 
cystic, fibrous, and other tumors, which call for no spe- 
cial observations here, after the general remarks upon 
morbid growths of the maxillse which have been made 
in a previous section. PIVOTING TEETH. 
173 
PIVOTING TEETH. 
After the partial or complete destruction of the 
crown of a tooth by injury or disease, it is possible in 
many cases to attach permanently an artificial crown to 
the root by means of a peg or pivot fixed in the pulp- 
canal—the pulp having been, of course, previously re- 
moved. The incisors and canines are, as a rule, alone suit- 
able for this operation, but it may occasionally be prac- 
ticed successfully upon the bicuspids. The root should 
be free from disease. If periostitis exist, it must be 
treated, and even in cases where no symptoms are 
apparent, it is good practice to dress the canal with 
carbolic acid, and to plug it for a few days before per- 
manently closing it by the pivot. An attack of acute 
periostitis will often follow the operation if this precau- 
tion be not observed. 
In preparing the tooth the remaining portion of the 
crown must be excised. This is accomplished by means 
of a small saw, cutting forceps, and suitable files. The 
edge of the root must be reduced to the level of the 
gum, and its surface should be concave. The depth of 
the canal having been ascertained by probing, it must 
be reduced to an equal calibre throughout, to near the 
apex. The most suitable calibre for the canal is one 
that will admit a wire of ordinary dental pin size. It 
often happens, however, that the canal has been already 
enlarged to a greater size by decay, and in such cases 
the softened tissue must be cut away, and the walls of 174 
PIVOTING TEETH. 
the cavity rendered smooth. The canal will remain in 
these cases tapering in form. 
A model of the part should then be taken by the 
following method. A wooden pin is cut to fit the canal 
and long enough to project slightly beyond the orifice 
when inserted. With the peg in place an impression of 
the root and adjacent teeth is taken in the usual way 
(plaster of Paris is preferable for the purpose), and in 
this the pin comes away. The cast which is prepared 
from the impression shows, on withdrawal of the peg, 
the size and diameter of the canal, and an artificial 
crown can be fitted to the root and attached to a pin in 
the patient’s absence. In the case of bicuspids, it is 
sometimes a good plan to fill one division of the bifid 
pulp-cavity with gold and attach the new crown by a 
single pin. Sometimes a split pin or two pins may be 
used. 
The material of which the pivot is made will depend 
on the size of the canal. If it be small, metal—gold 
or platinum—answers best, if large, a piece of com- 
pressed hickory is more suitable, or perhaps better, a 
metal pin may be screwed into the wood which can be 
filed down to the desired size. 
If wire alone, the pin should fit the canal accurately, 
but not tightly. It should be roughened by the file 
and covered with a thin even layer of floss silk. The 
canal having been thoroughly dried, the silk should be 
saturated with solution of gum copal in ether or mastic 
in spirit, and the pivot tooth may be then pushed firmly 
into place. 
If a wooden or a wood-coated pin be used, the pro- 
cedure is the same, save that no cement or silk is used. 
The pin should fit the canal so tightly as to require PIVOTING TEETH. 
175 
a moderate amount of force to drive it home. When 
there the moisture of the mouth causes the wood to ex- 
pand, and binds it with great firmness in position. 
Pivot teeth should be so arranged as to escape contact 
with the teeth of the opposing jaw during mastication. 
Where the bite is close, a flat tooth mounted on a plate 
covering the surface of the root is most suitable; where 
the bite is free, a tube tooth may be employed. 176 
NEURALGIA AND DISEASES 
NEURALGIA AND DISEASES OF THE NERVOUS 
SYSTEM. 
Facial Neuralgia.—The fact is well known that irri- 
tation of a nerve commonly manifests itself by pain at 
some point distant from, instead of at the seat of injury 
or disease. This phenomenon cannot be accounted for, 
yet nevertheless presents itself daily to clinical observa- 
tion, and may be exemplified by the case of an inflamed 
liver giving rise to pain about the right shoulder, a dis- 
eased hip-joint producing pain at the knee, and an irri- 
tated tooth-pulp exciting pain at remote parts of the 
head and face. Pain of this reflected or sympathetic 
character is called neuralgia. Neuralgia, or nerve pain 
in a part may also occur without the existence of a le- 
sion of any kind. It may be caused by debility, by 
cold, or by malaria, or it may accompany pregnancy. 
It may be due to disease of the great nerve centres, the 
brain or spinal cord. Finally lesions of nerves not nec- 
essarily painful may give rise to neuralgia in consequence 
of disorder of the general health—thus cases are met 
with frequently in which the diseased nerves of carious 
teeth, previously the seat of little or no pain, give rise 
to severe neuralgia when the patient has become lowered 
by disease or by exhaustion. 
Neuralgic pain is usually of a plunging, lancinating, 
or burning character, following the course of the nerve 
branches. It occurs in paroxysms, which are often regu- 
larly periodic, the pain commencing at a particular hour OF THE NERVOUS SYSTEM. 
177 
of the day, lasting a certain period and then disappear- 
ing completely for a time. 
The pathology of neuralgia has not yet been clearly 
made out, and the causation of the disease is often ex- 
tremely obscure. When we remember the physiological 
fact mentioned at the opening of this section, and con- 
sider that the fifth nerve which supplies the teeth is 
distributed also to nearly the whole of the head and 
face, it is at least not difficult to understand that diseases 
of the teeth may act as frequent exciting causes of facial 
neuralgia. And since, as is pretty generally acknowl- 
edged, there are no symptoms which serve to distinguish 
neuralgia due to constitutional causes from that set up 
entirely by local disease, it is impossible to overrate the 
importance of searching for lesions of the nerve in all 
cases in which doubt exists. 
Any of the pathological conditions of the teeth which 
have been described in preceding sections are capable of 
giving rise to neuralgic pain, but among them all chronic 
inflammation of the pulp is the most frequent cause. In 
every case of facial neuralgia a careful examination of 
the teeth should be made. It is not sufficient to take 
the patient’s assurance that his teeth are not decayed, or 
that he does not suffer from toothache. Patients are 
often unconscious of the presence of disease, and teeth 
which do not ache are frequently the excitants of neu- 
ralgic pain. Neither is it sufficient to cast a glance into 
the mouth for carious cavities; each tooth should be 
separately explored with the aid of a probe and mouth 
mirror. Cavities hidden in the interstices or below the 
gum must be sought for, and the signs of necrosis, exos- 
tosis, inflammation, and thickening of the dental peri- 
osteum must not be overlooked. Decayed and broken 178 
NEURALGIA AND DISEASES 
down wisdom teeth (common causes of neuralgia and 
especially of pain in the ear) are often, owing to their 
position, difficult to discover. They are in many in- 
stances placed at the extremity of the alveolar ridge, 
and in the upper jaw are invisible except with a mouth 
mirror; whilst in the lower jaw they are commonly 
hidden by folds of the cheek or by overhanging gum. 
Decaying in many instances before they are completely 
erupted, these teeth after the destruction of their crowns 
by caries are occasionally quite invisible, and their pres- 
ence in the sockets can be ascertained only by passing a 
probe through the small fistulous tract in the gum which 
covers, them. A condition similar to this may also exist 
in the case of any other tooth, and buried roots, espe- 
cially when the seat of exostosis, are the excitants of 
neuralgia in numerous instances. 
Although in cases of obstinate neuralgia there can be 
no doubt of the propriety of removing such diseased 
teeth as cannot be brought by treatment into a healthy 
state, it must be borne in mind that all decayed teeth 
need not be condemned to extraction. Neuralgia may 
be often guarded against by filling decayed cavities and 
protecting the sensitive structures of the teeth from irri- 
tation. In these operations care should be taken to 
avoid increasing the susceptibility of the teeth to changes 
of temperature. For this purpose the oxychloride of 
zinc cements answer admirably, and in cases in which 
the pulp is exposed or protected only by a thin layer of 
dentine a layer of this material should be applied to the 
bottom of the cavity in the manner described in a former 
page. 
There are other surgical diseases besides those of the 
teeth which involve branches of the fifth nerve, and OF THE NERVOUS SYSTEM. 
179 
which may therefore originate neuralgia, and in every 
case of doubtful diagnosis it is necessary to examine as 
far as possible the whole course of the nerve. The 
nerve, or its branches, may be compressed by tumors or 
aneurisms, or be affected by the inflammation, exostosis, 
or necrosis of the bony canals through which they pass. 
Inflammation of the mucous membrane of the antrum 
may include the superior dental nerves. One case is re- 
ported by Niemeyer in which a foreign body was im- 
bedded in a branch of the nerve. Syphilitic nodes of 
the head are accompanied by pain, with nightly exacer- 
bations of a character similar to neuralgia. 
The discovery and removal of the exciting cause (as 
above remarked) must be the first care in dealing with 
neuralgia, but the treatment of the predisposing causes 
must not be overlooked. It has been already pointed 
out that the state of the general health often determines 
whether we have to attack slight local pain or severe 
neuralgia. Conversely, with improvement of the gen- 
eral health the pain frequently disappears, although the 
exciting cause may remain. If the disease has been de- 
veloped by any form of debility, or by malaria, full 
doses of quinine give almost always excellent results, 
and where this drug fails Fowler’s solution of arsenic is 
said to prove effectual. Ansemia, rheumatism, and syph- 
ilis will each receive their appropriate treatment. 
In those cases (by no means unknown) in which the 
cause of the neuralgia, whether local, central, or consti- 
tutional, cannot be discovered, an attempt alone can be 
made to destroy the excitability of the painful nerves. 
For this purpose electricity in various forms is employed. 
Cold, which diminishes for a time the excitability of 
the nerves, may be applied to the skin by means of ice 180 
NEURALGIA AND DISEASES 
or evaporating lotions; and ointments of aconite or vera- 
tria, or lotions of belladonna and chloroform, produce 
similar effects. 
The division of the nerve at some point between the 
seat of pain and the brain, or (as section would be 
speedily followed by reunion) the cutting out of a por- 
tion of the nerve, is a procedure which theoretically 
seems likely to prove efficacious by preventing commu- 
nication between the affected nerve and the brain. This 
operation is sometimes attempted, especially when the 
pain appears to have its seat in the ramifications of the 
mental nerve. It is, however, seldom followed by good 
results, and for two reasons, first, because it is difficult 
to pick out the nerve which is really the seat of pain, 
and secondly, because it is difficult to get at and divide 
a part of the nerve between the brain and seat of the 
disease which excites the neuralgia. This point is doubt- 
less often so deeply placed that, even if discoverable, to 
reach it would be impossible. 
Nervous Disorders.—Irritation of a peripheral nerve, 
besides exciting distant pain, may give rise to reflex irri- 
tation, or to functional disturbance of the brain or other 
great nerve-centres, resulting in various phases of mor- 
bid action; and although dental diseases no doubt rarely 
excite nervous affections of a nature more grave than 
neuralgia, yet there is abundant evidence that neuroses 
of the severer kind do occasionally result from irritation 
of the dental nerves. Reflex irritation may be trans- 
mitted both to motor and sympathetic fibres. Severe 
neuralgia of the face, for example, is sometimes accom- 
panied by convulsion of the facial muscles, together with 
profuse flow of tears, saliva, and mucus, and perspiration 
on the skin at the seat of pain. OF THE NERVOUS SYSTEM. 
181 
Esquirol and Ashburner relate cases in which mania 
and delusions accompanied difficult eruption of wisdom 
teeth, and were cured by incisions into the gum over 
these teeth. Mr. Tomes reports two cases of epilepsy 
consequent upon diseased teeth, the seat of exostosis, 
which were cured by the extraction of the teeth. Many 
cases of amaurosis due to diseased teeth are recorded, 
and these have been accounted for on the supposition 
that irritation of dental branches of the fifth nerve may 
be transmitted through the ciliary system to the retina, 
producing hyperaemia and inflammation. 
These affections call only for the same remark which 
was made in regard to neuralgia—viz., that in every 
ease of doubtful diagnosis a careful examination of the 
teeth should be made, with a view to the removal of 
every cause of nerve irritation due to dental disease. 182 
EXTRACTION OF TEETH. 
EXTRACTION OF TEETH. 
During the operation of extraction the dentist stands 
on the right side of the patient, who is placed low when 
a tooth of the under jaw is to be drawn, and raised when 
an upper tooth is to be removed. The instrument is held 
in the right hand, whilst the left hand, fingers, and arm 
are employed according to circumstances, in steadying 
the head, grasping and fixing the lower jaw, drawing 
back the commissure of the lips, and assisting to direct 
the instrument. 
The instruments employed almost exclusively are for- 
ceps. These are made with blades of various patterns 
adapted to fit the different classes of teeth, and to grasp 
without crushing them. Their edges are sharp that they 
may be readily insinuated between the free edge of the 
gum and the neck of the tooth, and forced towards the 
socket. 
The operation consists of two distinct actions, firstly, 
the seizure of the tooth, and secondly, the loosening of 
its connections, and its withdrawal from the socket. 
The seizure of the teeth of each class is effected in 
the same manner. The forceps is lightly applied to the 
neck, and then forcibly pushed along the root until it 
becomes stopped at or within the edge of the alveolus. 
The grasp is then tightened, but not to such an extent 
as to crush the tooth, and the next step of the operation 
is proceeded with. As soon as the tooth is felt to yield 
the forceps may be pressed still deeper, so as to embrace EXTRACTION OF TEETH. 
183 
the tooth within the socket; to obtain more power over 
it, and to avoid breaking off the crown. It is not nec- 
essary to separate the gum from the neck of the tooth 
by means of the lancet before applying the forceps—a 
proceeding recommended by some authors. The con- 
nection of these parts is slight, and they are readily di- 
Fig. 58. 
vided by the cutting edges of the forceps. The mode of 
holding the forceps and applying them to the teeth is 
shown in Figs. 58 and 59 from Druitt. 
Fig. 59. 
In the second stage of the operation the method of 
applying the force is modified with each class of tooth, 184 
EXTRACTION OF TEETH. 
the roots varying in number, position, form, and size, 
and the investing bone offering less resistance in some 
directions than in others. This stage of the operation, 
although distinct from the first, is really continuous with 
it, the whole operation being effected with one even move- 
ment. It may be performed rapidly, by a practiced 
hand, but it must be remembered that an attempt to 
wrench a tooth from its socket by force, either wrongly 
directed or indiscriminately applied, will, in most cases, 
result in fracture of the tooth, and may also inflict severe 
injury Tipon the jaw and surrounding parts. 
The forceps for the extraction of the upper incisors is 
shown in Fig. 60. These teeth have conical roots, and 
their extraction is accomplished by rotating them to the 
slight degree necessary to loosen them, and pulling them 
downwards and a little forwards. The upper canines 
require a stronger but similar instrument, and they are 
removed by the same method. 
The forceps for the upper bicuspids is shown in Fig. 
61. It resembles that used for the incisors and canines, 
but has narrower blades, and handles bent to clear the 
lower teeth. The upper bicuspids having roots flattened 
laterally cannot be rotated. They are loosened by forc- 
ing them steadily outwards. They are then moved to 
and fro from within outwards, and pulled downwards. 
Two forceps are required for the upper molars, one 
adapted to the teeth of the right side, one to those of the 
left (Figs. 62, 63). The outer blade is formed in two 
curves to contain the external roots, the inner blade is 
designed to grasp the internal root. The force in ex- 
tracting these teeth is first applied in the outward direc- 
tion, for the reason that the external alveolar plate offers 
less resistance than the inner, while the direction of the EXTRACTION OF TEETH. 
185 
palatine root is such that it is likely to be snapped in an 
attempt to move the tooth inwards. As soon as the 
Fig. 60. 
Fig. 61. 
Fig. 62. 
Fig. 63. 
tooth yields it is moved from side to side, and pulled 
downwards. 
The upper wisdom-teeth are extracted in the same 
way as the upper molars. The removal of these teeth, 
however, rarely requires great force, their roots being 
often connate, and the bone around being cancellated 
and soft. Ordinary molar forceps may be used for these 
teeth, but they are more conveniently reached by an 
instrument specially curved to pass to their position at 
the extremity of the jaw. 186 
EXTRACTION OF TEETH. 
The lower incisor roots are much flattened laterally. 
They are loosened by bending them forwards, and com- 
pletely detached by a to-and-fro movement from within 
outwards, combined with an upward pull. The forceps 
for these teeth is depicted in Fig. 64. 
The lower canines, having somewhat conical roots, are 
loosened by a rotatory movement, and drawn by an up- 
Fig. 64. 
Fig. 65. 
ward pull. The forceps closely resemble those used for 
the incisors. 
The lower bicuspids, having roots flattened laterally, 
are extracted by forcing them outwards until they are 
felt to give, then moving them from side to side, and at EXTRACTION OF TEETH. 
187 
the same time drawing them upwards; the forceps is 
shown in Fig. 65. 
In applying the forceps to the lower bicuspids and 
molars, the point of the thumb of the left hand may be 
placed over the joint of the instrument whilst the fingers 
press the jaw upwards from beneath. In this way the 
forceps is guided in the desired direction, enough power 
is obtained to drive it home, and the instrument is 
prevented from coming into violent contact with the 
upper jaw at the moment the tooth leaves the socket, 
whilst at the same time the danger of dislocating the jaw 
is guarded against. This accident has occurred in some 
cases. 
The lowrer molars are loosened by force directed first 
in the outward direction. They are then moved to and 
fro from within outwards, and pulled upwards. Should 
the tooth offer great resistance, a backward and forward 
movement may be adopted, the better to free the roots, 
which are curved more or less in the backward direc- 
tion. The forceps for these teeth is shown in Fig. 66. 
The lower wisdom-teeth are extracted by the same 
method as the first and second lower molars, than which, 
however, they require usually less force. A forceps is 
provided with the blades bent at such an angle to the 
shafts as permits their ready application to these teeth. 
Extraction of the roots of the incisors, canines, and 
bicuspids, the single-fanged teeth of both the upper and 
lower jaws, is carried out on the principles already de- 
scribed—that is to say, the forceps is steadily pushed 
along the root, and a sufficient grip upon a sound portion 
obtained before an attempt is made to complete the oper- 
ation. As the root yields, the thrusting of the instru- 
ment deeper may be continued, and by giving the forceps 188 
EXTRACTION OF TEETH. 
at this time a rotary movement, the blades are made to 
penetrate more readily. When the root is extensively 
decayed or broken within the alveolus, forceps are used 
with smaller and more tender blades (Fig. 67), that they 
may be more easily passed into the socket and insinu- 
ated between the root and the surrounding bone. 
Fig. 66. 
Fig. 67. 
Fig. 68. 
Fig. 68 represents a forceps designed for the extraction 
of roots of upper front teeth, which are so extensively 
excavated by caries as to be readily crushed by the 
ordinary instrument. They are provided with a screw, 
which is inserted into the cavity before the blades, be- 
tween which the screw slides, are forced into the alve- 
olus. EXTRACTION OF TEETII. 
189 
In extracting the roots of molars the procedure is 
guided by the extent of the decay. If the roots are still 
firmly united together they may be removed by the 
ordinary forceps, used in the manner already described. 
Where it appears difficult to obtain a sufficiently deep 
hold with the ordinary instrument, forceps specially de- 
Fig. 69. 
Fig. 70. 
signed may be employed. These special instruments 
are provided with long and sharp-pointed blades, which 
are either thrust into the alveolus or forced through the 
alveolar plate. Fig. 69 shows an instrument of this kind 190 
EXTRACTION OF TEETH. 
applied to the roots of an upper molar. Fig. 70 shows 
that used for the same purpose in the lower jaw. 
It may be here remarked that in extracting the roots 
of teeth of any class, if they cannot he seized by other 
means, there need be no hesitation in including the edge 
of the alveolus in the forceps, or in breaking through 
the thin alveolar walls. If this is done with due care 
the operation may be rapidly performed, whilst no per- 
manent damage is inflicted, seeing that the small portion 
of bone forming the thin edge of the alveolus which is 
injured or broken away would be under ordinary cir- 
cumstances soon removed by absorption after the extrac- 
tion of the root. 
In those cases in which the roots of molars are de- 
tached from one another by decay, or so slightly united 
as to preclude the possibility of their removal in a mass, 
they must be extracted separately. Root-forceps (simi- 
lar to those in Fig. 67) are used. They are thrust as 
deeply as possible into the socket. The roots of the 
upper teeth being conical, may be detached by a rotary 
movement; those of the lower, owing to their flattened 
shape, require a rocking movement from within out- 
wards. 
Roots which are so deeply buried in the sockets as to 
be with difficulty readied with the forceps may be ex- 
tracted with the elevator. This instrument consists of 
a stout handle carrying a steel shaft, which terminates 
in a narrow blade. The blade is thin, and concave on 
its inner surface, and has either a spear-shaped or a 
sharp horizontal edge. Various patterns are used by 
different operators, but the right and left instruments 
depicted in Figs. 71 and 72 suffice for all ordinary pur- 
poses. In applying the elevator the blade is thrust as EXTRACTION OF TEETH. 
191 
far as possible into the socket along the root. The 
handle is then turned, so that the point of the blade im- 
pinges upon the root, and by a levering movement prizes 
it from the socket. In this procedure the fulcrum is 
necessarily formed, altogether or to a great extent, by 
the alveolar wall or by the adjoining tooth, and as the 
force exercised by the elevator is great, unless care be 
Fig. 71. 
Fig. 72. 
taken the former may be extensively fractured or the 
latter dislodged. The elevator should be, therefore, 
firmly grasped, the fingers reaching close to the blade. 
The thumb and fingers of the left hand may in some 
instances serve partly or entirely as a fulcrum, and in 
every case they should be employed in guiding and sup- 
porting the instrument and controlling the force. 192 
EXTRACTION OF TEETH. 
The elevator should not be, as a rule, inserted between 
the external alveolar wall and the root, this part of the 
bone being too thin to sustain much pressure. It should 
never be used for the extraction of upper wisdom teeth. 
The bone around these teeth is so weak as to be readily 
fractured by force in the direction in which it must be 
exerted by the elevator. 
The foregoing description of the operation of extrac- 
tion has been based on the supposition that the teeth to 
be removed were of normal character. It must be now 
pointed out that occasionally difficulties arise, in conse- 
quence of irregular formation of the roots. Thus they 
may be so curved or, in the case of molars, so spread as 
to require more than ordinary force to remove them; 
indeed, the roots are sometimes so placed in the jaw 
that it is impossible to remove the tooth without snap- 
ping one or more of the roots or breaking away a por- 
tion of the alveolus. The portion of the alveolus most 
liable to be thus fractured is the septum between the 
roots of the molars, and especially the lower molars. 
The roots of these teeth, wide apart at the neck, some- 
times converge towards.their apices, and cannot be sepa- 
rated from the plate of bone which they inclose. 
If unusual resistance be met with, an abnormal ar- 
rangement of the roots may be suspected. Such being 
the case, the operator must proceed cautiously and de- 
liberately to exercise a sufficient amount of force to 
overcome the obstruction; and as it is impossible to 
ascertain the precise form of the irregularity, it will be 
found safer in applying this extra force to follow the 
directions given for the extraction of a normal tooth. 
In spite of due care it will happen sometimes that a 
portion of a root is left in the socket. The broken piece EXTRACTION OP TEETH. 
193 
is commonly loosened, and may be picked ont with the 
root-forceps or elevator; but should the fragment, con- 
sisting only of the apex of the fang, remain fixed in its 
original position it may be in some cases better to leave 
it rather than to inflict the injury upon the bone which 
its withdrawal would entail. It rarely gives rise to irri- 
tation, but in due course the changes which take place 
in the surrounding bone lead to its loosening or extru- 
sion. The separation of a small portion of the alveolar 
process during extraction is a matter of little or no im- 
portance. 
Figs. 73, 74, and 75 show teeth with roots in such 
conditions as to give rise to unusual difficulties in their 
Fla. 73. 
Fig. 74. 
Fig. 75. 
extraction. The canine (Fig. 73) obviously could not 
be removed without either leaving the curved extremity 
behind in the socket or extensively breaking away the 
investing bone. The lower molar (Fig. 74) exemplifies 
the “dovetailing” of the roots of these teeth with the 
bone, which occasionally occurs. The presence of exos- 
tosis at the apices of the fangs of this specimen would 
render its removal entire hardly possible. Fig. 75 ex- 
hibits upper molars with similar irregularity of the 
roots, and Fig. 76 exhibits an upper molar of great 194 
EXTRACTION OF TEETH. 
size with unusually divergent roots. The difficulties 
which might arise in extracting a tooth organically 
Fig. 76. 
Fig. 77. 
united to its neighbor, as illustrated in Fig. 77, and in 
Fig. 17 on a previous page, are obvious. 
It sometimes happens that a molar with abnormal 
roots of these kinds may be loosened so as to move 
readily from side to side, but yet cannot be drawn by 
any amount of force which can be safely applied. In 
such cases it has been recommended that the fangs of the 
teeth should be separated by cutting-forceps, and removed 
one by one. Forceps with blades fitted to be thrust into 
the alveolus are made for this purpose. It is often good 
practice to adopt a similar procedure in the removal of 
molars in which caries has advanced so far as completely 
to destroy the crown and to render the union of the roots 
with each other at the neck of the tooth but slight. If 
an attempt in these cases be made to extract the mass 
at once, the decayed tissues often give way, and ren- 
der it difficult afterwards to grasp the broken fangs; 
but if the roots be first separated from each other, they 
may be easily removed one by one by the stump-forceps 
or elevator. 
The Casualties of Tooth Extraction.—On this subject EXTRACTION OF TEETH. 
195 
Mr. Salter writes : “ In estimating the casualties which 
may arise in extracting teeth it is well to consider the 
essential nature of the operations themselves. They are 
different from all or nearly all other surgical proceedings. 
In removing a tooth the operator wrenches or tears an 
organ from its living connection with the rest of the 
body, frequently by the exercise of great force. And 
this force is often applied with little intelligence—the 
operator being necessarily ignorant, from the hidden and 
varying nature of the parts, of many of the conditions 
with which he has to deal. I would not for a moment 
imply that the extraction of teeth does not require the 
application of dexterity with anatomical knowledge, but 
where great force has to be applied, that per se is adverse 
to mechanical delicacy. The force which the operator 
has to expend in removing a tooth is often very great 
indeed; occasionally one has to exercise the whole mus- 
cular power of the hand and forearm. It would be 
difficult to estimate, in measure of so many pounds, what 
is the force thus sometimes employed, but it must be 
immense; and with the exception of the reduction of 
dislocations of the larger joints, is probably in excess 
of that which is used in all other operations of surgery.” 
From these remarks it may be inferred that accidents 
in the operation of tooth extraction may occasionally 
happen, even in the hands of the most experienced, and 
therefore they must occur much more frequently in those 
of the unskilful. 
The following list, compiled by Mr. Salter, probably 
includes every variety of casualty of this kind on record. 
Several of them have been already sufficiently referred 
to; others it will suffice merely to enumerate; the re- 
mainder will bear some further observations. 1. Break- 196 
EXTRACTION OF TEETH. 
ing of tooth. 2. Breaking of jaw. 3. Taking out 
wrong teeth. 4. Taking out two teetli instead of one. 
5. Removing capsule of growing permanent tooth in ex- 
tracting its temporary predecessor. 6. Tearing gum. 7. 
Wounds produced by slipping of elevator. 8. Extracted 
tooth falling into air-passages. 9. Extracted tooth fall- 
ing into pharynx and being swallowed. 10. Crushing 
the inferior maxillary nerve. 11. Dislocating the lower 
jaw. 12. Breaking one tooth in extracting another. 13. 
Cutting lip in removing a jagged extracted tooth. 14. 
Forcing tooth or tooth-fang into the antrum. 15. Forc- 
ing tooth-fang into an abscess excavation in maxilla. 
Fractures involving the alveolus only to a slight extent 
occasionally occur, and are rarely followed by an untoward 
result. Fractures extending through the ramus of the 
lower jaw, or completely severing a considerable portion 
of the upper maxilla, have in rare instances been caused 
by the extraction of a tooth. This accident might hap- 
pen either in consequence of inherent weakness of the 
bone or the existence of some abnormal form of the fangs 
of the tooth, such as already exemplified. This accident, 
like most of those in the above list, could be guarded 
against only by the application of the principles already 
inculcated in the general observations upon the extraction 
of teeth. The treatment of fractured jaw due to this 
cause would not differ from that arising from other forms 
of violence, and requires therefore no description here. 
The possibility of the occurrence of the third accident 
has been casually alluded to in a previous section, where 
it was pointed out that the pain arising from an inflamed 
pulp sometimes becomes neuralgic in character and mani- 
fests itself in a neighboring tooth, whilst the seat of 
disease remains free. Patients thus frequently present EXTRACTION OF TEETH. 
197 
themselves and request that a certain tooth be extracted 
which on examination is found to be sound, or at least 
not the source of pain. In all cases in which doubt 
exists a careful inspection must be made to discover the 
offending tooth before an operation is attempted. The 
extraction of a wrong tooth in consequence of the slip- 
ping of the instrument is an inexcusable accident. Should 
the instrument become displaced, the operation should 
be stopped until it is readjusted. 
The accidental extraction of two teeth instead of one 
may occur when force, as in using the elevator, is im- 
properly exerted on an adjoining tooth when the latter 
is already loose, or when the teeth are organically united. 
Some few cases are recorded in which in extracting a 
temporary molar, the rudimentary permanent bicuspid, 
which lies within the diverging fangs of that tooth, has 
been also brought away. In such instances adhesion 
between the two teeth had probably existed as a result 
of previous inflammatory action. 
Laceration of the gum, common with the obsolete key, 
ought not to occur with the forceps. It sometimes hap- 
pens, however, that a tooth or root has become attached 
to the gum by strong fibrous adhesions, which are dis- 
covered when, on loosening its bony connections, it still 
remains attached to the soft tissues of the jaw. In these 
cases, if the tooth were torn away, an extenseve laceration 
of the gums might ensue. This is to be prevented by 
dividing the adhesions by a scalpel. 
Several cases are reported in which, after the extrac- 
tion of a lower molar, sensation was lost at that part of 
the face supplied by the inferior dental nerve, which had 
evidently received some injury in the operation. This 198 
EXTRACTION OF TEETH. 
accident would arise from abnormal proximity of the 
nerve to the fang of the tooth. In most of these cases 
slow recovery took place. 
The pain following the extraction of the tooth is rarely 
severe, unless periostitis exist. It is best treated by 
warm fomentations within the mouth. Mr. Tomes 
states that relief is often afforded by plugging the al- 
veolus lightly with wool saturated with the following 
solution, after washing away the blood-clots; Acidi 
carbolici glacialis, liq. potass®, aa 5j, aquae 5j- 
The haemorrhage which follows the extraction of teeth in 
most cases is slight, and continues but for a few minutes. 
Occasionally, however, oozing goes on for a considerable 
time, whilst in rarer instances the flow is so severe as to 
require active measures for its arrest. The bleeding 
may be due to a haemorrhagic condition of the patient, 
or may result from laceration of an artery. The former 
variety, which usually takes the form of general capil- 
lary oozing, is perhaps the more common, but the latter, 
in which the blood issues in a jet, or in a full florid 
stream, is not unknown. The vessel liable to be 
wounded in extracting a tooth is the dental artery, or 
one of its branches, which may run in abnormal prox- 
imity to the root; but it must be remembered that in 
consequence of periostitis which has existed for a long 
period, capillary vessels, previously too minute to give 
rise to more than trivial bleeding, may become enlarged, 
so as to pour out when lacerated a considerable stream. 
It occasionally happens that haemorrhage, which has 
ceased for a time after the extraction of a tooth, recurs 
with severity after an interval of hours or days. 
Treatment.—Slight haemorrhage may be usually ar- EXTRACTION OF TEETH. 
199 
rested by cold—the mouth being freely rinsed with cold 
water, or better with iced water. If this do not suffice, 
a plug formed of matico leaf—an efficient haemostatic in 
these cases—softened in hot water, may be pressed into 
the cavity. Should the flow persist in spite of these 
measures, or should it be copious or arterial in character 
from the first, the alveolus must be at once firmly 
plugged. The clots having been removed by syringing 
with cold water, a narrow strip of lint is taken and 
tightly packed into the alveolus by a blunt probe, fold 
upon fold, care being taken to pass it to the bottom of 
each division of the socket. A compress of lint is then 
placed in position, and pressure is kept up by causing 
the patient to bite forcibly upon it, and fixing the jaw 
by a bandage passed over the head and beneath the point 
of the chin. The plug—which often gives rise to con- 
siderable irritation—may be carefully withdrawn after 
the lapse of twenty-four to forty-eight hours. 
Seeing how effectually pressure may be maintained 
upon the whole bleeding surface by plugging the socket 
in the manner described, the instances must be extremely 
infrequent which call for other treatment. Such cases 
are, however, recorded. The treatment to be adopted 
would consist in the application of powerful styptics 
and the internal administration of tincture of steel, or 
acetate of lead with opium, to promote coagulation of 
the blood. The best local styptic is perchloride of iron, 
and it may be applied upon strips of lint packed into 
the cavity. This application excites inflammation, and 
should therefore be used only in the severe eases in 
question. In cases which resist this treatment the ac- 
tual cautery may be resorted to, the iron being used at 200 
EXTRACTION OF TEETH. 
a black heat. Instances, although extremely rare, are 
recorded, in which every effort to arrest the haemorrhage, 
including the last resource, ligature of the common caro- 
tid artery, has failed, and the patient being of haemor- 
rhagic diathesis has at last perished from the loss of 
blood. * INDEX. 
Chronic inflammation of dental peri- 
osteum, 140 
gums, 151 
pulp, 134 
Copper amalgam, 108 
Crystal gold, 106 
Cuticula dentis, 18, 24, 36 
Cylinder fillings, 116 
Cysts of the jaws, 166 
Decussation of enamel prisms, 20 
Defective dentine, 78 
enamel, 78 
Deformities of teeth, 50 
Dentigerous cysts, 166 
Dentinal cells, 34 
fibrils, 21 
tubes, 21 
Dentine, defects in structure of, 78 
development of, 28, 34 
papilla, 28 
secondary, 25, 124, 155 
sensibility of, 23 
structure of, 20 
treatment of, 91, 94, 155 
Dentition, permanent, 40 
temporary, 37 
Development of jaws, 37 
teeth, 26 
Dilaceration, 50 
Dislocation of teeth, 156 
Drills, 92 
Elevators, 190 
Enamel, carious, 81 
chisels, 91, 92 
defects in structure of, 78 
development of, 27, 32 
organ, 27 
structure of, 18 
Epilepsy, from dental disease, 181 
Epulis, 168 
Abnormal development of jaws, 58 
Abrasion of the teeth, 155 
Absorption of alveoli, 150 
roots of permanent teeth, 150 
temporary teeth, 40 
Alveoli, growth of, in first dentition, 
46 
second dentition, 46 
Amalgams, 107 
Amaurosis due to dental disease, 181 
Antrum, diseases of, 171 
Arsenious acid in treatment of in- 
flamed pulp, 130 
sensitive dentine, 94 
Buried teeth, 48 
Calcification of cement, 36 
dentine, 33 
enamel, 33 
pulp, 25, 124, 155 
Cancrum oris, 154 
Capping the pulp, operation of, 122 
Caries, 76 
acid in, 76 
artificial production of, 77 
comparative liability of differ- 
ent teeth to, 85 
consolidation of fibrils in, 83 
fungoid growth found in, 82 
incipient, treatment of, 89 
in dentine, 81 
in enamel, 81 
pain during, 84 
preventive treatment of, 87 
zone of transparency in, 83 
Cavities, preparation of, for filling, 
92 
Cementura, development of, 36 
exostosis of, 147 
necrosis of, 148 
structure of, 23 202 
INDEX. 
Eruption of permanent teeth, 42 
temporary teeth, 37 
Exanthematous necrosis, 146 
Excavators, 92 
Exostosis of cement, 147 
jaws, 170 
Extraction of teeth, 182 
casualties of, 194 
difficulties in, 192 
haemorrhage following, 198 
pain following, 198 
Eye, amaurosis of, 182 
Fang filling, 132 
Fangs, union of, 51, 148 
Filing in treatment of incipient cases, 
90 
Filling, materials used in, 104 
operation of, 91 
permanent, 105 
temporary, 105 
with amalgams, 120 
gold, 113 
gutta percha, 121 
oxychloride of zinc, 121 
tin, 120 
Fistulous openings on face, 142 
Follicular ulceration, 152 
Forceps, extracting, 182 
plugging. Ill 
Fracture of teeth, 156 
Gemination of teeth, 51 
Gold, filling with, 113 
instruments used in filling with, 
111 
used in filling teeth, 106 
Gumboil, 142 
Gums, diseases of, 151 
Gutta percha filling, 121 
Haemorrhage after tooth extraction, 
198 
Hereditary abnormalities, 55, 58 
Histology of der.tal tissues, 18 
Hypertrophy of gums, 151 
Inflammation of alveolar perios 
teum, 137 
gums, 151 
periosteum of jaw, 145 
pulp, 126 
Instruments for extracting teeth, 
182 
preparing cavities, 92 
Interglobular spaces, 79 
Irregularities of teeth, 52 
Jaw, dislocation of, 187 
tumors of, 164 
Jaws, growth of, 37 
necrosis of, 146 
Lancing gums, 38 
Leptothrix buccalis, 82 
Mallet in filling operations, 113, 120 
Maxillae, development of, 37 
V-shaped, 60 
Mechanical injuries to the teeth, 155 
Membrana eboris, 35 
Membrane, Nasmyth’s, 18, 24, 36 
Microscopical character of carious 
tissues, 82 
Moisture, methods of excluding, 101 
Nasmyth’s membrane, 18, 24, 36 
Necrosis, exanthematous, 145 
ofjaw, 145 
teeth, 148 
Nervous disorders connected with 
the-teeth, 180 
Neuralgia, 176 
Odontoblasts, 34 
Odontomes, 161 
Operation of extraction, 182 
filling, 91 
Palladium amalgam. 108 
Papilla, absorbent, 41 
dentinal, 28 
Periosteum, dental, 23 
inflammation of, 137 
of jaw, inflammation of, 145 
Permanent teeth, 13 
Phagedsena of gums and cheek, 154 
Pivoting teeth, 173 
Pluggers, forms of, 112 
Plugging, operation of, 91 
tweezers, 111 
Polypus, 135 
Pulp, atrophy of, 134 
calcification of, 25, 124, 155 
cavity, 18 
dentinal, 28 
exposure of, 122 
gangrene of, 127 
inflammation of, 126 
irritation of. 123 
polypus of, 135 INDEX. 
203 
Pulp, structure of, 24 
ulceration of, 134 
Retarded eruption of teeth, 47 
Reunion of dislocated teeth, 157 
Roots of teeth, absorption of, 150 
irregularities in form of, 192 
necrosis of, 148 
Rubber dam, use of, 102 
Saliva, methods of excluding, 101 
Salivary calculus, 158 
Second dentition, 40 
Secondary dentine, 25, 124, 155 
Sensibility of dentine, 23 
Sensitive dentine, treatment of, 91 
94, 155 
Separation of teeth, 90, 99 
Sequestrum, detachment of, 147 
Shedding of temporary teeth, 40 
Silver amalgam, 107 
Sinus opening through cheek, 143 
gum, 143 
Sponge gold, 106 
Stumps, extraction of, 187 
Sullivan’s cement, 108 
Supernumerary teeth, 51 
Sympathetic toothache, 124 
Tartar, 158 
Teeth, abrasion of, 155 
anatomy and histology of, 13 
development of, 26 
dislocation of, 156 
eruption of permanent, 42 
temporary, 37 
Teeth, fracture of, 156 
gemination of, 51 
imbedded, 47 
irregularities of, 52 
malformations of, 50 
permanent, 13 
relative liability to caries, 62, 
85 
supernumerary, 51 
temporary, 16 
union of, 148 
Teething, disorders due to, 38 
Temporary fillings, 105 
teeth, 16 
Thrush, 152 
Tongue, ulcers of, 153 
Torsion, actual, 70 
Transparency, zone of, in caries, 83 
Tubes, dentinal, 21 
Tumors, cystic, 166 
dentigerous, 166 
fibrous, 168 
osseous, 170 
Ulceration of gums, 151 
lips, 153 
pulp. 134 
tongue, 153, 
Union of teeth, 148 
Wisdom teeth, eruption of, 43 
Zone of transparency in caries, 83